Presentation on theme: "Global Blood Resources LLC"— Presentation transcript:
1Global Blood Resources LLC Blood Management in Cardiac Surgery Using Multidisciplinary Multimodality ApproachesGlobal Blood Resources LLC
2Roadmap Discuss Blood Conservation Where we are today with blood The multidisciplinary playersTheir multimodality approachesWhat Perfusionists Can DoChanging the ParadigmWhat else can we do !Disclosure statement:GBR is the maker of the Hemobag® for ATSEXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests2
3ETHICS OF BLOOD MANAGEMENT -First Do No Harm “Primum Non Nocere”-Transfuse only when absolutely necessary-Transfuse Only what’s Required / SparinglyThe Freshest Components PossibleMinimal Blood Draws SamplingAvoid Waste/ Recover as much Autologous as possUse POC Labs to Justify TransfusionsUse Evidence Based Medicine in Decisions
6First, A Surprise Quiz! Don’t ponder, just raise your hand if you Generally Agree with the question Do you feel like you have an excellent report with your Surgeons in surgery ? Do they listen ?Do you feel like you have an excellent report with Anesth in surgery and do they listen ?Do your Anesthesiologists use pressors to keep the SVR up instead of Volume ?Do you feel like your Anesthesiologists gives too much crystalloid in general ?Do you feel that most of your Surgeons really try to avoid giving any donor products?Do you feel that most of your Anes really try to avoid giving any donor blood products?Do you RAP before going on bypass and does Anesthesia help and the Surgeon wait ?Do you use Osmitrol/Mannitol or Albumin? More than once ?Do you use the pump sucker during the case to return blood to the ECC in Valve cases ?Do you use the pump sucker during the case to return blood to the ECC in CABG cases ?Do you use the pump sucker during the case to return blood to the ECC in Aortic cases ?Do you feel that your processing too much cell washer volume by the end of the case ?Do you have a waste sucker in the field, and do they use it ?Do you use a Hemoconcentrator on at least 20% of your cases, 40%, >40% of the time ?Do you use a Hemoconcentrator to salvage the ECC at the end of the case, or Bag the Vol ?Is your Transfusion trigger on CPB generally < 7gm Hgb or < 8gm Hgb ?Do you feel that a transfusion is an organ transplant ?
7DeAnda, Spiess, et al. $1,422 / PRBC unit Bank Blood CostsCost of blood products rising withno direct reimbursement.MC does not pay until 4th unit…Red Blood Cell Units: $500 – $1,000Platelet Pheresis pack: $536Plasma Units FFP: (4) $300+Cryoprecipitate:(5+fee) $250Transfusion reactions: Infections, viruses and most importantly Immunosupression / ImmunomodulationIncidence of TRALI (>1:2,000 donor exposures)Nationwide range of “blood admin charges per discharge:” $2,240DeAnda, Spiess, et al. $1,422 / PRBC unitJC will be evaluating blood management as part of AccreditationJoint Commission Perspectives on Pt. Safety: Jan. Vol. 7:1, 2007
9Older Blood carries Greater Morbidity and Mortality Duration of red-cell storage and complications after cardiac surgery.N England J Med 2008 Mar 20;358(12): Koch CG, et al.BACKGROUND: Stored red cells undergo progressive structural and functional changes over time. We tested the hypothesis that serious complications and mortality after cardiac surgery are increased when transfused red cells are stored for more than 2 weeks. METHODS: We examined data from patients given red-cell transfusions during coronary-artery bypass grafting, heart-valve surgery, or both between June 30, 1998, and January 30, A total of 2872 patients received 8802 units of blood that had been stored for 14 days or less ("newer blood"), and 3130 patients received 10,782 units of blood that had been stored for more than 14 days ("older blood"). Multivariable logistic regression with propensity-score methods was used to examine the effect of the duration of storage on outcomes. Survival was estimated by the Kaplan-Meier method and Blackstone's decomposition method. RESULTS: The median duration of storage was 11 days for newer blood and 20 days for older blood. Patients who were given older units had higher rates of in-hospital mortality (2.8% vs. 1.7%, P=0.004), intubation beyond 72 hours (9.7% vs. 5.6%, P<0.001), renal failure (2.7% vs. 1.6%, P=0.003), and sepsis or septicemia (4.0% vs. 2.8%, P=0.01). A composite of complications was more common in patients given older blood (25.9% vs. 22.4%, P=0.001). Similarly, older blood was associated with an increase in the risk-adjusted rate of the composite outcome (P=0.03). At 1 year, mortality was significantly less in patients given newer blood (7.4% vs. 11.0%, P<0.001). CONCLUSIONS: In patients undergoing cardiac surgery, transfusion of red cells that had been stored for more than 2 weeks was associated with a significantly increased risk of postoperative complications as well as reduced short-term and long-term survival.
