Today’s Webinar will begin at 11:00

2/9/12

Welcome from Barb DeBaun, RN, MSN, CIC

Introduction

• Please do not put your phone on hold; use the mute function or *6

• Please type questions into text box• If time permits, we will open up the

phone lines at the conclusion of the presentation

BloodConservationin CABG Surgery

February 9, 2012

Participants• Barry Johnson, MD

– CV Surgery Anesthesiologist– barryjonsn@aol.com

• Pablo Zubiate, CCP– Cardiovascular Surgery Coordinator– Pablo.zubiate@enloe.org

• Marcia Nelson, MD, FAAFP– Vice President, Medical Affairs– Marcia.nelson@enloe.org

Perspective

• Historically, >50% of bypass surgeries transfused– Lundy’s hemoglobin threshold of 1942

• Study recommended transfusion for Hb < 8-10

• New studies focus on safety• Enloe creating new evidence-based

standards

The Public is Watching

Wall Street Journal, October 19, 2010

Enloe Medical Center• 298-bed Level II Trauma

Center• 14,500 admissions/year• Planetree affiliate• Hospital-owned Flight

Care• New Magnolia Tower

Spring 2012– New CV ICU– Doubles the number of OR

suites

Quality at Enloe

• Created organizational focus in 2009

• Annual Quality Summit• Organizational quality initiatives• Program-based poster presentations

Enloe Heart Program

• Blue Distinction for Cardiac Care

• STEMI Receiving Center

• Cardiology, Interventional Cardiology, Electrophysiology

• Cardiac Surgery

Cardiothoracic Surgery Team• Surgeons

• Miguel Puig, MD• Guy Lemire, MD• Phil Faraci, MD

• Anesthesiologists• Barry Johnson, MD• Michael Hieb, MD• Jeni Henrie, MD• Robert Ertner, MD• Roger Phillips, MD

• Physician Assistants• Shari Miller, PA-C• Michael Mohr, PA-C• Todd Richter, PA-C

• Perfusionists• Pablo Zubiate, CCP• Bob Hayes, CCP• Jack Reed, CCP

Background: CV Quality Initiative

• Model: Physician champion leading multi-disciplinary team

• Administration alignment• Evidence-based decision making

– 2007 Guidelines published by the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologist Ann Thorac Surg 2007;83:27-86

– 2011Guidelines Update published Ann Thorac Surg 2011;91:944–82

Project Design

• Transfusion Committee oversight• Step 1: 2007-09 data analyzed• Step 2: Opportunities for improvement

identified and goals set• Step 3: Physician champions

established• Step 4: Education provided including

new predictors for blood usage

Special Considerations

• Advanced age • Low pre-op RBC volume – anemia, small

body size • Pre-op antiplatelet or antithrombotic drugs • Re-operative, complex procedures • Emergency operations • Non-cardiac co-morbidities• Inherited coagulation abnormalities

Enloe Heart Program Volumes

Baseline Data: 2007-2009

• In 2009, 65% of Enloe’s CABG patients received intra-operative blood

• Goal: Reduce intra-operative blood usage to meet STS benchmark

Methods: Role of the Team

• Multidisciplinary blood conservation program

• Surgeon role– Selective use of off-pump technique for CABG– Utilize evidence-based transfusion indications– Topical agents and tissue glues– Prophylaxis

• Interventions outside the OR

Methods: Role of the Team

• Anesthesiologist Role– Hemostatic drugs with anti-fibrinolytic

properties• Aprotinin, Amicar, Tranexamic acid

– Erythropoietin ( EPO )– DDAVP and Factor VIIA– Intra-operative autologous blood donation

Methods: Role of the Team

• Perfusionist Role– Minimize extracorporeal circuits– Use of bonded circuits– Use of cell savers– Pump salvage & intra-op auto-

transfusion– Post-operative shed blood

re-infusion– Retrograde autologous priming (RAP)– Hemofiltration

Methods: Role of the Team

• Physician Assistants– Endoscopic vein harvesting

• Latest equipment to prevent hemorrhage– Vein mapping– Post-op transfusion guidelines

• Nursing– ICU processes and practices

Actions Taken

• Reintroduction of guidelines– Review of blood utilization practices

led to new protocols

• Acquisition of new cell savers• Reduction of perfusion circuit• Anesthesia reduced crystalloid use

CABG: On vs. Off Pump

Results: 2009-Current

CABG blood use decreased by 57% from 2009

Next Steps

• February 13 pilot: Thromboelastograph (TEG) in CABG surgery

• Educate non-CV surgeons and OR staff around cell saver use

Challenges

• Evolution of protocols

• Dealing with high-risk profiles

• Introduction of new thrombin inhibitors

Thank youAny questions?

Next Cynosure ‘Beyond SCIP” and other events

• March 15th: in-person meeting in San Francisco

• March 27th: webinar with Dr. Heather Young from Colorado

• April 12th: webinar with Sue Barnes from Kaiser Permanente

• May 21st: Cynosure Summit: the great quality swap meet

Improvement Capacity Building

Contact Us

• www.Cynosurehealth.org

• Contact Barb DeBaun at bdebaun@cynosurehealth.org

• Check in for updates on webinar and in-person meetings