the management of massive blood loss and resuscitation · pdf file ·...
TRANSCRIPT
Elyse Parchmont RN MSN, CRNA
Pediatric Anesthesiology
Pediatric
Anesthesiology
The Management of Massive Blood Loss and
Resuscitation during Redo Sternotomy in a
Patient Supported with a Ventricular Assist Device
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Objectives
Pediatric Anesthesiology
•Address preoperative concerns and make effective preparations for caring for the
patient with a VAD at risk for massive blood loss.
•Discuss the assessment and required communication and intervention in the
exsanguinating patient with a VAD.
•Recognize the endpoints for volume and blood product administration, including
laboratory study and monitor data.
•Be familiar with the complications of massive blood loss and transfusion in this
setting.
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Case Study – Patient History
Pediatric Anesthesiology
• 15 y/o presenting to CVOR for orthotopic heart
transplant
• Severe TR/MR; Mod-severe LA dilation
• DCM, decreased myocardial function/congestive
heart failure (mildly depressed RV function)
• S/p HeartMate II LVAD placement
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Case Study - Medications
Pediatric Anesthesiology
Aspirin
Enalapril
Warfarin
Furosemide
Metoprolol
Lansoprozole
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Increased Risk with Redo Sternotomy
Pediatric Anesthesiology
•Staged or multiple cardiac procedures
•Presence of bioprosthetic conduits
•Dissection of adhesions
•Risk may be higher in older, teenage patients
•Decreased risk of injury over the recent decades
Kirshbom, et al. 2009
Morales, et al. 2008
Russell, et al. 1998
Andropoulos, et al. (2002)
Fabrizio, et al. (1999)
George, et al. (2012)
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Redo Sternotomy Preparation
Pediatric Anesthesiology
•Surgery, anesthesia, and OR staff experienced in pediatric
congenital heart disease
•Appropriate blood products ordered and delivered to the
CVOR
•Femoral bypass available
•CT evaluations
Andropoulos, et al. (2002
Hamid, et al. (2014
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Pediatric Ventricular Assist Devices
Pediatric Anesthesiology
•Use and challenges VADs in pediatric patients
•VADs vs ECMO
•Need for sedation
•Mechanical ventilation
•Anticoagulation/risk of thromboembolic phenomena
•Lack of mobility
•Risk of renal failure and/or stroke
•Risk of mortality > 2 weeks
Davies, et al. (2014)
George, et al. (2012)
O’Connor & Rossano (2014)
Sharma, et al. (2012)
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Pediatric Ventricular Assist Devices
Pediatric Anesthesiology
•Who gets a VAD? - Cardiogenic shock and/or progressive decline due to:
•End stage cardiomyopathy
•Myocarditis
•Univentricular failure
•Congenital heart disease/post cardiotomy
•VAD contraindications
•Irreversible end organ dysfunction
•Recent stroke
•Significant life limiting neurological disabilityO’Connor & Rossano 2014
Sharma, et al. 2012
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Pediatric Ventricular Assist Devices
Pediatric Anesthesiology
Davies, et al. 2014
O’Connor & Rossano 2014
Sharma, et al. 2012
•Hematologic
•Prolonged ventilator dependence
•Device change/reoperation
•Infection/sepsis
•Neurologic complications
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Types of VADs for Pediatric Patients
Pediatric Anesthesiology
Device Type Indication
HeartMate II Continuous-flow BTT,DT
Berlin Heart EXCOR pediatric Pulsatile paracorporeal BTT
Thorotec pVAD Pulsatile paracorporeal BTT, PC
Debakey VAD Child Continuous-flow BTT
TandemHeart Centrifugal ECS < 6 h
HeartWare Ventricular Assist System Centrifugal BTT
SynCardia Total Artificial Heart Artificial heart BTT
Impella Continuous-flow ECS < 6 h
Centrimag Centrifugal ECS < 6 h
O’Connor & Rossano 2014
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Increased Risk with Redo Sternotomy/VAD
Pediatric Anesthesiology
HeartMate II
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Increased Risk with Redo Sternotomy/VAD
Pediatric Anesthesiology
HeartMate II
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http://www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/cardiology/heart-failure/
J Am Coll Cardiol. 2009;54(18):1647-1659. doi:10.1016/j.jacc.2009.06.035
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Case Study – Intraoperative Course/Post Bypass
Pediatric Anesthesiology
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Monitoring During Massive Transfusion
Pediatric Anesthesiology
• Monitoring during blood transfusion
• Access
• Volume
Miller (2010)
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Blood Transfusion - Pediatrics
Pediatric Anesthesiology
Products:
•Packed red blood cells (PRBCs)
•Fresh frozen plasma (FFP)
•Cryoprecipitates of clotting factors (Cryo)
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Blood Transfusion for Pediatric Patients
Pediatric Anesthesiology
Age Estimated Blood Volume,
ml/kg
Premature infant 90-100
Term infant to 3 months 80-90
Children older than 3 months 70
Obese Children 65
Dehmer & Adamson (2010)
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Blood Transfusion ABO Compatability
Pediatric Anesthesiology
Miller (2010)
Donor Recipient
O O,A,B,AB
A A,AB
B B,AB
AB AB
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Massive Transfusion – Definition
Pediatric Anesthesiology
• Adult
• The loss of one or more circulating blood volumes in 24 hours
• Loss of 50% of blood volume in 3 hours
• An ongoing loss of 150 ml/hour
• Pediatrics
• Weight based
Dehmer & Adamson (2010)
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TCH Massive Transfusion Protocol –
PRBC Units/Kg Weight Total Blood Volume
Pediatric Anesthesiology
17.6-26.5 4
26.6-33.0 5
33.1-40.0 6
40.1-46.5 7
46.6-53.0 8
53.1-60.0 9
>60.0 10
Patient’s Weight
(Kg)
Number of Red Cell Units to
Equal Total Blood Volume
< 11.5 2
11.6-17.5 3
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Massive Transfusion – Age of Blood
Pediatric AnesthesiologyDehmer & Adamson (2010)
Miller, R.D. (2010)
Pizzini & Pizzini (2014)
•Older PRBC units:
•May be depleted in
2,3 diphosphoglycerate and
adenosine triphosphate
•May have elevated levels of
potassium
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Systemic oxygen delivery
Pediatric Anesthesiology
Three main factors
•Cardiac output
•Oxygen saturation
•Hemoglobin levels
Dehmer & Adamson (2010)
Hall & Chantigian (2010)
Pizzini & Pizzini (2014)
O2 content = 1.39 x (Hgb) x SaO2 + (0.003 x PaO2)
http://www.cvphysiology.com/Microcirculation/M002.htm
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Massive Transfusion Protocol –A Starting Point
Pediatric Anesthesiology
• Initiation of massive transfusion protocol in traumatic hemodynamic
instability
• Blood component ratios
• Maintenance of temperature, calcium, and pH
• FVIIa
Dehmer & Adamson (2010)
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TCH Massive Transfusion Protocol - Purpose
Pediatric Anesthesiology
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TCH Massive Transfusion Protocol – Pack Contents
Pediatric Anesthesiology
- Massive pack consists of up to 4 units of group O Rh negative
RBC (<14 days old). When massive pack requested, 2 units of
group AB FFP will be started to thaw.