10Circulation 2007 Nov 12 Murphy GJ, Reeves BC, Rogers CA, Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.Circulation 2007 Nov 12 Murphy GJ, Reeves BC, Rogers CA,BACKGROUND: Red blood cell transfusion can both benefit and harm. To inform decisions about transfusion, we aimed to quantify associations of transfusion with clinical outcomes and cost in patients having cardiac surgery. Methods andRESULTS: Clinical, hematology, and blood transfusion databases were linked with the UK population register. Additional hematocrit information was obtained from intensive care unit charts. Composite infection (respiratory or wound infection or septicemia) and ischemic outcomes (myocardial infarction, stroke, renal impairment, or failure) were prespecified as co-primary end points. Secondary outcomes were resource use, cost, and survival. Associations were estimated by regression modeling with adjustment for potential confounding. All adult patients having cardiac surgery between April 1, 1996, and December 31, 2003, with key exposure and outcome data were included (98%). Adjusted odds ratios for composite infection (737 of 8516) and ischemic outcomes (832 of 8518) for transfused versus non-transfused patients were 3.38 (95% confidence interval [CI], 2.60 to 4.40) and 3.35 (95% CI, 2.68 to 4.35), respectively. Transfusion was associated with increased relative cost of admission (any transfusion, 1.42 times [95% CI, 1.37 to 1.46], varying from 1.11 for 1 U to 3.35 for >9 U). At any time after their operations, transfused patients were less likely to have been discharged from hospital (hazard ratio [HR], 0.63; 95% CI, 0.60 to 0.67) and were more likely to have died (0 to 30 days: HR, 6.69; 95% CI, 3.66 to 15.1; 31 days to 1 year: HR, 2.59; 95% CI, 1.68 to 4.17; >1 year: HR, 1.32; 95% CI, 1.08 to 1.64).CONCLUSIONS. Red blood cell transfusion in patients having cardiac surgery is strongly associated with both infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital costs.
11Blood transfusions may be killing some of the people they are intended to save Dr. Sunny Rao Duke Cardiologist 2004IF THERE were any sure bets in medicine, you might think that “blood transfusions save lives” would be one of them. But there aren't. Even though deaths caused in the 1980s by accidental HIV infection mean that donated blood is now screened meticulously to keep it free of infectious agents, there is still a nagging feeling that something is wrong.In 2004, Sunil Rao of Duke University Medical Centre, in North Carolina, carried out a retro study of 24K people suffering from acute coronary syndrome. One conclusion drawn from his research was that unnecessary blood transfusions might be causing tens of thousands of deaths in America alone. Rao found that patients who had had a transfusion because of a low red blood- cell count had an 8% chance of dying within 30 days, and those without a transfusion, only 3% died. Those numbers need to be treated with caution. As Dr Rao points out, the patients who underwent transfusion were, on average, sicker and older than those who did not. Nevertheless, this study is not the only indication of something amiss with transfused Allogeneic blood products.
