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Slide 1: PHILOSOPHY OF ACHIEVING BLOODLESS SURGERY IN CARDIAC PATIENTS: The Challenges Dr. Hema Nair Consultant Department of Anesthesia Narayana Hrudayalaya
Slide 2: Philosophy: A set or system of beliefs     Blood can be life saving (J. Blundell 1818) Transfusions are an essential part of major surgeries Blood transfusions are innocuous and harmless Blood transfusions are absolutely essential for paediatric open heart surgery
Slide 3: Change in Philosophy     Allogenic Blood therapy is not innocuous Two thirds of blood transfusions were inappropriate Even paediatric open heart surgeries and liver transplants can be done bloodless Change in attitude, conceptualisation and implementation needed
Slide 5: Estimated risk of transfusion transmitted infection Virus testing standard HIV 1&2 Ab HIV Ab+NAT Window period 22 D 9D Point estimate of residual risk/unit 1 in 2,404,000 1in 7,299,000 1in 330,000 1in 3,663,000 1in 1,339,000 HCV antibody 66 D HCV Ab+ NAT 7 D HBV vCJD Westnile virus 45 D Yrs
Slide 6: Infections in screened blood 8% 25000 20000 15000 10000 5000 0 1110 11 months Total Donors Discarded 10% 26% 56% HBsAg HIV HCV VDRL
Slide 7: Effect of Blood Transfusion on long term survival after cardiac operations 1915 patients who underwent first time isolated CABG surgery were followed up over 5 years. Blood transfusion during or after the surgery were associated with increased long term mortality.
Slide 8: Kaplan-Meier estimates of survival and hazard functions in the transfused groups Engoren M. C. et al.; Ann Thorac Surg 2002;74:1180-1186 Copyright ©2002 The Society of Thoracic Surgeons
Slide 9: Risk factors for high 5 yr mortality      Old age Presence of peripheral vascular disease COPD NYHA Class IV Blood Transfusion
Slide 10: Transfusion related morbidities      Nosocomial Pneumonia Sternal wound Infections Severe Sepsis Renal Dysfunction Increased post operative morbidities in women
Slide 11: Economic Burden from Transfusions     • Acquisition cost of one Blood Bag Rs 250. Actual expenditure incurred Rs 1600-2500. A unit with a case load of 450/month spends 11.5 lakh on blood.
Slide 13: Blood Utilisation Total issued:50772 (4615/month) Annual expenditure 20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 11 months 3588 1068 13161 18012 14943 WB PC FFP PLT CRY 1.7 Crore
Slide 14: Indications for transfusions     Strict Guidelines formulated for allogenic blood transfusions Specific Transfusion trigger Periodic blood utilisation Audits Logical Component Therapy
Slide 15: Packed Cells  Hb < 6 gm% transfusion recommended Platelets  10-20 x109/l risk of spontaneous bleeding <50 x109/l in case of surgeries FFP  PT>1.5 times normal  INR > 2  Aptt > 2 times normal Cryoppt  Transfuse at levels <80-100mg/dl with excessive micro vascular bleeding
Slide 16: Transfusion free Medicine      Integrated multidisciplinary approach Optimise patient’s reserve Minimise blood Loss Maximise blood Conservation Monitor for tissue hypoxia
Slide 17: Pre admission preparation       Pharmacological Stop Aspirin and Clopidogrel Iron Folate Vit C Human recombinant erythropoietin
Slide 18: Erythropoietin    300 IU/kg daily s/c for 14 days started 10 days pre op and continued post op 600 IU/kg alternate days Polysaccharide iron complex- 200mg of elemental iron.
Slide 19: Pre admission preparation    Autologous Blood predonation Cessation of smoking Micro sampling, only for mandatory investigations- 0.3 ml
Slide 20: Intraoperative Management        Normovolemic / hypervolemic haemodilution Use of Cell savers Lasers, Argon Beam Coagulators, Harmonic scalpel Selective emobolisation Port surgery, use of scopes Hypotensive Anesthesia Plasma Heparin level based Heparin/protamin management
Slide 21: Procoagulant Drugs      Aminocaproic acid Aprotinin- shown to be effective in children also Desmopressin, Vasopressin Vit K Recombinant Activated Factor VII
Slide 22: Modifications to CPB circuits      Tubings, reservoir and oxygenators tailored to patient size Blood containing part of circuit brought close to the operating table Remote pump head on masts Small tubing size (4.6mm) silicone tubing for pump head Vacuum assisted venous drainage
Slide 23: Post operative Management   Haemostatic agents, microsampling, Erythropoietin have to continue Monitoring with T- stat oximeter- will detect tissue hypoxia by measuring blood oxygen saturation in the capillaries.
Slide 24: Case Reports       3.55 kg Neonate Day 7 TOF with absent pulmonary valve and LPA aneurysm Erythropoietin Lines previous day Aprotinin Hepcon Heparin management systems
Slide 25: Modified CPB         Short Tubings – close to table Tube diameter 4.7mm 6.35mm silicone for roller pump segment Total prime volume 190 ml Crystalloid Cardioplegia Cross clamp time 50mts, reperfusion 53mts Vacuum assisted venous drainage -20mmHg ABG – 0.3 ml sample
Slide 26:         Weaning – venous line and reservoir used for preload Noradrenalin boluses for vasoconstriction apart from ionotropes Off CPB- oxygenator and heat exchanger blood given through arterial line Decannulation- residual blood transfused in through the central line Post op blood loss- 25 ml Extubated on day 5 Hb from 12.5 to 8.5, went up to 10 on 7th POD Erythropoietin continued post op.
Slide 27: Case Reports 2.2 Kg Jehovah’s Witness neonate TAPVC with PFO Haemoglobin 16.5 to 8 gm %  4.5kg – Hypoplastic Left Heart Syndrome Norwood stage I repair done Could not be weaned off CPB on first attempt Successful after transfusing 100 ml of PC 
Slide 28: Conclusion      Transfusion free medicine departments have been set up Patients are opting for it Multidisciplinary approach Needs legal cover Safety should not be compromised
Slide 29: Thank you