LIQUID TRANSPLANT: A LOOK AT COMPREHENSIVE BLOOD MANAGEMENT

Transcription

1 LIQUID TRANSPLANT: A LOOK AT COMPREHENSIVE BLOOD MANAGEMENT CHRISTOPHER L. AYLSWORTH, PA-C CARLOS R. ORTEGA, MS, PA-C HANS M. HAUPT, MD

2 BODILY FLUIDS: WHAT HAPPENS IN VEGAS DOESN T ALWAYS STAY IN VEGAS CHRISTOPHER L. AYLSWORTH, PA-C CARLOS R. ORTEGA, MS, PA-C HANS M. HAUPT, MD

3 BACKGROUND EVERY 2 SECONDS SOMEONE IN THE U.S. REQUIRES A BLOOD TRANSFUSION OVER 30 MILLION COMPONENTS ARE TRANSFUSED EACH YEAR IN THE U.S. TRANSFUSION MEDICINE RECEIVES LITTLE ATTENTION IN TRADITIONAL PROGRAMS WE TRANSFUSE RED CELLS BASED ON THEORY OF GAS TRANSPORT NO FDA APPROVAL SURGICAL TRAINING MYTHOLOGICAL/SACRED STATUS

4 GOALS: OPTIMIZING OUTCOMES BALANCING RISK CONTROLLING COSTS

5 DYNAMIC PROCESS

6 DYNAMIC PROCESS PRE-IMPLEMENTATION PHASE: DATA REVIEW RISK/BENEFIT MORTALITY IDENTIFIED KEY STAKEHOLDERS DEVELOPMENT OF PROTOCOLS PRE- ALGORITHM, HISTORY, IRON, ESA, ADDITIONAL W/U, DELAY INTRA- CIRCUIT, HEMOCONCENTRATION, HEMOSTATIC AGENTS, ANTIFIBRINOLYTICS, TEG/PLATELETWORKS POST- AVOID EXCESS HEMODILUTION, LIMIT HYPERTENSION, IRON SUPPLEMENTS, +/- ESA, REASON TO TRANSFUSE STAFF EDUCATION CULTURE CHANGE

7 PRE-IMPLEMENTATION PHASE RISK OF INFECTION: 1:200,000 TO 360,000 HEPATITIS B 1:1,000,000 TO 2,000,000 HEPATITIS C 1:1,500,000 TO 2,000,000 HIV 1:2,000,000 HUMAN T-CELL LYMPHOMA/LEUKEMIA

8 PRE-IMPLEMENTATION PHASE OTHER RISKS: TRALI/TACO ALLERGY GRAFT VS. HOST DISEASE ABO INCOMPATIBILITY FEBRILE NONHEMOLYTIC TRANSFUSION REACTION

9 PRE-IMPLEMENTATION PHASE DOES IT DO WHAT WE THINK IT DOES???

10 MORPHOLOGY OF BLOOD IN STORAGE

11 PRE-IMPLEMENTATION PHASE STORED RBCS: RELEASE OF INFLAMMATORY MEDIATORS ALTERATIONS IN LEVELS OF 2,3- DPG IMPAIRMENTS IN NO MEDIATED VASODILATION MICROVASCULAR INJURY

12 Outcome of Patients Who Refuse Transfusion After Cardiac Surgery: A Natural Experiment With Severe Blood Conservation. Pattakos, MD, et al. Arch Intern Med. 2012;172(15):

13 The Independent Effects of Anemia and Transfusion on Mortality After Coronary Artery Bypass Engoren, MD, et al. Ann Thorac Surg. 2014;97,

14 Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery N = 14,259 patients ( ) - nonemergency, primary, isolated CABG operations [2 Groups -pre-guideline (n = 7059) vs. post-guideline (n = 7200,)] Overall intraop (24% vs 18%) and postop (39% vs 33%) (P <.001) blood product transfusion were significantly reduced in the post-guideline era Post-guideline era - reduced morbidity with decreased pneumonia, prolonged ventilation, renal failure, new-onset hemodialysis and major complications Operative mortality (P <.001) and postop ventilation time (P <.001) were reduced in the postguideline era Post-guideline era were associated with a 47% reduction in the odds of death Intra & post op transfusions - associated with increased costs ($4408 and $10,479, respectively) LaPar, MD, et al. J Thorac Cardiovasc Surg Mar;145(3):

