The Perfusionist’s Role in a Collaborative Multidisciplinary Approach to Blood Transfusion Reduction in Cardiac Surgery

Abstract: Red blood cell transfusion is associated with adverse outcomes. Transfusion practices remain varied in cardiac surgery and are a subject of growing debate. We initiated a data-driven, multidisciplinary effort to decrease allogeneic red blood cell transfusion at our institution. Creative perfusion strategies are an essential component of our program and led to a low transfusion rate. Innovations in treatment protocols were implemented and evaluated to reduce hemodilution associated with the cardiopulmonary bypass machine. Frequent review of outcomes guided our evolving clinical practice. Standardization among the perfusionists was the first step to a successful blood conservation program. Techniques included vacuum assisted venous drainage with dry 3/8² tubing, a short (10 foot) arterial-venous loop, retrograde autologous prime, and saline prime removal from the primary and cardioplegia circuit. We used a polymer-coated perfusion circuit. Hemoconcentrator and cell saver use was determined on a case-by-case basis. Normothermia was maintained except in cases of circulatory arrest or specific surgeon request. Two thousand nine hundred and seventy-nine consecutive cardiac surgical procedures (2.8% off pump coronary artery bypass) were performed from January 1, 2003 to December 31, 2008. Our overall utilization of red blood cell transfusion decreased from 43.2% to 13.6% for all patients and 38.5% to 8.7% for coronary artery bypass graft only patients. Patient outcomes were not significantly changed through 2007. Cardiopulmonary perfusion can be performed safely with low utilization of allogeneic red blood cell transfusions. Standardization and creative perfusion techniques, in the presence of a multi-faceted approach to blood management, play an important role in blood conservation.