Blood transfusion in cardiac surgery
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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…..

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Blood Transfusion in Cardiac Surgery

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Blood transfusion in cardiac surgery

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 O2

Mobilized

HCT 25.5% → I unit of RBC → Hct 29%


Blood transfusion in cardiac surgery

What is the problem?

Blood transfusions are…..

Inherently dangerous

  • Each transfusion poses new set of immune challenges: increase in serious complications, ICU and hospital length of stay, as well as short term and long term mortality rates.

  • Transfusions are not risk free and cause some degree of harm in every patient.

  • Serious morbidity and mortality increase with the amount transfused.

  • By some estimates each unit of allogeneic blood increases nosocomial infection rates by 50%.

    References:

    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.


Blood transfusion in cardiac surgery

Risks of Blood Transfusion

  • Fatal hemolytic reaction (1:500,000)

  • HIV (1:7,800,000), HCV (1:1,935,000), HBV (1:220,000)

  • Other infections (CMV, Yersinia, malaria, West Nile)

    • Human herpesvirus-8 (NEJM 2006; 355:1331)

  • Immunomodulation (anti-leucocyte antibodies) →

    TRALI (priming: recent surgery, active infection)

    Perioperative infection

    • Cancer

  • Problem of “old blood”: decreased deformability, 2,3- DPG, pH and NO.


Blood transfusion in cardiac surgery

Transfusion and Perioperative Infection

  • Hill, J Trauma 2003; 54:908

    • Meta-analysis of 20 perioperative studies

    • Increased odds ratio (OR = 3.45) for postoperative bacterial infection


Transfusion and cardiac surgery

Transfusion and Cardiac Surgery

Gerber, Crit Care Med 2008; 36:1068


Blood transfusion in the icu

Blood Transfusion in the ICU

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)


Trial results i

Trial Results (I)

All results favored the restrictive (Hgb 7) strategy


Trial results ii

Trial Results (II)

  • Subgroup analyses

    • Decreased 30 day mortality in less severely ill patients (9% vs. 16%)

    • Decreased 30 day mortality in patients < 55 years (6% vs. 13%)

    • Equal mortality in patients with cardiac disease (21% vs. 23%)


Risks and benefits of transfusion

Risks and Benefits of Transfusion

  • Marik, Crit Care Med 2008; 36:2667

  • Systematic review of 45 observational trials

    • 1 study demonstrated benefit > risk

    • 2 studies demonstrated benefits = risks

    • 42 studies with risks > benefits

    • Pooled OR for death 1.7 (1.4 – 1.9)

    • Pooled OR for infection 1.8 (1.5 – 2.2)

    • Pooled OR for ARDS 2.5 (1.6 – 3.3)


Blood usage comparison for all blood products transfused

Blood usage Comparison(For all Blood products transfused)

Source: UHC 2009 Blood Management Special Project

Compared to its peers, SHC utilizes more than twice the units of blood per discharge.