- Standard pack consists of 2 units of group O Rh negative RBC
(<14 days old).
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Objectives
Pediatric Anesthesiology
•Address preoperative concerns and make effective preparations for caring for the
patient with a VAD at risk for massive blood loss.
•Discuss the assessment and required communication and intervention in the
exsanguinating patient with a VAD.
•Recognize the endpoints for volume and blood product administration, including
laboratory study and monitor data.
•Be familiar with the complications of massive blood loss and transfusion in this
setting.
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References
Pediatric Anesthesiology
Andropoulos, D.B., Stayer, S.A, Skjonsby, B.S., East, D.L., McKenzie, E.D., Fraser, C.D. (2002). Anesthetic
and Perioperative Outcomes of Teenagers and Adults with Congenital Heart Disease. Journal
of Cardiothoracic and Vascular Anesthesia. Vol. 16 (6):731-736
Davies, R.R., Hadleman, S., McCulloch M.A., Pizzaro, C. (2014). Ventricular assist devices as a bridge to
transplant improve early post-transplant outcomes in children. The Journal of Heart and Lung
Transplantation. Vol. 33 (7): 704-712.
Dehmer, J.J & Adamson, W.T. (2010) Massive Transfusion and Blood Product Use in the Pediatric Trauma
Patient. Seminars in Pediatric Surgery. Vol. 19:286-291
Fabrizio, M.F., Pett, S.B., Miller, K.B., Wong, R.S., Temes, R.T., Wernly, J.A. (1999) Catastrophic
Hemorrhage on Sternal Reentry: Still a Dreaded Complication? Annals of Thoracic Surgery.
Vol. 68:2215-9.
George, T.J., Beaty, C.A., Ewald, G.A., Russell, S.D., Shah, A.S., Conte, J.V., and Whitman, G.J. (2012)
Reoperative Sternotomy is Associated with Increased Mortality. Annals of Thoracic Surgery.
Vol. 94(6):2025-32.
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References
Pediatric Anesthesiology
Hamid, U. I., Digney, R., Soo, L., Leung, S., and Graham, A.N.J. (2014). Incidence and Outcome of
Reentry Injury in Redo Cardiac Surgery: Benefits of Preoperative Planning. European
Journal of Cardio-Thoracic Surgery. doi:10.1093/ejcts/ezu261
Kishbom, P.M., Myung, R.J., Simsic, J.M., Kramer, Z.B., Leong, T., Kogon, B.E., and Kanter, K.R.
(2009) One Thousand Repeat Sternotomies for Congenital heart surgery: Risk Factors fro
Reentry Injury. Annals of Thoracic Surgery. Vol. 88(1):58-61.
Miller, R.D. (2010) Miller’s anesthesia: Seventh ed. Philadelphia:Churchill Livingstone
Morales, D.L.S., Zafar, F., Arrington, K.A., Gonzalez, S.M., McKenzie, E.D., Heinle, J.S., Fraser, C.D.
(2008) Repeat Sternotomy in Congenital Heart Surgery: No Longer a Risk Factor. Annals of
Thoracic Surgery. Vol. 86:897-902.
O’Connor, M.J., Rossano, J.W. (2014) Ventricular assist devices in children. Obtained from
www.cardiology.com Vol 29(1).
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References
Pediatric Anesthesiology
Russell, J.L., LeBlanc, J.G., Sett, S.S., Potts, J.E. (1998) Risks of Repeat Sternotomy in Pediatric Cardiac
Operations. Annals of Thoracic Surgery. Vol. 66:575-8
Sesok-Pizzini, D., Pizzini, M.A. (2014) Hyperkalemic Cardiac Arrest in Pediatric Patients Undergoing
Massive Transfusion: Unplanned Emergencies. DOI:10.1111/trf.12470 Transfusion Vol.
54(1):4-7.
Sharma, M. S., Forbess, M.J., & Guleserian, K. J. (2012) Ventricular Assist Device Support in Children
and Adolescents with Heart Failure: The Children’s Medical Center of Dallas Experience
Artificial Organs. Vol. 36 (7): 635-48.