1. Vigneshwar Kasirajan, M.D. Division of Cardiothoracic Surgery Vigneshwar Kasirajan, M.D. Division of Cardiothoracic Surgery

3. Results Higgins, et al AATS 2003

4. Results Green, et al. SCA 2003 *=p<0.05 **

5. Results Spiess, et al. SCA 2003 Total Savings=$1.4M Unit and Xmatch=$295K Fixed overhead=$274K Adverse Events=$863K

6. HEMOGLOBIN HEMOGLOBIN

7. Retrograde Autologous Priming (RAP) Eight month data review at VCU MEDICAL CENTER November ’04-June ‘05

8. TOTAL CASES ATTEMPTED

9. No RAP Cases

10. Pre-Post RAP Hgb

11. RAP Volume

12. AUTOLOGOUS BLOOD OFF BY ANESTHESIA AFTER INDUCTION AVERAGED 516 mls.

13. HGBS ON BYPASS

14. PATIENT’S HGB AFTER ARRIVING TO ICU AVERAGED 10.2 g/dl

15. CONCLUSIONS Enhances communication between perfusionist, anesthesiologist, and surgeon. Enhances communication between perfusionist, anesthesiologist, and surgeon. One month to achieve comfort level performing RAP. One month to achieve comfort level performing RAP. Priming volume of pump has been reduced from 1800mls to 650mls. Priming volume of pump has been reduced from 1800mls to 650mls. Only 11% of RAP patients received bank blood. Only 11% of RAP patients received bank blood. 27% of No RAP(26 patients), received bank blood on bypass. 27% of No RAP(26 patients), received bank blood on bypass. 46% of RAP patients received aprotinin 46% of RAP patients received aprotinin Cell saver used on 66% of RAP patients Cell saver used on 66% of RAP patients Entire pump volume washed with cell saver on 46% of RAP patients after bypass. Entire pump volume washed with cell saver on 46% of RAP patients after bypass.

16. VCU Blood Conservation Policy VCU Blood Conservation Policy  Transfusion Guidelines  Hematocrit 17% ANDAND  Signs of Oxygen Debt  Conservation Strategies (commonly used methods in cardiac surgery, often concurrently)  ANH (Autologous Normovolemic Hemodilution)  RAP (Retrograde Autologous Priming of CPB circuit)  Cell Saver Use  Antifibrinolitic Drugs Use in All Patients Aprotinin or Epsilon AminoCaproic Acid (EACA)Aprotinin or Epsilon AminoCaproic Acid (EACA)

17. Methods IRB Approved Retrospective Review IRB Approved Retrospective Review All patients in the period from All patients in the period from  November 1 st, 2004  to  July 1 st, 2005 were studied Statistical Analysis Statistical Analysis  Mixed Effect Repeated Measures ANOVA

18. Results A total of n=205 patients were included A total of n=205 patients were included  146 males (71%)  59 females (29%) Mean age 58.4 ± 13.5 years old Mean age 58.4 ± 13.5 years old Mean Ejection Fraction 45 ± 15% Mean Ejection Fraction 45 ± 15%  Interquartile Range (25-75) 35-60% History of History of  Myocardial Infarction40%  Congestive Heart Failure35% Hemoglobin Levels Hemoglobin Levels  PreOp HGB12.0 ± 1.9  Lowest HGB on CPB7.6 ± 1.5  First HGB in ICU10.0 ± 1.8

19. Results Procedures Procedures  CABG49% (100)  Valve14% (30)  Aortic Surgery9% (18)  VAD1% (2)  Combined Procedure27% (55)  Previous Sternotomy28% (57) Anticoagulation Medication Anticoagulation Medication  Heparin11% (22)  Coumadin10% (20)

20. Results Complications Complications  Mortality5% (10)  Stroke2% (5)  MI1% (2)  Reoperations5% (10)

21. Results GroupCount% ANH Only63 No Action2010 RAP + ANH7436 RAP Only10551 Total205100 Antifibrinolitics Use Aprotinin49% (101) EACA51% (104)

22. Results Main Outcome Measures Main Outcome Measures  Transfusion rate  Hemoglobin Drop (from PreOp to ICU) Transfusion Rate 11% (23) Transfusion Rate 11% (23)  83% patients had aprotinin

