Cardiovascular surgeries, Transfusion triggers, and wastage

[bangingmyhead]

Hello.

I have a plethora of questions I want to ask, but i will ambitiously try to roll this into one topic.

Those of you out there with Cardiovascular (open heart) surgeries... Do you have a different policy for transfusing CV patients vs normal surgery patients. This includes triggers (HGB, PLT, etc), minimal units of plts on hand, etc. Any information would be helpful.

We have recently started CV surgeries, and currently Doctors are unchecked. We essentially musth thaw, XM, and tag whatever they request. This is resulting in increased waste. A large increase. Of course they are using the fact that they are CV and the surgeries are high risk as the reason we cannot have transfusion triggers.

Any ideas, strategies, or anecdotes would be helpful.

[Malcolm Needs ☆]

It may be worthwhile you getting hold of, and referring to, a copy of

Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. New England Journal of Medicine 1999; 340 (6): 409-417?

[Malcolm Needs ☆]

Another source of information (although I must warn you, this one is a bit of a "tome") may be:

Report from the STS Workforce on Evidence Based Surgery (The Society of Thoracic Surgeons Blood Conservation Guideline Task Force and The Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion). Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery: The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline. Ann Thorac Surg 2007; 83: S27-86.

[carolyn swickard]

Our cardiovascular surgeons routinely order 4 RBCs Xm'd, 4 FFPs on standby (not thawed) and 2 PLTPHs on standby. Their transfusion trigger for RBCs post surgery is HCT 28, a little high for current trends, but they creep along 1 unit at a time, at least. We no longer have to thaw 2 FFPs in advance because we now have a Helmer waterbath that can get the units thawed in no more than 20 minutes, but they still waste some FFP. We lose less now that we extend our unused FFPth to Thawed Plasma - gives us a little longer to use FFP they don't use. The Plts can go back to the center if not used (we have consignment priviledges - we have a Helmer plt incubator), though they frequently just get used on our oncology pts. The cadiovascular surgeons do like to see a plt count of at least 100,000 before starting surgery - can't say as I blame them. Recent trends here are for very little blood use on these surgeries anyway. More than 50% use nothing and the other 50% only use a couple of units most of the time. They were closing many surgeries with 2 FFP and 1 plt, but that has changed and is not happening much now. They used to be practically our only users of Cryo, but they use very little of that now too (just after we finally got pooled Cryo!).

If your Cath Lab cardiologists are new and just learning their procedures - that may be where your problem is coming from. Things were crazy around here when we first opened our Cath Labs and many pts went straight from the Cath lab to the OR, especially the ones on ReoPro - a nasty drug. The newer drugs are more "reversable", so the pt doesn't arrive in the OR with a functional plt count of "0" - those were fun. As everyone gets more experience, hopefully things will settle down for you. They like blood and components to be "ready", but they don't have to use a lot of it and they really shouldn't waste a lot.

[L106]

I am not aware if our open heart surgeon have set transfusion triggers, and we haven't heard anything about ReoPro. Other than that, our experience is very similar to that described by cswickard.

Donna

[John C. Staley]

I noticed over the years that the blood usage by CV surgeons varied widely from surgeon to surgeon and from facility to facility. At my previous facility 2 of the 4 used very little if any blood and when they did it was usually on re-do surgeries. These were the older and more experienced 2. The younger 2 were not bad but still seemed to use more and want more readily available.

At another facility in the same corporation about 60 miles south, they had trouble keeping enough blood products on hand to keep up with their CV surgeons. (possibly a slight stretch of the facts but not much!) I also discovered that often, during the surgery, it's the gas passers (never could spell anesthesiologist!!) that do most of the blood ordering and the surgeon is sometimes surprised at the amount of blood being transfused.

I know none of this helps you with your problem, just thought it had been awhile since I posted. :writersbl

[L106]

I noticed over the years that the blood usage by CV surgeons varied widely from surgeon to surgeon and from facility to facility. At my previous facility 2 of the 4 used very little if any blood and when they did it was usually on re-do surgeries. These were the older and more experienced 2. The younger 2 were not bad but still seemed to use more and want more readily available.

Very, very true. We have seen the entire spectrum: One surgeon was absolutely phenomenal (ie: excellent), and one was absolutely disastrous.

Donna

[DPruden]

Our Blood Bank medical director is very involved with utilization questions/problems. It is very helpful to have an MD that is knowledgeable about transfusion medicine to directly talk to the surgeons.