Blood Conservation: A team approach to optimize blood management

1. Blood Conservation:A team approach to optimize blood management Justin Resley CCP, LP Chief of Cardiovascular Perfusion Bloodless Medicine Surgery Program Georgia Health Sciences University Augusta, Georgia USA

2. Disclosure Thank Terumo Cardiovascular for bringing me to speak to you today

4. Our Challenges… • US • Economic Challenges (Debt >$16 trillion) • Soaring Food and Energy Costs • Unsustainable Healthcare Costs • Georgia • Economic Challenges (Budget Shortfall) • Unsustainable Healthcare Costs

5. Our Challenges… • Less Revenue • Dramatic reductions in Medicaid and Medicare Reimbursements to hospitals and physicians – estimated at $423 billion over ten years • Bundled Payments (2012) • Value Based Purchasing

6. Value Based Purchasing

7. Perfusionist… • A specialized health professional that is highly trained in the discipline of physiological and metabolic support of cardiac surgery patients.

8. Perfusion Metrics

12. Our Vision… To be remembered by each patient as providing the care and compassion we want for our families and ourselves.

13. An initial meeting… • Surgeons, Anesth, Perf, CRNA, STS, CVICU • Reviewed Literature, discussed various approaches • Continue practices already in place • PreOp EPO? • Pediatric Blood Tubes? • Safe Set for drawing samples • Decrease Dilutional Anemia • ANH • Anti-Fibrinolytic Therapy • Trigger 7.0 or 8.0? Now stands at 7.0 Intra-Op and 7.5 Post-Op • Minimize Pump Volume • Post Pump Blood/Volume Management • Initial: Isolated CABG but spillover care may take place

14. ANH?? • Acute (in the operating room) • Normovolemic (keeping patient volume the same) • Hemodilution (taking blood off before surgery and replacing with crystalloid or albumin)

15. Data Collection Tool Blood Conservation Tool Patient Label Date:______________________ CRNA:_____________________ Surgeon:___________________ Procedure:__CABG ONLY______________________________________________ 1. Total cyrstalloids =/< 1800ml? Yes No 2. Closed-circuit "Safe Set" used on arterial line? Yes No 3. Acute NormovolemicHemodilution used? Yes No (>70kg with Hgb =/> 12g/dl for on-pump and =/> 10 g/dl for off-pump) 4. Retrograde Autologous Priming done? Yes No Explanation for any no answers:_____________________________________________

16. The Bloody Truth… • Transfusions are inherently hazardous • Blood Collection Industry has reduced risk of viral transmission • Bacterial Contamination of Platelets 1:2,000-3,000 • Transfusion errors from patient misidentification 1:16,000-19,000 • TRALI 1:1,000-5,000 Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411. Goodnough LT. Risks of blood transfusion. [Review] [124 refs]. Critical Care Medicine 2003;31:S678-S686. Toy P, Popovsky MA, Abraham E et al. Transfusion-related acute lung injury: definition and review. Crit Care Med 2005;33:721-6. Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003;43:1190-9.

17. The Bloody Truth… • “ Blood transfusion is associated with a 35% greater risk of serious bacterial infection and a 52% greater risk of pneumonia. Postoperative infections are costly. The risk of bacterial infection may be the most common life-threatening adverse effect of allogeneic blood transfusion. • Carson et al. Transfusion 1999;39:694-700

18. The Bloody Truth… • Blood is a Liquid Transplant • Blood Transfusion = Organ Transplant • Immune System function changes in recipient • Stepwise increase with each new donor • Infection Rates • Ventilator Acquired Pneumonia • Central Line Sepsis • ICU and Hospital LOS • Short and Long Term Mortality Rates Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411. Shorr AF, Duh MS, Kelly KM et al. Red blood cell transfusion and ventilator-associated pneumonia A potential link Crit Care Med 2004;32:666-74. Taylor RW, Manganaro L, O'Brien J et al. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002;30:2249-54. Shorr AF, Jackson WL. Transfusion practice and nosocomial infection: assessing the evidence. CurrOpinCrit Care 2005;11:468-72.

19. The Bloody Truth… • Transfusions Progressively Increase Infection Rates • Each Unit increases Nosocomial Infection by 50% • “Lets order TWO units” Shorr AF, Duh MS, Kelly KM et al. Red blood cell transfusion and ventilator-associated pneumonia A potential link?Crit Care Med 2004;32:666-74. Taylor RW, Manganaro L, O'Brien J et al. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002;30:2249-54. Shorr AF, Jackson WL. Transfusion practice and nosocomial infection: assessing the evidence. CurrOpinCrit Care 2005;11:468-72.

