PowerPoint Presentation (PDF) - Perfusion.com

Microcircuitry
Strategies to maintain hematocrit
Daniel Gomez MT, CCP
The Heart Center @ Nationwide Children’s Hospital
Columbus, OH

Disclosures
• I have no relationships, financial or
otherwise, to disclose.
• IRB approval (IRB06-00498) for data
harvest @ Nationwide Children’s Hospital

Outline
• Nationwide Children’s system
• Nationwide Children’s techniques
• Our data
• Evidence mixed within

Literature
• Nearly 20% of blood
transfusions in the US are
associated with cardiac
surgery.
• It is the individual physician
and institutional behavior that
have been identified as the
main reasons for transfusion,
not patient co-morbidity or
blood loss.
J Thorac Cardiovasc Surg. 2007 Aug;134(2):284-9.
Pediatric cardiac surgery without homologous blood
transfusion, using a miniaturized bypass system in
infants with lower body weight.
Miyaji K, Kohira S, Miyamoto T, Nakashima K, Sato H, Ohara K, Yoshimura H.

Team Effort…Pre
Post
• Family
• Interventional Cardiology
• Surgeon
• Anesthesiology
• Perfusion
• Intensive Care
• Nursing
• Laboratory
• Blood Bank
• Legal Services

Pre-Operative Considerations
• Family Discussion
– Pre-op donation
• Intervention vs Palliation vs Repair
– Cath lab technique
• Epogen / +/- Iron Supplementation
• Pre-Op labs
• Kg weight & fitting circuits

Intra-op Perfusion Techniques
• Circuit selection
• Arterial sampling – 2 stopcock, waste
• Autologous Donation (ANH)
• RAP/VAP
• CI protocol = smaller circuits/less hemodilution
• ZBUF
• MUF
• Autotransfusion
– Washed prbc, if needed anytime for CPB
– Circuit flush to ‘cellsaver’ s/p MUF
– 60ml minimum return

Calculations
Pre-op Hct
Post ANH Hct
Est Hct on CPB
w/o ANH, no RBC’s
Est Hct on CPB
w ANH, no RBC’s

Circuit Selection
Pt Weight < 6.1 Kg 6.1 - 15 Kg 15.1 - 20.0 Kg 18.0 – 25.0 Kg 25 -40 Kg 40.1 - 70 Kg > 70 Kg
AV Loop 1/8 x 3/16 5/32 x 1/4 3/16 x 1/4 1/4 x 5/16 1/4 x 3/8 3/8 x 3/8 3/8 x 1/2
Suck/Sump 1/8 1/8 1/8 1/8 1/4 1/4 1/4
Oxygenator FX 05 FX 05 FX 05 FX 15 FX15 FX15 SX18
ALF Integral Integral Integral Integral Integral Integral Integral
Plegia CSC14 CSC14 CSC14 CSC14 CSC14 CSC14 CSC14
Ultrafilter DHF02 DHF02
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Prime (ml) 163 227 233 419 457 596 780
Flow
(L/min)
< 0.65 0.65 - 1.35 1.35 - 1.8 1.5 – 2.5 2.5 - 3.0 3.0 - 4.5 > 4.5

Tubing
• Tubing Size and Length
– APPROXIMATE TUBING PRIMES & MAX BLOOD FLOW RATES
Tubing Prime Volume +
1/8" ID 2.5 ml/ft 2002
5/32" ID 3.7 ml/ft 2003
3/16” ID 5.0 ml/ft 1998
1/4" ID 9.65 ml/ft
5/16” ID 13.5 ml/ft 2008
3/8" ID 21.71 ml/ft
1/2" ID 38.61 ml/ft
– ~ FLOWS (Gravity)
Tubing Arterial (ml/min) Venous (ml/min)
1/8 650
5/32 1250
3/16 1400 650
1/4 3000 1800
5/16 5500 2300
3/8 > 5000 4500
1/2 7000

Circuit 2010
(1/8 x 3/16 FX05)
CSC 14
FX05
DHF02

2010 NCH Cardiac OR

1 st Assistant
Suckers / Vent
Arterial Line
Venous Line

Terumo Capiox FX Series

Terumo Capiox FX Series

(ANH) Acute Normovolemic Hemodilution
• Savings: test $, time to pre-donate, ‘fresh whole blood’
• Weight limit?
– Proper volume to remove for benefit?
• Resternotomy
– Target 100%
– If first time sternotomy, depends on patient size and
procedure
• Anticoagulant
– 8 mL ACD / 60 mL
• Target Hct
– dilutional hct on CPB ≥ 21% post ANH & RAP/VAP

