Transcript Blood Management PPT

Blood Management in Cardiac Surgery
Using
Multidisciplinary Multimodality Approaches
Global Blood Resources LLC
www.mybloodfirst.com
Roadmap
Discuss Blood Conservation
Where we are today with blood
The multidisciplinary players
Their multimodality approaches
What Perfusionists Can Do
Changing the Paradigm
What else can we do !
Disclosure statement:
GBR is the maker of the Hemobag® for ATS
ETHICS OF BLOOD
MANAGEMENT
-First Do No Harm “Primum Non Nocere”
-Transfuse only when absolutely necessary
-Transfuse Only what’s Required / Sparingly
-The Freshest Components Possible
- Minimal Blood Draws Sampling
-Avoid Waste/ Recover as much Autologous as poss
-Use POC Labs to Justify Transfusions
-Use Evidence Based Medicine in Decisions
To Start What is Blood?
First, A Surprise Quiz!
Don’t ponder, just raise your hand
if you Generally Agree with the question
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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 ?
Bank Blood Costs
• Cost of blood products rising with
no direct reimbursement.
MC does not pay until 4th unit…
Red Blood Cell Units: $500 – $1,000
Platelet Pheresis pack: $536
Plasma Units FFP: (4) $300+
Cryoprecipitate:(5+fee) $250
DeAnda, Spiess, et al. $1,422 /
PRBC unit
• Transfusion reactions: Infections, viruses and most importantly
Immunosupression / Immunomodulation
• Incidence of TRALI (>1:2,000 donor exposures)
• Nationwide range of “blood admin charges per discharge:” $2,240
JC will be evaluating blood management as part of Accreditation
Joint Commission Perspectives on Pt. Safety: Jan. Vol. 7:1,
2007

Allogeneic Blood
Problems!
Morbidity
andblamed
mortality
associated
withbypass
red blood cell and blood-component
Transfusions
forrisk
deaths
after heart
transfusion in isolated coronary artery bypass grafting* April 2006
NEW YORK (Reuters Life) - Getting a blood transfusion during or after heart bypass
Koch
CG,
Li raise
L, Duncan
Cosgrove
DM, after
Loopthe
FD,operation,
Starr NJ,new
surgery
may
the riskAI,
of Mihaljevic
dying in theT,next
few months
Blackstone
EH.
research suggests.
From
the Departments
of Cardiothoracic
Anesthesia
(CGK,
AID,
NJS),
Moreover,
this may explain
in part why women
are more
likely
than
menQuantitative
to die after
Health
Sciences
(LL, EHB),
and(CABG),
Thoracicsince
and Cardiovascular
Surgery (TM,
coronary
artery bypass
grafting
women more commonly
needDMC, FDL,
EHB),
The Cleveland
transfusions
than menClinic
do. Foundation; Cleveland, OH.
"To the best of our knowledge, this is the first study to state that ... transfusions may be
MEASUREMENTS
ANDhave
MAIN
RESULTS:
12K 48.6%
were transfused.
of
the reason why women
a greater
post-CABG
mortality
than men," Transfusion
Dr. Mary A. M.
red
bloodfrom
cellsthe
was
associated
with a risk-adjusted
increased
for every
Rogers,
University
of Michigan
in Ann Arbor,
said in arisk
statement.
postoperative
morbid event:
mortality
95% [CI],88
renal
failure,
prolonged
ventilatory
In a study of Michigan
Medicare
beneficiaries,
percent
of female
CABG
patients
support,
cardiac
complications
& neurological
events.
received serious
a blood infection,
transfusion
compared
with 67 percent
of male patients.
CONCLUSIONS:
Perioperative
red blood cell
transfusion
the single
factor
most
Patients who received
a blood transfusion
were
5.6-timesismore
likely to
die within
reliably
with heart
increased
risksurgery
of postoperative
events after
100 daysassociated
of undergoing
bypass
than weremorbid
non-transfused
patients,
isolated
bypass
grafting.
Each
unit of red cells transfused is
the reportcoronary
indicates.artery
© Reuters
2007.
All Rights
Reserved.
associated with incrementally increased risk for adverse outcome.
Older 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):1229-39. 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, 2006. 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 riskadjusted 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.
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 and
RESULTS: 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.
Blood transfusions may be killing some
of the people they are intended to save
Dr. Sunny Rao Duke Cardiologist 2004
IF 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 bloodcell 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.
What 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."
So how can we manage blood better and who
are the Multidisciplinary Players involved?
