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Behind the 8 Ball Why Do Cardiac Surgery Patients Have a Low Hematocrit Before the Operation Truly Begins? Michelle D. Tozer CCP Massachusetts General.

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Presentation on theme: "Behind the 8 Ball Why Do Cardiac Surgery Patients Have a Low Hematocrit Before the Operation Truly Begins? Michelle D. Tozer CCP Massachusetts General."— Presentation transcript:

1 Behind the 8 Ball Why Do Cardiac Surgery Patients Have a Low Hematocrit Before the Operation Truly Begins? Michelle D. Tozer CCP Massachusetts General Hospital Boston, Massachusetts

2 The Who, How and Why of Hemoglobin Decrease Who is responsible? Who is responsible? More caregivers than you might think! More caregivers than you might think!

3 (Hint) - YOU Might Be One of Them

4 The Who, How and Why of Hemoglobin Decrease How does this happen? How does this happen? Each caregiver and subsequent procedure progressively depletes the patient’s existing blood stores. Each caregiver and subsequent procedure progressively depletes the patient’s existing blood stores.

5 The Who, How and Why of Hemoglobin Decrease Why does this happen? Why does this happen? Caregivers perform their patient service in a relative “bubble”, rather than focusing on the BIG picture. Caregivers perform their patient service in a relative “bubble”, rather than focusing on the BIG picture. Each of our small “normal” contributions to patient blood loss adds up to a potential transfusion. Each of our small “normal” contributions to patient blood loss adds up to a potential transfusion.

6 Blame it on the person who handed the patient off to you?

7 Who is Responsible ?? Patient Patient Primary Care Physician Primary Care Physician Cardiologist Cardiologist Physician’s Assistant / Nurse Practitioner Physician’s Assistant / Nurse Practitioner Unit Nurse Unit Nurse Anesthesiologist Anesthesiologist Surgeon Surgeon Perfusionist Perfusionist OR Nurse OR Nurse

8 The Patient underlying anemia underlying anemia co-existing medical conditions co-existing medical conditions poor nutrition status poor nutrition status

9 How Common is Patient Anemia? In general surgical population (Kumar): pre-op anemia in 5% to 76% pre-op anemia in 5% to 76% In a group of 227 octogenarians undergoing cardiac surgery (Carrascal et al study): the incidence of pre-op anemia the incidence of pre-op anemia 41.9 % Kumar, A. Perioperative management of anemia: Limits of blood transfusion and alternatives to it. Cleveland Clinic Journal of Medicine 2009; 76(suppl 4): S112 – S118. Carrascal, Y., Maroto, L., Rey, J., Arévalo, A., Arroyo, J., Echevarria, J., Arce, N., Fulquet, E. Impact of preoperative anemia on cardiac surgery in octogenarians. Interactive Cardiovascular and Thoracic Surgery 2010:10: Available at Accessed June 22, 2010.

10 Adequate Pre-op Screening and Identification of Anemia Question patient regarding any:  history of bleeding  previous transfusions  symptoms of anemia Kumar, A.

11 Pre-op Screening Review patient medications for those that contribute to bleeding and anemia:  aspirin and NSAIDs  anticoagulants  thienopyridenes –ADP receptor/P2Y12 inhibitors clopidogrel – Plavix ticlopidine –Ticlid prasugrel – Effient  GP IIb/IIIa inhibitors abciximab – ReoPro eptifibatide – Integrilin tirofiban - Aggrastat abciximab – ReoPro eptifibatide – Integrilin tirofiban - Aggrastat Kumar, A.

12 Review of Patient Medications Which Contribute to Bleeding  Question patient regarding use of herbal/natural supplements:  Vitamin E  Garlic  Ginger  Ginkgo  Ginseng  Feverfew Chang, LK, Whitaker, DC: The Impact of Herbal Medicines on Dermatologic Surgery. Dermatol Surg 2001; 27:

13 Adequate Pre-op Screening and Identification of Anemia  Evaluate patient physical and nutritional status  body habitus and condition  Be attentive to physical signs of anemia:  pallor  shortness of breath  fatigue  petechiae Kumar, A.

