Blood Conservation in a Congenital Cardiac Surgery Program

Article Outline

• ABSTRACT
• Preoperative Management
• Intraoperative Management
  • Blood draws
  • Intraoperative autologous blood donation
  • Intraoperative cell salvage
  • Modifications in CPB
• Postoperative Management
• Risks
• A Study of Congenital Cardiac Procedures
• Conclusion
• Examination
  • Blood Conservation in a Congenital Cardiac Surgery Program
    • Purpose/Goal
    • Behavioral Objectives
    • Questions
  • Answer Sheet
    • Blood Conservation in a Congenital Cardiac Surgery Program
  • Learner Evaluation
    • Blood Conservation in a Congenital Cardiac Surgery Program
    • Purpose/Goal
    • Objectives
    • Content
    • Test Questions/Answers
    • Learner Input
• References
• Copyright

ABSTRACT 

BLOODLESS SURGERY PROGRAMS are being instituted because of increasing public concerns about blood transfusions and the need to accommodate some patients' religious beliefs. Patients' desires to forego transfusion must be identified during the preoperative screening process and subsequently reflected on the surgical consent.

PATIENTS ARE MANAGED preoperatively with erythropoietin and dietary supplements. The surgical team employs a variety of intraoperative and postoperative blood conservation techniques to help avoid the need for transfusion.

A RETROSPECTIVE REVIEW of congenital cardiac procedures in a blood conservation program confirmed that bloodless cardiac surgery is effective. AORN J 87 (June 2008) 1180-1186. © AORN, Inc, 2008.

The increase in public concern regarding allogenic blood transfusions (ie, transfusions using the stored blood of others) has led many institutions to develop blood conservation programs.¹ This is primarily a result of

In addition, members of certain religions (eg, Jehovah's Witnesses) refuse blood transfusions because they believe blood is sacred.³ In the Jehovah's Witness faith, when blood is detached (ie, completely separated) from the body, it should not be returned.⁴ The patient's own blood may exit the body, however, and be readministered if it is kept in a continuous closed circuit.

The term bloodless surgery refers to the act of performing surgery and recovery without transfusing any blood or blood products.⁵ The term blood conservation refers to the treatment strategies used to achieve bloodless surgery.⁵ Innovative surgical techniques aimed at blood conservation continue to be developed, including

Cardiopulmonary bypass (CPB) techniques also have been modified in ways that increase the possibility of bloodless cardiac surgeries.⁷

Bloodless surgery is not exclusively about surgical strategies, however. Preoperative, intraoperative, and postoperative clinicians must work in unison when caring for these patients to deliver optimal comprehensive care.

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Preoperative Management 

When a patient wants to forego blood transfusion, attention must be focused on legal consent. For example, most Jehovah's Witnesses refuse transfusion of red blood cells, platelets, plasma, or whole blood, and also refuse to undergo preoperative autologous blood donation. It is considered a matter of conscience, however, for the Jehovah's Witness patient to accept plasma products and other coagulation factors.³ Each patient must make his or her own decision on whether to accept blood products based on his or her own interpretation of the Bible and own moral and ethical beliefs.⁸

Clear delineation is required in the surgical consent to reflect the patient's wishes. Although adults have the right to refuse blood products even if death is imminent, many state laws prohibit withholding blood from a minor when there is a threat to organs or life.⁹ Each state and federal law is uniquely written. According to the US Supreme Court in Prince v Commonwealth of Massachusetts, the court determines the person's right to practice religion freely, however, that does not include the liberty to expose children to ill health or death.¹⁰ These issues need to be clearly discussed so that all members of the perioperative team act in accordance with the patient's desires and adhere to legal statutes.

Preoperative screening and management of a patient in a blood conservation program is critical to achieving successful patient outcomes. A patient with a prior history of unexpected bleeding or clotting problems or the presence of underlying conditions (eg, cardiac or pulmonary disease, hyperlipidemia, hypertension, anemia, history of cerebral vascular disease, use of beta-blockers) has a greater risk of requiring surgical blood transfusions.⁶ Neonates or older adult patients also have a greater risk.⁶ Health care practitioners must ensure that the patient fully understands what measures will be taken in the attempt to conserve blood and the risks associated with each measure.

