The Practice Pulse August 2018

Blood conservation in cardiac surgery

Scared, alone, fearful, angry, anxious, petrified and nervous are just a few of the feelings expressed by people when they know they need medical attention. None of these feelings are positive or reassuring. What happens when we shift our methods of caring for a person with feelings, thoughts, fears and dreams just as real as our very own? Does our perspective shift? Does our capacity to heal deepen? I believe it does and I believe this is how the team members that make up the Florida Heart and Lung Institute and the North Florida Regional Medical Center’s cardiovascular surgical service line share a common goal in caring for their patients. That goal is a mission to the deliver high quality, expert care with compassion and consideration to every patient, every time.

Florida Heart and Lung Institute and North Florida Regional Medical cardiovascular surgical service team is known for promoting patient advocacy, patient wellness and exceptional patient care. From a patient advocacy perspective, the attention to delivering quality care is of utmost importance within our practice and we have initiated a multifaceted blood conservation strategy with a dramatic reduction in blood utilization for cardiac surgery, (42% in 2016 to 12% in 2017), with a projected utilization of less than 10% for 2018.

There was a dramatic reduction in blood utilization after careful analysis of each phase of the perioperative course was performed and goal targeted strategies were instituted.

In the preoperative phase, consideration was given to inpatient consults requiring surgery to determine need for surgical intervention during consultative admission or if there was an opportunity for potential discharge and elective readmission after a period of optimization with pharmacologic red cell augmentation with iron and Procrit. Every preoperative patient now undergoes coagulation analysis with platelet mapping TEG and P2Y12 to guide timing of surgical intervention and anticipate potential coagulopathic obstacles that may be encountered intraoperatively.

During the intraoperative phase attention was given to acute normovolemic hemodilution, size specific bypass circuits, retrograde/antegrade autologous CPB priming, routine use of ultrafiltration during bypass, thromboelastopgraph guided hemostasis, acceptance of lower hematocrit during bypass, lower nadir of hematocrit thresholds for transfusion and meticulous intraoperative hemostasis coupled with infusion of surgeon patience which all contributed to the significant decrease of perioperative blood use.

In the postoperative phase a rigid transfusion threshold was set which included careful observation of the physiologic needs for transfusion (SvO2, inotrope dependence, lactate, hemodynamics., etc) versus treating the absolute number. Pharmacologic RBC augmentation continues during the postoperative phase with iron, folic acid and epoetin alfa. In addition, there was initiation of a monthly Morbidity and Mortality conference with individual case reviews of any readmissions, mortalities, major morbidities and blood transfusions. Blood transfusion cases are reviewed and preoperative hematocrit, procedure, indications, chest tube output and areas of opportunities are discussed.

As the name implies, teamwork in health care employs the practices of collaboration and enhanced communication to expand the traditional roles of health workers and to make decisions as a unit that works toward a common goal. This collaboration has inspired the cardiovascular surgical team to institute practices that have allowed for the delivery of high quality, compassionate care, taking into consideration the anxieties and feeling of the patients all while seeing an improvement in the outcomes of cardiothoracic surgical interventions.

Aubrey J. Hall, ARNP

For insights, answers to questions, or to share commentary contact: Aubrey Hall, NP and Publisher of The Practice Pulse, at Aubrey.hall2@hcahealthcare.com

The latest murmurs

“Everything about my operation and care was excellent. Dr. Zeyl is both a Gator and a runner, an outstanding combination.” – Patient, Age 62

“Everyone from the Florida Heart and Lung Institute is incredible. Courteous, friendly - so appreciative of the positive experience I had!! Thank you to everyone!!” – Patient, Age 65

Florida Heart and Lung Institute

6440 Newberry Rd, Suite 102 | Gainesville, FL 32605 | Phone: (352) 333-5610 | Fax: (352) 333-5611 | FL Heart and Lung | Email: nfrm.fhli@hcahealthcare.com