Rethinking Blood Conservation and the Role of Autotransfusion

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Rethinking Blood Conservation and the Role of
Autotransfusion

• John Rivera
• Additional Content from Jeff Riley, CCP, PhD

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Realities of Blood

• The need for blood conservation in cardiac
  surgery is driven by three key factors
• Blood Shortages Complex surgeries, low donation
  rate cause blood shortages
• Blood Cost Additional safety measures add costs
  to blood products
• Patient Safety Blood transfusion introduces
  patient risk
• Correlated to increased viral and bacterial
  infections
• Longer length of stay (LOS)
• Increased incidence of adverse reactions

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Key Societies Create Blood Conservation Guidelines

• STS/SCA Perioperative Blood Transfusion and Blood
  Conservation in Cardiac Surgery Clinical Practice
  Guidelines
• Collaborated to assist physicians in clinical
  decision making regarding approaches to blood
  conservation for cardiac surgery patients

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STS / SCA Guidelines

• STS and SCA Committees worked together
• Ferraris Spiess, Surgeon and Anesthesiologist
• Evidence Based Literature Review
• 753 peer reviewed articles
• 30 reviewers
• Over 2 years to complete
• Recommendations
• 7 Pre-operative and 14 Peri-operative guidelines

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STS Guidelines

• Blood is still being misused
• Large variance in blood usage between
  institutions
• The STS Guidelines are used to educate
• Written by peers
• Goal everyone using similar protocols

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STS Guidelines Focus

• Based on Pre-operative/Peri-operative
  Interventions
• Two Main Foci
• Reduce BLEEDING
• Reduce the NEED for Transfusion

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STS Guidelines

• 2011 Update
• Blood Salvage Interventions
• Expanded use of blood salvage (using
  centrifugation) to include patients with
  malignancy llb (B)
• Pump salvage of residual blood in CPB circuit lla
  (C)
• Centrifugation of pump blood vs direct reinfusion
  llb (B)
• Perfusion Interventions
• Microplegia to reduce hemodilution llb (B)
• Mini-circuits to reduce hemodilution I (A)
• Biocompatible CPB circuits to limit hemostatic
  activation and lime inflammatory response llb(A)
• Modified ultrafiltration l (A)
• Conventional or zero-balance ultrafilitration
  during CPB llb (A)

• 2007 Initial Release
• Evidence based medicine guidelines
• Patients at risk-age low pre-op Hct small body
  size pre-op drugs complex cases emergent
  co-morbidities
• TRX triggers Hgb , 7g/dl
• TRX based indicators oxygenation/bleeding
• Drug Therapy amicar tranexamic acid
• Products and practices
• Pump type
• Heparin management
• Heparin coated circuits
• Cell washers
• Low prime circuits
• Minimized circuits (RAP prime)
• Hemofiltration
• Transfusion algorithms

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Dr. C. Koch Critical Care Medicine 2006 Vol.
34,No.6 1608-1616

• Morbidity and mortality risk associated with red
  blood cell and blood-component transfusion in
  isolated coronary artery bypass grafting
• Colleen Gorman Koch well published Cardiac
  Anesthesiologist from the Cleveland Clinic
• 11,963 pts who had isolated CABG Jan 1995 July
  2002
• 48.6 of the patients were transfused RBCs
• 9.8 received Platelets and 2.4 received FFP
• Mortality and measures of morbidity were compared
  between patients transfused and those not
  transfused
• Red blood cell transfusion is the single most
  important factor most reliably associated with
  increased risk of morbid events

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Dr. Koch - Complications

• Complications Not Transfused Transfused
• Renal morbidity 0
  1.81
• Prolonged ventilation 0.44 9.14
• Post-op infection 0.24 5.03
• Cardiac morbidity 0.05 3.03
• Neurologic morbidity 0.37 2.41
  
• Overall 0.96 12.33
• Mortality 0.05 3.07

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Dr. Koch - Transfusion vs. Risk of Complications

• Each unit of PRBCs was associated with
• gt 100 increased odds for renal morbidity
• 79 increased odds for prolonged ventilation
• 76 increased odds for serious infection
• 55 increased odds for cardiac morbidity
• 37 increased odds for neurologic morbidity
• 73 increased odds for overall morbidity

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Dr. Koch - Summary

• Transfusion of PRBCs was associated with a
  dose-dependant, risk adjusted increase in the
  occurrence of every post-op morbidity
• Given the apparent risk, our results suggest
  that transfusions should be avoided, if
  possible
• Application of interventional blood conservation
  measures, in particular for the majority of
  patients who would commonly receive only 1 or 2
  PRBC units, may circumvent the need for
  transfusion

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Pay for Performance
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STS Guidelines Recommendations

• Identification of high risk patients who should
  receive all pre- and peri-operative blood
  conservation interventions
• Use of available evidence-based blood
  conservation techniques
• Total quality management (TQM) approach to the
  measurement and analysis of all blood
  conservation interventions used

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Who is a High Risk Patient?

