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Blood Conservation in Cardiopulmonary Bypass

Blood Conservation in Cardiopulmonary Bypass. 서울대학교병원 김경환. Introduction. A minority of patients in cardiac surgery (15~20%) consume more than 80% of the blood products. Blood must be viewed as a scarce source that carries risks and benefits.

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Blood Conservation in Cardiopulmonary Bypass

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  1. Blood Conservation inCardiopulmonary Bypass 서울대학교병원 김경환

  2. Introduction • A minority of patients in cardiac surgery (15~20%) consume more than 80% of the blood products. • Blood must be viewed as a scarce source that carries risks and benefits. • Careful review of available published evidence can provide guidelines. • As CABG became accepted surgical intervention, there was concern that the nation’s entire blood supply might be consumed by cardiac surgery alone. • Tector et al. Reduction of blood usage in open heart surgery. Chest 1976;4:283-287.

  3. ACC/AHA guideline

  4. Risks of blood transfusion • Infection • HIV, HBV, HCV, bacterial infection • Immunologic reactions • Febrile nonhemolytic transfusion reaction (1%) • Anaphylactic transfusion reaction (1/20000~50000) • ABO mismatch • Hemolysis (1/60000) • Death (1/600000) • Transfusion-related acute lung injury (1/2000) • Posttrasfusion purpura (rare) • Leukocyte-related target organ injury (2%)

  5. Transfusion on CPB (1) • class IIa (level of evidence C) • During CPB with moderate hypothermia, transfusion of red cells for a hemoglobin of 6.0 g/dl or less is reasonable. • In high risk patients, higher hemoglobin is needed. • stroke history, DM, cerebrovascular ds, carotid stenosis • Transfusion : reasonable in case of • patient-related factors: age, severity of illness, cardiac function, critical end organ ischemia • massive or active blood loss • Lab: abnormal EKG, elevated cardiac enzyme etc…

  6. Transfusion on CPB (2) • Transfusion during CPB: associated poor outcomes • In Cleveland clinic, 15,000 operations using CPB • strong association between the use of transfusions and postoperative infection • If for transfusion, notify to staff surgeons.

  7. Postoperative considerations • Class IIa • After cardiac operations with hemoglobin 6 g/dl or less, red blood cell transfusion is reasonable and can be life-saving. • Transfusion in patients of hemoglobin below 7.0 g/dl is reasonable, but no high-level evidence supports this recommendation

  8. Autotransfusion Ultrafiltration NovoVII Special CPB circuit Comprehensive Approach for blood conservation !!

  9. Topics • Introduction • Autologous blood donation • Red cell saving with cell savor • Retrograde autologous priming • Ultrafiltration • Heparin bonded circuit • Drugs: Aprotinin, NovoSeven • Conclusions

  10. Autotransfusion

  11. Autotransfusion • Inexpensive simple method for providing fresh blood that is essentially free of risk from transmission of disease, allergic reaction, alloimmunization, and blood banking mishaps.

  12. Should be deferred from autoTf • Evidence of infection and bacteremia • Scheduled for AS surgery • Unstable angina, High grade left main ds • AMI or CVA with 6m • Active seizure disorder (within last 3m) • Significant cardiopulmonary disease without optimal medical Mx • Cyanotic heart ds • Uncontrolled hypertension

  13. Erythropoietin • High-dosage erythropoietin regimen of 300 U/kg IV load, maintenance 500 U/kg subcutaneously every other day, supplemented by IV iron, folate, vit C.→ Hct increases of 2~3%/day within 5~7 days • Effective even in hemolysis from perivalvular prosthetic leaks (endogenous Epo levels & erythropoiesis would be maximized) • Cost: 4,000 US dollars

  14. Red cell scavenging

  15. heparin10000-100000 IU/ 1L NS

  16. Intraop blood scavenging • Final Hct 70% • Revoming freeHb, coagulation factors, debris, other plasma components • Concerns: • Bacteria, malignant cells, certain drugs • Topical hemostatics: Avitene, Surgicel

  17. Retrograde autologous priming

  18. Retrograde Autologous Priming (RAP)

  19. Retrograde Autologous Priming (RAP)

  20. Retrograde Autologous Priming (RAP)

  21. During RAP Process… • Minimum systolic BP of 100 mmHg during entire RAP • After ACT reached 400 seconds • Exclusion: • Age: < 16, > 80 years old • Exclusion for comparison of homologous transfusion • LV dysfunction(EF<30%) • Aorta surgery • TCA case