15 COST OF OWNERSHIP Nominal price tag of a unit of allogeneic blood Hidden costs of blood

16 PRE-OPERATIVE PHASE: Timing of operative intervention Anti-platelet drugs Post-cath hemodilution Iron replacement therapy Erythropoetic stimulating agents Ruling out occult blood loss

17 PRE-OPERATIVE ALGORITHM: Hgb < 13 g/dl IRON STATUS FERRITIN < 30 ug/l TSAT < 15-20% FERRITIN ug/l TSAT > 20% FERRITIN > 100 ug/l TSAT > 20% ASSESS RENAL FUNCTION IRON DEFICIENCY ANEMIA R/O IRON DEFICIENCY ANEMIA LOW NORMAL FOLATE, B12 LEVELS CONSIDER GI CONSULT CONSIDER COLONOSCOPY CHRONIC KIDNEY DISEASE REFER TO NEPHROLOGIST NORMAL ANEMIA OF CHRONIC DISEASE LOW IRON IV/PO ESAs IRON IV FOLATE, B12 REPLACEMENT

18 INTRA-OPERATIVE PHASE: Hemoconcentration CPB pump prime Microplegia Cardiotomy suction Surgical hemostasis Hemostatic agents POC testing- TEG, Plateletworks

19 POST-OPERATIVE PHASE: Minimize Phlebotomy Goal-directed therapy Team approach

20 POST-OPERATIVE ALGORITHM: HGB < 7 NO AWAIT INPUT FROM CT SURGERY YES YES SVO 2 < 50% NEW ECG CHANGES DECREASE IN CARDIAC PERFORMANCE (CI < 2.0) PERSISTENT AG ACIDOSIS (NOT ATTRIBUTED TO RENAL TUBULAR ACIDOSIS) INCREASED LACTATE LEVEL ACTIVE HEMORRHAGE EVIDENCE OF END-ORGAN ISCHEMIA CURRENT HGB < 50% PRE-OP HGB NO NOTIFY CT ATTENDING TRANSFUSE IF INDICATED OPTIMIZE HEMODYNAMICS WITH COLLOID OR CRYSTALLOID LIMIT UNECESSARY BLOOD DRAWS YES RENAL FAILURE NO OBTAIN IRON, FOLATE, B12 STUDIES EPOGEN 100 IU/KG IV/SQ THREE TIMES A WEEK IV IRON EVERY 3 DAYS FOLATE AND B12 REPLACEMENT IF INDICATED LABS IN AM IF NO CHANGE CLINICALLY OBTAIN IRON, FOLATE, B12 STUDIES EPOGEN 300 IU/KG IV/SQ IV IRON EVERY 3 DAYS FOLATE AND B12 REPLACEMENT IF INDICATED LABS IN AM IF NO CHANGE CLINICALLY

21 POST-IMPLEMENTATION PHASE MEASURE RATES OF TRANSFUSION MEASURE OUTCOMES- STS FACTOR COST IMPLICATIONS SHARE INFORMATION WITH KEY STAKEHOLDERS IDENTIFY FURTHER AREAS OF IMPROVEMENT- DYNAMIC PROCESS ASK FOR GENEROUS RAISE BASED ON YOUR SAVINGS TO THE INSTITUTION

22 2012 DATA REVIEW AVERAGE PRBC USAGE BY CAB STATUS ELECTIVE URGENT EMERGENT INTRA POST

23 2013 DATA REVIEW AVERAGE PRBC USAGE BY CAB STATUS ELECTIVE URGENT EMERGENT INTRA POST

24 2014 DATA REVIEW AVERAGE PRBC USAGE BY CAB STATUS ELECTIVE URGENT EMERGENT INTRA POST

25 DATA REVIEW INTRA OP CAB COMPARISON 60.0% 50.0% 40.0% 30.0% % 10.0% 0.0% CRYO FFP PLAT PRBCS

26 DATA REVIEW POST OP CAB COMPARISON 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% CRYO FFP PLAT PRBCS

27 IMPROVED OUTCOMES

28 DATA REVIEW TOTAL BLOOD SPEND BY YEAR 2012 $125, $42, $15, CRYO FFP PLAT PRBC

29 DATA REVIEW $80, ANNUAL BLOOD SPEND YOY- CAB $70, $60, $50, $40, $30, $20, $10, $

30 WHAT WOULD BLADE DO?

31 QUESTIONS?