Surgical blood use in cardiac surgery Flashcards
“In the late 50s…it was typical to transfuse
15-20 units of atologus whole blood per case
The average blood use per case in 1979 was
8.5 units
What drives transfusion variables?
Surgeon: %
Disease variables : %
Patient variables: %
Surgeon 56%
Disease variables 9%
Patient variables 35%
What is the perfect Hct to come of CPB?
23 - 24 Hct
Mortality post CPB was directly influenced by
transfusion
Jehova’s Witnesses Believe that blood transfusions are absolutely prohibited by God.
Population in the USA?
- 5 million followers
* 20% in the USA
What blood products are off limits when managing JW’s?
- PRBC
- Platelets
- FFP
What blood products are acceptable when managing JW’s?
- Albumin
- Fibrinogen
- (Cryo)
NY Hospital - Cornell Medical Center Protocol. If Hct. < 18% delay surgery and treat with_____. > 18% proceed with surgery.
EPO
After 5-7 days at high dose EPO regimen Hct. can get what type of increase?
2 -3 % increase per day
In regard to managing JW’s patients, all blood in ECC must be kept in ?
continuous circulation with the patients vascular system
3 facts of Directed Donors?
- risk of disease transmission is as much as 2x in DD blood pool vs the standard homologus pool.
- Reduce ability to receive a bone marrow transplant from relatives in the future.
- Costly, without reducing risk of infection therefore, reimbursement is poor.
(PAD)
Preoperative donation
IADH definition
intraoperative donation with hemodilution
– Performed by anesthesia
IAD definition
Intra operative donation without hemodilution
– Performed by the perfusionist
Cell Saver Techniques
– Preoperative / intraoperative apheresis
– Shed blood collection
• Intraoperative cell salvage
• Postoperative drainage
Advantages of autologous blood?
- ↓ donor exposure
- ↓ chance of disease transmission
- Prevents alloimmunoization
- Eliminates transfusion reaction
- Reduced storage lesion /increased component function
Disadvantages of autologous blood?
• Infusion of activated compliment system
4 Things to be aware of with Autologus donation
– Outdated Blood
– Admin. of wrong blood
– Units should be administered in proper sequence
– Blood stored at room temp may culture bacterial contamination
Pre-operative Autologus Donation is often supplemented with what?
IM injections of Iron or EPO.
Risk of Pre-operative Autologus Donation?
preoperative anemia (RBC volume does not recover to baseline before surgery
4 risks of Pre-operative Autologus Donation ?
- Of limited value to unstable patients
- Impossible for emergent patients
- Introduces storage lesion into otherwise fresh blood
- Unnecessary cost and inconvenience
Storage and handling of IAD (Intraoperative donation at the pump).
- 8 hr expiration if stored at room temp.
* 24 hour expiration if stored at 1-6°C within 6 hours of collection
Storage and handling of IAD, you should not ?
Do not refrigerate platelets
Storage Lesion definition
RBC does not live well inside of the blood bag. Loss of 2,3 DPG from the RBC shifts the deoxyhemoglobin curve to the right and increase the Hgb affinity.
IADH facts/numbers
- Anesthesia removes 2-4 units)
- crystalloid replaced 2:1 or 3:1
- Colloid replaced 1:1
• Albumin 5%
• Hespan (6% - Blood reinfused in reverse collection order after protamine.
– Most concentrated blood
re-infused last
4 Contraindications to IADH
- Preoperative anemia
- Compromised myocardial function
- Preoperative ischemia
- Preoperative clotting deficiencies
IAD facts/numbers
- Perfusionist removes 1-2 L from the venous line upon initiation of CPB.
- Advantage = reasonable option for the more unstable patient.
- Disadvantage = blood has been heparinized.
