The Management of Massive Blood Loss and Resuscitation · PDF file · 2015-02-13Pediatric Ventricular Assist Devices Pediatric Anesthesiology •Use and challenges VADs in pediatric

Elyse Parchmont RN MSN, CRNA

Pediatric Anesthesiology

Pediatric

Anesthesiology

The Management of Massive Blood Loss and

Resuscitation during Redo Sternotomy in a

Patient Supported with a Ventricular Assist Device

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•No financial disclosures

•No conflicts of interest

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Objectives


•Address preoperative concerns and make effective preparations for caring for the

patient with a VAD at risk for massive blood loss.

•Discuss the assessment and required communication and intervention in the

exsanguinating patient with a VAD.

•Recognize the endpoints for volume and blood product administration, including

laboratory study and monitor data.

•Be familiar with the complications of massive blood loss and transfusion in this

setting.

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Case Study – Patient History


• 15 y/o presenting to CVOR for orthotopic heart

transplant

• Severe TR/MR; Mod-severe LA dilation

• DCM, decreased myocardial function/congestive

heart failure (mildly depressed RV function)

• S/p HeartMate II LVAD placement

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Case Study - Medications


Aspirin

Enalapril

Warfarin

Furosemide

Metoprolol

Lansoprozole

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Increased Risk with Redo Sternotomy


•Staged or multiple cardiac procedures

•Presence of bioprosthetic conduits

•Dissection of adhesions

•Risk may be higher in older, teenage patients

•Decreased risk of injury over the recent decades

Kirshbom, et al. 2009

Morales, et al. 2008

Russell, et al. 1998

Andropoulos, et al. (2002)

Fabrizio, et al. (1999)

George, et al. (2012)

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Redo Sternotomy Preparation


•Surgery, anesthesia, and OR staff experienced in pediatric

congenital heart disease

•Appropriate blood products ordered and delivered to the

CVOR

•Femoral bypass available

•CT evaluations

Andropoulos, et al. (2002

Hamid, et al. (2014

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Pediatric Ventricular Assist Devices


•Use and challenges VADs in pediatric patients

•VADs vs ECMO

•Need for sedation

•Mechanical ventilation

•Anticoagulation/risk of thromboembolic phenomena

•Lack of mobility

•Risk of renal failure and/or stroke

•Risk of mortality > 2 weeks

Davies, et al. (2014)

George, et al. (2012)

O’Connor & Rossano (2014)

Sharma, et al. (2012)

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•Who gets a VAD? - Cardiogenic shock and/or progressive decline due to:

•End stage cardiomyopathy

•Myocarditis

•Univentricular failure

•Congenital heart disease/post cardiotomy

•VAD contraindications

•Irreversible end organ dysfunction

•Recent stroke

•Significant life limiting neurological disabilityO’Connor & Rossano 2014

Sharma, et al. 2012

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Davies, et al. 2014

O’Connor & Rossano 2014

Sharma, et al. 2012

•Hematologic

•Prolonged ventilator dependence

•Device change/reoperation

•Infection/sepsis

•Neurologic complications

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Types of VADs for Pediatric Patients


Device Type Indication

HeartMate II Continuous-flow BTT,DT

Berlin Heart EXCOR pediatric Pulsatile paracorporeal BTT

Thorotec pVAD Pulsatile paracorporeal BTT, PC

Debakey VAD Child Continuous-flow BTT

TandemHeart Centrifugal ECS < 6 h

HeartWare Ventricular Assist System Centrifugal BTT

SynCardia Total Artificial Heart Artificial heart BTT

Impella Continuous-flow ECS < 6 h

Centrimag Centrifugal ECS < 6 h

O’Connor & Rossano 2014

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Increased Risk with Redo Sternotomy/VAD


HeartMate II

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Increased Risk with Redo Sternotomy/VAD


HeartMate II

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http://www.clevelandclinicmeded.com/medicalpubs/

diseasemanagement/cardiology/heart-failure/

J Am Coll Cardiol. 2009;54(18):1647-1659. doi:10.1016/j.jacc.2009.06.035

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Case Study – Intraoperative Course


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Case Study – Intraoperative Course/Post Bypass


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Monitoring During Massive Transfusion


• Monitoring during blood transfusion

• Access

• Volume

Miller (2010)

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Blood Transfusion - Pediatrics


Products:

•Packed red blood cells (PRBCs)

•Fresh frozen plasma (FFP)

•Cryoprecipitates of clotting factors (Cryo)

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Blood Transfusion for Pediatric Patients


Age Estimated Blood Volume,

ml/kg

Premature infant 90-100

Term infant to 3 months 80-90

Children older than 3 months 70

Obese Children 65

Dehmer & Adamson (2010)

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Blood Transfusion ABO Compatability


Miller (2010)

Donor Recipient

O O,A,B,AB

A A,AB

B B,AB

AB AB

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Massive Transfusion – Definition


• Adult

• The loss of one or more circulating blood volumes in 24 hours

• Loss of 50% of blood volume in 3 hours

• An ongoing loss of 150 ml/hour

• Pediatrics

• Weight based


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TCH Massive Transfusion Protocol –

PRBC Units/Kg Weight Total Blood Volume


17.6-26.5 4

26.6-33.0 5

33.1-40.0 6

40.1-46.5 7

46.6-53.0 8

53.1-60.0 9

>60.0 10

Patient’s Weight

(Kg)

