Intraoperative Patient Blood Management

Edwin G. Avery, IV, M.D., C.P.I.

Chief, Division of Cardiac Anesthesia

Chairman, Transfusion Committee

University Hospitals Case Medical Center

Case Western Reserve University School of Medicine

Cleveland, OH

Disclosures:

Covidien: funded research, consultant, speaker’s bureau

CSL Behring: funded research

www.casecag.com

Learning Objectives:

Gain practical knowledge of basic preoperative anemia management, assessment of the hemostatic system, how to address antithrombotic/antiplatelet medications, and when to involve hematology consultants.

Gain practical knowledge of point-of-care coagulation monitoring, surgical and pharmacologic strategies to reduce the need for blood component therapy, and evidence-based indications for appropriate administration of blood components.

Learn about specialized devices used both intraoperatively and postoperatively that promote conservation of a patient’s red cell mass.

Overview:

Intraoperative Blood Conservation Strategies

Intraoperative Transfusion Strategies

Surgical Techniques

Intraoperative Blood Conservation Strategies

Intraoperative Blood Conservation Strategies

Optimizing red cell mass & coagulation

Intraoperative hemostasis monitoring

Acute normovolemic hemodilution

Pharmacologic bleeding prophylaxis

Cell salvage

Intraoperative Blood Conservation Strategies

Full preoperative assessment

Anemia/hemostatic system management/assessment

with hematology consultation as indicated

Maximum surgical blood ordering schedule

Optimizing red cell mass & coagulation

Intraoperative Blood Conservation Strategies

Full preoperative assessment

Optimizing red cell mass & coagulation

Center for Perioperative Medicine – Preadmission Testing

Preoperative assessments are now being conducted in an area of the hospital termed the Center for

Perioperative Medicine, which was formerly referred to as the Preadmission Testing Clinic. The Center

for Perioperative Medicine offers a more complete assessment of the surgical patient’s perioperative

needs and a plan to meet those needs.

Rosenbaum SH, Silverman DG. The Value of Preoperative Assessment. Perioperative Medicine: Managing for Outcome. In: Newman MF, Fleisher L, Finak MP, (eds). Saunders Elsevier. Philadelphia, PA, 2008. p. 37-44.

Intraoperative Blood Conservation StrategiesOptimizing red cell mass & coagulation

Identify & mitigate non-cardiac comorbidities that are associated with

increased perioperative hemorrhage

HepaticDysfunction

RenalDysfunction

§2007 Ann Thorac Surg;83: S27-86

Intraoperative Blood Conservation Strategies

Anemia management

Optimizing red cell mass & coagulation

Patients with pre-existing anemia or coagulopathy who are scheduled for surgical or invasive procedures (especially

those associated with a high incidence of transfusion) should be considered for hematology consultation and possibly

preoperative therapies aimed at increasing their red cell mass or optimizing their coagulation system (for example,

through enteral or parenteral iron supplementation, erythropoietin, parenteral factor concentrates or by discontinuing

antiplatelet and/or antithrombotic medications).

Marcucci CE, Chassot PG, Asmis LM, Spahn DR. Hematologic Risk Assessment. In: Newman MF, Fleisher L, Finak MP, (eds). Saunders Elsevier. Philadelphia, PA, 2008. p. 121-138

Intraoperative Blood Conservation Strategies

Hemostatic system assessment with hematology consultation as indicated

Optimizing red cell mass & coagulation

Only perioperative clinicians with depth knowledge of more complex

coagulation pathologies and their treatment should manage these issues;

involving hematology consultation is highly recommended.

†Klick JC. Avery EG. Anesthesiology 2nd ed. 2012; Chap 16; 196-217

Intraoperative Blood Conservation Strategies

Optimizing red cell mass & coagulationMaximum surgical blood ordering schedule-MSBOS

Frank SM, Rothschild JA, Masear CG, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013;118(6):1286-97.

Intraoperative Blood Conservation Strategies

Maximum surgical blood ordering schedule-MSBOS

Optimizing red cell mass & coagulation

Frank SM, Rothschild JA, Masear CG, et al. Optimizing preoperative blood ordering with data acquired from an anesthesia information management system. Anesthesiology 2013;118(6):1286-97.