14 Identify and Assess Anemia Assess patient CBC – hemoglobin and red blood cell indices Anemia (WHO) is classified as: Hemoglobin ≤ 13 g/dl in males Hemoglobin ≤ 12 g/dl in females Kumar, A. Carrascal et al.

15 Positive Anemia Screening Anemia present and associated with additional hematologic abnormality? Anemia present and associated with additional hematologic abnormality? Refer to hematologist for bone marrow exam and further study Refer to hematologist for bone marrow exam and further study Kumar, A.

16 Positive Anemia Screening Anemia present with no other blood abnormality? Anemia present with no other blood abnormality? Perform anemia work-up to identify possible cause Perform anemia work-up to identify possible cause Kumar, A.

17 Anemia Work-Up for Abnormal Hemoglobin Level “Anemia Panel” laboratory tests: IronFerritin Total Iron Binding Capacity Vitamin B12 RBC Folate Kumar, A.

18 Clinical care pathway for identifying and evaluating anemia in patients with abnormal hemoglobin levels undergoing elective surgery Clinical care pathway for identifying and evaluating anemia in patients with abnormal hemoglobin levels undergoing elective surgery. KUMAR A Cleveland Clinic Journal of Medicine 2009;76:S112-S118 ©2009 by Cleveland Clinic

19 Anemia Work-up Goal is to identify conditions which can be corrected Goal is to identify conditions which can be corrected Anemia of chronic disease Anemia of chronic disease Iron deficiency Iron deficiency Vitamin B12 deficiency Vitamin B12 deficiency Kumar, A.

20 Pharmacologic Treatments for Anemia Intravenous (IV) Iron Supplementation Intravenous (IV) Iron Supplementation Effect on hemoglobin starting at 1 week, max at 2 weeks Effect on hemoglobin starting at 1 week, max at 2 weeks Iron Sucrose or Iron Gluconate – 2 doses Iron Sucrose or Iron Gluconate – 2 doses These newer IV iron preparations safer These newer IV iron preparations safer Potential side effects: hypotension, arthralgia, abdominal discomfort, back pain Potential side effects: hypotension, arthralgia, abdominal discomfort, back pain Kumar, A.

21 Pharmacologic Treatments for Anemia Oral iron supplement Oral iron supplement Ferrous sulfate – 325 mg, three times daily Ferrous sulfate – 325 mg, three times daily Oral vitamin supplements Oral vitamin supplements Vitamin C – 500 mg twice daily Vitamin C – 500 mg twice daily Folic acid – 1 mg daily Folic acid – 1 mg daily Vitamin B12 – 100 mcg/kg daily Vitamin B12 – 100 mcg/kg daily Vitamin K – as needed Vitamin K – as needed Helm, RE, Rosengart, TK, et al.: Comprehensive Multimodality Blood Conservation: 100 Consecutive CABG Operations Without Transfusion. Ann Thorac Surg 1998;65: John, T., Rodeman, R. Colvin, R. Blood Conservation in a Congenital Cardiac Surgery Program. AORN J, June 2008; 87(6):

22 Cleveland Clinic’s anemia protocol for patients undergoing major joint replacement surgery. KUMAR A Cleveland Clinic Journal of Medicine 2009;76:S112-S118 ©2009 by Cleveland Clinic

23 Erythropoietin (EPO) Naturally occurring hormone Naturally occurring hormone Stimulates synthesis of red blood cells Stimulates synthesis of red blood cells Produced mainly by the kidneys (less than 5% by liver in adults) Produced mainly by the kidneys (less than 5% by liver in adults) Seeber, Petra; Shander, Aryeh (2007). Basics of Blood Management. Blackwell Publishing.

24 Erythropoietin (EPO) No stores of EPO in the body No stores of EPO in the body is produced based on demand is produced based on demand EPO believed to be secreted in response to hypoxia: EPO believed to be secreted in response to hypoxia: Anemia Anemia Lung disease Lung disease High-altitude environment High-altitude environment Seeber, P. and Shander, A.