12What are expert thoughts about the recent articles on Nitric Oxide and banked blood? Neil Blumberg, Prof of Path & Lab Med, Univ of Rochester MC"I think it is well established in the scientific literature that stored red cells do weird things to the microcirculation. It is also well established in observational studies that patients with acute coronary syndromes (e.g., MI, unstable angina) seem to do markedly worse when transfused than not transfused at similar hematocrits. Red cells that are nitric oxide poor will presumably scavenge nitric oxide, a vasodilator, and thus cause vasoconstriction and reduced oxygen delivery and thus impair its delivery. Most of the clinical correlative studies in the literature mentioned above involve patients getting non-leukoreduced transfusions rich in inflammatory, pro-thrombotic mediators, as well as residual platelet microparticles, white cell membranes and microparticles, and Lord knows what else. So it's not clear how much either factor, nitric oxide scavenging and infusion of a mixture of deleterious mediators contributes to the clinical observations. My bet is on both. What is clear to me and some others in the field is that fewer patients should be transfused and we are doing more harm than good with our current transfusion practices in many cases."
13So how can we manage blood better and who are the Multidisciplinary Players involved?Primary DoctorCardiologistAdmission Care TeamPre Game Plan with the Big Three*Surgeon, Anesthesia, Perfusion*AnesthesiaSurgeonPerfusion (Its not your fault !) GWHICU Care Team, NursesAdministratorsEXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests13
14The Primary Doctors Office Baseline lab work (preferably 6 wks early)Micro-sampling (Peds Tubes)Iron therapy 50% of the Population are LowEpo therapy 2-3 weeks to raise Hct 2-3%Help patient to select best HospitalHelp patient to select best CardiologistHelp guide patient to select best SurgeonEXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests14
15The Cardiologist Minimal Labs with Micro Sampling at all times Meticulous attn to blood loss during Cath, Rao MDMinimize the use of Heparin and ACT’s < 999The Use of Anti-Platelet drugs like Plavix < is bestIdentify the best hospital to have Surgery done atIdentify the best Surgeon to do the Case (specialist)No more than 2 easy Stents w/o Stent Jail please or send me to Surgery as grafts last longer!DES=5.5% BMS=7.8% On Pump CABG=EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests15
16The Admission Care Team Preferably the day of surgery Micro Sampling for Labs (a must)That first I.V. Line (Let the games begin)For every 1 liter of Crystalloid givenOnly 250 mls will stay Intravascular within 30 minutes, the rest of the 750mls will cross extravascularly causing Organ Edema/Dysfx dropping the Viscosity and COP. It’s a lot easier to add volume than it is to take it off!EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests16
18Capillary "Type" Permeability varies with type of capillary Capillary type varies with organ function1. Tight (brain) Continuous (skeletal muscle, skin) Fenestrated (secretory glands, kidney, gut) 4. Discontinuous (liver, spleen, bone marrow)
20Edema: Most common clinical manifestation of an imbalance of forces at the capillary wall Excess accumulation of fluid in the interstitial space that has not been readsorbed into capillaries or taken up by the lymphaticsCauses includeObstructionPermeability or change in reflection coefficientIncreased protein permeability results in an imbalanceOccurs in trauma, thermal injury, inflammationLife threatening manifestations - endotoxic shock, ARDSPlasma ProteinReduction in circulating plasma proteins, especially albuminLiver dysfunction, malnutrition, or acute alteration of fluid statusAlbumin attenuates extravasation of fluid out of intravascular space to interstitial spaceCapillary pressure
21Pre Game Plan (The Big 3)When ever possible the members of the Cardiac surgical team (The Surgeon, Anesthesia, and Perfusion) should meet prior to surgery and discuss the best course of action for optimizing the case and avoiding Allogeneic Blood Products.The Team Approach to Blood Management !
