Blood conservation in cardiac surgery

STS PRACTIC

E

STS PRACTIC

E

GUIDELIN

ES FOR

GUIDELIN

ES FOR

BLOOD

BLOOD

CONSERVATION

CONSERVATION

STRATEGIES I

N

STRATEGIES I

N

CARDIAC S

URGERY

CARDIAC S

URGERY

By- Dr.

Armaan S

ingh

By- Dr.

Armaan S

ingh

STS/SCA BLOOD CONSERVATION CLINICAL PRACTICE GUIDELINES

Transfusions in cardiac surgery patients:

•50% of patients undergoing cardiac procedures receive blood transfusions

•Complex cardiac operations like redo procedures, aortic operations, and implantation of VADs require blood transfusion with much greater frequency

•Increasing evidence suggests that blood transfusion during cardiac procedures portends worse short and long-term outcomes

•Interventions aimed at reducing bleeding and blood transfusion during cardiac procedures are an increasingly important part of Quality Improvement


Revised 2011 recommendations for blood conservation in patients undergoing cardiac procedures:

Preoperative intervention Class of Recommendation Level of Evidence

Discontinue P2Y12 inhibitors I B

POC testing for platelet ADP IIb C

Postop P2Y12 inhibitors III B

Preop EPO + Fe IIa B

Preop EPO for autologous donation IIa A

Dr. Armaan Singh



•Continuation of aspirin, and discontinuation of clopidogrel in ACS patients provides a reasonable risk-benefit relationship in surgical patients.

•Ticagrelor compared with clopidogrel was associated with a substantial reduction in mortality without excess risk of CABG-related bleeding.

Dr. Armaan Singh



Intraoperative intervention Class of Recommendation Level of Evidence

ε-ACA or Tranexamic acid I A

Aprotinin risks outweigh benefits III A

Dr. Armaan Singhonservation clinical practice guidelines. Ann Thorac Surg 2011;91:944-982.


Aprotinin:

Mangano DT, et al: The risk associated with Aprotinin in cardiac surgery. N Engl J Med 2006;354:353-365.


Head-to-head comparison of antifibrinolytic agents:

Brown JR, et al: Meta-analysis comparing the effectiveness and adverse outcomes of antifibrinolytic agents in cardiac surgery. Circulation 2007;115:2801-2813.



Use of blood derivates Class of Recommendation Level of Evidence

PCC for warfarin reversal IIa B

FFP if multiple factor deficiencies IIa B

FFP as part of massive transfusion IIb B

Prophylactic FFP not indicated III A

FFP not indicated if no bleeding III A

Leukoreduced donor blood IIa B




•Prothrombin complex concentrate (PCC) is preferred for reversing warfarin.

•Plasma should not be considered for warfarin reversal unless PCC is not available and/or severe bleeding is present.

•PCC contains relatively high levels of factors II, IX, and X.

•Current PCC preparations available in the United States contain reduced or negligible amounts of factor VII.

Dr. Armaan Singh


Warfarin reversal with Prothrombin complex concentrate (PCC):

•FFP can be effective but requires transfusion of several units. With FFP transfusion there is a delay in therapeutic effect of up to several hours. •PCC can be infused rapidly (10 mL/min) for partial or complete reversal of warfarin effect. •PCC preparations currently available in the United States contain reduced or negligible amounts of factor VII. •The addition of 2 units of plasma to PCC infusion significantly improved the proportion of patients with satisfactory INR values.

Holland L, et al: Suboptimal effect of a three-factor prothrombin complex concentrate (Profilnine-SD) in correcting supratherapeutic international normalized ratio due to warfarin overdose. Transfusion 2009;49:1171-1177.


Warfarin reversal with Prothrombin complex concentrate (PCC):

Lubetsky A, et al: Efficacy and safety of a prothrombin complex concentrate (OctaplexR) for rapid reversal of oral anticoagulation. Thromb Res 2004;113:371-378.



Other blood derivates Class of Recommendation Level of Evidence

Intraoperative platelet plasmapheresis IIa A

Recombinant factor VIIa concentrate IIb B

Factor XIII for clot stabilization IIb C

Antithrombin III for heparin resistance I A

Factor IX conc for pts with hemophilia B IIb C



Intraoperative platelet plasmapheresis:

Stover EP, et al: Platelet-rich plasma sequestration, with therapeutic platelet yields, reduces allogeneic transfusion in complex cardiac surgery. Anesth Analg 2000;90:509-516.


Recombinant factor VIIa:

Tatoulis J, et al: Safe use of recombinant activated factor VIIa for recalcitrant postoperative haemorrhage in cardiac surgery. Interact Cardiovasc Thorac Surg 2009;9:459-462.


Recombinant factor VIIa:

Masud F, et al: Recombinant factor VIIa treatment of severe bleeding in cardiac surgery patients: a retrospective analysis of dosing, efficacy, and safety outcomes. J Cardiothorac Vasc Anesth 2009;23:28-33.


Thrombotic complications with recombinant factor VIIa:

•No cases of rFVIIa associated thromboembolic events. median dose 55.2 g/kg

Masud F, et al: Recombinant factor VIIa treatment of severe bleeding in cardiac surgery patients: a retrospective analysis of dosing, efficacy, and safety outcomes. J Cardiothorac Vasc Anesth 2009;23:28-33.

•4% thromboembolic event rate. median dose 92 g/kg

Dunkley S, et al: Recombinant activated factor VII in cardiac surgery: Experience from the Australian and New Zealand Haemostasis Registry. Ann Thorac Surg 2008;85:836-844.

•Recombinant factor VIIa appears to be relatively safe with a 1-2% incidence of thrombotic complications based on published trials.

Levi M, et al. Efficacy and safety of recombinant factor VIIa for treatment of severe bleeding: a systematic review. Crit Care Med 2005;33:883-890.



Blood salvage interventions Class of Recommendation Level of Evidence

Centrifugation of salvaged blood IIa A

Pump salvage and reinfusion IIa C

Centrifugation in pts w/malignancy IIb B




•Centrifugation instead of direct infusion of residual pump blood is reasonable for minimizing post-CPBP allogeneic RBC transfusion. (Level of evidence A).

•Centrifugation of residual CPBP blood produces concentrated red cells mostly devoid of plasma proteins.

•Ultrafiltration produces protein-rich concentrated whole blood.




Perfusion interventions Class of Recommendation Level of Evidence

Minicircuits (MECC) I A

Vacuum-assisted venous drainage IIb C

Microplegia technique IIb B

Biocompatible CPBP circuits IIb A

Modified ultrafiltration I A

Leukocyte filters may be harmful III B



Minimized Extracorporeal Circulation (MECC):

Kamiya H, et al: Preliminary experience with the mini-extracorporeal circulation system (Medtronic resting heart system). Interact Cardiovasc Thorac Surg 2006;5:680-682.



Benedetto U, et al: Miniaturized cardiopulmonary bypass and acute kidney injury in coronary artery bypass graft surgery. Ann Thorac Surg 2009;88:529-536.


Ultrafiltration:

•Conventional UF starts during rewarming and continues until the end of CPBP.

The ultrafiltrated blood is directly returned to the venous reservoir.

•Modified UF is carried out in the first 15 min after cessation of CPBP.

The arterial and venous lines are kept in situ.


Ultrafiltration:

Blood conservation in cardiac surgery

Health & Medicine

Transcript of Blood conservation in cardiac surgery