Terumo Cardiovascular Group

Bloodless Cardiac Surgery is a Team Sport

Since starting a multi-disciplinary blood management program, transfusions have been substantially reduced at The Heart Center at Nationwide Children's Hospital in Columbus, Ohio.

"Ninety percent of our patients weighing more than 25 kilos have surgery without receiving blood," says Vincent Olshove, CCP, Chief Perfusionist at The Heart Center at Nationwide Children's Hospital.

He lists blood management strategies employed by the Nationwide Children's Hospital perfusion team after six years of developing procedures and protocols:

  • Move oxygenator and heart-lung machine close to the sterile field and work with surgeons to cut down tubing lines
  • Use intraoperative acute normovolaemic hemodilution (ANH): draw 10-20 cc's of blood per kilogram before the surgical incision. At the end of the surgery, return the patient's blood — the patient benefits by having his own clotting factors and platelets
  • Use retrograde autologous prime (RAP): Displace crystalloid in the circuit with patient's own blood before going on bypass
  • Employ aggressive hemofiltration and ultrafiltration to keep hematocrit as high as possible
  • Reduce circuit size to 1/8 inch arterial line and 3/16 inch venous line
  • Select size of hemoconcentrators, circuit and oxygenators to patient need — not one size fits all
  • Use continuous blood gas monitoring to decrease the need to draw blood samples for arterial blood gases
  • Use modified ultra filtration (MUF) at the end of procedure: increases red blood cells, oxygen delivery and hematocrit, and reduces exposure to donor blood.

"It's helpful to have so many protocol variables to choose from," says Tom Preston, CCP, Nationwide Children's Hospital. "And while we have an aggressive bloodless approach, we still use blood if it's the right thing to do." He says the situation dictates whether blood products must be given, such as in a neonate's prime circuit or when warming a patient with low hematocrit.

What is Blood Management?

Mr. Olshove, who helped implement the hospital's formal blood management program in 2006, defines blood management:

"Blood management is minimizing blood, or blood product use, and, alternatively, basing transfusions on patient need — not based on the comfort level of the clinician."

Through experience, the Nationwide Children's Hospital perfusion team learned that establishing a blood management program requires a multi-disciplinary approach; the buy-in expands beyond the operating room. Mr. Olshove suggests starting with the surgeons, and then anesthesiologists, and then the intensive care unit team. "It's impossible to achieve results without everyone on board," says Mr. Preston.

An effective blood management program involves all hospital areas that contact the patient. "Every couple of cc's make a difference," Mr. Olshove adds. "We need to change the mind set of everyone. Lab testing and sampling, tends to be the biggest consumer of the patients' blood for kids. Through our blood management program, we get the bedside clinicians and lab involved to help minimize blood draws and find a way to scale back sampling."

Mr. Olshove believes ICU nurses and physicians have been ‘protocolized.' "If the hematocrit hits a magic number, they have to give blood. What about symptomology?" he asks. "We should look at the patient, physiologic parameters, and lab values to determine triggers to give blood.

When they see the blood management results, they support the effort rather easily, adds Mr. Olshove. "Bloodless cardiac surgery is a team sport."