Primary Doctor
Cardiologist
Admission Care Team
Pre Game Plan with the Big Three
*Surgeon, Anesthesia, Perfusion*
Anesthesia
Surgeon
Perfusion (Its not your fault !) GWH
ICU Care Team, Nurses
Administrators
The Primary Doctors Office
Baseline lab work (preferably 6 wks early)
Micro-sampling (Peds Tubes)
Iron therapy 50% of the Population are Low
Epo therapy 2-3 weeks to raise Hct 2-3%
Help patient to select best Hospital
Help patient to select best Cardiologist
Help guide patient to select best Surgeon
The
Cardiologist
Minimal Labs with Micro Sampling at all times
Meticulous attn to blood loss during Cath, Rao MD
Minimize the use of Heparin and ACT’s < 999
The Use of Anti-Platelet drugs like Plavix < is best
Identify the best hospital to have Surgery done at
Identify 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= 2.8%@3yr
The 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 given
Only 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!
The “Epicenter” of Life & Fluid Balance
Capillary "Type"
Permeability varies with type of capillary
Capillary type varies with organ function
1. Tight (brain)
2. Continuous (skeletal muscle, skin)
3. Fenestrated (secretory glands, kidney, gut)
4. Discontinuous (liver, spleen, bone marrow)
Edema: 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 lymphatics
Causes include
•
•
Obstruction
Permeability or change in reflection coefficient
Increased protein permeability results in an imbalance
–
Occurs in trauma, thermal injury, inflammation
–
Life threatening manifestations - endotoxic shock, ARDS
•
Plasma Protein
–
–
•
Reduction in circulating plasma proteins, especially albumin
Liver dysfunction, malnutrition, or acute alteration of fluid status
•
Albumin attenuates extravasation of fluid out of intravascular
space to interstitial space
Capillary pressure
Pre 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 !
Anesthesia
*8 gm – 10 gm Hgb
DUKE 2006 / Henry Ford 2009
No Benefit and No Harm
Meticulous 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 between 800-1200.
ANH 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)
Red Cell Mass Contributes to
Hemostasis By Pushing the
Platelets out to the Endothelium
HCT OF AT LEAST 24%
Anesthesia
Continued
Hypotension is NOT Hypovolemia! (Chappell Fluid Article)
Push the SVR not the Starling Curve! normal 800-1200.
Hemodilution 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 Volume
The Surgeon
Communicate clearly during the case and work diligently
Have patience with the Perfusionists while they are RAP’ing
Refrain from cooling as much, as it stuns/hurts the Platelets
Meticulous surgical technique should be employed throughout
the surgical procedure when bleeding
When 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 !
**The**
Perfusionist
Condense your Circuit Prime down safely to 1000 - 1400mls !
Calculate the Post-Dilutional Hct, Protein, COP values
RAP/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).
Perfusion 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.
Blood
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 8- 10 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 Care
The 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.
“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, Plavix
• Conservation cellular blood •
components & proteins.
•
– Hct
Improves organ fx
– myocardial fx
– cerebral oxygenation
– pulmonary compliance
Reduces post-op blood loss &
transfusions
Removes platelet-activating
factor
Critical Care Medicine. 23(1):99-107,
“…A
majority of
plateletsfactors
having functional
aggregation
– platelets
& clotting
January 1995
activity
still exist
in residual
blood in the CPB circuit.”
– albumin
& plasma
proteins
• Reduces anaphylatoxins
–
–
–
–
C3a, C4a, C5a
IL-1, IL-2, IL-6, IL-8,
TNF, TNF
MDF, bradykinins
• Adjunct to diuretics for the
treatment of fluid retention.
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
The Big Picture about Whole Blood
Choices/ Alternatives Publication Vol 4 Issue 2, Center for Bloodless Medicine and Surgery, University of Miami / Jackson Med Ctr.
30
Priming Volume
Generally
Crystalloid Fluid
PATIENT
CPB CIRCUIT
2 Separate Circuits
with
2 Different Volume Types
That are not exactly the same
On CPB
Now Only 1 (ONE) Circuit
with the
Same Volume Type
That is exactly the Same
PATIENT
Once
Disconnected
from CPB
CPB CIRCUIT
Once
Disconnected
from the
PATIENT
Primed with
Whole Blood
2 Separate Circuits Now
with the
Same Volume Types
Of Exactly the Same Blood
Processing Residual Circuit Whole
Blood
Three re-infusion methods
– Direct Ann Thorac Surg. 1993;56(4):938-43.
– Cell-Wash JECT. 1996;28(3):134-9.
– Ultrafiltration Perfusion. 2005;20(6):343-9.