22Anesthesia *8 gm – 10 gm Hgb No Benefit and No Harm DUKE 2006 / Henry Ford 2009No Benefit and No HarmMeticulous placement of Lines to function correctly and not loose any blood or make any extra holes.Limit the amount of Crystalloid given during the case and opt for Colloids like Albumin instead for Volume.Vascular Tone (SVR) use Pressors as tolerated by cardiac output to achieve a normal SVR of betweenANH Acute Normovolemic Hemodilution, usually 1-2 units or more can be removed safely and still keep a good Hct while on Pump. This should be the first vol seen post CPB.Targeted Pharmacotherapy (Amicar, Aprotinin, DDAVP, rFVIIa Novo 7, Vitamin K and other recombinant factors)EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests22
23Red Cell Mass Contributes to Hemostasis By Pushing the Platelets out to the Endothelium erythrocytes modulate hemostasis is the rheological effect of red cells on the margination of platelets.Eberst ME, Berkowitz LR. Hemostasis in renal disease: pathophysiology and management. Am J Med 1994; 96: 168–79.the near wall concentration of platelets is enhanced up to about seven times the average concentration.54Uijttewaal WS, Nijhof EJ, Bronkhorst PJ, Den Hartog E, Heethaar RM. Near- wall excess of platelets induced by lateral migration of erythrocytes in flowing blood. Am J Physiol 1993; 264(4 Pt 2): H1239–44.HCT OF AT LEAST 24%23
24AnesthesiaContinuedHypotension is NOT Hypovolemia! (Chappell Fluid Article)Push the SVR not the Starling Curve! normalHemodilution is the Enemy! It leads to Organ Edema and Organ Dysfunction that leads to Morbidity and Mortality!HD creates to a Dilutional Anemia and a Dilutional Coagulopathy that leads to Blood Products leads to M&M!Give No Volume and keep Patient tight till the H/C VolumeEXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests24
25The Surgeon Communicate clearly during the case and work diligently Have patience with the Perfusionists while they are RAP’ingRefrain from cooling as much, as it stuns/hurts the PlateletsMeticulous surgical technique should be employed throughout the surgical procedure when bleedingWhen ever there is obvious surgical bleeding the surgeon should stop to tie down or cauterize the area to reduce the waste of blood. (And also fix the venous air) Micro-bubbles !Remember that transfusion of any Allogeneic blood or blood products is an “Organ Transplant", and not just another medication that is without side-effects. Treat everyone like a JW !EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests25
26**The**PerfusionistCondense your Circuit Prime down safely to mls !Calculate the Post-Dilutional Hct, Protein, COP valuesRAP/VAP (Auto Prime) both sides of your Circuit with the help of Anesthesia and the Surgeon. This is not only proven very effective in many studies, and its $$$ economical as it costs nothing.Add Albumin / Osmitrol to Increase the COP / Diuresis of the patient.Limit the Cell Washer to the Pre and Post Heparinization periods!Use the pump’s Coronary Sucker during the Heparinization period to preserve frank Autologous Whole Blood lost outside the heart inside the pericardium and return it to back to the patient’s circulation.A waste sucker should be kept in the field for undesirable shed blood and irrigant solutions (or a cell washer for this as well).EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests26
27Perfusion Cont.On-site coagulation monitoring like the thromboelastography TEG, Sonoclot and Heparin concentration determination like the Hepcon are essential tools in determining the Hemostasis.Targeted pharmacotherapy (antifibrinolytics and desmopressin acetate) are an integral part to prevent empiric transfusions of allogenic blood and blood products.Hemoconcentration should be considered for use to reverse excess fluid administration perioperatively, eliminate undesirable byproducts including antiplatelet medications and concentrate the patient’s red cell mass and plasma proteins during the case.Once safely off bypass Salvage the CPB circuit with Ultrafiltration so you don’t waste any of the patient’s OWN viable and vital blood cell fractions and components to a waste bag.EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests27
