Transfusion Therapy and Blood Conservation

Question 1

Name five factors that are associated with increased rates of RBC transfusions after cardiac surgery

Answer 1

Low preoperative hemoglobin, older age, female sex, renal insufficiency, urgency of surgery

Question 2

What options are there to increase preoperative red blood cell mass?

Answer 2

EPO and pre-operative iron

Question 3

Antiplatelet and anticoagulant hold guidelines in elective patients

Answer 3

ASA - 6 days without atherosclerotic disease, 0 with atherosclerotic disease
Plavix 5-7 days
Ticagrelor 5-7 days (some say 2-3 days is enough)
Prasugrel 7 days
Apixaban 2-3 days
Rivaroxaban 3 days
Dabigatran 3 days
Warfarin 5 days
Abciximab 24-48 hours
Eptifibatide 3 hours
Fondaparinux 4 days
Danaparoid 4 days
LMWH (prophylaxis) 1 day
LMWH (treatment) 1 day - give half dose in AM, hold in evening prior to surgery
Heparin (prophylaxis) hold day of surgery
Heparin (treatment) 1 day - give half dose in AM, hold in evening prior to surgery
IV Heparin Infusion - hold on call to OR
Argatroban 4 hours
NSAIDs - 5 days
Herbals - 7 days

Question 4

How does TXA work?

Answer 4

Binds to plasminogen and inhibiting its binding to fibrin, impairing fibrinolysis

Question 5

What is aprotinin?

Answer 5

Aprotinin is a bovine derived serine protease inhibitor of plasmin removed due to concerns over renal toxicity

Question 6

What is the Hb target for transfusion in cardiac surgery? What are the three trials that have guided this evidence?

Answer 6

1. Hb < 60-80 depending on guideline, Hb <75 according to TRICS III 2. (TRICC, TRACS, TRICS III)

Question 7

Name the different types of blood products/blood conservation products

Answer 7

pRBCs, Platelets, FFP, Fibrinogen, PCC, rfVIIa, TXA, DDAVP

Question 8

Name the different types of surgical sealants

Answer 8

oxidized regenerated cellulose (surgicel), gelatin matrix (gelfoam), gelatin matrix-thrombin combination (floseal), fibrin sealant (tisseel, evicel)

in order from least expensive to most expensive

Question 9

Name the NOAC reversal agents

Answer 9

Idarucizumab - dabigatran

Andexanet alfa - apixaban, rivaroxaban, edoxaban

Question 10

Name strategies to reduce transfusion rates

Answer 10

pre-operative iron/EPO, discontinuing antiplatelet/anticoagulant agents pre-op, pre-operative autologous blood donation, mini circuit pumps, acute normovolemic hemodilution (remove whole blood and replacing with crystalloid/colloid pre-CPB), retrograde autologous priming (priming CPB circuit with patient’s blood), modified UF (discard patient’s blood), TXA, pump sucker, cell-saver, off-pump CABG, minimally invasive surgery, topical hemostatic agents

Question 11

What is DDAVP used for?

Answer 11

Desmopressin (DDAVP) is a haemostatic agent
that was developed to prevent and treat bleeding in patients with mild haemophilia (5–50% of the normal concentration of clotting factors VIII and IX) and patients with von Willebrand’s deficiency, e.g. due to aortic stenosis. DDAVP stimulates the release of von Willebrand factor from endothelial cells. DDAVP is sometimes administered to treat postoperative bleeding in patients undergoing cardiac surgery with
impaired platelet function.

Question 12

Why use leucocyte depleted blood?

Answer 12

Reduced risk of infections compared to control (buffy-coat depleted blood)

Question 13

When to transfuse platelets?

Answer 13

Platelets <50 on antiplatelet therapy or when bleeding