Blood Conservation Program: Successful Results in Cardiothoracic Surgery

1. VigneshwarKasirajan, M.D. Division of Cardiothoracic Surgery

3. Results Higgins, et al AATS 2003

4. Results * * *=p<0.05 Green, et al. SCA 2003

5. Results Total Savings=$1.4M Unit and Xmatch=$295K Fixed overhead=$274K Adverse Events=$863K Spiess, et al. SCA 2003

6. HEMOGLOBIN

7. Retrograde Autologous Priming (RAP) Eight month data review at VCU MEDICAL CENTER November ’04-June ‘05

8. TOTAL CASES ATTEMPTED

9. No RAP Cases

10. Pre-Post RAP Hgb

11. RAP Volume

12. AUTOLOGOUS BLOOD OFF BY ANESTHESIA AFTER INDUCTION AVERAGED 516 mls.

13. HGBS ON BYPASS

14. PATIENT’S HGB AFTER ARRIVING TO ICU AVERAGED10.2 g/dl

15. CONCLUSIONS • Enhances communication between perfusionist, anesthesiologist, and surgeon. • One month to achieve comfort level performing RAP. • Priming volume of pump has been reduced from 1800mls to 650mls. • Only 11% of RAP patients received bank blood. • 27% of No RAP(26 patients), received bank blood on bypass. • 46% of RAP patients received aprotinin • Cell saver used on 66% of RAP patients • Entire pump volume washed with cell saver on 46% of RAP patients after bypass.

16. VCU Blood Conservation Policy • Transfusion Guidelines • Hematocrit 17% • AND • Signs of Oxygen Debt • Conservation Strategies (commonly used methods in cardiac surgery, often concurrently) • ANH (Autologous Normovolemic Hemodilution) • RAP (Retrograde Autologous Priming of CPB circuit) • Cell Saver Use • Antifibrinolitic Drugs Use in All Patients • Aprotinin or Epsilon AminoCaproic Acid (EACA)

17. Methods • IRB Approved Retrospective Review • All patients in the period from • November 1st, 2004 • to • July 1st, 2005 were studied • Statistical Analysis • Mixed Effect Repeated Measures ANOVA

18. Results • A total of n=205 patients were included • 146 males (71%) • 59 females (29%) • Mean age 58.4 ± 13.5 years old • Mean Ejection Fraction 45 ± 15% • Interquartile Range (25-75) 35-60% • History of • Myocardial Infarction 40% • Congestive Heart Failure 35% • Hemoglobin Levels • PreOp HGB 12.0 ± 1.9 • Lowest HGB on CPB 7.6 ± 1.5 • First HGB in ICU 10.0 ± 1.8

19. Results • Procedures • CABG 49% (100) • Valve 14% (30) • Aortic Surgery 9% (18) • VAD 1% (2) • Combined Procedure 27% (55) • Previous Sternotomy 28% (57) • Anticoagulation Medication • Heparin 11% (22) • Coumadin 10% (20)

20. Results • Complications • Mortality 5% (10) • Stroke 2% (5) • MI 1% (2) • Reoperations 5% (10)

21. Results Antifibrinolitics Use Aprotinin 49% (101) EACA 51% (104)

22. Results • Main Outcome Measures • Transfusion rate • Hemoglobin Drop (from PreOp to ICU) • Transfusion Rate 11% (23) • 83% patients had aprotinin

23. Results • Blood Conservation Maneuver Groups

24. Results (Excluding Patients Transfused)

25. Conclusions • Successful Blood Conservation Program • Transfusion Rate 11% • The combination of RAP and ANH is particularly effective • Transfusion Rate 3% • Selection Bias or Channeling of more likely to bleed patients towards the use of Aprotinin • 83% of transfused patients received Aprotinin

26. Conclusions • Despite this Channeling, the most effective maneuver to conserve blood was the use of Aprotinin • Hgb drop 1.8 vs 2.4 gr/dL compared with EACA • Only maneuver statistically effective despite the channeling • Effective multimodal approach even though individual contribution by each maneuver is not statistically significant

27. Blood Usage – All Cases

28. Blood Usage – CAB Only

29. POST CABG COMPLICATIONS

30. TRANSFUSION RATES (CABG)

32. 56 y MALE – Acute MI, Cardiogenic shock, on IABP • Hb 9.9 g/dl • On plavix, ASA (prev PCI) • Integrellin and iv heparin • Emergent surgery due to worsening CP and ST elevations.

33. TEG PRE CPB

34. Hb 6.0 – 1 prbc Hb < 5 – 2 prbcs

35. TEG POST CPB AFTER PROTAMINE No factors or platelets due to absence of clinical bleeding

37. VCSQI STUDY Transfusion Triggers: On Pump RBC transfusion for Hgb < 6.0 or HCT <18 + One objective criteria for tissue hypoperfusion. ·        Low SVO2 ·        Elevated Lactate ·        Elevated base deficit, Low HCO3 Post Op ( ICU and Step Down Units ) RBC transfusion for Hgb < 7.0 or HCT <21 + One objective criteria . ·        Elevated O2 need ·        Hypotension ·        End Organ dysfunction ·        Ongoing Bleeding Prospective Follow Up: The following data will be collected for each patient: All data routinely collected for the STS Adult Cardiac Surgery Database will be collected as usually done for quality improvement purposes. In addition the following custom fields will be collected prospectively. ·        Pre-Op Hgb/Hct ·        Hgb/Hct Pre-Bypass ·        Lowest Hgb/Hct on Bypass ·        Hgb/Hct at end of surgery ·        Hgb/Hct at discharge from ICU ·        Hgb/Hct at discharge from hospital ·        Hgb/Hct at first post-op visit ·        Amicar vs. Aprotinin vs. None ·        Retrograde Autologous Priming ·        Ultrafiltration ·        Degree of hypothermia ·        Cell saver use ·        Volume of Cardioplegia ·        Total volume of Crystalloid/Colloid during surgery. ·        Leukoreduced v. Non-leukoreduced ·        Factor VIIa ·        Every unit transfused will be recorded with the time and Hgb/Hct trigger. ·        Date blood was harvested.