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 Table of Contents  
REVIEW ARTICLE
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 40-42

Effective strategies for total blood management during cardiopulmonary bypass: Perfusion's contribution and perspective


Perfusion.com, Inc., Fort Myers, Florida, USA

Date of Web Publication16-Dec-2016

Correspondence Address:
April Radicella
Chief Perfusionist, Atlanta Medical Center, 303 Parkway Dr NE Atlanta, GA 30312
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2468-7391.195924

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  Abstract 

Total blood management during cardiopulmonary bypass requires intentional strategies to be effective. Key areas of impact involve creating a team atmosphere, reducing hemodilution, and optimizing a point of care testing. True team atmospheres realize innovative collaboration by establishing an appropriate discussion platform and maximizing complimentary gender-specific contributions. Technical strategies, from a perfusion standpoint, focus on disposable components, autologous blood management, and cardioplegia modifications. Finally, point of care testing is utilized to justify, improve, and standardize practices. Perfusion's contribution to strategic blood management contributes to improved patient outcomes.

Keywords: Autologous blood management, blood management, cardioplegia, gender, gender intelligence, perfusion, point of care, strategies, team


How to cite this article:
Radicella A. Effective strategies for total blood management during cardiopulmonary bypass: Perfusion's contribution and perspective. Niger J Cardiovasc Thorac Surg 2016;1:40-2

How to cite this URL:
Radicella A. Effective strategies for total blood management during cardiopulmonary bypass: Perfusion's contribution and perspective. Niger J Cardiovasc Thorac Surg [serial online] 2016 [cited 2020 Dec 5];1:40-2. Available from: http://www.nigjourcvtsurg.org/text.asp?2016/1/2/40/195924


  Introduction Top


Total blood management for patients undergoing cardiovascular (CV) procedures requiring cardiopulmonary bypass (CPB) demands deliberate strategies to be effective. Perfusionists play a key role in modifying risk and contributing to blood management, symbiotically leading to improved patient outcomes and decreased costs. Successful perfusion strategies include promoting a team environment, strategically decreasing hemodilution, and optimizing point of care testing available. Note that a close relationship exists between blood management and blood transfusion rates during and surrounding CPB. Problems surrounding blood transfusion rates are related to risk, cost, and frequency. Common transfusion risks include transfusion-related acute lung injury, transfusion-associated circulatory overload, acute hemolytic transfusion reactions, bacterial infection, and leukocyte-related target organ injury. [1] The prevalence of these risks has been, and continues to be, underestimated, underdiagnosed, and underreported. The reality is that transfused patients consistently have higher morbidities and mortalities; anemia can be detrimental, but transfusions can be worse. In addition, blood transfusion costs are high and continue to increase. In the USA, complete hospital cost for one unit of blood is nearly $1400. [2] Finally, the lack of standardization in transfusion practice and its perceived benefits across institutions results in gross overuse. Overused procedures are described as those circumstances where the transfusion benefit is negligible; therefore, the patient is essentially only exposed to the harmful effects. The Joint Commission named blood transfusions among the top five overused procedures in 2012. [3] Since transfusion rates are easily quantifiable and costly, they are a convenient indicator of impact and efficiency. By combining perfusion technology and innovation with techniques contributing to smarter blood management, the cardiac team can move toward optimal clinical results.


  Team Environment Top


Effective communication is a fundamental concept of successful cardiac surgery, and it is heavily influenced by teamwork, culture, and task complexity. In a prospective analysis of 1.5 million procedures, the most common precursor to serious adverse events, such as a wrong-site error, was inadequate communication. [4] No clinician in the operating room is isolated; anesthesia, perfusion, physician assistants, and nursing interweave experience and innovation, toward a common goal, under the authority of the surgeon. High technical skill does not necessarily ensure a successful procedure. Rather, team collaboration must be an intentional and structured effort to step into effectiveness. Constructing a team atmosphere comprises the creation of a CV service line and education on gender intelligence.

Cardiovascular service line

Creation of a CV service line unifies all members of the cardiac team, from pre- to post-operation. Surgeons, assistants, perfusionists, nurses, and pharmacists must participate directly, not just be represented by a spokesperson. Participants designate and commit to a time to meet to open lines of communication. Frequency of meeting depends on case volume, with a recommended minimum of meeting once a month to maintain relevance. The purpose is to establish an appropriate platform where clinicians collaborate to develop and improve protocols, discuss new research or techniques, and establish a safe place to discuss events. Discussing protocols minimizes confusion and miscommunication, and establishes a low-pressure atmosphere to propose improvements. Exploring emerging research and techniques helps the team improve outcomes, combatting the human tendency toward complacency. Finally, CV service line meetings encourage an environment of transparency and accountability. Effective meetings are free from blame, shame, or scapegoating and must have a commitment from all providers. Implementation of a CV service line is associated with improved patient outcomes. [5] An effective CV service line improves teamwork and communication between all members of the cardiac surgery team.

