Blood conservating therapy

 Blood consercation
o Risk of allogenic blood transfusion
o Shortage allogenic blood
o Patients choice
o Improvement in availability of transfusion alternative
 High risk predictors
o Advance age
o Low preoperative red blood cell volume
 Preop anemia/antithrombotic drugs
o Preoperative antiplatlet/antithrombotic agent
o Reoperative/complex procedure
o Emergency operation
o Non cardiac patient comorbidity
 Risk of blood transfusion
o Infectious
 HIV – 1 in 1.4 x 106
 Hep B – 1 in 150 000
 Hep C – 1 in 1.7 x 106
 Bac infection- 1 in 2 000
o Immunologic reaction
 Febrile nonhemolytic transfusion reaction – 1 in 100
 Anaphylactic transfusion reaction- 1 in 50 000
 ABO mismatch
 Hemolysis – 1 in 60 000
 Death – 1 in 600 000
 Leukocyte- related target organ injury – 1 in 20
 Transfusion related acute lung injury – 1 in 2000
 Post transfusion purpura - rare
o Transfusion service error – 1 in 14 000
 Benefits
o Enchanced oxygen carrying capacity
o Improved haemostasis associated with blood component therapy
o Vol support of cardiac output
 Intervention to limit blood transfusion
o Pharmacological agents
 Hemostatic drug with antifibrinolytic properties
 Erythropoietin
 DDAVP
 Recombinant Factor VIIa
 o Device to aid blood conservation
 Cell saver
 Ventilator- assited blood conservation : PEEP
 Oxygenator types
 Perfusion blood pumps
 Heparin- bonded circuits
 Leukocyte filteration
o Perfusion technique and OPCAB
 Heparin management
 Protamine dosing
 Acute normovolemic hemodilution
 Preoperative autologous blood transfusion
 Minimized extracoeporeal bypass circuits
 Retrograde autologous priming
 Hemofiltration
 Off pump procedures for blood conservation
o Topical agents/ tissue glue
o Interventions outside operating room
 Catheterization laborotoey intervention
 Preoperative laboratory testing
 Intensive care unit processes and practice

PHARMACOLOGICAL AGENTS

 Antifibrinolytic agents
o Aprotinin
 A Serine Protease inhibitor
 Binds with human serine protease :
 Trypsin DECREASING AFFINITY
 Plasmin
 Plasma kallikrein
 Elastase
 Urokinase
 Thrombin
 Pharmacokinetics
 Inactive orally
 Plasma half life 10 hrs
 Not cross blood brain barrier
 Mechanism of action
 Inhibit serine protease ( kallikrein,plasmin) that attenuates
 Inflammatory responses
 Fibrinolysis
  Thrombin generation
 Inhibit pro-inflamatory cytokine release and maintain glycoprotein
haemostasis
 Platlets – reduces glycoprotein loss
 Granulocytes – prevets expression of pro inflammatory
adhesive glycoprotiens
 Adverse effects
 Hypersensitivity
 Graft occlusion
 Heart failure
 Renal dysfunction
 Stroke
 mortality
o Lysine Analogous
 Epsilon amino caproic acid
 Tranexemic acid
 Mechanism of action
 Inhibit plasminogen by binding to the lysine binding site on the
plasminogen molecule
 Spare platlet function by inhibiting the deleterious effect of plasmin
 Tranexamic acid similar action – 10 x more potent
o Erythropoeitin
 Endogenous glycoprotein
 stimulates red cell production in response to hypoxia and anemia.
 Recombinant EPO
 Reduce preoperative anaemia in patients undergoing autologous blood
donation
 Safe and effective
 Drawbacks
 Expensive Hypertension
 Lag period: 4-6 days
 less effective post operatively
 Beta blockers and cardiopulmonary bypass inhibit effect
o Desmopresion ( DDAVP)
 Releases
 Endogeneous Factor VII precursors
 Von Willibrand factor
 Tissue type plasminogen activator
 Not helpful prophylactically to reduce bleeding after cardiac procedure
  Helpful in patients with demonstrable and specific platlet dysfunction known to
respond to this agent ( eg : uremic/CPB- induced platlet dysfunction, type I von
Willebrans disease)
o Recombinant Factor VIIa
 Vitamin K-dependent glycoprote
 treatment of severe bleeding episodes in hemophiliacs with factor inhibitors or
patients with FVII deficiency
 Binds to tissue factor→ Activation of factor X (FXa) on the platelet surface (a
phospholipid surface); FXa + Activated factor V→ prothrombinase complex →
Thrombin formation.
o Recombinant Factor VII a
 Recombinant Factor VII a
 Full activation of Thrombin (Thrombin burst)
 Recommended
 rescue therapy for severe intractable bleeding without an identifiable
surgical source that is unresponsive to routine approaches
 after cardiac procedures using CPB.

 Devices
o Cell Salvage systems
 3 Applications
 Intraoperative recovery of blood
 Washing of blood collected in postoperative phase
 Sequestration
 Autotransfusion Procedure
 Autotransfusion Procedure Collection Priming Washing Emptying
 Sequestration Procedure
 Sequestration Procedure Blood Taking Priming Spilling Emptying
o Cell Salvage
 Advantages
 Safer in patients with rare blood groups & multiple antibodies
 No immunosuppression
 ? Acceptable to Jehovahâ Witnesses
 Disadvantages
 risk of infection
 risk of transfusion reaction
 “ demand for allogenic blood products
 cost- setup cost inc. staff training
 Unused blood wasted
 risk of bacterial contamination
o ACUTE NORMOVOLEMIC HEMODILUTION (INTRAOPERATIVE AUTOLOGOUS
DONATION)
 Removal of one to two units of blood immediately before surgery
 To maintain circulating blood volume, the volume is replaced with crystalloid /
colloid.
 Contraindications:
 Evolving acute myocardial infarction
 Unstable angina
 Cardiogenic shock
 Preoperative anemia
 Sepsis known bacteremia.
 Relative contraindications
 Low EF (< 30%)
o ACUTE NORMOVOLEMIC HEMODILUTION
 Principle
 Lowering the red blood cell concentration (hematocrit) during surgery
decreases the reduction in red cell mass lost for any given volume of
blood lost.
o PREOPERATIVE AUTOLOGOUS BLOOD DONATION
 Autologous blood donation of as much as 2 units a few days to a few weeks
preoperatively.
 Useful in carefully selected (mostly elective) patients particularly when coupled
with appropriately dosed erythropoietin therapy and/or iron therapy.

o Topical Agents/Tissue Glues

 Fibrin glue preparations
 Bovine thrombin
 Aprotinin Containing Preparations
 Topical sealants are used to assist in the repair of complex, high-risk cardiac and
aortic procedures (e.g, left ventricular free wall rupture and aortic dissection)