In an effort to reduce the effects of blood loss during surgery, the primary health care provider or surgeon may prescribe epoetin alpha, a synthetic form of erythropoietin (EPO), for at least four weeks before surgery. Erythropoietin is a naturally occurring glycoprotein that stimulates the bone marrow to produce red blood cells in response to tissue hypoxia.

Epoetin alpha (eg, Procrit, Epogen) is administered intramuscularly in weekly doses of 500 units/kg during the preoperative period to elevate the hematocrit (HCT) in preparation for intraoperative blood loss.¹¹ In addition, the primary care clinician should advise the patient to take an iron supplement and a multivitamin containing vitamin C for iron absorption, folic acid, and B₁₂ for DNA synthesis and red cell production. The clinician also may recommend that the patient take supplements or eat foods high in vitamin K, which aids the liver in the synthesis of clotting factors.

The perioperative nurse must review and document all medications and herbal or dietary supplements that the patient currently is taking. The nurse should note whether the patient takes anticoagulants and other nonsteroidal anti-inflammatory medications that may interfere with coagulation. Certain antibiotics (eg, cephalosporins) may cause coagulation abnormalities by affecting the patient's bowel flora, which can affect vitamin K absorption.¹² It is important for the nurse to specifically ask the patient whether he or she uses herbal or dietary supplements, which may affect the body's hemostatic process. The primary care clinician or surgeon should instruct the patient to discontinue these therapies before surgery, if possible.

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Intraoperative Management 

Intraoperative techniques aimed at blood conservation continue to increase the possibility of performing more complex cardiac procedures without having to transfuse allogenic blood. Intraoperative techniques include modified blood draws, intraoperative autologous blood donation, intraoperative cell salvage, and modifications in CPB (Figure 1).

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• Figure 1. 

  The patient's blood is maintained in a continuous closed circuit for cell salvage, bypass, and autologous blood transfusion.

Blood draws 

The circulating nurse or anesthesia care provider performs a blood type and cross match in the OR after peripheral and arterial lines are placed, drawing only 1 mL to 3 mL of blood. Measures are taken to preserve every drop of blood by limiting percutaneous line attempts, and fluid administration is monitored closely to avoid unnecessary hemodilution. Arterial blood gas, electrolyte, chemistry, coagulation, hematology, and cardiac marker samples are kept to a minimum by using a clinical analyzer that only requires three drops of sample to obtain results.¹³ Another technique is the double-stopcock technique for blood sampling (Figure 2). This technique is employed in an effort to conserve blood for arterial blood sampling by allowing the diluted blood that was drawn initially, which typically is wasted, to be readministered within the same continuous circuit.

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• Figure 2. 

  The double-stopcock technique minimizes blood loss by allowing re-administration of initial blood drawn during blood sampling in a continuous circuit.

Intraoperative autologous blood donation 

During intraoperative autologous blood donation, the anesthesia care provider allows 20% of the patient's blood volume to drain directly into an IV bag. The anesthesia care provider monitors the patient's vital signs closely for hypotension during the process. When complete, the anesthesia care provider clamps and inverts the bag so it is ready for post-bypass transfusion (Figure 3). Although the blood is now outside the body, it is always kept attached to the patient through IV tubing lines in a continuous, unbroken system to comply with the Jehovah's Witness patient's religious beliefs.

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• Figure 3. 

  Pre-bypass autologous blood donation in continuous circuit with the patient prepared for post-bypass transfusion.

Intraoperative cell salvage 

Cell salvage suction is used throughout the entire surgical procedure. This allows blood from the surgical field to be collected, spun down, and routed via tubing in a continuous circuit into the patient's IV bag, ready for transfusion.

Modifications in CPB 

To avoid hemodilution from CPB, the perfusion team may employ retrograde arterial priming and venous antegrade priming after cannulation. Members of the perfusion team use these techniques to draw blood from the patient, displacing the crystalloid “prime volume” of the pump with the patient's own blood.⁶ A perfusionist initiates bypass slowly to avoid a rush of crystalloid fluid into the patient's coronary arteries, which could cause arrhythmias.