25 Erythropoiesis-Stimulating Agents (ESAs) Recombinant Human Erythropoietin (rHuEPO) Recombinant Human Erythropoietin (rHuEPO) biologically active biologically active requires parenteral dosing (IV or subcutaneous) requires parenteral dosing (IV or subcutaneous) Epoetin alfa approved by FDA for use in surgical patients Epoetin alfa approved by FDA for use in surgical patients post-op erythropoietic effect is almost immediate post-op erythropoietic effect is almost immediate increased reticulocyte count seen in 2 – 3 days increased reticulocyte count seen in 2 – 3 days higher initial doses lead to faster hematocrit recovery higher initial doses lead to faster hematocrit recovery Seeber, P. and Shander, A.

26 rHuEPO Dosage Dependent upon patient condition and response to EPO therapy. Dependent upon patient condition and response to EPO therapy. In elective surgical patients: In elective surgical patients: once weekly doses over 3 or more weeks pre-op, plus one dose on day of surgery. once weekly doses over 3 or more weeks pre-op, plus one dose on day of surgery. In severe anemia or a need for rapid red cell mass increase: In severe anemia or a need for rapid red cell mass increase: daily doses may be necessary daily doses may be necessary Must continue oral or IV iron during epoetin alfa therapy. Must continue oral or IV iron during epoetin alfa therapy. Seeber, P. and Shander, A. Kumar, A. Seeber, P. and Shander, A. Kumar, A.

27 Pharmacologic Anemia Therapy Goals of iron, vitamin and rHuEPO therapies are two-fold: Goals of iron, vitamin and rHuEPO therapies are two-fold: Pre-op Pre-op To increase patient total red blood cell mass To increase patient total red blood cell mass To optimize patient hemoglobin level before surgical blood loss occurs To optimize patient hemoglobin level before surgical blood loss occurs Post-op Post-op To stimulate patient production of additional red blood cells To stimulate patient production of additional red blood cells To replace blood cells lost due to the procedure and subsequent care To replace blood cells lost due to the procedure and subsequent care

28 Cardiac Catheterization and Intervention 2.2 million percutaneous coronary interventions (PCIs) are performed annually 2.2 million percutaneous coronary interventions (PCIs) are performed annually Significant “non-surgical” bleeding is common Significant “non-surgical” bleeding is common 7% of emergent cases 7% of emergent cases and and 4% of elective cases 4% of elective cases incur major bleeding Shander, A. Financial and clinical outcomes associated with surgical bleeding complications. Surgery 2007;142(4S):S20-S25. O’Neill, WW. Risk of bleeding after elective percutaneous coronary intervention. N Engl J Med 2006;355:

29 Acute Blood Loss and PCI Study by Kim et al., at William Beaumont Hospital, Royal Oak, MI Study by Kim et al., at William Beaumont Hospital, Royal Oak, MI collected serial hematocrit (HCT) data on 6,799 patients undergoing PCI collected serial hematocrit (HCT) data on 6,799 patients undergoing PCI baseline and nadir HCT were recorded and used to quantify blood loss baseline and nadir HCT were recorded and used to quantify blood loss Kim, P., Dixon, S., Eisenberry, AB., O’Malley, B., Boura, J., O’Neill, W. Impact of Acute Blood Loss Anemia and Red Blood Cell Transfusion on Mortality after Percutaneous Coronary Intervention. Clin. Cardiol. 2007;30(Suppl. II),II-35-II-43.

30 Acute Blood Loss and PCI Categories of Blood Loss in Kim et al. study: (1) Negligible = HCT decrease < 4% (2) Mild = HCT decrease 4.0 – 5.9% (3) Moderate = HCT decrease 6.0 – 10% (4) Severe = HCT decrease > 10%

31 Kim et al. Study Results Blood Loss Category (% of HCT) No. of patients % of study population Negligible < 4% 2,85842% Mild 4 – 5.9% 1,71125% Moderate 6 – 10% 1,66925% Severe >10% 5618%

32 Factors Contributing to Blood Loss in PCI Demographics associated with greater blood losses: Demographics associated with greater blood losses: older age older age female gender female gender lower body weight lower body weight renal insufficiency renal insufficiency hypertension hypertension recent MI recent MI urgent PCI urgent PCI pre and post-procedure heparin pre and post-procedure heparin Kim et al.

