Intraoperative Patient Blood Management

Transcription

1 Intraoperative Patient Blood Management Edwin G. Avery, IV, M.D., C.P.I. Chief, Division of Cardiac Anesthesia Chairman, Transfusion Committee University Hospitals Case Medical Center Case Western Reserve University School of Medicine Cleveland, OH

2 Disclosures: Covidien: funded research, consultant, speaker s bureau CSL Behring: funded research

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6 Learning Objectives: Gain practical knowledge of basic preoperative anemia management, assessment of the hemostatic system, how to address antithrombotic/antiplatelet medications, and when to involve hematology consultants. Gain practical knowledge of point-of-care coagulation monitoring, surgical and pharmacologic strategies to reduce the need for blood component therapy, and evidence-based indications for appropriate administration of blood components. Learn about specialized devices used both intraoperatively and postoperatively that promote conservation of a patient s red cell mass.

7 Overview: Intraoperative Blood Conservation Strategies Intraoperative Transfusion Strategies Surgical Techniques

8 Intraoperative Blood Conservation Strategies

9 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Intraoperative hemostasis monitoring Acute normovolemic hemodilution Pharmacologic bleeding prophylaxis Cell salvage

10 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Full preoperative assessment Anemia/hemostatic system management/assessment with hematology consultation as indicated Maximum surgical blood ordering schedule

11 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Full preoperative assessment Center for Perioperative Medicine Preadmission Testing Preoperative assessments are now being conducted in an area of the hospital termed the Center for Perioperative Medicine, which was formerly referred to as the Preadmission Testing Clinic. The Center for Perioperative Medicine offers a more complete assessment of the surgical patient s perioperative needs and a plan to meet those needs. Rosenbaum SH, Silverman DG. The Value of Preoperative Assessment. Perioperative Medicine: Managing for Outcome. In: Newman MF, Fleisher L, Finak MP, (eds). Saunders Elsevier. Philadelphia, PA, p

12 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Identify & mitigate non-cardiac comorbidities that are associated with increased perioperative hemorrhage Hepatic Dysfunction Renal Dysfunction 2007 Ann Thorac Surg;83: S27-86

13 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Anemia management Patients with pre-existing anemia or coagulopathy who are scheduled for surgical or invasive procedures (especially those associated with a high incidence of transfusion) should be considered for hematology consultation and possibly preoperative therapies aimed at increasing their red cell mass or optimizing their coagulation system (for example, through enteral or parenteral iron supplementation, erythropoietin, parenteral factor concentrates or by discontinuing antiplatelet and/or antithrombotic medications). Marcucci CE, Chassot PG, Asmis LM, Spahn DR. Hematologic Risk Assessment. In: Newman MF, Fleisher L, Finak MP, (eds). Saunders Elsevier. Philadelphia, PA, p

14 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Hemostatic system assessment with hematology consultation as indicated Only perioperative clinicians with depth knowledge of more complex coagulation pathologies and their treatment should manage these issues; involving hematology consultation is highly recommended. Klick JC. Avery EG. Anesthesiology 2 nd ed. 2012; Chap 16;

15 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Maximum surgical blood ordering schedule-msbos Frank SM, Rothschild JA, Masear CG, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013;118(6):

16 Intraoperative Blood Conservation Strategies Optimizing red cell mass & coagulation Maximum surgical blood ordering schedule-msbos Frank SM, Rothschild JA, Masear CG, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013;118(6):

17 Intraoperative Blood Conservation Strategies Intraoperative hemostasis monitoring Hemostasis monitoring protocols-service specific Microsampling Core laboratory Point of Care Testing (POCT)

18 Intraoperative Blood Conservation Strategies Intraoperative hemostasis monitoring Hemostasis monitoring protocols-service specific 20index%20page.html

19 Intraoperative Blood Conservation Strategies Intraoperative hemostasis monitoring Microsampling Dillen L, Loomans T, Van de Perre G, et al. Blood Microsampling Using Capillaries for Drug-exposure Determination in Early Preclinical Studies: A Beneficial Strategy to Reduce Blood Sample Volumes. Bioanalysis 2014;6(3):

20 Intraoperative Blood Conservation Strategies Intraoperative hemostasis monitoring Core laboratory For centers that rely solely on the core laboratory for hemostasis monitoring, rapid sample processing protocols should be in place to minimize delay in obtaining results. Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