The challenge of avoiding hypovolemia or hemodilution for pediatric patients has led to the tailoring of pump circuits to shorter, smaller tubing. Increased size and length of the bypass circuit not only increases the amount of prime volume required, but also increases cellular damage as a result of contact with the tubing surface. The perfusion team strives to use the smallest circuit possible according to the patient's body surface area.⁶ In an average 7-kg infant, the smallest customized bypass circuit would hold 175 mL, which is equivalent to 31% of the patient's blood volume. The next largest available bypass circuit holds 250 mL, which equates to 44% of a 7-kg infant's total blood volume. In order to minimize prime volume, the surgeon and perfusion team collaborate regarding the surgical plan and the timing of an elective procedure, particularly if the patient's size is approaching the upper limit for a circuit. Modified ultrafiltration is performed after bypass before the patient is separated from the bypass machine. A perfusionist draws blood from the patient through the pump where free water is removed with an ultrafilter.⁶ The hemoconcentrated blood then is returned to the patient, raising the HCT as much as 10%.

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Postoperative Management 

Blood conservation techniques continue after the patient has left the OR. Noninvasive monitoring methods, such as cerebral saturation and vital signs, are employed in the cardiac intensive care unit (CICU) as the primary means of assessment. Blood sampling is limited, using the same techniques described intraoperatively, and arterial blood gas sampling is limited to one time upon arrival to the CICU and is not performed again until the next morning unless otherwise indicated. Nurses administer fluids cautiously to avoid hemodilution and promptly address any postoperative bleeding. Aprotinin, a serine protease inhibitor commonly given in the OR, may be repeated postoperatively for platelet deficiency.⁷ Although not frequently used, a chest-tube drainage autotransfuser also may be connected in a continuous system. Autotransfusion of chest-tube drainage is dependent on physician preference and the amount and quality of drainage. When the patient is transferred to the cardiac step-down unit, administration of epoetin alpha and iron are resumed to help the patient recover hematologically from the insult of bypass surgery.

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Risks 

There are very few risks involved in being treated in a blood conservation program. The greatest risk is the risk of receiving a blood transfusion. A common concern for patients is the fear of contracting infectious agents from donated blood. Health care practitioners can help ease the patient's fear by providing the patient with information on the chance of contracting one or more of these infectious diseases. The risk of contracting HIV is only about one per 1.9 million transfusions while the risk of contracting hepatitis B is only one per 200,000 and the risk of contracting hepatitis C is one in 3,000 to 5,000.¹⁴

There also are risks associated with erythropoietin injections.¹⁵ An occasional side effect (ie, 1% to 10%) of erythropoietin use is high blood pressure, especially in people who already suffer from high blood pressure and congestive heart failure. This occurs more frequently in adults or after long-term use of this medicine. Rare side effects (ie, less than 1%) of erythropoietin are flu-like syndrome, high potassium, deep venous thrombosis, vein inflammation with clotting, rapid heartbeat, myocardial infarction, pulmonary embolism, brain swelling, seizures, and stroke. These side effects occur more frequently in adults or after long-term use of this medicine. As with any medication, allergic reactions can occur. Common symptoms may include redness at the injection site, rash, or hives. Rarely, a severe and possibly life threatening allergic reaction can occur. Symptoms of a severe reaction include difficulty breathing, hives, or swelling.

The FDA has labeled this medication as a “black box drug” for patients in end-stage renal failure and patients on dialysis. In that patient population, studies have shown that administration of erythropoietin increases mortality rates.¹⁶ There are currently no studies regarding the usage of erythropoietin strictly in the pediatric population.¹⁵

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A Study of Congenital Cardiac Procedures 

Investigators conducting an institutional review board-approved, retrospective study reviewed the charts of 76 patients with congenital cardiac disease who were treated at Nationwide Children's Hospital Heart Center, Columbus, Ohio, from September 2002 to October 2007. One hundred two procedures were reviewed including CPB, cardiothoracic, interventional cardiac, and electrophysiological procedures. Open heart procedures included septal defect and tetralogy of Fallot repairs, single ventricle palliations, valve replacements, and arterial switches. Data collected included

Blood conservation strategies employed were consistent with those previously described.