Final Infusion Volume Contents
Technique
Volume cc
%
HCT
Plt Cnt
109/L
[Fib]
mg/dL
% Clot
Factors
Direct
700-1800+
17-25
50-140
80-135
15-40
Cell-wash
225-450
40-58
5-25
10-30
2-10
Ultrafiltration
450-1000
45-55
125-325
225-385
85-259
Note: 90 percent confidence limits for pre-protamine
infusion volumes and blood component values
(Proc Amer Soc Extra Corpor Technol. 2006)
Hemobag®
www.mybloodfirst.com/
J Extra Corpor Technol. 2004;36(2):162-5.
Ultrafiltration Versus Cell Washing
Residual CPB Circuit Whole Blood
Issue
Ultrafiltration
Cell-Washing
Clotting factor preservation
Concentrates remaining factors
Discards clotting factors
Protein (fibrinogen) preservation
Concentrates Albumin and Fibrinogen
Discard albumin and fibrinogen
Allogeneic transfusion avoidance
Helps to avoid use of PRBCs and
component therapy
Helps to avoid use of PRBCs;
May increase the use of
component therapy
Heparin / drug removal
Concentrates some drugs
Removes many drugs
Platelet / RBC / WBC preservation
Concentrates Functional Blood Cells
May waste or activate Platelets,
WBCs and RBCs
Interleukin / complement removal
Removes some ILs complements
Removes some ILs or
complements
Contamination
Should not introduce bacteria
CW product contains bacteria
Fat removal
May remove some fat
Removes some fat
Cost-savings
Cost savings with decreased
allogeneic component therapy
Some cost savings with
reduced allogeneic PRBC use
1 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.
Ideal End Product Given
Back to the Patient !
•
•
•
•
•
•
•
•
High HCT
High Albumin
High Total Protein
High Platelets
Normal Electrolytes
Very High Fibrinogen
8-10 Minute Procedure
Keeps the CPB Circuit
Safety primed for
Security
• All Autologous Cells are
returned to the patient!
What’s the Next Evolution of
Autotransfusion for ECC’s in CV Surgery
ULTRAFILTRATION
ULTRAFILTRATION
has the benefit of
Concentrating
Whole Blood
quickly & easily
Saving All the
Plasma as well
as the RBC’s !
So How Can We Make
It Really Easy
Cell Washer Waste
Whole Blood
FDA 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 any
Extracorporeal Circuit or any
anticoagulated blood Reservoir
*In compliance with Jehovah’s Witness
patients wishes & guidelines
HEMOBAG®
2.4 Liters
Code of Ethics for Blood Donation and
Transfusion
ISBT / SITS
#3. …transfusion must be in the best interest of
the patient.
#17. Wastage should be avoided in order to
safeguard the interest of all potential
recipients and the donors
#15. Blood is a costly public resource
Blood 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.
Cell Washing Devices
ONLY CONTAMINATED BLOOD
SHOULD BE CELL WASHED !!!
Inherent waste by discarding
all viable platelets & plasma
~280-300ml per bowl
Improved Coagulation
• (Example of typical results in when ECC is returned with UF) =
HCT
PRE-OP
35%
PT
9.9 sec.
11.2 sec
PTT
27 sec
34 sec
INR
1.0
1.1
ACT
155 sec
PLT. COUNT 276,000
INTRA-OP
25%
594 sec
POST- INFUSION
33%
142 sec
241,000 (Functional)
Typically the Total 24 hour Chest Tube Drainage is 100- 300 mls of Serous Fluid
Patients are discharged with No Blood Products and No Complications.
ATS Waste Calculator (JECT 2007)
Clotting Factors
Factor I
Fibrinogen Half life 3-5 days)
Factor II
Pro-thrombin
Factor III
Tissue Thromboplastin (TT)
Factor IV
Calcium
Factor V
Labile factor (proaccelerin)
Factor VI
not assigned
Factor VII
Stable factor (proconvertin)
Factor VIII
Anti-hemophilic factor A (AHF)
Factor IX
Christmas Factor
Factor X
Stuart - Prower Factor
Factor XI
Plasma Thromboplastin antecedent
Factor XII
Hageman factor
Factor XIII
Fibrin Stabilizing factor
The higher up the cascade the clotting factor deficiency is
the worse and more detrimental the coagulopathy can be
The Clotting Cascades
FFP & 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 coagulopathies
• Frozen for up to 1 year, must be used within 24hrs of thawing
• Fibrinogen meshes with the Platelet plug and converts to a stable
Fibrin clot
• Normal blood levels are 150- 400 mg/dl
• Normal concentrations in plasma are about 3mg/ml
• Ea unit of FFP 200-300mls has 1-2mg/ml of Fibrinogen
• It’s an important parameter in the diagnosis of CAD.