Intraoperative Blood Conservation Strategies

Intraoperative hemostasis monitoring

Hemostasis monitoring protocols-service specific

Microsampling

Core laboratory

Point of Care Testing (POCT)

Intraoperative Blood Conservation Strategies

Intraoperative hemostasis monitoring

Hemostasis monitoring protocols-service specific

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Intraoperative Blood Conservation Strategies

Intraoperative hemostasis monitoring

Microsampling

Dillen L, Loomans T, Van de Perre G, et al. Blood Microsampling Using Capillaries for Drug-exposure Determination in Early Preclinical Studies: A Beneficial Strategy to Reduce Blood Sample Volumes. Bioanalysis 2014;6(3):293-306.

Intraoperative Blood Conservation StrategiesIntraoperative hemostasis monitoring

Core laboratory

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

For centers that rely solely on the core laboratory for hemostasis monitoring, rapid sample

processing protocols should be in place to minimize delay in obtaining results.

Intraoperative Blood Conservation Strategies

Intraoperative hemostasis monitoring

Point-of-Care-Testing

A laboratory located

near the operating

rooms dedicated to

providing rapid

sample processing

can provide these

point-of-care testing

services or the testing

devices can be

located within the

operating room.

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

Intraoperative Blood Conservation Strategies

Acute normovolemic hemodilution - ANH

Use of a short, medium gauge arterial

cannula & a scale provides the ability

to precisely & rapidly sequester whole

blood pre-incision

Avery E. http://casecag.com/clinical%20protocols%20index%20page.html

Waters JH. Perioperative Blood Sequestration: Acute NormovolemicHemodilution. In: Waters JH (ed). Blood Management: Options for Better Patient Care. AABB Press. Bethesda, MD. 2008. p. 191-6

Intraoperative Blood Conservation Strategies

Pharmacologic bleeding prophylaxis

Intraoperative Blood Conservation Strategies

Pharmacologic bleeding prophylaxis

Ann Thorac Surg 2011;91:944-82.

http://casecag.com/clinical%20protocols%20index%20page.html

Intraoperative Blood Conservation Strategies

Pharmacologic bleeding prophylaxis

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

Intraoperative Blood Conservation Strategies

Pharmacologic bleeding prophylaxis

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

Intraoperative Blood Conservation Strategies

Pharmacologic bleeding prophylaxis

Intravenous vs. Topical

Video provided by the courtesy of Brian Hamlin, MD

Intraoperative Blood Conservation StrategiesPharmacologic bleeding prophylaxis - Topical

Konig G, Hamlin B, Waters JH. Topical Tranexamic Acid Reduces Blood Loss and Transfusion Rates in Total Hip and Knee Arthroplasty. J Arthroplasty 2013;28:1473-76.Wong J, Abrishami A, El Beheir HE, et al. Topical Application of Tranexamic Acid Reduces Postoperative Blood Loss in Total Knee Arthroplasty. J Bone Joint Surg 2010;92-A(15):2503-13.

Intraoperative Blood Conservation StrategiesPharmacologic bleeding prophylaxis - Pediatrics

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Intraoperative Blood Conservation Strategies

Cell salvage

Note that the cell saver

device can also be used

to “wash” allogeneic

banked red cell units to

reduce the free

hemoglobin insult to the

kidneys, reduce the K+ &

lactate load as well as

remove unstable RBCs

with weakened cell

membranes.

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

Esper SA, Waters JH. Intra-operative Cell Salvage: A Fresh Look at the Indications and Contraindications. Blood Transfus 2011;9:139-47.

Intraoperative Transfusion Strategies

Intraoperative Transfusion Strategies

Transfusion Guidelines/Surveillance Software

IO Laboratory/POCT Guided Transfusion Algorithms

Massive Transfusion Protocol (MTP)

Pharmacologic Transfusion Adjuncts

Fluid/Patient Warming Systems

Intraoperative Transfusion Strategies

Transfusion Guidelines/Surveillance Software

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Images courtesy of Jason Steyer – Haemonetics Inc.

