Patient Blood Management: Acute Normovolemic Hemodilution Mark T. Lucas, MPS, CCP Chief of Perfusion Denver Cardiovascular Perfusionists Centura St Anthony Hospital – Lakewood, CO Exempla Lutheran Medical Center – Wheatridge, CO

Acute Normovolemic Hemodilution is the pre or intra-operative removal and sequestration of one or more units of whole blood from the patient with a replacement volume using colloid, crystalloid, or a combination of both to maintain adequate circulating blood volume. A numbers game Show you why 1972 and is performed worldwide

Blood Management Strategies Blood Management Awareness Epoetin/Nutrition supplementation – pre-op anemia for elective surgery Perioperative Acute Normovolemic Hemodilution Low Prime Bypass Systems Retrograde Autologous Priming Micro and pediatric sample blood draws AT-III replacement protocol Restrictive bypass sucker use Autotransfusion/Cell Salvage Antifibrinolyitics Surgical hemostasis/sealants Endoscopic Vein Harvesting Heparin level monitoring Point of Care Coagulation and Hematologic Monitoring Hemofiltration/Zero Balance Ultrafiltration/Modified Ultrafiltration Euvolemic anesthetic technique These are some of the procedures we undertake to maintain the patient’s red cell volume so we won’t have to replace it with allogeneic red cells.

Indications and Selection for ANH Surgical Procedures with potential blood loss greater than 20% and/or disturbance of coagulation system requiring the use of allogeneic blood products All major surgical patients without contraindications or sequestration intolerance

Contraindications Known coagulopathy with active bleeding Active ischemic organ disease Hemodynamic instability, BP < 100 mmHg, CI < 1.8 Acute renal failure Anemia with Hgb < 10 g/dl Hemoglobinopathy processes Peripheral arterial vascular disease Acute ischemic stroke Sudden deafness Acute pancreatitis Multiple organ failure Sepsis Severe Aortic Stenosis Cardiac output <25% and/or use of inotropes

Collection Intolerance DECREASED CARDIAC OUTPUT Moderate and clinically significant increase in heart rate Increasing base deficit Signs of peripheral ischemia Signs of coronary ischemia Decrease in core temperature

Calculate removable blood volume to Hct 24% on bypass Blood Volume Nomogram Ht in Ht cm Blood vol   male female 58 147.32 3312.4 3075.8 59 149.86 3490.2 3240.9 60 152.4 3668 3406 61 154.94 3845.8 3571.1 62 157.48 4023.6 3736.2 63 160.02 4201.4 3901.3 64 162.56 4379.2 4066.4 65 165.1 4557 4231.5 66 167.64 4734.8 4396.6 67 170.18 4912.6 4561.7 68 172.72 5090.4 4726.8 69 175.26 5268.2 4891.9 70 177.8 5446 5057 71 180.34 5623.8 5222.1 72 182.88 5801.6 5387.2 73 185.42 5979.4 5552.3 74 187.96 6157.2 5717.4 75 190.5 6335 5882.5 76 193.04 6512.8 6047.6 77 195.58 6690.6 6212.7 78 198.12 6868.4 6377.8 Calculated Blood Volume Male (Ht(cm)-100) x 70 ml Female (Ht(cm)-100) x 65 ml (assuming lean BMI 24) RCVi = bld vol x hct% RCVi – 189 = RCV2 RCV2/bld vol = Hct2 RCV2 – 189 = RCV3 RCV3/bld vol = Hct3 Is actually a variation on the Texas Heart calculation that can be found in Reed and Stafford. TH Allen 1956 – over estimates William Shoemaker, M.D. – blood volume based on radio labeled red cells and serum albumin Hct 24% leaves room for error, more than anticipated anesthesia dilution and loss from shed blood sequestration. Hct of 20% is absolute minimum. Mark Lucas

Case Report - Jehovah’s Witness 55 yr male, 180 cm, 77 kg, BMI 23.76 Hct 42%, Plt 167, fib 243 Htn, H-Chol, CHF 3+ Aortic insufficiency, 3+ Mitral insufficiency 80% dLAD, 80% dRCA A case report for a Jehovah’s Witness patient serves to show what can be performed and then used for every patient.

Surgical Plan Initiate bypass, drift cool, place retrograde plegia cannula apply cross clamp and arrest with retrograde plegia, Perform right coronary distal, attach proximal to retro plegia line Place Left ventricular vent Open aorta and administer direct coronary antegrade plegia Replace aortic valve, close aortotomy Rewarm patient Perform proximal vein anastomosis Perform mammary artery distal to LAD De-air and remove from CPB

Blood Management Plan Perform ANH to sequester whole blood, preserving cells and clotting factors. Reducing cellular components of blood volume to reduce loss in shed blood, consumption and destruction in bypass system Carmeda coated system to reduce inflammatory response to bypass system Patient specific anticoagulation dosing and maintenance to preserve clotting factors and platelet function. Continuous in-line blood gas monitoring to reduce testing and blood loss Antifibrinolytics to aid in reducing bleeding Shed blood collection for washing and removing tissue factor Recovery of residual pump volume by concentration and return to patient

ANH calculations Target on bypass Hct 24% ANH removal vol – 3 units (1350 ml WB, 25% BV) Replacement crystalloid 1400 ml + 600 ml maintenance Unit #1 – Hct 42% - 189 ml rbc, 14,000 plts Unit #2 – Hct 34% - 173 ml rbc, 12,700 plts Unit #3 – Hct 31% - 158 ml rbc, 11,500 plts 520 ml rbc 38,200 plts

Patient Access to Right Internal Jugular The side port of the Swan sheath provides an excellent source for blood sequestration and return. This performed before the Swan is floated for maximal flow.

Continuous Connection Manifold A three-way stopcock connects the tubings for all three units and remains connected during the procedure to the patient’s vascular access.

Bypass 1st Hct on bypass – 26% Total time on support 130” Cross clamp time – 108” Hct post return (3) ANH units, 32% Hct post return concentrated residual pump volume, 36% 650 ml @ hct 60% Shed blood collected 400 ml, processed to 89 ml and returned “No bleeding” “Preserved Cellular Quantity and Quality”

Efficacy ANH Measured changes in Hct during procedure

Efficacy to Reduce Allogeneic Transfusion Primary CABG – non ANH Jan – Dec 2010 Primary CABG – ANH Jan – Dec 2010 N = 103 % transfusion rate PRBC FFP Plts Cryo 15.65 10.98 4.65 0.00 N = 48, % transfusion rate PRBC FFP Plts Cryo 11.33 6.52 3.26 0.00 Results for ANH in 2010. Total of 187 units harvested (84,400 ml) from 103

Improved Coagulation Function Post Administration of ANH Positive changes in Sonoclot variables post return of ANH.

Outcomes Measures CABG: No Bld ANH/No ANH Time On Ventilator ANH - Mean 5.86 days, SD 5.83 No ANH – Mean 8.69 days, SD 11.07

Outcomes Measures CABG: No Bld ANH/No ANH Post-op Length of Stay ANH - Mean 6.8 days, SD 2.7 No ANH – Mean 7.6 days, SD 3.1

Summary Acute Normovolemic Hemodilution is a proven Blood Management modality All patients with an expected coagulation disturbance or potential for allogeneic transfusion are candidates Contraindications and intolerance are well defined Technique, equipment and planning are required Vascular access and monitoring are required Results in higher hematocrit, improved platelet and coagulation function and reduced transfusions post procedure