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Interact CardioVasc Thorac Surg 2009;9:480-482. doi:10.1510/icvts.2009.203034 © 2009 European Association of Cardio-Thoracic Surgery
Multi-modality blood conservation strategy in open-heart surgery: an auditCardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India Received 20 January 2009; received in revised form 5 June 2009; accepted 12 June 2009
*Corresponding author. All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110 029, India. Tel.: +91-11-26589646; fax: +91-11-26588663.
The objective of this study was to perform an audit of the use of homologous blood and blood products in patients undergoing open-heart surgery by a single surgical team that follows an in-house protocol for blood conservation. The hospital records of 310 consecutive patients (age >15 years) undergoing open-heart surgery over a period of 8 months were retrospectively reviewed to assess the comprehensive blood conservation protocol. Homologous blood and blood product usage during and after surgery, in the intensive care unit and up to hospital discharge was analyzed. Two hundred and fifty-six patients (82.6%) did not receive any blood or blood products. Only 54 patients (17.4%) received one or more units of allogenic transfusion either intraoperatively or postoperatively until discharge. Mean hemoglobin at discharge was 9.8 Grams% (8.9–12 Grams%). A standardized multidisciplinary approach to blood conservation in cardiac surgery decreases bleeding and transfusion requirements in a safe and cost effective manner.
Key Words: Blood component transfusion; Heart surgery; Clinical audit
Efforts at reducing the use of homologous blood in cardiac surgery date back nearly to the advent of cardio-pulmonary bypass itself, but the goal of performing ‘bloodless’ open-heart surgery without homologous blood transfusion remains elusive even today. Even in the most recent series, homologous blood transfusions have been required in 30–70% of open-heart surgery patients with two to four donor exposures required per patient [1, 2]. The impetus for blood conservation in open-heart surgery has several origins including: (1) national blood shortages that surface periodically; (2) infectious sequelae of transfusion; and (3) incompatibility and other immunological reactions associated with any allogenic blood transfusion [3]. Currently, cost and resource efficiency considerations also play a prominent role in mandating a reduction in blood transfusions in addition to the overwhelming patient concern for avoiding blood transfusions. Although many new technical and pharmacological modalities have been used separately to avoid homologous transfusion, the isolated, non-programmatic, and often sporadic application of these measures to a patient population at increasing risk for transfusion has limited progress towards ‘bloodless’ open-heart surgery. The results of numerous previous trials of single-component therapies in which homologous transfusions were successfully reduced but not eliminated are consistent with the hypothesis that comprehensively the independent risk factors for transfusion is a prerequisite to the total avoidance of homologous transfusion. A series of technical and pharmacological modalities can be combined into a multimodality blood conservation strategy in order to address the risk factors for blood transfusion following open-heart surgery in a comprehensive manner. The objective of present study includes the retrospective audit of usage of homologous blood and blood products in patients undergoing open-heart surgery performed by a single surgical team that follows an in-house protocol for blood conservation.
The study was conducted in the Department of Cardiovascular and Thoracic Surgery of All India Institute of Medical Sciences, New Delhi, India after obtaining approval from the Institutional Ethics Committee on Human Research. 2.1.1. Inclusion criteria All patients (age >15 years) undergoing open-heart surgery for various indications by a single surgical team over a period of 8 months between July 2006 and February 2007 were included in the study.
2.1.2. Methodology A standard comprehensive in-house blood conservation protocol was followed in all patents and it included the following strategies [4–6]: (i) maximizing autologous blood generation, preoperative iron supplementation/attention to nutrition, (ii) minimizing hemodilution – minimizing crystalloid administration and retro-grade autologous priming, (iii) minimizing autologous losses – meticulous hemostasis, intraoperative autologous donation, retransfusion of all extracorporeal fluid from tubing and reservoir, (iv) optimizing coagulation status – normothermic perfusion [7] and use of antifibrinolytics if indicated [8], and (v) minimizing unnecessary transfusions – adherence to strict transfusion guidelines and early return to operation theatre for excessive bleeding. Criteria for transfusion of blood products were:
Hospital records including blood bank records were carefully scrutinized for homologous blood and blood product usage during surgery, in the intensive care unit stay and up to hospital discharge. Data were analyzed with STATA 9.0 (College Station, TX, USA). Continuous and interval-related data are presented as the mean±S.D., whereas categorical variables are presented as frequency distribution and percentages. Qualitative data were analyzed by using 2-test and quantitative data using Student t-test.
