Embed Size (px)
Citation preview
Vigneshwar Kasirajan, M.D. Vigneshwar Kasirajan, M.D. Division of Cardiothoracic SurgeryDivision of Cardiothoracic Surgery
ResultsResource Utilization in Cardiac Surgery
05
1015202530354045
1997 1998 1999 2000 2001 2002
Year
% T
ran
sfu
se
d
0
50
100
150200
250
300
350
400
$ p
er
pa
tie
nt
TransfusionRate (%)
Cost perpatient ($)
Higgins, et al AATS 2003
Results
Hemoglobin Levels
6
7
8
9
10
11
12
13
Preop CPB MIN ICU DC
Time
gm/d
l Pre Program
Post Program
Green, et al. SCA 2003*=p<0.05
* *
ResultsFinancial Savings
0
200
400
600
800
1000
1200
1400
1600
1800
Pre Program Post Program
Th
ou
sa
nd
s o
f d
oll
ars
Adverse EventUnit & XmatchPersonnelTotal Cost
Spiess, et al. SCA 2003
Total Savings=$1.4MUnit and Xmatch=$295KFixed overhead=$274KAdverse Events=$863K
HEMOGLOBINHEMOGLOBIN
5
10
15
MINI 1
OPCAB 1
OPCAB 2
ONPUMP 1
ONPUMP 2
Retrograde Autologous Priming (RAP)
Eight month data review at Eight month data review at
VCU MEDICAL CENTERVCU MEDICAL CENTER
November ’04-June ‘05November ’04-June ‘05
TOTAL CASES ATTEMPTEDAttempted RAP Cases
179
260
50
100
150
200
TOTAL RAP Cases No RAP Cases
No RAP Cases
11.5
7.1
0
2
4
6
8
10
12
14
Pre Pump HGB 1st HGB onPump
HG
B
RAP CASES
8.4
12.0
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Pre RAP Post RAP
Pre-Post RAP Hgb
RAP Volume
703
393
0
100
200
300
400
500
600
700
800
Average Rapamount (mls)
Average Rapamount used (mls)
AUTOLOGOUS BLOOD OFF BY ANESTHESIA AFTER INDUCTION AVERAGED
516 mls.
HGBS ON BYPASS
RAP Cases
7.67.8
0.0
2.0
4.0
6.0
8.0
Lowest pump Hgb
Last pump Hgb
PATIENT’S HGB AFTER ARRIVING TO ICU AVERAGED
10.2 g/dl
CONCLUSIONS
Enhances communication between perfusionist, Enhances communication between perfusionist, anesthesiologist, and surgeon.anesthesiologist, and surgeon.
One month to achieve comfort level performing RAP.One month to achieve comfort level performing RAP. Priming volume of pump has been reduced from 1800mls Priming volume of pump has been reduced from 1800mls
to 650mls.to 650mls. Only 11% of RAP patients received bank blood.Only 11% of RAP patients received bank blood. 27% of No RAP(26 patients), received bank blood on 27% of No RAP(26 patients), received bank blood on
bypass.bypass. 46% of RAP patients received aprotinin46% of RAP patients received aprotinin Cell saver used on 66% of RAP patientsCell saver used on 66% of RAP patients Entire pump volume washed with cell saver on 46% of Entire pump volume washed with cell saver on 46% of
RAP patients after bypass.RAP patients after bypass.
VCU Blood Conservation PolicyVCU Blood Conservation Policy Transfusion GuidelinesTransfusion Guidelines
Hematocrit 17%Hematocrit 17%• ANDAND
Signs of Oxygen DebtSigns of Oxygen Debt Conservation Strategies (commonly used methods in Conservation Strategies (commonly used methods in
cardiac surgery, often concurrently)cardiac surgery, often concurrently) ANH (Autologous Normovolemic Hemodilution)ANH (Autologous Normovolemic Hemodilution) RAP (Retrograde Autologous Priming of CPB RAP (Retrograde Autologous Priming of CPB
circuit)circuit) Cell Saver UseCell Saver Use Antifibrinolitic Drugs Use in All PatientsAntifibrinolitic Drugs Use in All Patients
• Aprotinin or Epsilon AminoCaproic Acid Aprotinin or Epsilon AminoCaproic Acid (EACA)(EACA)
Methods
IRB Approved Retrospective ReviewIRB Approved Retrospective Review All patients in the period fromAll patients in the period from
November 1November 1stst, 2004, 2004toto
July 1July 1stst, 2005 were studied, 2005 were studied Statistical AnalysisStatistical Analysis
Mixed Effect Repeated Measures Mixed Effect Repeated Measures ANOVAANOVA
Results A total of n=205 patients were includedA total of n=205 patients were included
146 males (71%)146 males (71%) 59 females (29%)59 females (29%)
Mean age 58.4 ± 13.5 years oldMean age 58.4 ± 13.5 years old Mean Ejection Fraction 45 ± 15%Mean Ejection Fraction 45 ± 15%