20. Immune Soup: White Cell Microchimerism! Microchimerism had also been shown to exist after blood transfusions to a severely immunocompromised population of patients who suffered trauma. Reed W, et al Seminars in Hem.

21. The Bloody Truth… • Less is more for Transfusions “Doing more with less” • Saves Blood • Saves Money • Blood is Money! • Improves Outcomes • Improved Outcomes is Money! Hebert PC, Wells G, Blajchman MA et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-17. Corwin HL. Anemia and red blood cell transfusion in the critically ill. Semin Dial 2006;19:513-6

22. The Bloody Truth… Largest Cause of Death and Morbidity? • “ We estimate that the death rate from allogeneic transfusion-related postoperative infection and cancer recurrence combined may exceed the death rate due to all other transfusion risks combined.” Blumberg N., Allogeneic transfusion and infection: economic and clinical implications. Seminars in Hematology 1997;34:Suppl.34-40

23. The Bloody Truth… • Transfusion Education is Grossly Inadequate • MD’s no formal training in Transfusion Therapy • Nursing training in transfusion safety • Blood Utilization oversight Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003;43:1190-9. Stover EP, Siegel LC, Parks R et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998;88:327-33. Corwin HL, Gettinger A, Pearl RG et al. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med 2004;32:39-52.

24. The Bloody Truth… • Speaking of Education: Banked Red Cell Biochemsitry • pH-7.2 to 6.6 • K - 3.9 to 78 meq/L • Ionized Calcium- 0 • Ionized Magnesium-0 • Glucose- 25.5-44.6gm/L • Sodium Citrate- 23gm/L • Lactate-1.6-30.1 mmol/L • Free Hemoglobin-0-1gm/dl.

25. The Bloody Truth… • USA Transfusion Rates Highest • Higher than most Western Countries • 1999-2004 USA up 16% while UK down 8% Wallis JP, Wells AW, Chapman CE. Changing indications for red cell transfusion from 2000 to 2004 in the North of England. Transfus Med 2006;16:411-7. Yazer M, Triulzi D. Messages from national blood data collection reports. Transfusion 2007;47:366-8. MacPherson J, Mahoney CB, Katz L et al. Contribution of blood to hospital revenue in the United States. Transfusion 2007;47:114S-6S.

26. The Bloody Truth… • Blood Costs...Gas prices…on the RISE! • Blood acquisition Costs • Blood Production Costs • Supply struggles to meet Demand Hannon TJ, Paulson-Gjerde K. Contemporary economics of transfusions. In: Spiess BD, Spence RK, Shander A, eds. Perioperative Transfusion Medicine. Philadelphia: Lippincott Williams & Wilkins, 2005.

27. The Bloody Truth… • Blood Costs…Tip of the Iceberg Total Cost of Transfusion >5x Acquisition Costs Hannon TJ, Paulson-Gjerde K. Contemporary economics of transfusions. In: Spiess BD, Spence RK, Shander A, eds. Perioperative Transfusion Medicine. Philadelphia: Lippincott Williams & Wilkins, 2005.

28. The Bloody Truth… • Transfusions = “Risky Business” • Risk Exposure • Financial Liabilility of Inappropriate Transfusion • Eliminate Medication & Transfusion Errors Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411. http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Blood+Management+-+Utilization.htm

29. The Bloody Truth… • You Break it…..You Pay for it • Transfusion Complications 2009 • Financial Penalties

40. Post Pump Blood/Volume Management • Chase Venous, Remove Vents • Transfuse via Aortic Cannula • Anesthesia dilitation, legs down, head up • Advantages over bagging pump blood • During protamine administration • Minimize Cell Saver to process pump blood

41. CABG Intra-op blood products

42. Intra-Op: Any Product

43. Entire LOS: Any Product

44. Pre-Op to Discharge Hct

45. Bleeding

46. Intubation

47. Length of Stay

48. 2011 CABG INTRA/POST-OP PRBC vs. Any Product

49. Pressure… • We are all under pressure • Get involved • Now more than ever it is important to be proactive • What can perfusion do?????

50. Red Cell Changes