Gender intelligence

Effective communication cannot be achieved without including gender intelligence. In a review of 1400 critical incidents, a lack of teamwork skills exacerbates adverse events in the operating room, further emphasizing the importance of effective communication. [6] Furthermore, a prospective study observed that decreasing perceptual prejudices can reduce errors. [4] Gender intelligence maximizes the intrinsic, biological differences between men and women by illuminating gender blind spots; a gender blind spot describes erroneous interpretations of behaviors and statements leading to miscommunication, distrust, and frustration. Traditionally, behavior studies demonstrate that men tend toward physical aggression while women demonstrate enhanced social cognizance. [7],[8] Interestingly, a 2013 neurological study comparing decision processes between the genders revealed that men primarily display intrahemispheric connectivity whereas females display high interhemispheric connectivity. Male brains facilitate communication between observation and corresponding action, whereas female brains facilitate communication between analytical and intuitive processing methods. Men gravitate toward unifocal, convergent thought processing whereas women gravitate toward conceptual, divergent thinking. [9] Acknowledgment of these complimentary differences maximizes strategic problem-solving and innovation in the cardiac theater. Purposefully, practicing intergender communication improves participation in the decision-making and augments safety practices.


  Decreasing Hemodilution Top


Turning attention to the technical aspect, hemodilution reduction greatly contributes to successful blood management. Hemodilution levels are highly impacted via pump pack components, autologous blood management, and cardioplegia modifications.

Pump pack components

The disposables of the heart-lung machine have gone through many developments over the years, and it is important to consistently seek out and implement improvements. Small changes across the systems add up to big impacts. First, integrated arterial line filters decrease prime and operating volume. In a retrospective study of 1724 adults utilizing CPB, reducing prime volume by 150 mL was related to reduced transfusion rates and acute kidney injury. [10] Opting for integrated filters reduces prime volume by 100-300 mL. [11] When building the CPB disposables, the perfusionist and the surgeon should be conscientious to shorten every line possible in an effort to decrease the extracorporeal circulating volume. Positioning the CPB machine close to the patient permits further shortening of the systemic lines, once handed to the sterile field. Just one foot of half inch tubing holds nearly 40 mL, so every trim can make a difference. [12] Additional strategies include eliminating redundant purges, transitioning to a 3/8 inch venous line, and minimizing the distance between the cardioplegia pump and the oxygenator.

Autologous blood management

Autologous blood processing strategies include blood sequestration and autologous priming. Acute normovolemic hemodilution is a common blood conservation technique where a unit of whole blood is drawn from the patient just before the surgery. [13] Decreasing the pump flow rate in the cell saver and diverting the outflow into two collection bags allow the perfusionist to separate whole blood into red cells and plasma. By separating the blood into components, anesthesia or perfusion has the option to administer the red cells while preserving plasma and plasma components until after the bypass run. Another blood management strategy is retrograde autologous prime (RAP) and antegrade autologous prime (AAP). RAP occurs after aortic cannulation but prior to the initiation of CPB. The perfusionist gradually allows the patient to back bleed into the CPB circuit, displacing crystalloid prime with autologous blood prime. Similarly, AAP occurs after venous cannulation and prior to the initiation of CPB. The perfusionist slowly forward primes the CPB circuit via the venous line, displacing crystalloid prime with autologous blood prime. Communication with the surgeon and anesthesia is critical during this time to maintain patient stability. It is typical to treat low blood pressures with a vasopressor during the RAP/AAP. By displacing crystalloid prime with blood prime, perfusion can initiate bypass diluting the patient with only 500 mL versus the traditional 1200 mL (depending on circuit components), minimally affecting the patient's hematocrit levels.

Cardioplegia modification

In some practices, cardioplegia can be a burdensome source of hemodilution. While there are various schools of thought on the most appropriate cardioplegia technique, microplegia has been associated with a lower incidence of postoperative cardiac edema, reduced low cardiac output syndrome, and increased ventricular recovery. [14] Reducing crystalloid wherever possible will reduce the unwanted effects of hemodilution during CPB. In this regard, 8:1 is superior to 4:1, and microplegia is superior to 8:1. Many formulas can be effectively altered to minimize the blood to crystalloid ratio.