28Blood Salvaging With Ultrafiltration The HB tech is an easy way for Perfusionists to salvage any ECC circuit’s Whole Blood quickly, while still keeping your circuit safely primed in case you have to crash back on in an emergency.The process takes only min from Aortic decannulation till Anesthesia is infusing back this powerful unit into the patient.The Hemobag® and its TS3 tubing set allows for Ultrafiltration both during the case and at the end for Whole Blood Autotransfusion.This is a device made for Perfusionists by a Perfusionist for easy salvaging of blood, helping avoid Allogenic Tx’s & Improve Pt CareThe end product is a hyperoncotic Autologous Whole Blood packed with viably functioning Platelets, Clotting Factors, Albumin, Plasma Proteins and RBC’s with no morbidity or side effects.EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests28
29“The Big Bang of Hemofiltration: The Re-Beginning of a new era…” Selective, rapid removal of plasma water & dissolved solutes, (<50K Daltons) including drugs. i.e. Integrilin, ReoPro, Aggrestat, PlavixConservation cellular blood components & proteins.Hctplatelets & clotting factorsalbumin & plasma proteinsReduces anaphylatoxinsC3a, C4a, C5aIL-1, IL-2, IL-6, IL-8,TNF, TNFMDF, bradykininsImproves organ fxmyocardial fxcerebral oxygenationpulmonary complianceReduces post-op blood loss & transfusionsRemoves platelet-activating factor Critical Care Medicine. 23(1):99-107, January 1995Adjunct to diuretics for the treatment of fluid retention.“…A majority of platelets having functional aggregation activity still exist in residual blood in the CPB circuit.”Naik, 1991, Hospital for the Sick, Great Ormond St. UK. Luciani, 2001, MUF reduces morbidity after adult cardiac operations. A prospective, randomized clinical trial. Tanemoto, 2004, Platelet activity of residual blood remained in the cardiopulmonary bypass circuit after cardiac surgery
30The Big Picture about Whole Blood 30Choices/ Alternatives Publication Vol 4 Issue 2, Center for Bloodless Medicine and Surgery, University of Miami / Jackson Med Ctr.
31Priming Volume Generally Crystalloid Fluid CPB CIRCUITPATIENT2 Separate Circuitswith2 Different Volume TypesThat are not exactly the same
32That is exactly the Same On CPBNow Only 1 (ONE) Circuitwith theSame Volume TypeThat is exactly the Same
33Disconnected from the PATIENT CPB CIRCUITOnceDisconnected from the PATIENTPrimed with Whole BloodPATIENTOnceDisconnected from CPB2 Separate Circuits Nowwith theSame Volume TypesOf Exactly the Same Blood
34Processing Residual Circuit Whole Blood Three re-infusion methodsDirect Ann Thorac Surg. 1993;56(4):Cell-Wash JECT. 1996;28(3):134-9.Ultrafiltration Perfusion. 2005;20(6):343-9.Final Infusion Volume ContentsTechniqueVolume cc%HCTPlt Cnt109/L[Fib]mg/dL% Clot FactorsDirect17-2550-14080-13515-40Cell-wash40-585-2510-302-10Ultrafiltration45-5585-259Note: 90 percent confidence limits for pre-protamine infusion volumes and blood component values(Proc Amer Soc Extra Corpor Technol. 2006)Hemobag®J Extra Corpor Technol. 2004;36(2):162-5.34
35Ultrafiltration Versus Cell Washing Residual CPB Circuit Whole Blood IssueUltrafiltrationCell-WashingClotting factor preservationConcentrates remaining factorsDiscards clotting factorsProtein (fibrinogen) preservationConcentrates Albumin and FibrinogenDiscard albumin and fibrinogenAllogeneic transfusion avoidanceHelps to avoid use of PRBCs and component therapyHelps to avoid use of PRBCs; May increase the use of component therapyHeparin / drug removalConcentrates some drugsRemoves many drugsPlatelet / RBC / WBC preservationConcentrates Functional Blood CellsMay waste or activate Platelets, WBCs and RBCsInterleukin / complement removalRemoves some ILs complementsRemoves some ILs or complementsContaminationShould not introduce bacteriaCW product contains bacteriaFat removalMay remove some fatRemoves some fatCost-savingsCost savings with decreased allogeneic component therapySome cost savings with reduced allogeneic PRBC use1 Roeder. J Extra Corpor Technol. 2004;36(2):162-5.2 Samolyk. Perfusion. 2005;20(6):343-9.3 Jackson. J Extra Corpor Technol. 2006;38(1);A86.4 Beckmann. J Extra Corpor Technol. 2007;39(2):103-8.5 Riley. J Extra Corpor Technol. 2007;39(1)A3.35
36Ideal End Product Given Back to the Patient ! High HCTHigh AlbuminHigh Total ProteinHigh PlateletsNormal ElectrolytesVery High Fibrinogen8-10 Minute ProcedureKeeps the CPB Circuit Safety primed for SecurityAll Autologous Cells are returned to the patient!