33 Severe Blood Loss and PCI Complications Patients experiencing severe blood loss have significantly more complications: Patients experiencing severe blood loss have significantly more complications: shock shock intra-aortic balloon pump use (IABP) intra-aortic balloon pump use (IABP) more severe cardiac, renal and cerebral ischemia more severe cardiac, renal and cerebral ischemia higher incidence of MI, renal failure and stroke higher incidence of MI, renal failure and stroke Kim et al.

34 How Does PCI Cause Bleeding? Femoral artery approach is common Femoral artery approach is common vascular access guided by palpation and visualization of bony landmarks vascular access guided by palpation and visualization of bony landmarks high potential for vascular complications high potential for vascular complications inguinal hematoma inguinal hematoma retroperitoneal bleeding retroperitoneal bleeding arteriovenous fistula arteriovenous fistula femoral pseudoaneurysm femoral pseudoaneurysm Kim et al.

35 How Does PCI Cause Bleeding? Systemic anticoagulation/anti-platelet therapy Systemic anticoagulation/anti-platelet therapy Increases risk of bleeding Increases risk of bleeding gastrointestinal gastrointestinal genitourinary genitourinary intracranial intracranial Drug therapies used to decrease thrombosis in coronary vasculature may result in increased bleeding in other vascular beds Drug therapies used to decrease thrombosis in coronary vasculature may result in increased bleeding in other vascular beds low molecular weight heparin low molecular weight heparin thienopyridenes thienopyridenes GP IIb/IIIa Inhibitors GP IIb/IIIa Inhibitors Kim et al. Lardizabal, JA, Joshi, BK, Ambrose, JA: The Balance Between Anti-ischemic Efficacy and Bleeding Risk of Antithrombotic Therapy in Percutaneous Coronary Intervention: A. J Invasive Cardiol 2010;22:

36 Potential Strategies to Reduce Blood Loss from PCI Increased physician awareness regarding the importance of reducing patient blood loss Increased physician awareness regarding the importance of reducing patient blood loss Use of radial artery as an access site when possible Use of radial artery as an access site when possible Smaller sheath sizes Smaller sheath sizes Use of a fine 21-gauge needle with 0.018” initial guidewire Use of a fine 21-gauge needle with 0.018” initial guidewire instead of large bore 18-gauge needle instead of large bore 18-gauge needle Lardizabal et al. Thomas, M. Blood Loss During Percutaneous Coronary Intervention: Tedious or Important? Catheterization and Cardiovascular Interventions 2007;69: Fox, KAA, Carruthers, K., et al. Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome? The Global Registry of Acute Coronary Events. European Heart Journal 2010;31:

37 Potential Strategies to Reduce Blood Loss from PCI Careful choice of femoral puncture location Careful choice of femoral puncture location ideal access site is adjacent to lower half of femoral head, in the common femoral artery, below inferior epigastric branch ideal access site is adjacent to lower half of femoral head, in the common femoral artery, below inferior epigastric branch Closure devices, with a suitable puncture site Closure devices, with a suitable puncture site Timely sheath removal Timely sheath removal Use of bare-metal stents Use of bare-metal stents require shorter duration of post-PCI thienopyridine therapy require shorter duration of post-PCI thienopyridine therapy More conservative antithrombotic drug regimen More conservative antithrombotic drug regimen especially for patients with higher bleeding risk especially for patients with higher bleeding risk Lardizabal et al. Fox et al.

38 Diagnostic Test Blood Loss Laboratory blood sampling causes significant blood loss and anemia in the critically ill Laboratory blood sampling causes significant blood loss and anemia in the critically ill majority of critically ill patients are anemic when admitted to ICU majority of critically ill patients are anemic when admitted to ICU hemoglobin loss >0.5g/dL per day during first 3 days hemoglobin loss >0.5g/dL per day during first 3 days Published studies estimate blood loss due to lab sampling: Published studies estimate blood loss due to lab sampling: from 70 ml/day to over 300 ml/day from 70 ml/day to over 300 ml/day for patients in ICU longer than 3 days, 17% of total blood loss is due to lab sampling for patients in ICU longer than 3 days, 17% of total blood loss is due to lab sampling Seeber, P. And Shander, A. Fowler, RA, Berenson, M. Blood conservation in the intensive care unit. Crit Care Med 2003;31(12S):S715-S720 Barie, PS: Phlebotomy in the intensive care unit: strategies for blood conservation. Critical Care 2004;8(Suppl 2):S34-S36 Tinmouth, AT, McIntyre, L.A, Fowler, RA: Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients. CMAJ 2008;178(1):49-57