21 Intraoperative Blood Conservation Strategies A laboratory located near the operating rooms dedicated to providing rapid sample processing can provide these point-of-care testing services or the testing devices can be located within the operating room. Intraoperative hemostasis monitoring Point-of-Care-Testing Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

22 Intraoperative Blood Conservation Strategies Acute normovolemic hemodilution - ANH Use of a short, medium gauge arterial cannula & a scale provides the ability to precisely & rapidly sequester whole blood pre-incision Avery E. Waters JH. Perioperative Blood Sequestration: Acute Normovolemic Hemodilution. In: Waters JH (ed). Blood Management: Options for Better Patient Care. AABB Press. Bethesda, MD p

23 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis

24 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis Ann Thorac Surg 2011;91:

25 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

26 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

27 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis Intravenous vs. Topical Video provided by the courtesy of Brian Hamlin, MD

28 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis - Topical Konig G, Hamlin B, Waters JH. Topical Tranexamic Acid Reduces Blood Loss and Transfusion Rates in Total Hip and Knee Arthroplasty. J Arthroplasty 2013;28: Wong J, Abrishami A, El Beheir HE, et al. Topical Application of Tranexamic Acid Reduces Postoperative Blood Loss in Total Knee Arthroplasty. J Bone Joint Surg 2010;92-A(15):

29 Intraoperative Blood Conservation Strategies Pharmacologic bleeding prophylaxis - Pediatrics Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

30 Intraoperative Blood Conservation Strategies Cell salvage Note that the cell saver device can also be used to wash allogeneic banked red cell units to reduce the free hemoglobin insult to the kidneys, reduce the K + & lactate load as well as remove unstable RBCs with weakened cell membranes. Esper SA, Waters JH. Intra-operative Cell Salvage: A Fresh Look at the Indications and Contraindications. Blood Transfus 2011;9: Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

31 Intraoperative Transfusion Strategies

32 Intraoperative Transfusion Strategies Transfusion Guidelines/Surveillance Software IO Laboratory/POCT Guided Transfusion Algorithms Massive Transfusion Protocol (MTP) Pharmacologic Transfusion Adjuncts Fluid/Patient Warming Systems

33 HCMC%20Blood%20Transfusion%20Guidelines_v e.pdf Intraoperative Transfusion Strategies Transfusion Guidelines/Surveillance Software Images courtesy of Jason Steyer Haemonetics Inc.

34 Intraoperative Transfusion Strategies IO Laboratory/POCT Guided Transfusion Algorithms CPB_Transfusion_Clin_Guideline_ _FINAL.pdf

35 Intraoperative Transfusion Strategies Massive Transfusion Protocol (MTP) Algorithm guided vs. 1 : 1 : 1

36 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts

37 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts 3 Factor PCCs 4 Factor PCCs Recombinant activated Factor VII Fibrinogen concentrate DDAVP

38 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts 3 Factor PCCs (not recommended unless balanced 4 factor PCC not available) OFF LABEL - dose at IU Factor IX for intractable hemorrhage not responsive to treatment with allogeneic hemostatic products slow IV push 4 Factor PCCs OFF LABEL IU Factor IX activity for intractable hemorrhage not responsive to treatment with allogeneic hemostatic products slow IV push Gorlinger K, Dirkmann D, Hanke AA, et al. First-line Therapy with Coagulation Factor Concentrates Combined with Point-of-care Coagulation Testing is Associated With Decrease Allogeneic Blood Transfusion in Cardiovascular Surgery: A Retrospective, Single-center Cohort Study. Anesthesiology 2011;155(6):

39 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts Recombinant activated Factor VII OFF LABEL 35 to 90 µg/kg slow IV push (start with low dose [35 µg/kg] to test response), re-dosing may be required within 4-6 hrs thromboembolic complications are well documented with this agent thus it is appropriate to consider administration after hemostatic allogeneic blood components have failed to control bleeding (after 2 rounds of products) J Trauma 2005;59:8-18. J Cardiothorac Vasc Anesth 2011;25: J Obstet Gynaecol 2011;37(7): Neurocirugia (Astur). 2011; 22(3):

40 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts Recombinant activated Factor VII OFF LABEL Thromboembolic complications Ponschab M, Landoni G, Biondi-Zoccai G, et al. Recombinant Activated Factor VII Increases Stroke in Cardiac Surgery: A Meta- Analysis. J Cardiothorac Vasc Anesth 2011;25:

41 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts Fibrinogen concentrate OFF LABEL - formulaic based on target fibrinogen concentration and known fibrinogen level; slow IV infusion ~10 minutes; 1 vial 5 pack of cryoprecipitate for fibrinogen content PI_NZ-DS_3.00,0.pdf Levy JH, Szlam F, Tanaka KA, et al. Fibrinogen and Hemostasis: A Primary Hemostatic Target for the Management of Acquired Bleeding. Anes Analg 2012;114:

42 Intraoperative Transfusion Strategies Pharmacologic Transfusion Adjuncts DDAVP 0.3 µg/kg slow IV infusion ~10 minutes (rapid infusion can be associated with acute hypotension) not recommended for routine use but rather for POCT or Core Lab based evidence of platelet dysfunction or uremia induced platelet dysfunction Ann Thorac Surg 2011;91:

43 Intraoperative Transfusion Strategies Fluid/Patient Warming Systems

44 Surgical Blood Conservation Techniques

45 Surgical Blood Conservation Techniques Controlled Hypotension Retrograde Autologous Priming of the CPB circuit Surgical Pharmacologic Blood Hemostasis Adjuncts Autoregulating Surgical Suction Devices Cell Salvage (Revisited)

46 Surgical Blood Conservation Techniques Controlled Hypotension BMEYE - Edwards Anesth Analg. 2007;105: Anesth Analg 2008;107: INVOS Avery E. Cerebral Oximetry White Paper per%20series%20sms1415%20sts%20database%20v2.pdf

47 Surgical Blood Conservation Techniques Retrograde Autologous Priming of the CPB circuit Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

48 Surgical Blood Conservation Techniques Retrograde Autologous Priming of the CPB circuit Complication Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

49 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Topical agents Fibrin sealants

50 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Topical agents Gelfoam Surgicel Avitene Ultrafoam

51 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Fibrin Sealant Vitagel

52 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Topical agents Floseal Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

53 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Topical agents Coseal nstructions_for_use.pdf Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

54 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Topical agents Bioglue sive_syringe_ifu_dom.pdf Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

55 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Fibrin Sealants Tisseel Contains bovine derived antifibrinolytic (Aprotinin ) Potential anaphylaxis issues

56 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts -Pooled human fibrinogen -Human Thrombin -Tranexamic Acid The presence of the tranexamic acid precludes its contact with cerebrospinal fluid or dura mater Fibrin Sealants Evicel 4tbqe1t9fo4ahno?3

57 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Topical agents Plant based microporous polysaccharide hemospheres Arista AH %20Product%20Information.pdf

58 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Syvek Patch Topical agents Poly-N-acetyl glucosamine (P-NAG) is a naturally occurring complex polysaccharide derived from microalgal cultures. P- NAG s mechanisms are unclear but may involve tissue adhesiveness, attraction of circulating blood cells, nitric oxide scavenging, and vasoconstriction.

59 Surgical Blood Conservation Techniques Surgical Pharmacologic Blood Hemostasis Adjuncts Autologous Platelet Gel Topical agents Like fibrin sealants, autologous platelet gel is thought to have hemostatic and tissue-sealing properties. Autologous platelet gel is thought to speed wound healing and enhance osteogenesis through concentrated platelet-derived growth factors, although it has not been demonstrated by clinical trials.

60 Surgical Blood Conservation Techniques Autoregulating Surgical Cell Salvage Devices Transfusion 1996;36:57-60 Regulation of suction intensity reduces trauma to erythrocytes and increases the yield of cell salvage efforts. Smart Suction Harmony Cell Saver Elite - Haemonetics

61 Surgical Blood Conservation Techniques Cell Salvage (Revisited) These two systems work by incorporating centrifugal disc technology into a fully automated process of continually collecting, processing, washing and concentrating shed blood. Both systems are capable of processing volumes as small as 100 ml and have the capability to concentrate the washed cells when the hematocrit of the collected cells is less than 10% to create a final product for transfusion that has a consistently high hematocrit. Haemonetics Inc. CardioPAT %20Diagnostic%20Devices/cardioPAT.aspx %20Diagnostic%20Devices/OrthoPAT.aspx OrthoPAT

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