• FFP use is up over 40% here in the USA since 1979
• Use and demand has continued to grow each year
• The USA uses 3 times as much as Europe does!
• Plasma Tx is not benign it can cause TRALI, TACO,
TRIM and other Immunological consequences!
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, 2005
Equivalent Fibrinogen Volume
Average from HB 500 cases
• Frozen Plasma:
– 1 Average Hemobag ≈ 3.4 units of FFP (300ml @ 325mg) for Fbg. equivalency to one
average Hemobag reinfusion (800ml. @ 450mg/dl)
• Cryoprecipitate:
– 1 Average Hemobag ≈ 37 units of Cryo. (60ml. @150mg pooled units) for Fbg equivalency
to one average Hemobag reinfusion (800ml. @ 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, 2005. Dr. Dzik]
Current trend nationwide FFP usage:
‘03: 2.7M u.
‘04: 3.3M u.
’05: ↑ M u.
’06: ↑↑M.u
Fluid Volume Management
Circulation
Lymphatics
The “Epicenter” of Fluid Balance
STARLINGS LAW
Fluid Movement Between Compartments
How Microcirculation Works
Vascular
Interstitial
Lymphatic
Daxor
The Lymphatic System
Is 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
The lymph is not pumped through the
body like blood, it is moved predominately by the
contractions and movements of skeletal muscles
lymphatic system.
The 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.
The Lymphatic
System
Plasma Protein Effects on Total
Colloid Osmotic Pressure (COP)
Albumin
4.5
21.8
78
Globulins
2.5
6.0
21
Fibrinogen
0.3
0.2
1
Total
7.3
28.0
100
The Loss of Protein and Lymphatic Flow
Proteins
Lymph Flow
Edema: 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 lymphatics
Causes include
•
•
Obstruction
Permeability or change in reflection coefficient
Increased protein permeability results in an imbalance
–
Occurs in trauma, thermal injury, inflammation
–
Life threatening manifestations - endotoxic shock, ARDS
•
Plasma Protein
– Reduction in circulating plasma proteins,
especially albumin!
–
•
Liver dysfunction, malnutrition, or acute alteration of fluid status
•
Albumin attenuates extravasation of fluid out of intravascular space to
interstitial space
Capillary pressure
62
Albumin – Physiological role
• Major functions
– Most abundant protein in plasma (69 kDa)
– +/- 80% of plasma colloid osmotic pressure
Normal COP is 18-22 mmHg (Hemodilution really drops it)
– Transport and sequestration of bilirubin
– Transport of fatty acids, hormones, vitamins, enzymes, drugs
(Warfarin, Diazepam, Digoxin, NSAIDS, Midazolam, Thiopental
and others)
– Antioxidant and Free Radical Scavenger effect
– Inhibit Endothelial Cell Apoptosis and may influence the
Microcirculation by modifying the capillary permeability
– Buffer in Acid Base Balance (fixes to H+ ions)
– No Maximal Dose and No Effect on Hemostasis
78
Hypoalbuminemia leads to 3rd spacing “Anasarca”
…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
Perfusionists 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.
Osmitrol
Mannitol
LASIX
HEMOCONCENTRATORS
ALBUMIN
Perfusion Tools
Back to the players! ------
POST-OP
Nurses & The
ICU Care Team
Maintain Normothermia
Micro-sampling as little as possible
Rely on Oximetry instead of draws
Careful and judicious use of volume as needed
Pressors instead of volume
Albumin instead of crystalloids
Diuretics if necessary
Extubate ASAP !
No “Drive-by Transfusions” from on-call staff !
Hospital Administrators
Get to know them on a personal basis
Suggest the benefits of a Blood Mgmt Prgm
Get them involved in Blood Management!
Look at using Consultants: Infonale’,
HemoConcepts, Strategic Blood Mgmt.
Encourage trials of New Equipment / Drugs
Find a Champion for Blood Management !
Show them the facts in $$$ savings for all!
Other Things
You 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 PNBC
These 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!
More 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 Management
Strategic Blood Management
Mybloodfirst.com (Excellent site for Perfusionists)
Get Involved and Change the Paradigm of Blood Use!
Take Home Message of …….
Blood Management Principles
•
•
•
•
•
•
•
Multidisciplinary Communication is Jugular
Find or become a champion in this effort!
Maximize Preoperative Red Cell Mass
Correct any Coag disorder prior to Sx
Minimize blood loss in Sx (this is essential !)
Avoid Allogeneic Tx (balance need vs risk)
Salvage Autologous Whole Blood first then use alternatives
if necessary
• If 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!
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!
Thank you for your time!
Questions?