39 Blood Loss From Diagnostic Test Sampling Frequency of blood draws varies from 5 to nearly 24 samples per day Frequency of blood draws varies from 5 to nearly 24 samples per day Mean blood volume estimates are 4 to 10 ml each for hematology, chemistry and coagulation samples Mean blood volume estimates are 4 to 10 ml each for hematology, chemistry and coagulation samples Each blood draw from an indwelling catheter involves “wasting” 2 to 10 ml of blood Each blood draw from an indwelling catheter involves “wasting” 2 to 10 ml of blood The presence of an arterial catheter leads to more frequent blood draws The presence of an arterial catheter leads to more frequent blood draws Blood drawn twice as often Blood drawn twice as often Three-fold increase in blood volume drawn Three-fold increase in blood volume drawn Fowler, RA and Berenson, M.

40 Blood Loss From Diagnostic Test Sampling Arterial blood gases are the most commonly ordered ICU lab test Arterial blood gases are the most commonly ordered ICU lab test may account for almost 40% of blood drawn may account for almost 40% of blood drawn typically 1.5 to 10 ml drawn for sample, plus 2 to 10 ml “wasted” typically 1.5 to 10 ml drawn for sample, plus 2 to 10 ml “wasted” Continuous pulse oximetry and capnometry can eliminate some arterial blood gas sampling Continuous pulse oximetry and capnometry can eliminate some arterial blood gas sampling monitor Sa0 2 instead of Pa0 2 monitor Sa0 2 instead of Pa0 2 monitor end-tidal C0 2 instead of PaC0 2 monitor end-tidal C0 2 instead of PaC0 2 Fowler, RA and Berenson, M.

41 Strategies for Reducing Phlebotomy Blood Loss Reduce the number and frequency of laboratory tests ordered Reduce the number and frequency of laboratory tests ordered Excessive blood testing is commonplace – can lead to “anemia of chronic investigation ” Excessive blood testing is commonplace – can lead to “anemia of chronic investigation ” Consider the true clinical importance and impact on patient care Consider the true clinical importance and impact on patient care If lab results will not significantly impact patient care, DON’T order the tests. If lab results will not significantly impact patient care, DON’T order the tests. Eliminate “standing” orders for daily testing. Eliminate “standing” orders for daily testing. Try to batch necessary laboratory tests, drawing the minimum number of blood samples possible. Try to batch necessary laboratory tests, drawing the minimum number of blood samples possible. Prevent multiple caregivers from ordering duplicate testing. Prevent multiple caregivers from ordering duplicate testing. Barie, PS Fowler, RA, Berenson, M. Seeber, P., Shander, A.

42 Reducing Lab Testing Is Effective Studies by Barie et al. in the surgical ICU demonstrate: Studies by Barie et al. in the surgical ICU demonstrate: Lab blood testing can be reduced by at least 50%, without adverse effects on patient care. Lab blood testing can be reduced by at least 50%, without adverse effects on patient care. Caregiver attitudes and expectations can be adjusted to this strategy. Caregiver attitudes and expectations can be adjusted to this strategy. “learning not to know” “learning not to know” Barie, PS, Hydo, LJ: Learning not to know: results of a program for ancillary cost reduction in surgical critical care. J Trauma 1996;41: Barie, PS, Hydo, LJ: Lessons learned: durability and progress of a program for ancillary cost reduction in surgical critical care. J Trauma 1997;43:

43 Reducing Lab Testing Is Effective Improve accountability and awareness Improve accountability and awareness Keep log sheets at bedside for high risk patients Keep log sheets at bedside for high risk patients personnel sampling blood must document all volumes taken personnel sampling blood must document all volumes taken caregivers ordering lab sampling must document all testing ordered caregivers ordering lab sampling must document all testing ordered Seeber, P. and Shander, A.