ANH
• 20% est CBV target
– Replace with 1:1 crystalloid &/or 5% Albumin
– Neonates
• Minimum goal 52 mL plus ACD
– Adults
• Minimum goal 600mL including ACD
• Blood drawn prior to incision
• Blood Storage
– Stored @ RT for 8hrs per NCH BB

RAP/VAP
• Any patient with a crystalloid prime circuit
• 10-50mcg bolus via anesthesia
• Goal = ~ 60% of prime volume
• 3.5 Kg personal best

Zero-Balance UF

Preliminary Results
• Plasma TNF- leveled
off
• Effluent TNF-
continued to increase
PC/High UF
HFOV/High UF
PC/High UF
HFOV/High UF

CDI 500 Arterial Shunt Sensor
Limit lab draws
Arterial shunt with
CDI 500 Arterial
cuvette in place.

‘Not one drop of blood wasted’
NCH Experience

Overall Bloodless (CPB/OR)
All Ages
0.6
0.5
0.4
0.3
0.2
0.1
0
2002 2003 2004 2005 2006 2007 2008 2009 2010

ANH

RAP/VAP

Bloodless Cardiac Surgery
@ Nationwide Children’s Hospital
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
0 - 6 Kg 6.1-15 Kg 15.1 - 20 Kg 20.1 - 40 Kg 40.1 - 80 Kg > 80 Kg Overall
2004-2006 2007-2009 2010 ytd

Hct (%) all patients 2002-Present (CPB)
50.0
N = 1758
45.0
40.0
35.0
30.0
25.0
Bloodless
Transfused
20.0
15.0
10.0
5.0
0.0
Baseline On Pre-Term Off CICU

3.00
Lactate
2.50
Blood
Bloodless
2.00
* p = 0.000
1.50
* p = 0.024
1.00
0.50
0.00
LacBase Lac10min LacPreterm LacspProt Lac_CTICU

JW
• NCH IRB
• n=113
• 2002-present
• 7 deaths
– 4 combined Norwood/Glenn
– 2 MAPCAs/unifocalization
• Complications
– Pleural effusion, arrhythmias, hematuria,
hyperthermia, bleeding
– 2 documented neuro insults

The Future
• How can we as a team continue to
reduce transfusion percentage?
– Vacuum assist?
– Pumpless suckers?
– Change to ped centrifugal pumps/oxy/AF?
– Micro sampling with no waste?
– Non-absorbent towels?
– New medications around the corner?
• Attention to every detail

daniel.gomez@nationwidechildrens.org

Blood vs Bloodless
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Overall

Objective
• To understand techniques and
components available to the perfusion
team in an effort to reduce and/or avoid
blood product usage during CPB.

Circuit Selection
Pt Weight < 6.1 Kg 6.1 - 15 Kg 15.1 - 20.0 Kg 18.0 – 25.0 Kg 25 -40 Kg 40.1 - 70 Kg > 70 Kg
AV Loop 1/8 x 3/16 5/32 x 1/4 3/16 x 1/4 1/4 x 5/16 1/4 x 3/8 3/8 x 3/8 3/8 x 1/2
Suck/Sump 1/8 1/8 1/8 3/16 3/16 3/16 & 1/4 1/4
Oxygenator FX 05 FX 05 FX 05 FX 15 FX15 FX15 SX18
ALF Integral Integral Integral Integral Integral Integral Integral
Plegia CSC14 CSC14 CSC14 CSC14 CSC14 CSC14 CSC14
Ultrafilter DHF02 DHF02
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Prime (ml) 163 227 233 419 457 596 780
Flow
(L/min)
< 0.65 0.65 - 1.35 1.35 - 1.8 1.5 – 2.5 2.5 - 3.0 3.0 - 4.5 > 4.5

Circuit Selection
Pt Weight < 6.1 Kg 6.1 - 15 Kg 15.1 - 20.0 Kg 18.0 – 25.0 Kg 25 -40 Kg 40.1 - 70 Kg > 70 Kg
AV Loop 1/8 x 3/16 5/32 x 1/4 3/16 x 1/4 1/4 x 5/16 1/4 x 3/8 3/8 x 3/8 3/8 x 1/2
Suck/Sump 1/8 1/8 1/8 3/16 3/16 3/16 & 1/4 1/4
Oxygenator FX 05 FX 05 FX 05 FX 15 FX15 FX15 SX18
ALF Integral Integral Integral Integral Integral Integral Integral
Plegia CSC14 CSC14 CSC14 CSC14 CSC14 CSC14 CSC14
Ultrafilter DHF02 DHF02
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Prime (ml) 163 227 233 419 457 596 780
Flow
(L/min)
< 0.65 0.65 - 1.35 1.35 - 1.8 1.5 – 2.5 2.5 - 3.0 3.0 - 4.5 > 4.5