Isocabg postop rbc usage

isoCABG PostOp RBC Usage

Total Pts

2006 n=126

2007 n=90

2008 n=91

2009 n=102

*

^

* 1 pt w 35 units – mean 2.6 w/o outlier

^ 1 pt w 50 units – mean 3.4 w/o outlier


Avr only postop rbc usage

AVR only PostOp RBC Usage

Total Pts

2006 n = 30

2007 n = 47

2008 n = 68

2009 n=101


Comparison of shc 4 rbc unit use with sts like group

Comparison of SHC 4+ RBC Unit Use with STS Like Group

Iso AVR

Iso CABG


Stanford blood transfusion management guidelines proposal

Stanford Blood Transfusion Management Guidelines Proposal

MULTI MODALITY APPROACH

BA Reitz

PJA van der Starre


Stanford blood transfusion management guidelines proposal1

Stanford Blood Transfusion Management Guidelines Proposal

Bleeding Risk Assessed Preoperatively

  • Age and weight

  • Hct and Platelet count

  • Anti-platelet therapies

    • Stop clopidogrel 5 days pre op

    • Continue ASA for low risk, stop 2 days for high


Stanford blood transfusion management guidelines

Stanford Blood Transfusion Management Guidelines

Intra-Operative Management

  • Cell saver and Cell salvage

  • Anti-fibrinolytic drugs for high risk

  • DDAVP for high risk only

  • Retrograde priming

  • Autologous hemodilution

  • R-FVIIa for recalcitrant bleeding only

  • Topical hemostatics


Blood transfusion algorithms proposal

Blood Transfusion Algorithms Proposal

Ferraris VA, et al. STS Guidelines on blood conservation. Ann Thorac Surg, 2007.


Stanford blood transfusion management guidelines proposal2

Stanford Blood Transfusion Management Guidelines Proposal

Minimize blood draws

Erythropoietin

Iron and nutrition

Non Heme blood products used only as indicated for bleeding, with point of care testing (TEG!)


Blood transfusion in cardiac surgery

Endorsement

  • Clinical practice guidelines for the transfusion of red blood cells and platelets endorsed throughout Medical Staff leadership

  • Medical Executive Committee

  • Department Chairs, Kevin Tabb, Bryan Bohman

  • Blood Transfusion Taskforce

  • Norm Rizk, Dan Arber, Tim Goodnough, Clarence Braddock, Magali Fontain, Lisa Shieh, Maurene Viele, Paul Maggio, Ron Pearl, Pieter van der Starre

  • Clinical Effectiveness Leadership Team

  • John Norton, Neil Olcott, Ann Weinacker, Joe Hopkins, Pravene Nath


Blood transfusion in cardiac surgery

Evidence-based Guidelines

  • RBC Guidelines (for Hemo-dynamically stable, non-bleeding pts):

  • Transfusions indicated only for pts with Hgb <7g/dl (for post-cardiac surgery pts and pts with acute coronary syndrome Hgb <8 g/dl ).

  • Platelet Guidelines

  • A single dose of platelets (adult: one apheresis  product) is generally recommended as it increases the platelet count by 30,000- 60,000/ µL. (Guidelines for transfusions are based on specific disease states with corresponding platelet count triggers)


Blood transfusion in cardiac surgery

EPIC Interventions:Tools to help adherence to guidelines

  • Platelet Order template in EPIC (Live in Sep 2010)

  • Embedded into the Blood product Order screen:

  • Decision support built in to check the previous Platelet level prior to ordering additional units.

  • Guidelines on disease states/platelet levels that trigger the requirement of platelet transfusion.

  • Indications for platelet transfusion needs to be identified when ordering

  • Best Practice Alert (BPA) for RBC Transfusions

  • Pulls in most recent hemoglobin values and scans diagnoses on the problem list for active bleeding

  • If the requested transfusion does NOT meet the guidelines, a “pop up” reminder flashes


Blood transfusion in cardiac surgery

EPIC Best Practice Alert (BPA) : Live July 2010


Blood transfusion in cardiac surgery

Platelet Guidelines

A Single Dose of platelets (adult: one apheresis product) generally recommended as it increases the platelet count by 30,000- 60,000/ µl

  • Single unit of platelets indicated

    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?)


Blood transfusion in cardiac surgery

Platelets in Epic


Blood transfusion in cardiac surgery

Where do we stand now?

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

  • Decrease clinical complications resulting from transfusion

  • Preserve a precious resource

  • Reduce overall blood utilization


Blood transfusion in cardiac surgery

What you need to do!!

Follow the RBC and Platelet guidelines developed by the Blood Task Committee and endorsed by the Medical Staff leadership

  • BPA will remind you

  • For actively bleeding patients, document appropriate diagnosis in the in the problem list.

    Transfuse a single unit of platelets

  • Indicate the rationale for ordering platelets while placing the order.

    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


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