Blood Transfusion in Cardiac Surgery
 51 yrs old female patient
 In ICU, POD 2 after MVrepair
 isoproterenol/dopamine for junctional rhythm
 BP 105/60, HR 75/min, CVP 5
 ABG: normal. NC 4l O2
 Mobilized
 HCT 25.5% → I unit of RBC → Hct 29%
What is the problem?
Blood transfusions are…..
Inherently dangerous
Each transfusion poses new set of immune challenges: increase in
serious complications, ICU and hospital length of stay, as well as short
term and long term mortality rates.
Transfusions are not risk free and cause some degree of harm in every
patient.
Serious morbidity and mortality increase with the amount transfused.
By some estimates each unit of allogeneic blood increases nosocomial
infection rates by 50%.
Risks of Blood Transfusion
Fatal hemolytic reaction (1:500,000)
HIV (1:7,800,000), HCV (1:1,935,000), HBV (1:220,000)
Other infections (CMV, Yersinia, malaria, West Nile)
Human herpesvirus-8 (NEJM 2006; 355:1331)
Immunomodulation (anti-leucocyte antibodies) →
TRALI (priming: recent surgery, active infection)
Perioperative infection
Cancer
Problem of “old blood”: decreased deformability, 2,3DPG, pH and NO.
Transfusion and Perioperative Infection
Hill, J Trauma 2003; 54:908
Meta-analysis of 20 perioperative
studies
Increased odds ratio (OR = 3.45) for
postoperative bacterial infection
Transfusion and Cardiac Surgery
Gerber, Crit Care Med 2008; 36:1068
Blood Transfusion in the ICU
Hébert, N Engl J Med 1999; 340:409
−838 ICU patients with Hgb < 9 within 72 hours
of admission
−Randomized to transfusion Hgb trigger of 7 or
10 (restrictive vs. liberal)
Trial Results (I)
 All results favored the restrictive (Hgb 7) strategy
Trial Results (II)
 Subgroup analyses
Decreased 30 day mortality in less
severely ill patients (9% vs. 16%)
Decreased 30 day mortality in patients
< 55 years (6% vs. 13%)
Equal mortality in patients with cardiac
disease (21% vs. 23%)
Risks and Benefits of Transfusion
Marik, Crit Care Med 2008; 36:2667
Systematic review of 45 observational trials
−1 study demonstrated benefit > risk
−2 studies demonstrated benefits = risks
−42 studies with risks > benefits
−Pooled OR for death 1.7 (1.4 – 1.9)
−Pooled OR for infection 1.8 (1.5 – 2.2)
−Pooled OR for ARDS 2.5 (1.6 – 3.3)
Blood usage Comparison
(For all Blood products transfused)
FY09 Blood Usage Comparison
(includes RBCs, Platelets, Plasma)
Units per Discharge
Units per Discharge
3.00
2.82
2.50
2.00
1.79
1.50
1.71
1.64
1.54
1.46
1.43
1.35
1.31
1.27
1.00
1.21
1.16
0.98
0.50
-
Source: UHC 2009 Blood
Management Special Project
Hospital - Number of Units of Blood Transfused
Compared to its peers, SHC utilizes more than
twice the units of blood per discharge.
isoCABG PostOp RBC Usage
Total Pts
2006 n=126
2007 n=90
2008 n=91
2009 n=102
60
50
40
30
20
10
0
2006
2007
2008
2009
RBC Used % Mean Units Median Units
(of all pts) (pts w RBC's) (pts w RBC's)
57.9
46.7
42.8
43.1
3.4
2.3
3.4 *
4.5 ^
* 1 pt w 35 units – mean 2.6 w/o outlier
^ 1 pt w 50 units – mean 3.4 w/o outlier
2
2
2
2
AVR only PostOp RBC Usage
80
60
Total Pts
2006 n = 30
2007 n = 47
2008 n = 68
2009 n=101
40
20
0
2006
2007
2008
2009
RBC Used % Mean Units Median Units
(of all pts) (pts w RBC's) (pts w RBC's)
56.7
59.6
55.9
62.4
5.2
3.6
2.9
3.8
4
2
2
3
Comparison of SHC 4+ RBC Unit
Use with STS Like Group
Iso AVR
Iso CABG
20
40
15
30
10
20
5
10
0
4+ RBC
IntraOp%
4+ RBC
PostOp%
2006
14.3
19.0
2007
11.1
2008
0
4+ RBC
IntraOp%
4+ RBC
PostOp%
2006
30.0
36.7
8.9
2007
19.1
17.0
4.4
8.8
2008
19.1
20.6
STS Like 2008
11.9
10.2
STS Like 2008
11.8
12.7
2009
8.8
8.8
2009
16.8
23.8
Stanford Blood Transfusion Management
Guidelines Proposal
MULTI MODALITY APPROACH
BA Reitz
PJA van der Starre
Stanford Blood Transfusion Management
Guidelines Proposal
 Bleeding Risk Assessed Preoperatively
− Age and weight
− Hct and Platelet count
− Anti-platelet therapies
 Stop clopidogrel 5 days pre op
 Continue ASA for low risk, stop 2 days for high
Stanford Blood Transfusion Management
Guidelines
 Intra-Operative Management
− Cell saver and Cell salvage
− Anti-fibrinolytic drugs for high risk
− DDAVP for high risk only
− Retrograde priming
− Autologous hemodilution
− R-FVIIa for recalcitrant bleeding only
− Topical hemostatics
Blood Transfusion Algorithms Proposal
Transfusion indicated
Hgb ≤ 6.0 on CPB
Hgb ≤ 8.0 in high risk (age > 65, and/or
co-morbidity).
