INOVA Fairfax Hospital Perfusion Team’s Approach

The perfusion team at INOVA Fairfax Hospital believes that homologous blood transfusions should be treated like a drug. “We no longer routinely ‘prescribe’ a transfusion for all patients,” says David Fitzgerald, CCP, Chief of Perfusion. “In fact, we have now adopted many of the same blood management strategies we use for Jehovah’s Witness patients as standard practice for our entire cardiac surgery population– adult and pediatric.”

The INOVA Fairfax Hospital team describes their pediatric blood management strategies in a recently published case report in which a 5.9 kg Jehovah’s Witness patient underwent successful correction of a ventricular septal defect without the use of any homologous blood transfusions1.

In the report, the authors cite “mounting evidence that suggests deleterious effects associated with the transfusion of homologous blood products” as the impetus to create a pediatric blood management program. The team had recently implemented a blood management program for its adult patients.

The report notes the patient’s preoperative baseline hematocrit was 35.5%. Although the team prefers a pre–op hematocrit of 40% or more, they proceeded with the surgery due to the severity of the patient’s heart failure.

“Historically, we’d have automatically added a unit of blood to the prime for a pediatric patient. Instead, we compensated with a number of blood management strategies that crossed all disciplines: surgical, nursing, anesthesiology, and perfusion,” says Mr. Fitzgerald.

He adds that the most important strategies to allow the initiation of bypass without giving blood are the use of retrograde autologous priming (RAP) and a reduced prime circuit. “We use small cannulae and small tubing sizes, we put two sucker lines in the same roller head, and we remote–mount all our pumps.”

The perfusion team employed a number of other blood management strategies:

Pre–operative administration of erythropoietin and iron to increase red blood cell mass
Acute normovolemic hemodilution (ANH) before CPB
Retrograde autologous priming (RAP)
Cell salvage
Continuous ultrafiltration
Vacuum–assisted venous drainage (VAVD) to allow the use of smaller venous cannulae and tubing size
Near infrared spectroscopy (NIRS) to monitor cerebral and renal oxygenation
The patient’s post–operative hematocrit was 28.9% after transfusion of the ANH and cell saver blood. He was discharged after two days with a 27.0% hematocrit.

The report’s authors credit “excellent communication between the surgeons, perfusionists, and anesthesiologists during all stages of the operation” for the success of the blood management strategies. Mr. Fitzgerald notes that all members of the OR team have adapted their protocols to avoid transfusions. The surgeons are “meticulous with their technique, stopping even the smallest bleeders;” they administer cardioplegia at the table with a syringe; and they send shed blood to the cell saver. Nurses monitor blood loss in their sponges and limit post–operative blood draws. Anesthesiologists support the ANH process and limit the amount of crystalloid prior to bypass.