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Cardiac surgery and what it means for our blood bank?


jshafer
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Hello Everyone,

           We are in the process of bringing cardiac surgery next year. I have never worked in a hospital that performed cardiac surgery. What are some of the things that we should be thinking about for our blood bank? I understand the volume of products we have in house will have to increase. I'm thinking we will need a TEG or Rotem. Which one is the question? Should I also be concerned about brining cell saver in house? Ours is currently contracted out. Any tips would be greatly appreciated since I will most likely be involved in build process. Thank you in adavance!

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We have been doing open heart surgeries for decades and do not miss  having a TEG or Rotem.  (From what I understand, they are more sought after for trauma surgeries.)  For BB products to be held available, you may have to have platelets on hand.  Here, many OH patients end up having 2 units of RBCs on hold (or sent to OR in a cooler).  Cell savers are maintained by Surgery here.

Almost all of these issues should be determined by your cardiac surgery department--it is unlikely that you will have to make a decision one way or another for deciding on these types of services.  I would think that rather your job will be the Lab side implementation once decisions are made. 

Scott

Scott

Edited by SMILLER
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When we brought cardiac surgery on-line at our facility many years ago I made sure that I was included in planning meetings with the Cardiothoracic teams that way I didn't get blindsided with their expectations.

Our cell savers are run/managed by the perfusion team with oversight by the hospital Blood Utilization Committee and Transfusion Safety Officer.

Our MSBO has only a TYSC for OH surgeries. They do not always need blood products depending on the extent of the surgery. It's not unusual for the surgeon to want 2 RBCs available in surgery but patient may or may not get them. We also get requests for 2-4 FFP, 1-2 pooled Cryo (5u/pool) and 1 dose of platelets (we keep single donor Pheresed on hand) for the patient when they are bringing them off of By-Pass. They are usually good about giving us a heads up of when to thaw so we don't end up thawing too early or have them wasted if they decide later they won't need them after all.

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We do have a rotem but it is used mainly for trauma surgeries. Surgery is in charge of the running of the cell saver although the BB does review their QC, put it in a spread sheet and then transfusion committee  reviews it. The standing order is 3 red cells on the fresher side of expiration. And although it isn't order at the onset there is pphl on hand in the event it is needed.

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I have to say that the demands on blood bank will depend GREATLY on who your facility selects as a surgeon.  When we first started CVOR cases, we packed 2-4 units in a cooler and were required to have 4 platelets on hand.  Our blood supplier thought that was ridiculous, because none of their other hospitals performing CVOR procedures kept that many platelets.  That was 20 years ago, and the surgeons did not wait for Plavix to decrease in the patient's systems prior to operating.  We later stopped packing blood for the surgeries because the surgeon thought it was ridiculous, since he never used it.  I had never heard of TEG or Rotem until we became Trauma certified, and then we were not asked to get one. Our last surgeon barely used any products at all, but insisted that we get a TEG because that was "state of the art" care.  I don't think he ever looked at the results.  Since his retirement two months ago, we have had locum tenens physicians  who don't know what to do with TEG results, so don't order them, and we are back to using multiple platelets, as well as other blood products.

Best of luck to you.

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From my experience a lot depends on the team of surgeons and their philosophy and training in respect to transfusion.  In the last facility I supervised the blood bank in we had a group of surgeons who believe the less transfused the better and they rarely transfused anything.  About the only time they actually used any blood products was during a "redo".   It didn't hurt that my blood bank medical director was married to one of the lead surgeons.

 On the other hand, a sister hospital in the same corporation about 60 miles away used a lot of products on virtually every procedure, especially platelets.  They would use more platelets in one procedure than we would in over a year.  

The suggestion to be involved in the initial meetings is an excellent suggestion.  It's the only way to find out the surgeon's expectations ahead of time.  :coffeecup:

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On ‎10‎/‎07‎/‎2019 at 9:33 AM, jshafer said:

Hello Everyone,

           We are in the process of bringing cardiac surgery next year. I have never worked in a hospital that performed cardiac surgery. What are some of the things that we should be thinking about for our blood bank? I understand the volume of products we have in house will have to increase. I'm thinking we will need a TEG or Rotem. Which one is the question? Should I also be concerned about brining cell saver in house? Ours is currently contracted out. Any tips would be greatly appreciated since I will most likely be involved in build process. Thank you in adavance!

You should find out what your cardiac surgery team expects.  In the past, rbcs and cryo were the big users (but not a lot).  Rarely you'll have one go bad and they'll go thru a lot of components.   I worked in a place where we did our own donors - it worked out well for me as I got an apheresis instrument to obtain plts.  In the early 80s the routine cardiac usage was 2 rbcs and 4 cryos.  I haven't been in that situation in more than a few years.  I wouldn't expect usage to have increased/case.   Check w your surgeons.

 

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We have had open heart surgeries here for years. A few years back, anesthesia and one of the heart surgeon got a wild hair to have TEG.  It has been a major waste of time and money.  We had the results feed live into the OR so that they could see them.  The company came in a gave them all instructions on the system and how it could help them determine what blood products they needed.   They have never used it to make decisions during surgery.  Regardless of the results, if their patient is bleeding, they are going to want plasma, platelets, and possibly cryo.  We are currently keeping 1 plt pheresis.  2-4 prepooled (5 cryo/pool) cryoprecipitate in house on the days that we have surgeries.  We've started keeping 2 A plasma thawed at all times.  Most CABG procedures require few products,  Valves Replacements can be bigger users.

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I wholeheartedly agree with all the above comments for you to determine the surgeons expectations. 

One other thing we found VERY useful was asking if the patient has had prior heart surgeries, i.e. how much scar tissue was on/around the heart. We found that the more scar tissue the patient had the more products, especially RBC, would be needed. 

 

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  • 4 weeks later...

If at all possible, define a pre-admission process so that a T&S can be drawn prior to the day of surgery.  No one is happy when they find-out that the patient on the table has an antibody that will significantly delay packed cell availability.  I would also "make friends" with your Perfusion team.  Ours are the TEG experts in the OR, and help to guide the component utilization.  We still reserve two platelets for a CAGB, but rarely transfuse these patients.

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Definitely redos use more products, especially heart valve redos.  I think there are some patients on plavix that get more platelets because of that but most that get platelets get them when they are coming off the pump as those above said.  We don't have TEG or ROTEM so they just judge by how much oozing they see I think.  Ours don't give a ton of products but they still want a couple of red cells in the OR a fair amount.

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