• Elderly
• Obese
• Male
• Diabetic
• Smoker
• On anticoagulation, platelet inhibitor and/or
  nutritional supplement therapy
• Revision or secondary procedure
• Emergent activity

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What are the Real Costs of Transfusion?

• Activity-based costs of blood transfusion in
  surgical patients at four hospitals, Shander, A.
  et al, Transfusion 201050753-756
• Englewood Medical Center, Englewood, NJ, Rhode
  Island Hospital, Providence, RI, University
  Hospital, Lausanne, Switzerland and General
  Hospital, Linz, Austria
• COBCON (Costs of Blood Consensus) and ABC
  (Activity Based-Costing)
• Direct and indirect overhead costs, not just
  acquisition costs
• 552-1183 with a mean of 761 or- 294
• 3.2 to 4.8 fold higher than initial product costs
• Blood costs have been underestimated

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Autotransfusion

• Autotransfusion is the collection ofblood or
  blood products derived froma patients own
  circulation (autologous blood) which is collected
  or shed from a wound or body cavity prior to,
  during or following surgery for later reinfusion
  to the patient

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Why Autotransfusion?

• Reduced supply of allogeneic blood
• Reduces risk of infection
• Negates the risk of the immune phenomenon
• Religious considerations

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Why Autotransfusion?

• Immediate availability
• Conserves allogeneic blood forreal emergencies
• Eliminates blood bank clerical errors
• Is truly cost effective

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Autotransfusion Triggers

• Anticipated blood loss is equal to or greater
  than 1000 ml
• Procedures where 2 units of blood are routinely
  cross matched
• Procedures where 20 of the patients are
  routinely transfused
• Emergency procedures
• Patients with rare blood types or
  incompatibilities
• Patients with religious objections to allogeneic
  blood components

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Blood Components

• Plasma
• Water
• Proteins
• Electrolytes
• Lipids
• Formed Elements
• RBC
• White Cells
• Platelets

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Principles of Autotransfusion

• Density of Blood Components
• Plasma 1.025 - 1.029 gm/cc
• Leukocytes 1.065 - 1.09 gm/cc
• Erythrocytes 1.089 - 1.097 gm/cc

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Principles of Autotransfusion

• Centrifugal force separates these components
  relative to their respective densities. The
  higher density components will move farther from
  the axis of rotation than those of lower density.

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Autotransfusion System Components

• Suction tip
• Suction/Anticoagulant line
• Anticoagulant solution
• Filtered Collection Reservoir
• Centrifuge bowl and disposable tubing set
  (tubing, bowl, holding bag and waste bag)
• Normal saline (0.9) wash solution bags
• Blood transfer bags

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Anticoagulation

• Heparinized saline - 30,000 units of heparin per
  1000 ml 0.9 Normal saline or 15,000 units of
  heparin per 500 ml Normal saline
• Heparin complexes with Antithrombin III (ATIII)
• Heparin should not be used on ATIII deficient
  patients or patients prone to Heparin Induced
  Thrombocytopenia (HIT)
• ACD-A inhibits the early steps in the clotting
  cascade by chelating (binding) Calcium
• Do not use ACD-A on patients with impaired liver
  function
• ACD-A comes pre-mixed in 500 ml bags
• Do not aspirate blood mixed with Ringers Lactate
  irrigation solutions when using citrate based
  anticoagulants

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Contraindications

• Cesarean section where amniotic fluid is present
  (momentary and use dual reservoirs and leukocyte
  filtration if necessary)
• Grossly contaminated wounds (dual reservoirs and
  leukocyte filtration if necessary)
• Malignancies - cancer, sepsis, tuberculosis, etc.
  (again use dual reservoirs and suction lines and
  leukocyte filtration)
• Hemostatic agents
• Confirmed Sickle Cell Anemia Versus Trait
• Others Cold Agglutinin Antibody
• Use leukocyte reduction filters for potentially
  contaminated blood per AABB 2010 Guidelines for
  Blood Recovery and Reinfusion in Surgery and
  Trauma
• Use dual reservoirs and suction/anticoagulant
  lines for Jehovahs Witnesses, rare blood types,
  refractory patients and if there is no blood
  available in the Blood Bank

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Contraindications

• The final decision on whether to salvage is the
  autotransfusion teams decision (Blood Bank,
  Surgeon, Anesthesiologist and Autotransfusionist)
  
• See the November 2010 AABB Guidelines for Blood
  Recovery and Reinfusion in Surgery and Trauma,
  Appendix 1 Complications of and
  Contraindications to Perioperative Blood Recovery
• Understand that some contraindications are not
  absolute or may be temporary in nature
• Read and retain the product inserts regarding the
  approved use of that agent or device during
  autotransfusion

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Autotransfusion Final Product

• Washed red blood cells (RBCs) suspended in a
  small volume of saline
• 95 of supernatant and plasma is removed
• 90 of residual anticoagulant and free plasma
  hemoglobin is removed
• 70 to 90 of activated white cells and platelets
  are removed
• At 50 blood volume loss, coagulation factor
  testing and plasma transfusion is indicated
• At 100 blood volume loss, coagulation factor and
  platelet count and function testing and plasma
  and platelet transfusion are indicated
• Blood recovered via autotransfusion devices does
  NOT make the patient bleed, the washed RBCs are
  literally the best RBCs that can be transfused
  to a patient