Three hundred and ten consecutive patients (15 years and older) undergoing open-heart surgery for various indications were included in the study. Preoperative demographic characteristics, intraoperative data and postoperative variables are summarized in Tables 1–3. Only 54 patients (17.42%) received one or more units of allogenic transfusions either intraoperatively or postoperatively until discharge. A total number of 184 units, 135 units of packed red blood cell (RBC), 24 units of fresh frozen plasma and 25 units platelet concentrate were used for transfusion. Of the 135 units of packed RBC used, only 34 units were transfused in the postoperative period. Mean hemoglobin at the time of discharge was 9.8 Grams% (8.9–12.6 Grams%).
The application of a standardized multidisciplinary blood conservation strategy markedly decreased allogeneic blood exposure in patients undergoing cardiac surgery. This effect was essentially related to a reduction in allogeneic blood product use in the intensive care unit and in the ward. This result was obtained without any increase in early postoperative morbidity or mortality. The developed strategy involved first, a rigorous blood conservation protocol aimed at decreasing perioperative blood loss and second, a standardized blood transfusion practice shared by surgical team. The primary method of our blood conservation strategy during preoperative period is attention to nutrition and oral or intravenous iron supplementation. Although preoperative administration of recombinant human erythropoietin is associated with a significant reduction in the risk of exposure to allogenic blood transfusion [9], it was not used in our study because of cost factor. This program, directed toward minimizing bleeding in the intraoperative period, resulted in significant changes in our practice. Technical and pharmacological interventions for blood conservation are directed towards minimizing both the hemodilution and the coagulopathy associated with cardio-pulmonary bypass. The use of antifibrinolytic agents though has become popular to decrease blood loss, but recent concerns over their safety, especially that of aprotinin, and their cost has limited the use of these expensive therapies to high-risk population like advanced age, preoperative antiplatelet or antithrombotic drugs usage, reoperative or emergency or complex procedures and non-cardiac patient comorbidities. Technical interventions [10, 11] include modifications in the performance of cardio-pulmonary bypass, intraoperative autologous blood donation, retrograde priming, normovolumic hemodilution and perioperative blood salvage; these interventions represent simple, generally inexpensive measures that are safe and effective in decreasing transfusion requirements. The capacity of acute normovolumic hemodilution to reduce perioperative allogeneic transfusion remains controversial [12]. However, several studies tend to demonstrate its efficacy after cardiac surgery. This technique, along with retrograde autologous priming, meticulous hemostasis and operative technique constituted a major component of our intraoperative blood conservation program. Both the number of patients and the volume of blood collected were increased. The efficacy of intraoperative cell salvage techniques and ultra-filtration remain controversial in cardiac surgery [13]. Therefore, their use was restricted to very specific situations associated with expected high blood losses or a high priming volume. Hypothermia has been shown to significantly increase postoperative blood loss, probably by impairing platelet function and reducing clotting factor function. Normothermic perfusion helps in less postoperative blood loss as demonstrated in our previous publication [7]. There is increasing evidence that postoperative blood transfusion should be guided by clinical indications and not only by specific hematocrit or hemoglobin values. In the present study, the use of clinical judgment as the main transfusion trigger resulted in a 50% decrease in allogeneic blood utilization. The most important factor in reducing excessive postoperative blood transfusion [13] is establishing a total quality management or ‘TQM’ approach by monitoring institution transfusion practices, emphasizing physician education and introducing transfusion algorithms. This observation stresses the importance of involving intensive care unit physicians and surgeons in any perioperative blood transfusion strategy. Transfusion of fresh frozen plasma was significantly reduced in our study, especially in the early postoperative period. These results are in accordance with previous studies demonstrating that hemostatic blood product requirement is significantly reduced by the use of a transfusion algorithm based on coagulation testing [15]. Finally, the marked reduction in allogenic blood transfusion did not seem to be associated with any increase in postoperative morbidity or mortality, as already observed in other studies [16]. In conclusion, a standardized multidisciplinary approach to blood conservation in cardiac surgery decreases bleeding and transfusion requirements in a safe and cost effective manner.
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Abstract
1. Introduction
