Blood Conservation Effectiveness at Virginia Commonwealth ...

Blood Conservation Effectiveness at Virginia Commonwealth ...

Vigneshwar Kasirajan, M.D. Division of Cardiothoracic Surgery Results 45 40 35 30 25 20 15 10 5 0 400 350 300 250 200 150 100 50

0 1997 1998 1999 2000 2001 $ per patient % Transfused Resource Utilization in Cardiac Surgery Transfusion Rate (%) Cost per patient ($) 2002

Year Higgins, et al AATS 2003 Results Hemoglobin Levels 13 12 gm/dl 11 * 10 * Pre Program Post Program 9

8 7 6 Preop *=p<0.05 CPB MIN Time ICU DC Green, et al. SCA 2003 Results Financial Savings 1800 Total Savings=$1.4M

Unit and Xmatch=$295K Fixed overhead=$274K Adverse Events=$863K Thousands of dollars 1600 1400 1200 1000 800 600 Adverse Event Unit & Xmatch Personnel Total Cost 400 200 0 Pre Program

Post Program Spiess, et al. SCA 2003 HEMOGLOBIN 15 10 5 MINI 1 OPCAB 1 OPCAB 2 ONPUMP 1 ONPUMP 2 Retrograde Autologous Priming (RAP) Eight month data review at VCU MEDICAL CENTER November 04-June 05

TOTAL CASES ATTEMPTED Attempted RAP Cases 200 150 100 179 50 26 0 TOTAL RAP Cases No RAP Cases No RAP Cases 14 12 HGB 10

11.5 8 6 7.1 4 2 0 Pre Pump HGB 1st HGB on Pump Pre-Post RAP Hgb RAP CASES 14.0 12.0 10.0 12.0

8.0 8.4 6.0 4.0 2.0 0.0 Pre RAP Post RAP RAP Volume 800 700 600 703 Average Rap amount (mls) 500

400 300 200 100 0 393 Average Rap amount used (mls) AUTOLOGOUS BLOOD OFF BY ANESTHESIA AFTER INDUCTION AVERAGED 516 mls. HGBS ON BYPASS RAP Cases 8.0 6.0 4.0 2.0 0.0

7.6 7.8 Lowest pump Hgb Last pump Hgb PATIENTS HGB AFTER ARRIVING TO ICU AVERAGED 10.2 g/dl 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. 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) 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 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 Results

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

Results Complications Mortality Stroke MI Reoperations 5% (10) 2% (5) 1% (2) 5% (10) Results Group Count % ANH Only

6 3 No Action 20 10 RAP + ANH 74 36 RAP Only 105 51

Total 205 100 Antifibrinolitics Use Aprotinin 49% (101) EACA 51% (104) Results Main Outcome Measures Transfusion rate Hemoglobin Drop (from PreOp to ICU)

Transfusion Rate 11% (23) 83% patients had aprotinin Results Blood Conservation Maneuver Groups Transfusions per Group RAP RAP + ANH No RAP \ No ANH ANH # Patients

105 73 20 6 PreOp Hgb 11.6 0.2 12.7 0.2 11.5 0.4 11.5 0.8 Cell Saver (Yes\No) 65 \ 40

53 \ 21 14 \ 6 4\2 APO \ EACA 48 \ 57 36 \ 38 12 \ 8 5\1 13% 3%* 30%* 17%

% patients transfused * p < 0.001 Results (Excluding Patients Transfused) Hgb Decrease (gr/dL) by Maneuver Antifibrinolitics LS Mean Lower 95% Upper 95% Amicar* 2.4 2.1 2.8 Aprotinin* 1.8 1.4 2.2 ANH No Yes 2.0 2.2

1.7 1.8 2.3 2.7 RAP No Yes 1.9 2.3 1.4 2.0 2.4 2.7 2.3 1.9 1.8

1.6 2.8 2.3 Cell Saver No Yes *p < 0.05 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 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 Blood Usage All Cases ALL CASES

2004 2005 2006 2007 IntraOp only 1.92% 7.42% 9.43% 18.01% PostOp Only IntraOp or PostOp IntraOp and PostOp

22.99% 23.63% 20.29% 9.32% 31.42% 42.31% 50.29% 47.20% 6.51% 11.26% 20.57%

19.88% Mortality OE Case Mix Index Ratio: Ratio: Ratio: Ratio: 1.42229 0.27324 0.72599 1.24046 Observed: Observed: Observed: Observed: 0.0462 0.0082 0.0240 0.0460 Expected: Expected: Expected: Expected: 0.0325 0.0299 0.0331

0.0371 3.8398 4.0057 4.0589 4.3872 Blood Usage CAB Only CAB Only IntraOp only PostOp Only IntraOp or PostOp IntraOp and PostOp Mortality OE Case Mix Index 2004 2005

2006 2007 0.00% 2.96% 11.05% 13.33% 18.66% 25.12% 26.16% 16.00% 23.13% 35.96% 46.51% 48.00% 4.48% 7.88% 9.30% 18.67% Ratio: Ratio: Ratio: Ratio: 0.55674 1.48771 0.20934 1.24154 Observed Observed Observed Observed: : 0.0373 : 0.0049 : 0.0292

0.0133 Expected: Expected: Expected: Expected: 0.0251 0.0235 0.0236 0.0239 3.8398 4.0057 4.0589 4.3872 POST CABG COMPLICATIONS 35.00% 30.00% 25.00% 20.00% male 15.00% female

10.00% 5.00% 0.00% Prolonged Vent Renal Failure Any Complication Mortality TRANSFUSION RATES (CABG) 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00%

0.00% Male Female 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. TEG PRE CPB Hb 6.0 1 prbc Hb < 5 2 prbcs TEG POST CPB AFTER PROTAMINE No factors or platelets due to absence of clinical

bleeding 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 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.

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