Interquartile Range (25-75) 35-60%Interquartile Range (25-75) 35-60% History ofHistory of
Myocardial InfarctionMyocardial Infarction 40%40% Congestive Heart FailureCongestive Heart Failure 35%35%
Hemoglobin LevelsHemoglobin Levels PreOp HGBPreOp HGB 12.0 ± 1.912.0 ± 1.9 Lowest HGB on CPBLowest HGB on CPB 7.6 ± 1.57.6 ± 1.5 First HGB in ICUFirst HGB in ICU 10.0 ± 1.810.0 ± 1.8
Results
ProceduresProcedures CABGCABG 49% (100)49% (100) ValveValve 14% (30)14% (30) Aortic SurgeryAortic Surgery 9% (18)9% (18) VADVAD 1% (2)1% (2) Combined ProcedureCombined Procedure 27% (55)27% (55) Previous SternotomyPrevious Sternotomy 28% (57)28% (57)
Anticoagulation MedicationAnticoagulation Medication HeparinHeparin 11% 11%
(22)(22) CoumadinCoumadin 10% (20)10% (20)
Results
ComplicationsComplications MortalityMortality 5% (10)5% (10) StrokeStroke 2% (5)2% (5) MIMI 1% (2)1% (2) ReoperationsReoperations 5% (10)5% (10)
Results
Group Count %
ANH Only 6 3
No Action 20 10
RAP + ANH 74 36
RAP Only 105 51
Total 205 100
Antifibrinolitics Use
Aprotinin 49% (101)
EACA 51% (104)
Results
Main Outcome MeasuresMain Outcome Measures Transfusion rateTransfusion rate Hemoglobin Drop (from PreOp to Hemoglobin Drop (from PreOp to
ICU)ICU)
Transfusion Rate 11% (23)Transfusion Rate 11% (23)83% patients had aprotinin83% patients had aprotinin
Results
Blood Conservation Maneuver Blood Conservation Maneuver GroupsGroups
RAP RAP + ANHNo RAP \ No ANH
ANH
# Patients 105 73 20 6
PreOp Hgb 11.6 ± 0.2 12.7 ± 0.2 11.5 ± 0.4 11.5 ± 0.8
Cell Saver (Yes\No)
65 \ 40 53 \ 21 14 \ 6 4 \ 2
APO \ EACA 48 \ 57 36 \ 38 12 \ 8 5 \ 1
% patients transfused
13% 3%* 30%* 17%
* p < 0.001
Transfusions per Group
Results (Excluding Patients Transfused)
Antifibrinolitics LS Mean Lower 95% Upper 95%Amicar* 2.4 2.1 2.8Aprotinin* 1.8 1.4 2.2
ANHNo 2.0 1.7 2.3Yes 2.2 1.8 2.7
RAPNo 1.9 1.4 2.4Yes 2.3 2.0 2.7
Cell SaverNo 2.3 1.8 2.8Yes 1.9 1.6 2.3*p < 0.05
Hgb Decrease (gr/dL) by Maneuver
Successful Blood Conservation ProgramSuccessful Blood Conservation Program Transfusion Rate 11%Transfusion Rate 11%
The combination of RAP and ANH is particularly The combination of RAP and ANH is particularly effectiveeffective Transfusion Rate 3%Transfusion Rate 3%
Selection Bias or Channeling of more likely to Selection Bias or Channeling of more likely to bleed patients towards the use of Aprotininbleed patients towards the use of Aprotinin 83% of transfused patients received Aprotinin83% of transfused patients received Aprotinin
Conclusions
Conclusions
Despite this Channeling, the most effective Despite this Channeling, the most effective maneuver to conserve blood was the use of maneuver to conserve blood was the use of AprotininAprotinin Hgb drop 1.8 vs 2.4 gr/dL compared with Hgb drop 1.8 vs 2.4 gr/dL compared with
EACAEACA Only maneuver statistically effective Only maneuver statistically effective despite despite
the channelingthe channeling Effective multimodal approach even though Effective multimodal approach even though
individual contribution by each maneuver is not individual contribution by each maneuver is not statistically significant statistically significant
ALL CASESALL CASES 20042004 20052005 20062006 20072007
IntraOp onlyIntraOp only 1.92%1.92% 7.42%7.42% 9.43%9.43% 18.01%18.01%
PostOp OnlyPostOp Only 22.99%22.99% 23.63%23.63% 20.29%20.29% 9.32%9.32%
IntraOp or IntraOp or PostOpPostOp 31.42%31.42% 42.31%42.31% 50.29%50.29% 47.20%47.20%
IntraOp and IntraOp and PostOpPostOp 6.51%6.51% 11.26%11.26% 20.57%20.57% 19.88%19.88%
Mortality OE Mortality OE Ratio: Ratio: 1.422291.42229
Ratio: Ratio: 0.273240.27324
Ratio: Ratio: 0.725990.72599
Ratio: Ratio: 1.240461.24046
Observed: Observed:
0.04620.0462Observed: Observed:
0.00820.0082Observed: Observed:
0.02400.0240Observed: Observed:
0.04600.0460
Expected: Expected:
0.03250.0325Expected: Expected:
0.02990.0299Expected: Expected:
0.03310.0331Expected: Expected:
0.03710.0371
Case Mix IndexCase Mix Index 3.83983.8398 4.00574.0057 4.05894.0589 4.38724.3872