Sixty-eight of the procedures reviewed were open heart surgeries requiring bypass (Table 1). The results demonstrated that 20% of patients weighing less than 7 kg who underwent CPB required blood products, whereas only 7% of patients weighing 7 kg to 15 kg and no patients weighing more than 15 kg required blood-product transfusion (Table 2). Of the 20 non-bypass surgical procedures and 14 interventional procedures reviewed, one 3-kg patient with hypoplastic left-heart syndrome required blood administration in the CICU for low cardiac output after an atrial septostomy in the cardiac catheterization laboratory. Overall, the trend in monitored HCTs for the patients showed an intraoperative nadir HCT (ie, a dip or the lowest point of the HCT) followed by a rebound toward baseline levels (Table 3 and Figure 4).

TABLE 1. Cardiopulmonary Bypass Procedures Reviewed

TABLE 2. Blood Product Utilization

* CICU blood product utilization noted for the first 48 hours

TABLE 3. Hematocrit Levels of Cardiopulmonary Bypass (CPB) Patients

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• Figure 4. 

  Mean Hematocrit Levels

In all, five patients died within the first postoperative week. All of the patients were two years of age or younger and had various forms of complex congenital heart defects; three had single-ventricle anatomy. Each infant death was the result of pulmonary or cardiac arrest with two patients being placed on extracorporeal circulation membrane oxygenation. Four of the five patients who died received blood products during their hospitalization.

After reviewing the records, the researchers determined that the incidence of the need for blood administration rises in patients of lower weight. Patients undergoing cardiac procedures who were managed with blood conservation strategies, demonstrate a dip in HCT levels in the immediate operative period followed by a gradual rise postoperatively. Patients with higher weight have a higher success rate with bloodless surgery; however, it is possible to perform bloodless cardiac surgery even on patients of low weight. Cardiopulmonary bypass increases the risk of blood administration.

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Conclusion 

Health care providers must be aware of each patient's wishes regarding blood transfusions and blood conservation options. Perioperative nurses must participate in preparing patients preoperatively if bloodless cardiac surgery is going to be attempted. Intraoperative and postoperative strategies aimed at blood conservation greatly increase the likelihood of success. With ongoing developments, bloodless cardiac surgery is possible in a congenital heart program.

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Examination 

Blood Conservation in a Congenital Cardiac Surgery Program 

Purpose/Goal 

To educate perioperative nurses about treating surgical patients in a blood conservation program with an emphasis on treating pediatric patients undergoing bloodless surgery for congenital cardiac conditions.

Behavioral Objectives 

After reading and studying the article on blood conservation programs, nurses will be able to

Questions 

Answer Sheet 

Blood Conservation in a Congenital Cardiac Surgery Program 

Event #08039

Session #1307

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Learner Evaluation 

Blood Conservation in a Congenital Cardiac Surgery Program 

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This evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

Purpose/Goal 

To educate perioperative nurses about treating surgical patients in a blood conservation program with an emphasis on treating pediatric patients undergoing bloodless surgery for congenital cardiac conditions.

Objectives 

To what extent were the following objectives of this continuing education program achieved?

Content 

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Test Questions/Answers 

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References 

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8. The real value of blood. Thewatchtower.org. http://www.watchtower.org/e/200608/article_03.htm, Accessed April 26, 2008.
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9. Preferences of patients. Acessmedicine.com. http://www.accessmedicine.com/content.aspx?aid-=2613357. Accessed April 26, 2008.
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10. Groudine SB . The child Jehovah's Witness patient: a legal and ethical dilemma . Surgery . 1997;121(3):357–358
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11. Trovarelli T, Kahn B, Vernon S. Transfusion-free surgery is a treatment plan for all patients. AORN J. 998;68(5):773-784
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13. Product information: i-stat 1. Abbott Laboratories . http://www.abbottpointofcare.com/istat/www/products/analyzers.htm Accessed April 26, 2008.
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14. The Lewin Group  . In: Ensuring Blood Safety and Availability in the US: Technological Advances, Costs, and Challenges to Payment—Final Report . Washington, DC: Advanced Medical Technology Association; September 2002;p. 13–18
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15. In: Physicians Desk Reference . 60th ed.. Montvale NJ: Thomson Healthcare; 2008;p. 589
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16. Information for healthcare professionals: Erythropoiesis stimulating agents. US Food and Drug Administration . http://www.fda.gov/cder/drug/InfoSheets/HCP/RHE200711HCP.htm Accessed April 12, 2008.
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