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Typical Autotransfusion Devices
COBE
DIDECO
Fresenius
Haemonetics
autoLog
Sequestra
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Prevention of Air Embolism

• Use a Transfer Bag, remove air and disconnect and
  exchange the Transfer Bag (per AABB 2010
  Guidelines for Blood Recovery and Reinfusion in
  Surgery and Trauma)
• Primary cause of injury and death during
  autotransfusion procedures is air embolism
• Recovered product must be inspected by the
  operator prior to release for clots,
  discoloration, fat, particulate, hemolysis and/or
  fluid interface

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Autotransfusion MAC

• Minimal acceptable candidate
• Education?
• Training?
• Employment?
• Experience?
• Caseload?
• References?

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KSAs

• Job domain analysis
• Knowledge
• Skills
• Abilities
• Critical incident theory

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IBBM Perioperative Blood ManagementPBMTS Job
Domain AnalysisTheoretical, Hierarchical
Construct for KSAs for Competency Exam
Environmental Factors Equipment / Disposables Patient Care Procedures Critical Incidents
Assertiveness, lead team when required Application and operation of equipment Suggest changes to and author clinical procedure guidelines Design and practice team response to critical incident
Integration into surgical team and participate in care planning Follow manufacturer instructions-for-use and assembly Follow guidelines recognizing contraindications and exceptions Communicate / consult with team during critical incident
Inter-team member communication and patient privacy Disposable supplies and interface with hardware Follow guideline indications for use and record keeping Respond correctly to critical incidents and emergencies
Social structure and vocabulary of surgical teams Principles of operation for equipment aaBB (FDA, JCAHO) standards and guidelines Diagnose, troubleshoot and report critical incidents
Rules for sterile environment OSHA, CDC training Hardware and device technical knowledge Body of medical knowledge physiology, pharmacology Body of medical knowledge
First draft Riley and DCosta, July 2007
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Critical Incidents in Perioperative Autologous
Blood Management

• Contamination of sterile field and circuit
  components
• Set-up contamination
• Contamination during cell processing
• Bacteremia
• Record keeping errors
• Record entry error
• Record entry omission
• Mis-label autologous blood product
• Quality indicator failure
• Hemolysis
• Wrong cell wash solution
• Wrong heparin drip solution
• Inadequate de-airing of anesthesia red cell
  infusion bag
• Accidental venous air infusion
• Medication errors
• Wrong anticoagulant drug
• Wrong anticoagulant drug dose
• Wrong anticoagulant drip solution

• Allergic reactions
• Anaphylactic reaction
• Equipment failure
• Cell washing devices
• Platelet concentration devices
• Rapid infusion devices
• Blood warming devices
• Circuit disposable component failure
• Shed blood reservoir
• Cell washing bowl or chamber
• Circuit blood line separation
• Blood spray
• Blood loss
• Special patient management requirements
• Partial cell washing bowl volume
• Massive red blood cell and platelet loss
• Massive plasma protein and clotting factor loss
• Pediatric patients
• Jehovah Witness

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Exam Content Outline
1996-2001 Added
Basic science Terminology, principles Hematology Terminology, principles, blood components, coagulation, sequestration General knowledge Machines, disposables, components, circuits, set-up Preoperative preparation Machines, disposables, components Intraoperative Salvage, process, wash, QC, product, transfer, filtration, infuse, document Postoperative Vacuum, termination, circuit, machines Troubleshooting Pheresis Environmental factors Sterility, vocabulary, team behaviors Equipment and disposables Machines, principles, disposables, operation, applications Patient care procedures Body of knowledge, AABB, FDA, JCAHO, OSHA, clinical guidelines, contraindications Critical incidents Body of knowledge, diagnose, troubleshoot, critical incident response, communication
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PBMT Exam

• PBMT - Perioperative Blood Management
  Technologist
• Created and maintained by IBBM (International
  Board of Blood Management) via AmSECT
• Usually given in conjunction with AmSECT Meetings
• Now available for proctored on-line testing
• Consistent operator competencies
• Recognized by aaBB
• Will most likely be mandated in the future by
  liability insurers
• Annual recertification is already a regulatory
  requirement per aaBB, CAP, CLIA, FDA, Joint
  Commission and state Health Departments
• PBMS Perioperative Blood Management Specialist
  will be next for balloon pumps, PRP, etc.

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Conclusion

• Allogeneic blood is in very short supply and the
  cost of blood will continue to increase
• Patients who are transfused with allogeneic blood
  experience more adverse consequences than
  patients not receiving transfusion
• The STS Guidelines provide clear directives
  regarding blood conservation with new emphasis on
  perfusion based practices
• High risk patients require a multi-modality,
  evidence based medicine approach
• Autotransfusion is a very important blood
  conservation modailty
• Autotransfusionists must be appropriately trained
  and credentialed
• Blood conservation is both a very good clinical
  program as well as a very good business practice