44 Strategies for Reducing Phlebotomy Blood Loss Point-of-Care testing Point-of-Care testing Smaller blood samples needed (1 mL or less) Smaller blood samples needed (1 mL or less) Reduced turnaround time for results Reduced turnaround time for results Use of small-volume pediatric blood sample tubes Use of small-volume pediatric blood sample tubes Studies found a 42% decrease in blood loss when pediatric tubes were used instead of regular tubes. Studies found a 42% decrease in blood loss when pediatric tubes were used instead of regular tubes survey of English and Welsh adult ICUs: 2001 survey of English and Welsh adult ICUs: only 9.3% using pediatric or small volume blood tubes Survey of nine Canadian university-affiliated adult ICUs: Survey of nine Canadian university-affiliated adult ICUs: VERY FEW use any blood conservation techniques Fowler, RA and Berenson, M.

45 Strategies for Reducing Phlebotomy Blood Loss Don’t “waste” dead space volume when drawing blood samples Don’t “waste” dead space volume when drawing blood samples Reinfuse the 2-10 ml of diluted blood-infusate mixture initially drawn into syringe Reinfuse the 2-10 ml of diluted blood-infusate mixture initially drawn into syringe Two useful techniques: Two useful techniques: Double-Stopcock system Double-Stopcock system Closed blood sampling system Closed blood sampling system VAMP - Venous Arterial blood Management Protection system (Edwards Lifesciences) VAMP - Venous Arterial blood Management Protection system (Edwards Lifesciences) Fowler RA and Berenson M. John A, Rodeman R. and Colvin R. Seeber, P. and Shander, A. Mukhopadhyay A., Yip HS, Prabhuswamy D., Chan YH, Phua J, Lim TK, Leong P. The use of a blood conservation device to reduce red blood cell transfusion requirements: a before and after study. Critical Care 2010;14:R7

46 Double-Stopcock Double-Stopcock system Double-Stopcock system Connects central/venous line and arterial line Connects central/venous line and arterial line Blood/infusate drawn from arterial line into “discard” syringe Blood/infusate drawn from arterial line into “discard” syringe Blood for sample drawn from arterial line into second syringe Blood for sample drawn from arterial line into second syringe Blood/infusate mixture reinfused via central/venous line Blood/infusate mixture reinfused via central/venous line. John A, Rodeman R. and Colvin R

47 VAMP Closed Sampling Device Needleless, arterial line closed sampling device Needleless, arterial line closed sampling device Attached to existing arterial catheter and pressure transducer Attached to existing arterial catheter and pressure transducer Blood/infusate drawn into 12cc reservoir syringe. Blood/infusate drawn into 12cc reservoir syringe. Blood sample obtained from needleless port or direct draw site Blood sample obtained from needleless port or direct draw site Blood/infusate mixture reinfused via arterial line Blood/infusate mixture reinfused via arterial line Mukhopadhyay et al. Edwards Lifesciences: accessed 8/20/2010

48 ICU Blood Conservation is Effective Multifaceted blood conservation strategy in ICU Multifaceted blood conservation strategy in ICU Controlled pilot study by Fowler et al. Controlled pilot study by Fowler et al. 87.5% reduction in sample draw waste 87.5% reduction in sample draw waste Reductions in blood volume sampled for routine lab tests Reductions in blood volume sampled for routine lab tests 40.5% reduction for routine CBCs 40.5% reduction for routine CBCs 26.4% reduction for routine chemistry tests 26.4% reduction for routine chemistry tests 31.2% reduction for coagulation tests 31.2% reduction for coagulation tests VAMP closed sampling system study by Mukhopadhyay et al. VAMP closed sampling system study by Mukhopadhyay et al. 80 control patients, 170 active patients 80 control patients, 170 active patients 48% reduction in PRBC transfusions 48% reduction in PRBC transfusions Use of device associated with smaller decrease in hemoglobin levels between ICU admission and discharge Use of device associated with smaller decrease in hemoglobin levels between ICU admission and discharge