Number of Red Cell Units to

Equal Total Blood Volume

< 11.5 2

11.6-17.5 3

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Massive Transfusion – Age of Blood

Pediatric AnesthesiologyDehmer & Adamson (2010)

Miller, R.D. (2010)

Pizzini & Pizzini (2014)

•Older PRBC units:

•May be depleted in

2,3 diphosphoglycerate and

adenosine triphosphate

•May have elevated levels of

potassium

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Systemic oxygen delivery


Three main factors

•Cardiac output

•Oxygen saturation

•Hemoglobin levels


Hall & Chantigian (2010)

Pizzini & Pizzini (2014)

O2 content = 1.39 x (Hgb) x SaO2 + (0.003 x PaO2)

http://www.cvphysiology.com/Microcirculation/M002.htm

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Massive Transfusion Protocol –A Starting Point


• Initiation of massive transfusion protocol in traumatic hemodynamic

instability

• Blood component ratios

• Maintenance of temperature, calcium, and pH

• FVIIa


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TCH Massive Transfusion Protocol - Purpose


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TCH Massive Transfusion Protocol – Pack Contents


- Massive pack consists of up to 4 units of group O Rh negative

RBC (<14 days old). When massive pack requested, 2 units of

group AB FFP will be started to thaw.

- Standard pack consists of 2 units of group O Rh negative RBC

(<14 days old).

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Objectives


•Address preoperative concerns and make effective preparations for caring for the

patient with a VAD at risk for massive blood loss.

•Discuss the assessment and required communication and intervention in the

exsanguinating patient with a VAD.

•Recognize the endpoints for volume and blood product administration, including

laboratory study and monitor data.

•Be familiar with the complications of massive blood loss and transfusion in this

setting.

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References


Andropoulos, D.B., Stayer, S.A, Skjonsby, B.S., East, D.L., McKenzie, E.D., Fraser, C.D. (2002). Anesthetic

and Perioperative Outcomes of Teenagers and Adults with Congenital Heart Disease. Journal

of Cardiothoracic and Vascular Anesthesia. Vol. 16 (6):731-736

Davies, R.R., Hadleman, S., McCulloch M.A., Pizzaro, C. (2014). Ventricular assist devices as a bridge to

transplant improve early post-transplant outcomes in children. The Journal of Heart and Lung

Transplantation. Vol. 33 (7): 704-712.

Dehmer, J.J & Adamson, W.T. (2010) Massive Transfusion and Blood Product Use in the Pediatric Trauma

Patient. Seminars in Pediatric Surgery. Vol. 19:286-291

Fabrizio, M.F., Pett, S.B., Miller, K.B., Wong, R.S., Temes, R.T., Wernly, J.A. (1999) Catastrophic

Hemorrhage on Sternal Reentry: Still a Dreaded Complication? Annals of Thoracic Surgery.

Vol. 68:2215-9.

George, T.J., Beaty, C.A., Ewald, G.A., Russell, S.D., Shah, A.S., Conte, J.V., and Whitman, G.J. (2012)

Reoperative Sternotomy is Associated with Increased Mortality. Annals of Thoracic Surgery.

Vol. 94(6):2025-32.

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References


Hamid, U. I., Digney, R., Soo, L., Leung, S., and Graham, A.N.J. (2014). Incidence and Outcome of

Reentry Injury in Redo Cardiac Surgery: Benefits of Preoperative Planning. European

Journal of Cardio-Thoracic Surgery. doi:10.1093/ejcts/ezu261

Kishbom, P.M., Myung, R.J., Simsic, J.M., Kramer, Z.B., Leong, T., Kogon, B.E., and Kanter, K.R.

(2009) One Thousand Repeat Sternotomies for Congenital heart surgery: Risk Factors fro

Reentry Injury. Annals of Thoracic Surgery. Vol. 88(1):58-61.

Miller, R.D. (2010) Miller’s anesthesia: Seventh ed. Philadelphia:Churchill Livingstone

Morales, D.L.S., Zafar, F., Arrington, K.A., Gonzalez, S.M., McKenzie, E.D., Heinle, J.S., Fraser, C.D.

(2008) Repeat Sternotomy in Congenital Heart Surgery: No Longer a Risk Factor. Annals of

Thoracic Surgery. Vol. 86:897-902.

O’Connor, M.J., Rossano, J.W. (2014) Ventricular assist devices in children. Obtained from

www.cardiology.com Vol 29(1).

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References


Russell, J.L., LeBlanc, J.G., Sett, S.S., Potts, J.E. (1998) Risks of Repeat Sternotomy in Pediatric Cardiac

Operations. Annals of Thoracic Surgery. Vol. 66:575-8

Sesok-Pizzini, D., Pizzini, M.A. (2014) Hyperkalemic Cardiac Arrest in Pediatric Patients Undergoing

Massive Transfusion: Unplanned Emergencies. DOI:10.1111/trf.12470 Transfusion Vol.

54(1):4-7.

Sharma, M. S., Forbess, M.J., & Guleserian, K. J. (2012) Ventricular Assist Device Support in Children

and Adolescents with Heart Failure: The Children’s Medical Center of Dallas Experience

Artificial Organs. Vol. 36 (7): 635-48.

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Documents

The Management of Massive Blood Loss and Resuscitation · PDF file · 2015-02-13Pediatric Ventricular Assist Devices Pediatric Anesthesiology •Use and challenges VADs in pediatric