Aryeh Shander, MD, FCCM, FCCP Surgical Bleeding and Transfusions: The Issues in 2004 Chief, Dept of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital & Medical Center and Associate Clinical Professor, Mount Sinai School of Medicine
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Surgical Bleeding and Transfusions: The Issues in 2004
Surgical Bleeding and Transfusions: The Issues in 2004. Aryeh Shander, MD, FCCM, FCCP. Chief, Dept of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital & Medical Center and Associate Clinical Professor, Mount Sinai School of Medicine. Objectives. - PowerPoint PPT Presentation
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Aryeh Shander, MD,FCCM, FCCP
Surgical Bleeding and Transfusions: The Issues in 2004
Chief, Dept of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital & Medical Center and Associate Clinical Professor,
Mount Sinai School of Medicine
Objectives
Risks of bleeding, subsequent hypovolemia, and acute anemia
American College of Surgeons (ACS)Advance Trauma Life Support (ATLS)
Society of Critical Care Medicine (SCCM)
Failure of the circulatory system to maintain adequate cellular perfusion
Bleeding and Hemorrhage
•Macrocirculation Compensation Shifting of blood flow
•Microcirculatory response Cellular adaptation Phenotype survival SIR
MACMACROCIRCULATIONROCIRCULATION
MICMICROCIRCULATIONROCIRCULATION
PLASMAPLASMA
Baseline Delta max0
100
200Sy
stol
ic B
P (m
mHg
)
Human Hemorrhage and Blood Pressure
25-30% bleed25-30% bleed(n=6)(n=6)
Hamilton-Davies C et al, Hamilton-Davies C et al, Intensive Care Med 1997;23:276-81Intensive Care Med 1997;23:276-81
Baseline Delta max0
20
40
60
80He
art R
ate
Human Hemorrhage and Heart Rate
25-30% bleed25-30% bleed(n=6)(n=6)
Hamilton-Davies C et al, Hamilton-Davies C et al, Intensive Care Med 1997;23:276-81Intensive Care Med 1997;23:276-81
Baseline Delta max0.0
0.5
1.0
1.5
2.0
2.5im
-a C
O2
gap
(kPa
)
25-30% bleed25-30% bleed(n=6)(n=6)
p=0.002p=0.002
Human Hemorrhage and Gastric Perfusion
Hamilton-Davies C et al, Hamilton-Davies C et al, Intensive Care Med 1997;23:276-81Intensive Care Med 1997;23:276-81
Deliberate perioperative increase of DO2 >600 ml/min/m2 using volume loading and dopexamine in RCTProtocol (dopexamine) group had higher DO2 preop and postop (p<0.001)
Boyd O. JAMA 1993;270:2699-2707.
(n=107) Dopexamine Control P Complications 0.68±0.16 1.35±0.02 0.008 Mortality 5.7% 22% 0.015
– Local (surgery) Vs. Systemic (trauma) Pro and inflammatory response
The role of interleukin-10 in the regulation of the systemic inflammatory response following trauma-hemorrhage Schneider CP et al, Biochim Biophys Acta 2004;1689:22-32.
– Protective role
– Damaging role
Risks of Anemia
Anemia in CVD
Hgb = Mortality in CVDCarson/Gould – 300 Pts with Hgb <8
gm/dL - StratifiedCarson JL et al, Lancet
1996;348:1055-60
Hgb < 9.5 g/dL = high risk with CVD
Hebert PC at al, Am J Respir Crit Care Med 1997;155:1618-23
Hgb < 7.0 g/dL acceptable with normal coronary circulation
Low Hct and Adverse Outcome
Lowest CPB HCT of <14% in low risk patients and <17% in high risk patients associated with doubling of mortality risk (Fang WC, Circulation 1997)
Below 23%, CPB HCT is inversely related to mortality (Defoe GR, Ann Thorac Surg 2001)
In postop cardiac surgical pts, inverse relationship exists between hemoglobin and major morbidity (Hardy JF, Br J Anaesth 1998)
Perioperative vital organ dysfunction, short- and intermediate-term mortality increased with lowest HCT <22% (Habib RH, J Thorac Cardiovasc Surg 2003)
Blood transfusion in Elderly Patients with Acute Myocardial
InfarctionWu WC et al, NEJM 2001;345:1230-36
Cooperative Cardiovascular Project– 234,769 total patients 78,974 (33.6%) included– CMS ICD-9 discharge code for MI and anemia– Anemia – WHO definition Hct of 39% or less– Hct in the first 24 hrs– 30 day mortality
3324 (4.2%) had Hct less than 30%– These patients had more trauma, surgery,
internal bleeding, coexisting diseases, DNR, shock and less treatments (β blockers ASA etc.)
3680 (4.7%) of the cohort received transfusions
Low Hct and Adverse Outcome
Retrospective database reviews These studies did not assess impact of
transfusion or preoperative hematocrit Lowest HCT groups were transfused at a
McAlister FA et al, Br J Surg 1998;85:171-8.Innerhofer P et al, Transfusion 1999;39:1089-96.
Immune modulationAllogeneic transfusion may enhance tumor recurrence
following colorectal cancer resection (Heiss MM, J Clin Oncol 1994)
Allogeneic transfusion is associated with prolonged hospital LOS (Vamvakas EC, Transfusion 2000)
Allogeneic transfusion is associated with increased risk of bacterial infection (35%) and pneumonia (52%) (Carson JL, Transfusion 1999)
Length of storage of transfused RBCs was associated with postoperative pneumonia following CABG surgery, 5% per unit (Vamvakas EC, Transfusion 1999)
Donor Leukocytes
Persistence of donor WBCs in trauma patients for up to 1.5 years after an allogeneic blood transfusion‘Survival of donor leukocyte subpopulations in immunocompetent transfusion recipients: frequent long-term microchimerism in severe
trauma patients’
2 x 109 WBCs in one unit of packed red blood cells1 x 108 WBCs – centrifuged, buffy coat depleted1–5 x 106 WBCs – leukocyte filter, leukocyte-depleted
Lee TH et al, Blood 1999;93:3127–3139
Leukocyte reduction results in a significant reduction of mortality in patients undergoing cardiac surgery
Mortality Rates Are Lower When Leukocyte-Reduced
Blood Is Used
0
2
4
6
8
10
Allogeneic Leukocyte Reduced
van de Watering LMG et al, Circulation 1998;97:562–568
Mor
talit
y Ra
te
(%)
7.8%
3.3%
n=914Bc=306Ff=305Sc=303
A prospective, randomized clinical trial of universal WBC