49 Fluid Management Primary goal is to optimize cardiac preload Primary goal is to optimize cardiac preload Optimizing is not the same as maximizing Optimizing is not the same as maximizing Purpose of IV Fluids: Purpose of IV Fluids: Expand plasma volume Expand plasma volume Maintain cardiac stroke volume and output Maintain cardiac stroke volume and output Provide transport for red blood cells and O 2 Provide transport for red blood cells and O 2 Delivery of medications Delivery of medications Alter water and electrolyte balance Alter water and electrolyte balance Chappell, D., Jacob, M., Hofman-Kiefer, K., Conzen, P., Rehm, M. A Rational Approach to Perioperative Fluid Management. Anesthesiology 2008; 109: Seeber, P., and Shander, A.

50 Volume Therapy Used to replace lost plasma volume Used to replace lost plasma volume Body tolerates significant loss of red cell mass, but not blood volume loss Body tolerates significant loss of red cell mass, but not blood volume loss Blood flow and volume is critical to maintaining adequate cardiac output Blood flow and volume is critical to maintaining adequate cardiac output Cellular fluids (whole blood or PRBCs) increase blood viscosity Cellular fluids (whole blood or PRBCs) increase blood viscosity May actually reduce cardiac output and decrease tissue perfusion May actually reduce cardiac output and decrease tissue perfusion Use acellular fluids to restore plasma volume Use acellular fluids to restore plasma volume Seeber, P. and Shander, A.

51 Fluid Administration Regimens Are Not Standardized Lucas et al. study: Lucas et al. study: Determining the Factors Leading to Allogeneic Red Blood Cell Transfusions for On-pump Primary Coronary Artery Bypass, Advancing a Blood Management Strategy Mark T. Lucas, John Limoli, Joseph Schlut Presented at The 14 th Annual Symposium on New Advances in Perioperative Blood Management, Jackson Hole, WY August 26, 2006

52 Fluid and Hemodilution Dictionary definition : Dictionary definition : hemodilution [-dilo̅o̅′shən] hemodilution [-dilo̅o̅′shən] Etymology: Gk, haima, blood; L, diluare, to wash away Etymology: Gk, haima, blood; L, diluare, to wash away a condition in which the concentration of erythrocytes or other blood elements is lowered, usually resulting from an increase in plasma volume. a condition in which the concentration of erythrocytes or other blood elements is lowered, usually resulting from an increase in plasma volume. Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.

53 Fluid and Hemodilution Contributors to excessive hemodilution in cardiac surgery patients: Contributors to excessive hemodilution in cardiac surgery patients: IV Fluid Infusion: IV Fluid Infusion: Anesthesia providers Anesthesia providers ICU caregivers ICU caregivers Cardiopulmonary Bypass (CPB) Circuit: Cardiopulmonary Bypass (CPB) Circuit: Perfusionist Perfusionist

54 Hemodilution and Hematocrit Decrease Results from Perfusion.com Cardiac Surgery Hematocrit Trend Study: Results from Perfusion.com Cardiac Surgery Hematocrit Trend Study: Serial hematocrit data submitted by 49 perfusionists Serial hematocrit data submitted by 49 perfusionists 5 adult patients per perfusionist 5 adult patients per perfusionist Hematocrit data for six time points for each patient Hematocrit data for six time points for each patient from pre-anesthesia to end surgery from pre-anesthesia to end surgery End goal: characterizing the average change in hematocrit during adult cardiac surgical procedures End goal: characterizing the average change in hematocrit during adult cardiac surgical procedures Riley, JB, Samolyk, KA, Lich, BV, Moskowitz, D., Shander, A. Results from the Perfusion.com Cardiac Surgery Hematocrit Trend Survery: Observations and Evidence-Based Recommendations