Circuit Selection
Pt Weight < 6.1 Kg 6.1 - 15 Kg 6.1 - 20.0 Kg 18.0 – 25.0 Kg 20 -40 Kg 40.1 - 70 Kg > 70 Kg
AV Loop 1/8 x 3/16 5/32 x 1/4 3/16 x 1/4 1/4 x 5/16 1/4 x 3/8 3/8 x 3/8 3/8 x 1/2
Suck/Sump 1/8 1/8 1/8 3/16 3/16 3/16 & 1/4 1/4
Oxygenator FX 05 FX 05 FX 05 FX 15 FX15 FX15 SX18
ALF Integral Integral Integral Integral Integral Integral Integral
Plegia CSC14 CSC14 CSC14 CSC14 CSC14 CSC14 CSC14
Ultrafilter DHF02 DHF02
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Terumo
CXHC05
Prime (ml) 163 227 233 419 457 596 780
Flow
(L/min)
< 0.65 0.65 - 1.35 0.65 - 1.5 1.5 – 2.5 1.5 - 3.0 3.0 - 4.5 > 4.5

DHCA
Low-flow
J Thorac Cardiovasc Surg 2003;126:1765-74

Circuit Considerations
• Anything that holds, passes, transfers volume
• Pump type
• Tubing
– Arterial Line
– Venous Line
– Sucker/Sump Lines
– Ultrafilter Lines
– Cardioplegia Lines
– Manifold Lines
• Filters
– Arterial Line Filter
– Ultrafilter
– Pre-bypass
• Reservoirs
– Venous
– Cardiotomy
• Cardioplegia
• Oxygenator

%
50
Hematocrit Change
45
40
35
30
25
Blood Admission
Bloodless
20
15
10
P < 0.02 at all points
5
0
Baseline CPB CPB last Post-Protamine CTICU

Goals of Bloodless Surgery
• Avoidance of donor blood
– Infection
– Immunological problems – hemolytic transfusion reactions
– Metabolic problems
– Cost
– Parental / Religious preference
• Avoidance of hemodilution
– Increased capillary leak / edema (NCH target ≥ 21%)
– Dilution of circulating proteins
– Disruption of clotting mechanisms
• Reduction of exposure to synthetic surfaces (SIRS)

RAP
Retrograde Arterial Prime
Rousou et al, The primeless pump: a
novel technique for intraoperative
blood conservation
Cardiovascular Surgery 1999, 7:228-
235.

VAP
Venous Antegrade Prime
Rousou et al, The primeless pump:
a novel technique for intraoperative
blood conservation
Cardiovascular Surgery 1999,
7:228-235.

1998 – 2010
• Neonate, 3.7 Kg, 55 cm, BSA 0.23 m 2 , Hct 40%, CBV 316 ml
1998 2003 2010
Oxygenator Micro (52ml) Baby RX (43ml) Baby FX (43ml)
Arterial Line Filter Terumo (40mL) None Integral
Tubing 3/16 x 1/4 (270ml) 1/8 x 3/16 (85ml) 1/8 x 3/16 (57ml)
Cardioplegia w/ UF Vanguard (90ml) CSC14 (60 ml) CSC14 (63 ml)
Prime Volume 450ml 188 ml 163 ml
0 units Blood 17% 25% 26%
1 unit Blood 36% 55% 58%
2 units Blood 56% N/A N/A

Continuous Blood Gas Monitoring
May Equal Less Sampling
• Parameters
– pH
– pCO 2
– pO 2
– BE
– K +
I-Stat samples 0.1 ml
Hemochron Jr 0.1 ml
– S v O 2
– Hct/Hgb

Cell Saver
Fresenius C.A.T.S.
• Continuous Blood Processing
– no batch processing, no residual blood
• Volume Independent
– independent of the volume collected
– can process shed blood with as little
as 15 ml of PRC
• Entire circuit is flushed with 1Liter
Normosol-R post-MUF
• Used for washing bank pRBC’s if
needed

Other Considerations
• MUF
– Arterial-venous
– Cardioplegia circuit
– ~ 95% of patients
• Cell Save Circuit
– 1 L plasmalyte flush of circuit
• All sucker/sump lines cleared w/ 0.9% NaCl
• Return all red cells

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