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Transfusion in Cardiopulmonary Bypass

Transfusion in Cardiopulmonary Bypass. Blood Use & Cardiac Surgery. 1971 – average 8 units RBC per case Late 1980’s – Texas Heart Institute 1.4 units per case, 35% no blood, 31% one unit

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Transfusion in Cardiopulmonary Bypass

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  1. Transfusion in Cardiopulmonary Bypass

  2. Blood Use & Cardiac Surgery • 1971 – average 8 units RBC per case • Late 1980’s – Texas Heart Institute 1.4 units per case, 35% no blood, 31% one unit • Jehovah’s Witness series (N=36) - no blood given, blood loss 200-1200 cc, hgb 14.9-11.2 post op, to hgb 9.2 at lowest point post op day 6

  3. Why Reduced Blood Use? • Priming pump with electrolyte solution instead of whole blood or PRBC • Improved surgical technique • Better anesthesia, control of BP • Use of inhibitors of fibrinolysis* • Re-transfusion of shed blood/cellsaver • Tolerance of lower intra-, post-op hgb • Hemodilution, autologous donation

  4. Why do CABG patients bleed so much? • Aspirin, plavix (clopidogrel) • Heparin • Exposure of blood to non-endothelialized surfaces • Shear forces in pump • Hemodilution • Hypothermia • Systemic inflammatory response

  5. What is Excess Bleeding? • Bleeding usually occurs after coming off pump • Surgical vs Microvascular • CT output > 100-200 cc/hr • 2-5% re-operation rate

  6. Initial Interactions between Plasma Proteins and Biomaterials Edmunds L. N Engl J Med 2004;351:1603-1606

  7. Diagnostic Tools • PT/PTT, platelet count, fibrinogen • Often not well correlated with bleeding • TAT to slow to make decisions in OR • Activated Clotting Time (ACT) • Used to titrate heparin, no diagnostic value • Thromboelastography • Tricky to interpret and run • Info re fibrinolysis

  8. Therapy for Microvascular Bleeding • Blood Products • Platelets to treat dysfunction/pump defect • Platelets for count < 50-100K • FFP, CRYO, fibrin glue products • RBC hgb < ~8

  9. Antifibrinolytics • Aprotinin • Plasmin inhibitor, broader serine protease inhibitor • Tranexamic acid, aminocaproic acid • Lysine analog

  10. Recombinant FVIIa • Safety & efficacy under review • Exclude surgical cause, heparin • Correct deficits in platelets and coagulation factors • Persistent, excessive bleeding

  11. Relative Risk of In-Hospital Death in the Aprotinin Group as Compared with the Aminocaproic Acid Group, Based on Multivariate Analyses of the 78,199 Patients in the Primary Study Cohort, According to the Amount of Aprotinin Schneeweiss S et al. N Engl J Med 2008;358:771-783

  12. Relative Risk of In-Hospital Death among the 78,199 Patients Undergoing Coronary-Artery Bypass Grafting (CABG) in the Primary Study Cohort Schneeweiss S et al. N Engl J Med 2008;358:771-783

  13. Kaplan-Meier Estimates of Survival and Death Koch C et al. N Engl J Med 2008;358:1229-1239

  14. Postoperative Complications, According to the Duration of Blood Storage Koch C et al. N Engl J Med 2008;358:1229-1239

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