Transfusion and Blood Conservation

Kenneth G. Shann, CCP

Assistant Director, Perfusion Services

Senior Advisor, Performance Improvement

Department of Cardiovascular and Thoracic Surgery

Montefiore Medical Center

New York

Disclosures

No Relationships to Disclose

Overview

� Risks of anemia and transfusion

� Concept of balancing hemodilution and oxygen

delivery:

o Preserve red cell mass

Avoid low nadir hematocritso Avoid low nadir hematocrits

o Modify CPB flow according to hematocrit

� Salvage the patient’s blood at the end of the procedure

� Participate in the creation and management of a

multidisciplinary blood management team at your

center

J Thorac Cardiovasc Surg 2003;125: 1438-50

Anemia is Bad!

Does Transfusion Mitigate that?

� Swaminathan M et al. The asscoiation of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg. 2003;76:784-92

� Karkouti K et al. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg. 2005;129:391-400

� Ranucci M et al. Lowest hematocrit on cardiopulmonary bypass impairs the � Ranucci M et al. Lowest hematocrit on cardiopulmonary bypass impairs the outcome in coronary surgery: an Italian multicenter study from the National Cardiothoracic Database. Tex Heart Inst J 2006; 33: 300-5.

� Karkouti K et al. Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg 2005; 80: 1381-7.

� DeFoe GR et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg. 2001 71: 769-76.

Surgenor SD, Kramer RS, Olmstead EM, et al

Outcome Tx. and Heart Surgery

Banbury MK et al. Transfusion increases the

risk of postoperative infection after cardiac

surgery. J Am Col Surg 2006;202:131-138.

- Septicemia/bacteremia

- pneumonia

� Afib

� Prolonged ventilation

� Bleeding

� Renal Failure

� Quality of Life

� Mortality (short and long � Mortality (short and long

term)

0

2

4

6

8

10

12

14

16

18

1 2 3 >4

Severe Infection

Mediastinitis

Pneumonia

Sepsis

Leal-Noval et al. Chest 2001;119:1461

Relative Odds of Receiving Packed Red Blood Cells Transfusion

p value <0.001

Odds Ratio Adjusted*

Low HCT 15.5 Use of pump 7.91 Female Gender 2.37 Lower Body Weight 2.18 Older Age 1.99

2003;97:958-63

Which of these is modifiable by

the operative team?

Body size is related to low nadir

hematocrit during CPB

� DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit

on bypass and adverse outcomes associated with coronary

artery bypass grafting. Northern New England

Cardiovascular Disease Study Group. Ann Thorac Surg

2001;71:769-76.11.

� Swaminathan M, Phillips-Bute BG, Conlon PJ, et al. The

association of lowest hematocrit during cardiopulmonary

bypass with acute renal injury after coronary artery bypass

surgery. Ann Thorac Surg 2003;76:784-92.12.

� Habib RH, Zacharias A, Schwann TA, et al. Adverse effects of � Habib RH, Zacharias A, Schwann TA, et al. Adverse effects of

low hematocrit during cardiopulmonary bypass in the adult:

should current practice be changed? J Thorac Cardiovasc

Surg 2003;125:1438- 50.

� Ranucci M, Conti D, Castelvecchio S, et al. Hematocrit on

cardiopulmonary bypass and outcome after coronary

surgery in nontransfused patients. Ann Thorac Surg

2010;89:11-17.

We can’t change the size of our patients,

but we can customize our strategy to

accommodate their size

Ann Thorac Surg 2011;91:944–82Ann Thorac Surg 2011;91:944–82

� Minicircuits

(Class I Level of evidence A)

� Vacuum-assisted venous drainage

(Class IIb Level of evidence C)

� Retrograde autologous priming

(Class IIb Level B)

� Biocompatible CPB circuits

(Class IIb Level of evidence A)

Strategies to Minimize Hemodilution

• Oxygenator with integrated arterial filter

• 140mL prime

• 3/8 inch venous line

• All circuit tubing length minimized

Matching the Circuit to the Size of the Patient

Mrs. Nussbaum

• All circuit tubing length minimized

• Biocompatible surface coating

• Retrograde and antegradeautologous priming

• Net prime 400mL

Retrograde and Antegrade Autologous Priming

� The passive displacement of crystalloid

solution from the CPB circuit using the

patient’s blood volume via the arterial

and venous lines of the CPB circuit.

� Perceived benefits:

� Less hemodilution during the � Less hemodilution during the

initiation of CPB

� ↑ Hemoglobin, COP, plasma and

platelets

� ↓ diluIon of circulaIng

pharmacologic agent

� Reduced blood transfusions on CPB

� Inexpensive

Rosengart TK, DeBois W, O'Hara M, et al. Retrograde

autologous priming for cardiopulmonary bypass: a safe

and effective means of decreasing haemodilution and

transfusion requirements. J Thorac Cardiovasc Surg

1998;115:426-38.

26%

28%

30%

Old Circuit

Customized + RAP

Dil

uti

on

al

HC

T %

First HCT in OR 35%

Post Dilutional HCT vs Body Weight With

Different Hemodilution Strategies

16%

18%

20%

22%

24%

50 55 60 65 70 75 80 85

Customized + RAP

Customized + RAP + Fluid

Restriction

Weight (kg)

Po

st D

ilu

tio

na

l

Ann Thorac Surg 2005;80:2213–20

De

live

ry (

ml/

min

/m2)

DO2 = Q(indexed)*10*(HGB*1.36*SaO2 + pO2*0.003)

Cardiac Index272 ml/min/m2

.

Oxygen Delivery vs. HCT At Different Flow Rates

O2

De

live

ry (

ml/

min

/m

HCT (%)

Ann Thorac Surg 2011;91:944–82

� Pump salvage

(Class IIa Level of evidence C)

� Centrifugation instead of direct infusion

(Class IIa Level of evidence A)

� Modified ultrafiltration (MUF)

(Class I Level of evidence A)

� Multidisciplinary blood management

teams

(Class IIa Level of evidence B)

Blood Salvage and Collaboration

Modified Modified Modified Modified UltrafiltrationUltrafiltrationUltrafiltrationUltrafiltration

•Using the cardioplegiapump, blood is pumped retrograde out of aorta, hemoconcentrated, and returned to right atrium•Performed for 10 to 20 minutes

Ann Thorac Surg 1994;58:573-4

minutes •10-15mL/kg/min up to 500ml/min•Volume removed through ultrafiltration is replaced with volume from CPB circuit•Substances less than 65,000 daltons are removed

Blood Conservation Saves Lives?

Risk score matched patients!

Summary

• Anemia is bad• Transfusion is not the answer• Balance hemodilution and oxygen delivery

– Match CPB circuit to size of patient– Retrograde and antegrade autologous prime– Modifying CPB flow rate will modify oxygen delivery and should be – Modifying CPB flow rate will modify oxygen delivery and should be considered prior to transfusion

• Centrifugation and modified ultrafiltration should be considered for salvaging residual blood

• Perfusionists should actively participate in blood management efforts� Collect and report transfusion data� Report variation in blood loss