37What’s the Next Evolution of Autotransfusion for ECC’s in CV Surgery ULTRAFILTRATIONULTRAFILTRATION has the benefit of ConcentratingWhole Blood quickly & easilySaving All the Plasma as wellas the RBC’s !So How Can We Make It Really EasyCell Washer WasteWhole Blood37
38FDA Cleared Device Specifically made for Perfusionists for Autotransfusion and Blood Conservation Using “Multipass Ultrafiltration”A Universal Blood Reservoir for Salvaging and Concentrating Autologous Whole Blood from anyExtracorporeal Circuit or any anticoagulated blood Reservoir*In compliance with Jehovah’s Witness patients wishes & guidelines
39HEMOBAG®2.4 LitersThe Hemobag is a Multipass system that concentrates the blood left over in the ECC by drastically increasing the hematocrit of the blood while also saving all the factors of whole blood mentioned earlier which is then given back to the patient.Clinically the Hemobag is being used is centers across the world. It has been proven that the Hemobag does decrease blood product use and costs, additionally it has been shown to improve blood coagulation and hemostasis of the patient.The research presented today will be focusing on this part of the Hemobag, the hemoconcentrator.39
40Code of Ethics for Blood Donation and Transfusion ISBT / SITS #3. …transfusion must be in the best interest of the patient.#15. Blood is a costly public resourceBlood Industry, USA ~ $20 Billion / yr!#16. As far as possible the patient should receive only those particular components that are clinically appropriate and afford optimal safety and outcome.#17. Wastage should be avoided in order to safeguard the interest of all potential recipients and the donorsCell Washing DevicesInherent waste by discardingall viable platelets & plasma~ ml per bowlONLY CONTAMINATED BLOOD SHOULD BE CELL WASHED !!!
41Patients are discharged with No Blood Products and No Complications. Improved Coagulation(Example of typical results in when ECC is returned with UF) =PRE-OP INTRA-OP POST- INFUSIONHCT 35% % 33%PT sec secPTT 27 sec secINRACT sec sec secPLT. COUNT 276, ,000 (Functional)Typically the Total 24 hour Chest Tube Drainage is mls of Serous FluidPatients are discharged with No Blood Products and No Complications.
46Clotting Factors Factor I Fibrinogen Half life 3-5 days) Factor II Pro-thrombinFactor III Tissue Thromboplastin (TT)Factor IV CalciumFactor V Labile factor (proaccelerin)Factor VI not assignedFactor VII Stable factor (proconvertin)Factor VIII Anti-hemophilic factor A (AHF)Factor IX Christmas FactorFactor X Stuart - Prower FactorFactor XI Plasma Thromboplastin antecedentFactor XII Hageman factorFactor XIII Fibrin Stabilizing factorThe higher up the cascade the clotting factor deficiency isthe worse and more detrimental the coagulopathy can be
49FFP & FIBRINOGEN FACTS Fibrinogen is produced by the Liver (340 kDa) It is the main protein of blood coagulation and the mainstay in treatment of inherited coagulopathiesFrozen for up to 1 year, must be used within 24hrs of thawingFibrinogen meshes with the Platelet plug and converts to a stable Fibrin clotNormal blood levels are mg/dlNormal concentrations in plasma are about 3mg/mlEa unit of FFP mls has 1-2mg/ml of FibrinogenIt’s an important parameter in the diagnosis of CAD.FFP use is up over 40% here in the USA since 1979Use and demand has continued to grow each yearThe USA uses 3 times as much as Europe does!Plasma Tx is not benign it can cause TRALI, TACO,TRIM and other Immunological consequences!