55 Hemodilution and Hematocrit Decrease

56 Strategies to Reduce Hemodilution Strategies to Reduce Hemodilution Careful monitoring of IV fluid infusions Careful monitoring of IV fluid infusions Minimize volume of crystalloids and colloids infused Minimize volume of crystalloids and colloids infused Infuse volume boluses only when a plasma volume deficit exists Infuse volume boluses only when a plasma volume deficit exists as indicated by hemodynamic monitoring parameters as indicated by hemodynamic monitoring parameters it may be advantageous to infuse albumin or synthetic colloids it may be advantageous to infuse albumin or synthetic colloids increase colloid osmotic pressure increase colloid osmotic pressure help to maintain fluid within vasculature help to maintain fluid within vasculature Increase systemic vascular resistance to maintain patient blood pressure if possible Increase systemic vascular resistance to maintain patient blood pressure if possible phenylephrine or norepinephrine phenylephrine or norepinephrine Brevig, J., McDonald, J., Zelinka, ES, Gallagher, T., Jin, R., Grunkemeier, GL. Blood Transfusion Reduction in Cardiac Surgery: Multidisciplinary Approach at a Community Hospital. Ann Thorac Surg 2009;87: Helm, RE, Rosengart, TK et al. Comprehensive Multimodality Blood Conservation: 100 Consecutive CABG Operations Without Transfusion. Ann Thorac Surg 1998;65: DeAnda Jr., A., Baker, KM, et al. Developing a Blood Conservation Program in Cardiac Surgery. Am J Med Qual 2006;21:

57 Strategies to Reduce Hemodilution Reduce crystalloid volume in CPB circuit: Reduce crystalloid volume in CPB circuit: Smaller circuit prime volume Smaller circuit prime volume 1500 ml or less 1500 ml or less Retrograde Autologous Prime (RAP) Retrograde Autologous Prime (RAP) Reduces crystalloid prime volume even further Reduces crystalloid prime volume even further Performed just prior to initiation of CPB Performed just prior to initiation of CPB Retrograde drainage of patient’s blood into CPB circuit Retrograde drainage of patient’s blood into CPB circuit Displaces some crystalloid solution in CPB circuit prime Displaces some crystalloid solution in CPB circuit prime Anesthesia corrects temporary hypotension with vasopressors instead of volume bolus Anesthesia corrects temporary hypotension with vasopressors instead of volume bolus Brevig, J., et al. DeAnda Jr., A., et al. Helm, RE et al. Riley, JB, et al.

58 Preserve Patient Autologous Blood Acute Normovolemic Hemodilution (ANH) Acute Normovolemic Hemodilution (ANH) Simultaneous removal of patient whole blood while replacing volume with acellular fluid Simultaneous removal of patient whole blood while replacing volume with acellular fluid Maintains blood volume while decreasing hematocrit Maintains blood volume while decreasing hematocrit Pre-determined volume of blood removed via central venous line into CPD anticoagulated blood donor bag Pre-determined volume of blood removed via central venous line into CPD anticoagulated blood donor bag Prior to surgical incision and systemic heparinization Prior to surgical incision and systemic heparinization Prior to CPB Prior to CPB Blood volume removed depends upon: Blood volume removed depends upon: existing patient hematocrit existing patient hematocrit CPB circuit prime volume CPB circuit prime volume established acceptable hematocrit level during procedure established acceptable hematocrit level during procedure Re-infusion occurs at conclusion of surgical procedure Re-infusion occurs at conclusion of surgical procedure

59 ANH Benefits Preserves a portion of patient’s existing blood components Preserves a portion of patient’s existing blood components Surgical blood loss contains minimum red cell concentration possible Surgical blood loss contains minimum red cell concentration possible Red blood cells, platelets and clotting factors are conserved for later reinfusion. Red blood cells, platelets and clotting factors are conserved for later reinfusion. Cell salvage process actually discards platelets and clotting factors Cell salvage process actually discards platelets and clotting factors Jabbour, N., Gagandeep, S., et al. Live Donor Liver Transplantation Without Blood Products. Strategies Developed for Jehovah’s Witnesses Offer Broad Application. Ann Surg 2004:240: Ann Surg 2004:240: Helm, RE, et al. John, T, et al. Riley, JB et al.

60 Sometimes, There is an I in Team !! How does your care decrease the patient’s hemoglobin? How does your care decrease the patient’s hemoglobin? What can you do to change that? What can you do to change that? What can you do to help What can you do to help your co-workers ? your co-workers ? your care team ? your care team ? and your patient ? and your patient ?

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