Blood Usage – All Cases
CAB OnlyCAB Only 20042004 20052005 20062006 20072007
IntraOp onlyIntraOp only 0.00%0.00% 2.96%2.96% 11.05%11.05% 13.33%13.33%
PostOp OnlyPostOp Only 18.66%18.66% 25.12%25.12% 26.16%26.16% 16.00%16.00%
IntraOp or PostOpIntraOp or PostOp 23.13%23.13% 35.96%35.96% 46.51%46.51% 48.00%48.00%
IntraOp and PostOpIntraOp and PostOp 4.48%4.48% 7.88%7.88% 9.30%9.30% 18.67%18.67%
Mortality OE Mortality OE Ratio: Ratio: 1.487711.48771
Ratio: Ratio: 0.209340.20934
Ratio: Ratio: 1.241541.24154 Ratio: 0.55674Ratio: 0.55674
ObservedObserved: 0.0373: 0.0373
ObservedObserved: 0.0049: 0.0049
ObservedObserved: 0.0292: 0.0292
Observed: Observed: 0.01330.0133
Expected: Expected:
0.02510.0251Expected: Expected:
0.02350.0235Expected: Expected:
0.02360.0236Expected: Expected:
0.02390.0239
Case Mix IndexCase Mix Index 3.83983.8398 4.00574.0057 4.05894.0589 4.38724.3872
Blood Usage – CAB Only
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Prolonged Vent Renal Failure AnyComplication
Mortality
male
female
POST CABG COMPLICATIONS
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Male
Female
TRANSFUSION RATES (CABG)
56 y MALE – Acute MI, Cardiogenic 56 y MALE – Acute MI, Cardiogenic
shock, on IABPshock, on IABP Hb 9.9 g/dl On plavix, ASA (prev PCI) Integrellin and iv heparin Emergent surgery due to worsening CP and
ST elevations.
TEG PRE CPB
Hb < 5 – 2 prbcsHb < 5 – 2 prbcs
Hb 6.0 – 1 prbcHb 6.0 – 1 prbc
TEG POST CPB AFTER PROTAMINE
No factors or platelets due to absence of clinical No factors or platelets due to absence of clinical bleedingbleeding
Transfusion Triggers:On Pump RBC transfusion for Hgb < 6.0 or HCT <18 + One objective criteria for tissue hypoperfusion.Pump RBC transfusion for Hgb < 6.0 or HCT <18 + One objective criteria for tissue hypoperfusion. · Low SVO2· Low SVO2· Elevated Lactate· Elevated Lactate· Elevated base deficit, Low HCO3· Elevated base deficit, Low HCO3 Post Op ( ICU and Step Down Units ) RBC transfusion for Hgb < 7.0 or HCT <21 + One objective criteria .Post Op ( ICU and Step Down Units ) RBC transfusion for Hgb < 7.0 or HCT <21 + One objective criteria . · Elevated O2 need· Elevated O2 need· Hypotension· Hypotension· End Organ dysfunction· End Organ dysfunction· Ongoing Bleeding· Ongoing Bleeding Prospective Follow Up:Prospective Follow Up:The following data will be collected for each patient:The following data will be collected for each patient: All data routinely collected for the STS Adult Cardiac Surgery Database will be collected as usually done for quality improvement purposes. In All data routinely collected for the STS Adult Cardiac Surgery Database will be collected as usually done for quality improvement purposes. In addition the following custom fields will be collected prospectively. addition the following custom fields will be collected prospectively. · Pre-Op Hgb/Hct· Pre-Op Hgb/Hct· Hgb/Hct Pre-Bypass· Hgb/Hct Pre-Bypass· Lowest Hgb/Hct on Bypass· Lowest Hgb/Hct on Bypass· Hgb/Hct at end of surgery· Hgb/Hct at end of surgery· Hgb/Hct at discharge from ICU· Hgb/Hct at discharge from ICU· Hgb/Hct at discharge from hospital· Hgb/Hct at discharge from hospital· Hgb/Hct at first post-op visit· Hgb/Hct at first post-op visit· Amicar vs. Aprotinin vs. None· Amicar vs. Aprotinin vs. None· Retrograde Autologous Priming· Retrograde Autologous Priming· Ultrafiltration· Ultrafiltration· Degree of hypothermia· Degree of hypothermia· Cell saver use· Cell saver use· Volume of Cardioplegia· Volume of Cardioplegia· Total volume of Crystalloid/Colloid during surgery.· Total volume of Crystalloid/Colloid during surgery.· Leukoreduced v. Non-leukoreduced · Leukoreduced v. Non-leukoreduced · Factor VIIa· Factor VIIa· Every unit transfused will be recorded with the time and Hgb/Hct trigger.· Every unit transfused will be recorded with the time and Hgb/Hct trigger.· Date blood was harvested.· Date blood was harvested.
VCSQI STUDY