5045% 10% Do in vitro coagulation tests predict bleeding? The relationship between clotting factors and the PT is Exponential !45%10%Dzik WH, in Mintz PC ed. Transfusion therapy: principles and practice, 2nd edition. AABB Press, 200550
51Equivalent Fibrinogen Volume Average from HB 500 cases Frozen Plasma:1 Average Hemobag ≈ 3.4 units of FFP 325mg) for Fbg. equivalency to one average Hemobag reinfusion 450mg/dl)Cryoprecipitate:1 Average Hemobag ≈ 37 units of Cryo. pooled units) for Fbg equivalency to one average Hemobag reinfusion 450mg/dl)** FFP usage in the United States is rising each year and rising at a rate faster than RBC's. 30% of FFP transfusions do not meet current guidelines.[Transfusion Vol. 45: July, Dr. Dzik]Current trend nationwide FFP usage:‘03: 2.7M u.‘04: 3.3M u.’05: ↑ M u.’06: ↑↑M.u
57How Microcirculation Works Vascular Interstitial LymphaticDaxor
58The Lymphatic SystemIs a network of conduits that carry a clear fluid called lymph. It also includes the lymphoid tissue that the lymph travels through. Lymphoid tissue is found in many organs, particularly the lymph nodes, and in the lymphoid follicles associated with the digestive system such as the tonsils. The system also includes all the structures dedicated to the circulation and production of lymphocytes, which includes the spleen, thymus, bone marrow and the lymphoid tissue associated with the digestive system.The dissolved constituents of the blood do not directly come in contact with the cells and tissues in the body, but first enter the interstitial fluid, and then the cells of the body.Lymph is the fluid that is formed when interstitial fluid enters the conduits of the lymphatic system. The lymph is not pumped through the body like blood, it is moved predominately by the contractions and movements of skeletal musclesThe lymphatic system has three interrelated functions. It is responsible for the removal of interstitial fluid from tissues. It absorbs and transports fatty acids and fats as chyle to the circulatory system. The last function of the lymphatic system is the production of immune cells, such as lymphocytes, including antibody & producing monocytes. Diseases and dysfunction/obstruction of the lymphatic system can cause swelling , edema and other symptoms. Problems with the system can impair the body's ability to fight.