Acute blood loss (30% of blood
volume).
Rapid blood loss without immediate
control.
Hgb ≤ 10 g/dl in certain patients with
critical end-organ ischemia.
Ferraris VA, et al. STS Guidelines on blood
conservation. Ann Thorac Surg, 2007.
Transfusion not indicated
Hgb ≥ 10 after CPB without critical
end-organ ischemia.
Uncertain benefit of transfusion
Hgb between 8 -10g/dl in a stable
patient benefit is unclear.
Stanford Blood Transfusion Management
Guidelines Proposal
 Minimize blood draws
 Erythropoietin
 Iron and nutrition
 Non Heme blood products used only as indicated
for bleeding, with point of care testing (TEG!)
Endorsement
Clinical practice guidelines for the transfusion of red blood
cells and platelets endorsed throughout Medical Staff
leadership
Medical Executive Committee
 Department Chairs, Kevin Tabb, Bryan Bohman
Blood Transfusion Taskforce
 Norm Rizk, Dan Arber, Tim Goodnough, Clarence Braddock, Magali Fontain, Lisa
Shieh, Maurene Viele, Paul Maggio, Ron Pearl, Pieter van der Starre
Clinical Effectiveness Leadership Team
 John Norton, Neil Olcott, Ann Weinacker, Joe Hopkins, Pravene Nath
Evidence-based Guidelines
RBC Guidelines (for Hemo-dynamically stable, non-bleeding pts):
 Transfusions indicated only for pts with Hgb <7g/dl (for
post-cardiac surgery pts and pts with acute coronary
syndrome Hgb <8 g/dl ).
Platelet Guidelines
 A single dose of platelets (adult: one apheresis product)
is generally recommended as it increases the platelet
count by 30,000- 60,000/ µL. (Guidelines for
transfusions are based on specific disease states with
corresponding platelet count triggers)
EPIC Interventions:
Tools to help adherence to guidelines
 Platelet Order template in EPIC (Live in Sep 2010)
 Embedded into the Blood product Order screen:
 Decision support built in to check the previous Platelet level prior to ordering additional
units.
 Guidelines on disease states/platelet levels that trigger the requirement of platelet
transfusion.
 Indications for platelet transfusion needs to be identified when ordering
 Best Practice Alert (BPA) for RBC Transfusions

Pulls in most recent hemoglobin values and scans diagnoses on the problem list for active
bleeding

If the requested transfusion does NOT meet the guidelines, a “pop up” reminder flashes
EPIC Best Practice Alert (BPA) : Live July 2010
Platelet Guidelines
A Single Dose of platelets (adult: one apheresis product) generally
recommended as it increases the platelet count by 30,000- 60,000/
µl
 Single unit of platelets indicated
 Platelet count ≤ 10,000/ µL
 Platelet count ≤ 20,000/ µL and signs of hemorrhagic diathesis
 Platelet count ≤ 50,000/ µL in a patient with active hemorrhage
 Platelet count ≤ 50,000/ µL in a patient with invasive procedure (recent, in-progress, planned)
 Platelet count ≤ 100,000/ µL in a patient with bleeding in a closed anatomical space (eg. CNS)
 Platelet dysfunction with active or anticipated hemorrhage (TEG?)
Platelets in Epic
Where do we stand now?
 Despite the development of RBC guidelines and the Epic BPA, the
vast majority of RBC transfusions (60%) continue to occur at a Hgb
of 8 or above
 Increased guideline adherence will
 Decrease clinical complications resulting from transfusion
 Preserve a precious resource
 Reduce overall blood utilization
What you need to do!!
Follow the RBC and Platelet guidelines developed by the Blood Task Committee and
endorsed by the Medical Staff leadership
 BPA will remind you
 For actively bleeding patients, document appropriate diagnosis in the in the
problem list.
Transfuse a single unit of platelets
 Indicate the rationale for ordering platelets while placing the order.
Communicate this expectation to your peers and to your house staff
Incorporate the blood guidelines, and the clinical reasoning behind them, into the
teaching and communication provided to interns and residents
Direct feedback or questions to Blood Task Force regarding adoption of guidelines