Blood Transfusion in Cardiac Surgery. 51 yrs old female patient In ICU, POD 2 after MVrepair isoproterenol/dopamine for junctional rhythm BP 105/60, HR 75/min, CVP 5 ABG: normal. NC 4l O 2 Mobilized HCT 25.5% → I unit of RBC → Hct 29%. What is the problem?. Blood transfusions are…..
51 yrs old female patient
In ICU, POD 2 after MVrepair
isoproterenol/dopamine for junctional rhythm
BP 105/60, HR 75/min, CVP 5
ABG: normal. NC 4l O2
HCT 25.5% → I unit of RBC → Hct 29%
Blood transfusions are…..
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.
Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009; 37:3124-57.
TRALI (priming: recent surgery, active infection)
Gerber, Crit Care Med 2008; 36:1068
Hébert, N Engl J Med 1999; 340:409
838 ICU patients with Hgb < 9 within 72 hours of admission
Randomized to transfusion Hgb trigger of 7 or 10 (restrictive vs. liberal)
All results favored the restrictive (Hgb 7) strategy
Source: UHC 2009 Blood Management Special Project
Compared to its peers, SHC utilizes more than twice the units of blood per discharge.
* 1 pt w 35 units – mean 2.6 w/o outlier
^ 1 pt w 50 units – mean 3.4 w/o outlier
2006 n = 30
2007 n = 47
2008 n = 68
MULTI MODALITY APPROACH
PJA van der Starre
Bleeding Risk Assessed Preoperatively
Ferraris VA, et al. STS Guidelines on blood conservation. Ann Thorac Surg, 2007.
Minimize blood draws
Iron and nutrition
Non Heme blood products used only as indicated for bleeding, with point of care testing (TEG!)
EPIC Interventions:Tools to help adherence to guidelines
A Single Dose of platelets (adult: one apheresis product) generally recommended as it increases the platelet count by 30,000- 60,000/ µl
Platelet count ≤ 10,000/ µL
Platelet count ≤ 20,000/ µL and signs of hemorrhagic diathesis
Platelet count ≤ 50,000/ µL in a patient with active hemorrhage
Platelet count ≤ 50,000/ µL in a patient with invasive procedure (recent, in-progress, planned)
Platelet count ≤ 100,000/ µL in a patient with bleeding in a closed anatomical space (eg. CNS)
Platelet dysfunction with active or anticipated hemorrhage (TEG?)
Despite the development of RBC guidelines and the Epic BPA, the vast majority of RBC transfusions (60%) continue to occur at a Hgb of 8 or above
Increased guideline adherence will
Follow the RBC and Platelet guidelines developed by the Blood Task Committee and endorsed by the Medical Staff leadership
Transfuse a single unit of platelets
Communicate this expectation to your peers and to your house staff
Incorporate the blood guidelines, and the clinical reasoning behind them, into the teaching and communication provided to interns and residents
Direct feedback or questions to Blood Task Force regarding adoption of guidelines