Intraoperative Transfusion Strategies

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Intraoperative Transfusion Strategies

Massive Transfusion Protocol (MTP)

http://casecag.com/clinical%20protocols%20index%20page.html

Algorithm guided vs. 1 : 1 : 1

Intraoperative Transfusion Strategies

Pharmacologic Transfusion Adjuncts

Intraoperative Transfusion Strategies

Pharmacologic Transfusion Adjuncts

3 Factor PCCs

4 Factor PCCs

Recombinant activated Factor VII

Fibrinogen concentrate

DDAVP

Intraoperative Transfusion Strategies

Pharmacologic Transfusion Adjuncts3 Factor PCCs (not recommended unless balanced 4 factor

PCC not available) – OFF LABEL - dose at 20-30 IU Factor IX

for intractable hemorrhage not responsive to treatment with

allogeneic hemostatic products – slow IV push

4 Factor PCCs – OFF LABEL - 20-30 IU Factor IX activity for

intractable hemorrhage not responsive to treatment with

allogeneic hemostatic products – slow IV push

Gorlinger K, Dirkmann D, Hanke AA, et al. First-line Therapy with Coagulation Factor Concentrates Combined with Point-of-care Coagulation Testing is Associated With Decrease Allogeneic Blood Transfusion in Cardiovascular Surgery: A Retrospective, Single-center Cohort Study. Anesthesiology 2011;155(6):1179-91.

Intraoperative Transfusion Strategies

Pharmacologic Transfusion AdjunctsRecombinant activated Factor VII – OFF LABEL –

35 to 90 µg/kg slow IV push (start with low dose [35

µg/kg] to test response), re-dosing may be required within

4-6 hrs – thromboembolic complications are well documented with this

agent thus it is appropriate to consider administration after hemostatic

allogeneic blood components have failed to control bleeding (after 2

rounds of products)

J Trauma 2005;59:8-18.

J Cardiothorac Vasc Anesth 2011;25:804-10.

J Obstet Gynaecol 2011;37(7):901-7.

Neurocirugia (Astur). 2011; 22(3):209-23.

Intraoperative Transfusion Strategies

Pharmacologic Transfusion AdjunctsRecombinant activated Factor VII – OFF LABEL –

Thromboembolic complications

Ponschab M, Landoni G, Biondi-Zoccai G, et al. Recombinant Activated Factor VII Increases Stroke in Cardiac Surgery: A Meta-Analysis. J Cardiothorac Vasc Anesth 2011;25:804-10.

Intraoperative Transfusion Strategies

Pharmacologic Transfusion AdjunctsFibrinogen concentrate – OFF LABEL - formulaic

based on target fibrinogen concentration and known

fibrinogen level; slow IV infusion ~10 minutes; 1 vial

≈ 5 pack of cryoprecipitate for fibrinogen content

Levy JH, Szlam F, Tanaka KA, et al. Fibrinogen and Hemostasis: A Primary Hemostatic Target for the Management of Acquired Bleeding. AnesAnalg 2012;114:261-74.

http://www.cslbehring.com.au/docs/992/827/Riastap_AU-

PI_NZ-DS_3.00,0.pdf

Intraoperative Transfusion Strategies

Pharmacologic Transfusion AdjunctsDDAVP – 0.3 µg/kg slow IV infusion ~10 minutes (rapid

infusion can be associated with acute hypotension) – not

recommended for routine use but rather for POCT or Core

Lab based evidence of platelet dysfunction or uremia

induced platelet dysfunction

Ann Thorac Surg 2011;91:944-82.

Intraoperative Transfusion Strategies

Fluid/Patient Warming Systems

Surgical Blood Conservation Techniques

Controlled Hypotension

Retrograde Autologous Priming of the CPB circuit

Surgical Pharmacologic Blood Hemostasis Adjuncts

Autoregulating Surgical Suction Devices

Cell Salvage (Revisited)

Surgical Blood Conservation Techniques

Controlled Hypotension

Surgical Blood Conservation Techniques

Anesth Analg. 2007;105:918-925.

