|Year : 2016 | Volume
| 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 Publication||16-Dec-2016|
Chief Perfusionist, Atlanta Medical Center, 303 Parkway Dr NE Atlanta, GA 30312
Source of Support: None, Conflict of Interest: None
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|| |
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.  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.  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.  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|| |
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.  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.  An effective CV service line improves teamwork and communication between all members of the cardiac surgery team.
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.  Furthermore, a prospective study observed that decreasing perceptual prejudices can reduce errors.  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. , 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.  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|| |
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.  Opting for integrated filters reduces prime volume by 100-300 mL.  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.  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.  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.
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.  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|| |
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.  Furthermore, one-third of operating room transfusions are given without measuring the hemoglobin.  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. 
| Conclusion|| |
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.
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Conflicts of interest
There are no conflicts of interest.
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