60Plasma Protein Effects on Total Colloid Osmotic Pressure (COP) Albumin4.521.878Globulins2.56.021Fibrinogen0.30.21Total7.328.0100
61The Loss of Protein and Lymphatic Flow ProteinsLymph Flow
62Edema: Most common clinical manifestation of an Imbalance of forces at the capillary wall Excess accumulation of fluid in the interstitial space that has not been readsorbed into capillaries or taken up by the lymphaticsCauses includeObstructionPermeability or change in reflection coefficientIncreased protein permeability results in an imbalanceOccurs in trauma, thermal injury, inflammationLife threatening manifestations - endotoxic shock, ARDSPlasma ProteinReduction in circulating plasma proteins, especially albumin!Liver dysfunction, malnutrition, or acute alteration of fluid statusAlbumin attenuates extravasation of fluid out of intravascular space to interstitial spaceCapillary pressure62
63Albumin – Physiological role Major functionsMost abundant protein in plasma (69 kDa)+/- 80% of plasma colloid osmotic pressureNormal COP is mmHg (Hemodilution really drops it)Transport and sequestration of bilirubinTransport of fatty acids, hormones, vitamins, enzymes, drugs (Warfarin, Diazepam, Digoxin, NSAIDS, Midazolam, Thiopental and others)Antioxidant and Free Radical Scavenger effectInhibit Endothelial Cell Apoptosis and may influence the Microcirculation by modifying the capillary permeabilityBuffer in Acid Base Balance (fixes to H+ ions)No Maximal Dose and No Effect on HemostasisEXTRA NOTESAdd any uses that fit the experience of your audience63
653rd spacing “Anasarca” Hypoalbuminemia leads to …may cause generalized edema (swelling) via a decrease in oncotic pressure. Levels below 3.5 grams per deciliter are generally considered dangerous.50 mL of 25% I.V. Albumin draws approximately 175 mL of additional fluid into the circulation within 15 minutes
66Perfusionists can reverse the Fluid Shifts that cause 3rd Spacing from Hemodilution & CPB and optimize the Pt’s RCM, so that allogeneic blood products to treat a Dilutional Anemia and a Dilutional Coagulopathy can be minimized.OsmitrolLASIXMannitolHEMOCONCENTRATORSPerfusion ToolsALBUMIN
67Nurses & The ICU Care Team Back to the players! ------ POST-OP Maintain NormothermiaMicro-sampling as little as possibleRely on Oximetry instead of drawsCareful and judicious use of volume as neededPressors instead of volumeAlbumin instead of crystalloidsDiuretics if necessaryExtubate ASAP !No “Drive-by Transfusions” from on-call staff !EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests67
68Hospital Administrators Get to know them on a personal basisSuggest the benefits of a Blood Mgmt PrgmGet them involved in Blood Management!Look at using Consultants: Infonale’, HemoConcepts, Strategic Blood Mgmt.Encourage trials of New Equipment / DrugsFind a Champion for Blood Management !Show them the facts in $$$ savings for all!EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests68
69Other ThingsYou can Do!Join AmSECT & get involved with the PBM Taskforce !Take the PBMS exam & be a leader in your Hospital.Join the AABB, SABM, NATA or PNBCThese are finely tuned international organizations solely focused on better blood management and improved care!Surf the web & read current articles and share them with other members of the cardiac team (leave around).Get on your Hospital’s Transfusion Practices committee and make a difference (Go to the monthly meetings).Find and support a Champion MD who wants to change the paradigms of tx’s in your hospital’s Cardiac team.Work as a team that’s focused on improvement of care!EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests69
70More Things You can Do! Visit these sites and learn more! NoBlood.org Bloodless Medicine Research (Univ of Pisa)SABM (Society for the Advancement of Blood Mngmt)NATA (Network for Advancement of Tx Alternatives)PNBC (Physicians & Nurses for Blood Conservation)Medical Society for Blood ManagementStrategic Blood ManagementMybloodfirst.com (Excellent site for Perfusionists)Get Involved and Change the Paradigm of Blood Use!EXTRA NOTESIt’s a nice touch and required at many conferences today to mention any competing interests70
71Take Home Message of ……. Blood Management Principles Multidisciplinary Communication is JugularFind or become a champion in this effort!Maximize Preoperative Red Cell MassCorrect any Coag disorder prior to SxMinimize blood loss in Sx (this is essential !)Avoid Allogeneic Tx (balance need vs risk)Salvage Autologous Whole Blood first then use alternatives if necessaryIf a Transfusion is necessary: use safest, freshest and most effective product available (wash it !)Remember you can’t start saving blood until you actually start saving blood!EXTRA NOTESJust my thoughts on good transfusion practice71
72But most Importantly remember But most Importantly remember! “If its not yours its an Organ Transplant” with consequences, so try and do your best to avoid it! Your decisions effect the patient for the rest of their life!