23. Results Blood Conservation Maneuver Groups Blood Conservation Maneuver Groups

24. Results (Excluding Patients Transfused)

25. Successful Blood Conservation Program Successful Blood Conservation Program  Transfusion Rate 11% The combination of RAP and ANH is particularly effective The combination of RAP and ANH is particularly effective  Transfusion Rate 3% Selection Bias or Channeling of more likely to bleed patients towards the use of Aprotinin Selection Bias or Channeling of more likely to bleed patients towards the use of Aprotinin  83% of transfused patients received Aprotinin Conclusions

26. Despite this Channeling, the most effective maneuver to conserve blood was the use of Aprotinin Despite this Channeling, the most effective maneuver to conserve blood was the use of Aprotinin  Hgb drop 1.8 vs 2.4 gr/dL compared with EACA  Only maneuver statistically effective despite the channeling Effective multimodal approach even though individual contribution by each maneuver is not statistically significant Effective multimodal approach even though individual contribution by each maneuver is not statistically significant

27. ALL CASES 2004200520062007 IntraOp only 1.92%7.42%9.43%18.01% PostOp Only 22.99%23.63%20.29%9.32% IntraOp or PostOp 31.42%42.31%50.29%47.20% IntraOp and PostOp 6.51%11.26%20.57%19.88% Mortality OE Mortality OE Ratio: 1.42229 Ratio: 0.27324 Ratio: 0.72599 Ratio: 1.24046 Observed: 0.0462 Observed: 0.0082 Observed: 0.0240 Observed: 0.0460 Expected: 0.0325 Expected: 0.0299 Expected: 0.0331 Expected: 0.0371 Case Mix Index 3.83984.00574.05894.3872 Blood Usage – All Cases

28. CAB Only 2004200520062007 IntraOp only 0.00%2.96%11.05%13.33% PostOp Only 18.66%25.12%26.16%16.00% IntraOp or PostOp 23.13%35.96%46.51%48.00% IntraOp and PostOp 4.48%7.88%9.30%18.67% Mortality OE Mortality OE Ratio: 1.48771 Ratio: 0.20934 Ratio: 1.24154 Ratio: 0.55674 Observed : 0.0373 Observed : 0.0049 Observed : 0.0292 Observed: 0.0133 Expected: 0.0251 Expected: 0.0235 Expected: 0.0236 Expected: 0.0239 Case Mix Index 3.83984.00574.05894.3872 Blood Usage – CAB Only

29. POST CABG COMPLICATIONS

30. TRANSFUSION RATES (CABG)

32. 56 y MALE – Acute MI, Cardiogenic shock, on IABP Hb 9.9 g/dl On plavix, ASA (prev PCI) Integrellin and iv heparin Emergent surgery due to worsening CP and ST elevations.

33. TEG PRE CPB

34. Hb < 5 – 2 prbcs Hb 6.0 – 1 prbc

35. TEG POST CPB AFTER PROTAMINE No factors or platelets due to absence of clinical bleeding

37. Transfusion Triggers: Pump RBC transfusion for Hgb < 6.0 or HCT <18 + One objective criteria for tissue hypoperfusion. On Pump RBC transfusion for Hgb < 6.0 or HCT <18 + One objective criteria for tissue hypoperfusion. · Low SVO2 · Elevated Lactate · Elevated base deficit, Low HCO3 Post Op ( ICU and Step Down Units ) RBC transfusion for Hgb < 7.0 or HCT <21 + One objective criteria. · Elevated O2 need · Hypotension · End Organ dysfunction · Ongoing Bleeding Prospective Follow Up: The following data will be collected for each patient: All data routinely collected for the STS Adult Cardiac Surgery Database will be collected as usually done for quality improvement purposes. In addition the following custom fields will be collected prospectively. · Pre-Op Hgb/Hct · Hgb/Hct Pre-Bypass · Lowest Hgb/Hct on Bypass · Hgb/Hct at end of surgery · Hgb/Hct at discharge from ICU · Hgb/Hct at discharge from hospital · Hgb/Hct at first post-op visit · Amicar vs. Aprotinin vs. None · Retrograde Autologous Priming · Ultrafiltration · Degree of hypothermia · Cell saver use · Volume of Cardioplegia · Total volume of Crystalloid/Colloid during surgery. · Leukoreduced v. Non-leukoreduced · Factor VIIa · Every unit transfused will be recorded with the time and Hgb/Hct trigger. · Date blood was harvested. VCSQI STUDY