Vigneshwar Kasirajan, M.D.
Division of Cardiothoracic Surgery
Results
45
40
35
30
25
20
15
10
5
0
400
350
300
250
200
150
100
50
0
1997
1998
1999
2000
2001
$ per patient
% Transfused
Resource Utilization in Cardiac Surgery
Transfusion
Rate (%)
Cost per
patient ($)
2002
Year
Higgins, et al AATS 2003
Results
Hemoglobin Levels
13
12
gm/dl
11
*
10
*
Pre Program
Post Program
9
8
7
6
Preop
CPB
MIN
ICU
DC
Time
*=p<0.05
Green, et al. SCA 2003
Results
Financial Savings
1800
Total Savings=$1.4M
Unit and Xmatch=$295K
Fixed overhead=$274K
Adverse Events=$863K
Thousands of dollars
1600
1400
1200
1000
800
600
Adverse Event
Unit & Xmatch
Personnel
Total Cost
400
200
0
Pre Program
Post Program
Spiess, et al. SCA 2003
HEMOGLOBIN
15
10
5
MINI 1
OPCAB 1
OPCAB 2
ONPUMP 1
ONPUMP 2
Retrograde Autologous Priming
(RAP)
Eight month data review at
VCU MEDICAL CENTER
November ’04-June ‘05
TOTAL CASES ATTEMPTED
Attempted RAP Cases
200
150
100
179
50
26
0
TOTAL RAP Cases
No RAP Cases
No RAP Cases
14
12
HGB
10
11.5
8
6
7.1
4
2
0
Pre Pump HGB
1st HGB on
Pump
Pre-Post RAP Hgb
RAP Volume
800
700
600
703
Average Rap
amount (mls)
500
400
300
200
100
0
393
Average Rap
amount used (mls)
AUTOLOGOUS BLOOD OFF
BY ANESTHESIA AFTER
INDUCTION AVERAGED
516 mls.
HGBS ON BYPASS
PATIENT’S HGB AFTER
ARRIVING TO ICU
AVERAGED
10.2 g/dl
CONCLUSIONS








Enhances communication between perfusionist,
anesthesiologist, and surgeon.
One month to achieve comfort level performing RAP.
Priming volume of pump has been reduced from 1800mls
to 650mls.
Only 11% of RAP patients received bank blood.
27% of No RAP(26 patients), received bank blood on
bypass.
46% of RAP patients received aprotinin
Cell saver used on 66% of RAP patients
Entire pump volume washed with cell saver on 46% of
RAP patients after bypass.

VCU Blood Conservation Policy
 Transfusion Guidelines
 Hematocrit 17%
• AND
 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)
Methods
IRB Approved Retrospective Review
 All patients in the period from
st
 November 1 , 2004
 to
 July 1st, 2005 were studied
 Statistical Analysis
 Mixed Effect Repeated Measures
ANOVA

Results





A total of n=205 patients were included
 146 males (71%)
 59 females (29%)
Mean age 58.4 ± 13.5 years old
Mean Ejection Fraction 45 ± 15%
 Interquartile Range (25-75) 35-60%
History of
 Myocardial Infarction
40%
 Congestive Heart Failure
35%
Hemoglobin Levels
 PreOp HGB
12.0 ± 1.9
 Lowest HGB on CPB 7.6 ± 1.5
 First HGB in ICU
10.0 ± 1.8
Results


Procedures
 CABG
 Valve
 Aortic Surgery
 VAD
 Combined Procedure
 Previous Sternotomy
Anticoagulation Medication
 Heparin
 Coumadin
49% (100)
14% (30)
9% (18)
1% (2)
27% (55)
28% (57)
11% (22)
10% (20)
Results

Complications
 Mortality
 Stroke
 MI
 Reoperations
5% (10)
2% (5)
1% (2)
5% (10)
Results
Group
ANH Only
No Action
RAP + ANH
RAP Only
Total
Count
6
20
74
105
205
%
3
10
36
51
100
Antifibrinolitics Use
Aprotinin
49% (101)
EACA
51% (104)
Results

Main Outcome Measures
 Transfusion rate
 Hemoglobin Drop (from PreOp to
ICU)
 Transfusion
Rate 11% (23)
83% patients had aprotinin

Results

Blood Conservation Maneuver Groups
Transfusions per Group
RAP
RAP + ANH
No RAP \
No ANH
ANH
# Patients
105
73
20
6
PreOp Hgb
11.6 ± 0.2
12.7 ± 0.2
11.5 ± 0.4
11.5 ± 0.8
Cell Saver
(Yes\No)
65 \ 40
53 \ 21
14 \ 6
4\2
APO \ EACA
48 \ 57
36 \ 38
12 \ 8
5\1
% patients
transfused
13%
3%*
30%*
17%
* p < 0.001
Results (Excluding Patients Transfused)
Hgb Decrease (gr/dL) by Maneuver
Antifibrinolitics
Amicar*
Aprotinin*
LS Mean Lower 95% Upper 95%
2.4
2.1
2.8
1.8
1.4
2.2
ANH
No
Yes
2.0
2.2
1.7
1.8
2.3
2.7
RAP
No
Yes
1.9
2.3
1.4
2.0
2.4
2.7
2.3
1.9
1.8
1.6
2.8
2.3
Cell Saver
No
Yes
*p < 0.05
Conclusions



Successful Blood Conservation Program
 Transfusion Rate 11%
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
 83% of transfused patients received Aprotinin
Conclusions


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
Blood Usage – All Cases
ALL CASES
2004
2005
2006
2007
IntraOp only
1.92%
7.42%
9.43%
18.01%
PostOp Only
IntraOp or
PostOp
IntraOp and
PostOp
22.99%
23.63%
20.29%
9.32%
31.42%
42.31%
50.29%
47.20%
6.51%
11.26%
20.57%
19.88%
Ratio:
1.42229
Observed:
0.0462
Expected:
0.0325
Ratio:
0.27324
Observed:
0.0082
Expected:
0.0299
Ratio:
0.72599
Observed:
0.0240
Expected:
0.0331
Ratio:
1.24046
Observed:
0.0460
Expected:
0.0371
3.8398
4.0057
4.0589
4.3872
Mortality OE
Case Mix Index
Blood Usage – CAB Only
CAB Only
2004
2005
2006
2007
IntraOp only
0.00%
2.96%
11.05%
13.33%
PostOp Only
IntraOp or PostOp
18.66%
23.13%
25.12%
35.96%
26.16%
46.51%
16.00%
48.00%
IntraOp and PostOp
Mortality OE
Case Mix Index
4.48%
7.88%
9.30%
18.67%
Ratio:
Ratio:
Ratio:
Ratio:
1.48771 0.20934 1.24154
0.55674
Observed Observed Observed Observed:
: 0.0373 : 0.0049 : 0.0292
0.0133
Expected: Expected: Expected: Expected:
0.0251
0.0235
0.0236
0.0239
3.8398
4.0057
4.0589
4.3872
POST CABG COMPLICATIONS
35.00%
30.00%
25.00%
20.00%
male
15.00%
female
10.00%
5.00%
0.00%
Prolonged Vent
Renal Failure
Any
Complication
Mortality
TRANSFUSION RATES
(CABG)
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Male
Female
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.

TEG PRE CPB
Hb 6.0 – 1 prbc
Hb < 5 – 2 prbcs
TEG POST CPB AFTER PROTAMINE
No factors or platelets due to absence of clinical
bleeding
VCSQI STUDY
Transfusion Triggers:
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
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.