Vigneshwar Kasirajan M D Division of Cardiothoracic Surgery

Vigneshwar Kasirajan, M. D. Division of Cardiothoracic Surgery

Results Higgins, et al AATS 2003

Results * *=p<0. 05 * Green, et al. SCA 2003

Results Total Savings=$1. 4 M Unit and Xmatch=$295 K Fixed overhead=$274 K Adverse Events=$863 K Spiess, et al. SCA 2003

HEMOGLOBIN

Retrograde Autologous Priming (RAP) Eight month data review at VCU MEDICAL CENTER November ’ 04 -June ‘ 05

TOTAL CASES ATTEMPTED

No RAP Cases

Pre-Post RAP Hgb

RAP Volume

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 n n n n Enhances communication between perfusionist, anesthesiologist, and surgeon. One month to achieve comfort level performing RAP. Priming volume of pump has been reduced from 1800 mls to 650 mls. 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.

n VCU Blood Conservation Policy u Transfusion Guidelines t Hematocrit 17% • AND t Signs of Oxygen Debt u Conservation Strategies (commonly used methods in cardiac surgery, often concurrently) t ANH (Autologous Normovolemic Hemodilution) t RAP (Retrograde Autologous Priming of CPB circuit) t Cell Saver Use t Antifibrinolitic Drugs Use in All Patients • Aprotinin or Epsilon Amino. Caproic Acid (EACA)

Methods IRB Approved Retrospective Review n All patients in the period from u November 1 st, 2004 t to u July 1 st, 2005 were studied n Statistical Analysis u Mixed Effect Repeated Measures ANOVA n

Results n n n A total of n=205 patients were included u 146 males (71%) u 59 females (29%) Mean age 58. 4 ± 13. 5 years old Mean Ejection Fraction 45 ± 15% u Interquartile Range (25 -75) 35 -60% History of u Myocardial Infarction 40% u Congestive Heart Failure 35% Hemoglobin Levels u Pre. Op HGB 12. 0 ± 1. 9 u Lowest HGB on CPB 7. 6 ± 1. 5 u First HGB in ICU 10. 0 ± 1. 8

Results n n Procedures u CABG u Valve u Aortic Surgery u VAD u Combined Procedure u Previous Sternotomy Anticoagulation Medication u Heparin u Coumadin 49% (100) 14% (30) 9% (18) 1% (2) 27% (55) 28% (57) 11% (22) 10% (20)

Results n Complications u Mortality u Stroke (5) u MI u Reoperations 5% (10) 2% 1% (2) 5% (10)

Results Group ANH Only No Action RAP + ANH Count 6 20 74 % 3 10 36 RAP Only Total 105 205 51 100 Antifibrinolitics Use Aprotinin 49% (101) EACA 51% (104)

Results n Main Outcome Measures u Transfusion rate u Hemoglobin Drop (from Pre. Op to ICU) n Transfusion Rate 11% (23) 83% patients had aprotinin u

Results n Blood Conservation Maneuver Groups

Results (Excluding Patients Transfused)

Conclusions n n n Successful Blood Conservation Program u Transfusion Rate 11% The combination of RAP and ANH is particularly effective u Transfusion Rate 3% Selection Bias or Channeling of more likely to bleed patients towards the use of Aprotinin u 83% of transfused patients received Aprotinin

Conclusions n n Despite this Channeling, the most effective maneuver to conserve blood was the use of Aprotinin u Hgb drop 1. 8 vs 2. 4 gr/d. L compared with EACA u 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 Intra. Op only 1. 92% 7. 42% 9. 43% 18. 01% Post. Op Only Intra. Op or Post. Op Intra. Op and Post. Op 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 0. 27324 0. 72599 1. 24046 Observed: 0. 0462 0. 0082 0. 0240 0. 0460 Expected: 0. 0325 0. 0299 0. 0331 0. 0371 Case Mix Index 3. 8398 4. 0057 4. 0589 4. 3872 Mortality OE

Blood Usage – CAB Only Intra. Op only Post. Op Only Intra. Op or Post. Op Intra. Op and Post. Op Mortality OE Case Mix Index 2004 2005 2006 2007 0. 00% 2. 96% 11. 05% 13. 33% 18. 66% 25. 12% 26. 16% 16. 00% 23. 13% 35. 96% 46. 51% 48. 00% 4. 48% 7. 88% 9. 30% 18. 67% Ratio: 0. 55674 1. 48771 0. 20934 1. 24154 Observed: : 0. 0373 : 0. 0049 : 0. 0292 0. 0133 Expected: 0. 0251 0. 0235 0. 0236 0. 0239 3. 8398 4. 0057 4. 0589 4. 3872

POST CABG COMPLICATIONS

TRANSFUSION RATES (CABG)

56 y MALE – Acute MI, Cardiogenic shock, on IABP Hb 9. 9 g/dl n On plavix, ASA (prev PCI) n Integrellin and iv heparin n Emergent surgery due to worsening CP and ST elevations. n

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 SVO 2 Elevated Lactate Elevated base deficit, Low HCO 3 Post Op ( ICU and Step Down Units ) RBC transfusion for Hgb < 7. 0 or HCT <21 + One objective criteria. · · Elevated O 2 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 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.