  22. Retrograde Autologous Priming (RAP)

  23. Kim, KJTCS 2005;38:821-7 Patient Characteristics Control Group RAP Group Age(yrs) 41±15 46 ±17 Female 28/50(56%) 19/37(51.3%) BSA(m2) 1.64 ±0.18 1.64 ±0.16 Preop hct(%) 39.5±4.3 39.1±4.9 CPB(min) 105.5±58.1 174.0±84.7 ACC(min) 51.1±43.1 107.2±55.4

  24. RAP Volume Removed(ml)

  25. Postoperative Chest Tube Drainage(ml) * * * P<0.05

  26. Ultrafiltration

  27. Ultrafiltration in Cardiac Surgery

  28. Pre-bypass UF, CUF circuit CUF: conventional UF

  29. Prebypass UF • Following addition of blood to CPB circuit, ultrafiltrate removal is initiated, and volume replacement with a balanced electrolyte solution is titrated to maintain a minimum reservoir level. • Reduce bradykinin, FXIII, prekallikrein, HMWK • Eliminate initial drop in blood pressure commonly seen with initiation of CPB • Reduce edema, cardiac impairment and pulmonary dysfunction • Nagashima et al. ATS 2000;70:1901-06 • Nagatsu et al. Japanese JTCS 1995;48:281-85

  30. Z-BUF circuit

  31. Z-BUF • Removal of large volume of ultrafiltrate and the subsequent replacement of volume with a balanced electrolyte solution. • Water soluble inflammatory mediators are removed from circulation during ultrafiltration. • Journois et al: removal of TNF, IL-10, myeloperoxidase, C3a

  32. MUF circuit

  33. MUF in adults • Effectiveness is thought to diminish as the patient size increases. • Little clinical impact? • Grunenfelder et al. EJCTS 2000;17:77-83 • Tassani et al. J CT Vasc Anesth 1999;13:285-91 • Significant morbidity reduction? • Luciani et al. Circulation 2001;104:1253-1259

  34. Heparin bonded circuit

  35. Biomaterial-dependent strategies to minimize blood activation from CPB • Biomembrane mimicry: phosphorylcholine • Heparin-coated circuits • Surface with modified protein adsorption

  36. What is coating ? Like wax on the surface of your car, it protects and keep out unwanted deposits. Similarly the surface of plastics in Perfusion products are bonded with Carmeda or Trillium to prevent platelets and protein deposits Trillium surface Wax Paint

  37. Heparin coating • Ionic bonding • Gott shunt, Duraflo II • Dispersion • KIST shunt • Covalent bonding • Carmeda,Trillium • “Burst effect”

  38. Carmeda and Trillium bonded surface mimics the blood vessels, it reduces blood activation Blood flow 1. Platelets sticks onto the wall of an artificial surface Blood flow 2. Carmeda and Trillium bonded surface is less reactive to blood

  39. Carmeda or Trillium™coated fiber Uncoated oxygenator fiber Massive platelet deposition Less platelet deposition

  40. How Do The Coatings Compare to Natural Blood Vessels

  41. Comparison of two heparin-coated CPB circuits with reduced systemic anticoagulation in routine CABG • Carmeda BioActive Surface system • Duraflo II coating system Ovrum E. J Thorac Cardiovasc Surg. 2001;121(2):324-30.

  42. Clinical results favorable in both groups,

  43. Pharmacologic Intervention

  44. Medications ass with bleeding • Aspirin: Irreversible platelet inhibition by blocking platelet cyclooxygenase • Heparin: Inhibition of factors II and X, both direct and indirect thrombocytopenia mostly antibody-mediated (HIT) • Coumadin: Multiple factor deficiency by blocking gamma-carboxylation Vitamin K–dependent factors • Antibiotics: Multiple factor deficiency owing to vitamin K malabsorption • Multiple drugs: Thrombocytopenia owing to bone marrow inhibition of platelet production

  45. Acquired ds with  risk of bleeding • ESRD/uremia • Liver disease • Malabsorption • SLE • Amyloid • Malignancy

  46. Herbs with adverse effects • Garlic Increased bleeding • Ginger Platelet dysfunction Hypertension • Gingko Increased bleeding Platelet dysfunction • Ginseng Hypertension • Licorice Hypertension

  47. Antifibrinolytics • Epsilon-aminocaproic acid (Amicar): forms a complex with plasminogen through lysine-binding sites, thus blocking their adhesion to fibrin • Tranexamic acid (Cyklokapron): forms a complex with plasminogen through lysine-binding sites, thus blocking their adhesion to fibrin • Aprotinin (Trasylol): Serine protease inhibitor with an antifibrinolytic effect carried by the inhibition of plasmin and kallikrein Protection of platelet GP Ib, reducing thrombin-mediated consumption of the platelets

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