  Point of Care Testing Top


Appropriate lab tests empower clinicians to make wise decisions and better manage anemia. The international transfusion consensus estimated that approximately one-half of all transfusions are given without appropriate justification. [3] Furthermore, one-third of operating room transfusions are given without measuring the hemoglobin. [15] Hemoglobin levels should be tested not only prior to transfusion, but also after each unit of blood. Developing a transfusion trigger protocol should be discussed, although treating a hemoglobin result alone may still be considered inappropriate; consider other signs, symptoms, and physiologic indicators as well. Turning attention from red cells to products and whole-blood viscoelastic tests such as thromboelastography provides comprehensive insight into the patient's coagulation state, facilitating optimal product usage. Rapid point of care management is associated with reduced transfusions, reduced transfusion-related adverse events, and improved patient outcomes. [16]


  Conclusion Top


True effective strategy for total blood management requires team input, adjusted bypass techniques, and relevant point of care testing. Team input must not be underestimated, resisting stagnancy and encouraging transparency. Technical adaptations reduce hemodilution through pump pack components, autologous blood management, and cardioplegia modification. Finally, point of care testing should be utilized whenever it is available, justifying practice rather than fully relying on habit or instinct. Blood management strategies lead to smarter use of blood products and safer cardiac procedures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007;83(5 Suppl):S27-86.  Back to cited text no. 1
    
2.
Shander A, Hofmann A, Gombotz H, Theusinger OM, Spahn DR. Estimating the cost of blood: Past, present, and future directions. Best Pract Res Clin Anesthesiol 2007;21:271-89.  Back to cited text no. 2
    
3.
Shander A, Fink A, Javidroozi M, Erhard J, Farmer SL, Corwin H, et al. Appropriateness of allogeneic red blood cell transfusion: The international consensus conference on transfusion outcomes. Transfus Med Rev 2011;25:232-46.e53.  Back to cited text no. 3
    
4.
Thiels CA, Lal TM, Nienow JM, Pasupathy KS, Blocker RC, Aho JM, et al. Surgical never events and contributing human factors. Surgery 2015;158:515-21.  Back to cited text no. 4
    
5.
Hicks CW, Rosen M, Hobson DB, Ko C, Wick EC. Improving safety and quality of care with enhanced teamwork through operating room briefings. JAMA Surg 2014;149:863-8.  Back to cited text no. 5
    
6.
Rutherford JS, Flin R, Irwin A. The non-technical skills used by anaesthetic technicians in critical incidents reported to the Australian Incident Monitoring System between 2002 and 2008. Anaesth Intensive Care 2015;43:512-7.  Back to cited text no. 6
    
7.
Gur RC, Richard J, Calkins ME, Chiavacci R, Hansen JA, Bilker WB, et al. Age group and sex differences in performance on a computerized neurocognitive battery in children age 8-21. Neuropsychology 2012;26:251-65.  Back to cited text no. 7
    
8.
Halpern DF, Benbow CP, Geary DC, Gur RC, Hyde JS, Gernsbacher MA. The science of sex differences in science and mathematics. Psychol Sci Public Interest 2007;8:1-51.  Back to cited text no. 8
    
9.
Ingalhalikar M, Smith A, Parker D, Satterthwaite TD, Elliott MA, Ruparel K, et al. Sex differences in the structural connectome of the human brain. Proc Natl Acad Sci U S A 2014;111:823-8.  Back to cited text no. 9
    
10.
Ranucci M, Pistuddi V, Carboni G, Cotza M, Ditta A, Boncilli A, et al. Effects of priming volume reduction on allogeneic red blood cell transfusions and renal outcome after heart surgery. Perfusion 2015;30:120-6.  Back to cited text no. 10
    
11.
Sorin Inspire. Powerful Perfusion. Available from: http://www.cellplex.net/wp-content/uploads/2014/09/Inspire-8-Brochure.pdf. [Last accessed on 2016 Jul 31].  Back to cited text no. 11
    
12.
Gravlee G. Cardiopulmonary Bypass-Principles and Practice. Philadelphia, PA: Lippincott; 1993.  Back to cited text no. 12
    
13.
Loubser PG, Morell RI, Loubser IA. Impact of extracorporeal circuit prime volume reduction on whole blood sequestration during acute normovolemic hemodilution for adult cardiac surgery patients. J Extra Corpor Technol 2004;36:329-35.  Back to cited text no. 13
    
14.
Algarni KD, Weisel RD, Caldarone CA, Maganti M, Tsang K, Yau TM. Microplegia during coronary artery bypass grafting was associated with less low cardiac output syndrome: A propensity-matched comparison. Ann Thorac Surg 2013;95:1532-8.  Back to cited text no. 14
    
15.
Frank SM, Savage WJ, Rothschild JA, Rivers RJ, Ness PM, Paul SL, et al. Variability in blood and blood component utilization as assessed by an anesthesia information management system. Anesthesiology 2012;117:99-106.  Back to cited text no. 15
    
16.
Lier H, Vorweg M, Hanke A, Görlinger K. Thromboelastometry guided therapy of severe bleeding. Essener Runde algorithm. Hamostaseologie 2013;33:51-61.  Back to cited text no. 16
    




 

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Introduction
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Point of Care Te...
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