Anesth Analg 2008;107:59-67.

http://casecag.com/Avery%20E%202010%20INVOS%20White%20Pa

per%20Series%20SMS1415%20STS%20Database%20v2.pdf

Avery E. Cerebral Oximetry White Paper

BMEYE® - Edwards

INVOS

Retrograde Autologous Priming of the CPB circuit

Surgical Blood Conservation Techniques

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

Retrograde Autologous Priming of the CPB circuit

Surgical Blood Conservation Techniques

Complication

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Fibrin sealants

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Gelfoam®

Surgicel®

Avitene Ultrafoam®

http://labeling.pfizer.com/ShowLabeling.aspx?id=574

http://www.davol.com/default/assets/File/Avitene%20Ultrafoam%20IFU.pdf

http://www.recothrom.com/assets/docs/pi_recothrom.pdf

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Fibrin Sealant

Vitagel®

http://www.stryker.com/en-us/products/Orthobiologicals/SoftTissue/Vitagel/index.htm

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Floseal®

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

http://www.floseal.com/us/pdf/FLOSEAL_Needle-Free_5mL_IFU.pdf

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Coseal®

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

http://www.baxterbiosurgery.com/us/resources/pdfs/coseal/COSEAL_I

nstructions_For_Use.pdf

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Bioglue®

Avery EG, Klick JC. AABB Intraoperative Patent Blood Management 2014 (In Press)

http://www.cryolife.com/images/stories/assets/docs/BG_Surgical_Adhe

sive_Syringe_IFU_dom.pdf

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Fibrin Sealants

Tisseel®

http://tisseel.com/us/pdf/TISSEEL_PI.pdf

Contains bovine derived antifibrinolytic (Aprotinin®) – Potential anaphylaxis issues

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Evicel®

-Pooled human fibrinogen

-Human Thrombin

-Tranexamic Acid†

†The presence of the

tranexamic acid

precludes its contact

with cerebrospinal fluid

or dura mater

Fibrin Sealants

http://hostedvl106.quosavl.com/cgi-

isapi/server.dll?8000?IFUs?rkumar12@its.jnj.com?GetOneDocPureFullTxt?24vnohukg3l

4tbqe1t9fo4ahno?3

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Arista AH®

Plant based microporous

polysaccharide hemospheres

http://www.davol.com/default/assets/File/Arista

%20Product%20Information.pdf

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agents

Syvek Patch®

Poly-N-acetyl glucosamine

(P-NAG) is a naturally

occurring complex

polysaccharide derived from

microalgal cultures. P-

NAG’s mechanisms are

unclear but may involve

tissue adhesiveness,

attraction of circulating

blood cells, nitric oxide

scavenging, and

vasoconstriction.

http://www.syvek.com/

Surgical Pharmacologic Blood Hemostasis Adjuncts

Surgical Blood Conservation Techniques

Topical agentsAutologous Platelet Gel

Like fibrin sealants, autologous platelet gel is thought to have hemostatic and tissue-sealing properties.

Autologous platelet gel is thought to speed wound healing and enhance osteogenesis through concentrated

platelet-derived growth factors, although it has not been demonstrated by clinical trials.

http://www.perfusion.com/plateletgel/

Autoregulating Surgical Cell Salvage Devices

Surgical Blood Conservation Techniques

Regulation of

suction

intensity

reduces trauma

to erythrocytes

and increases

the yield of

cell salvage

efforts.

Smart Suction Harmony Cell Saver Elite® - Haemonetics

Transfusion 1996;36:57-60

Cell Salvage (Revisited)

Surgical Blood Conservation Techniques

CardioPAT® OrthoPAT®

These two systems work by

incorporating centrifugal disc

technology into a fully automated

process of continually collecting,

processing, washing and concentrating

shed blood. Both systems are capable of

processing volumes as small as 100 mL

and have the capability to concentrate

the washed cells when the hematocrit of

the collected cells is less than 10% to

create a final product for transfusion that

has a consistently high hematocrit.

Haemonetics Inc.

http://www.haemonetics.com/en-GB/Products/Devices/Surgical%20-

%20Diagnostic%20Devices/cardioPAT.aspx

http://www.haemonetics.com/en-GB/Products/Devices/Surgical%20-

%20Diagnostic%20Devices/OrthoPAT.aspx

The End - Mahalo

www.casecag.com