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Blood Conservation in Cardiac Surgery
Major surgeries result in some blood loss, but techniques are in place to conserve blood. Dr. Charles Klodell, Cardiothoracic Surgeon at Florida Heart and Lung Institute, discusses blood conservation in cardiac surgery.
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Learn more about Charles Klodell, MD
Charles Klodell, MD
Dr. Charles T. Klodell is a cardiothoracic surgeon that specializes in heart and lung surgical procedures including minimally invasive aortic and mitral valve repair or replacement, aortic aneurysm repair, transcatheter aortic valve replacement (TAVR) and open heart surgery. He has a special interest in minimally invasive procedures, valve repair, and innovative uses of technology and pharmacology to alleviate patient discomfort.Learn more about Charles Klodell, MD
Transcription:
Prakash Chandran (Host): During a major procedure like heart surgery, it’s common to lose a substantial amount of blood. But what are the possible complications of blood loss and what can be done to prevent it? Let’s talk about it with Dr. Charles Klodell, a cardiothoracic surgeon at North Florida Regional Medical Center. This is Helmet of Health, the podcast from Florida Heart and Lung Institute. I'm Prakash Chandran. So Dr. Klodell, tell us what kind of heart procedures could actually lead to a lot of heavy bleeding?
Charles Klodell, MD (Guest): Well, I think any time you're having that level of surgery, any of the procedures really could have significant blood loss. I think that it’s imperative that you have meticulous surgical technique and that you’re focused on trying to prevent blood loss. We don’t want patients to get transfusions. One of the things that we’ve put in place is a multifaceted blood conservation strategy, which is really an entire team of people that are focusing on preventing blood loss and preventing transfusions. So it’s a very important part in cardiac surgery today to be very focused on blood utilization.
Host: Asking a very basic question, but why is losing so much blood a problem?
Dr. Klodell: Well, it’s actually a really good question in that blood is our essential thing for life. It is what carries our oxygen to our tissues. We’re all meant to walk around with a hemoglobin of 14 or 15, but not many people actually do. most of are a little bit iron deficient. Some of us have one or another health issues that leads to a little bit lower blood count. What we do have is what we’re used to having. So if you get surgery and whatever your blood count is you come out at 80% or 70% of it, it’s not as good as if you had all of it. So we really want to be focused on not reducing the blood counts very much. If you say well why not give everyone a transfusion and make them come out at exactly the same number? Well every study that’s ever been done to my knowledge shows that getting blood really isn’t good for you. Now, it beats the alternative which may be that the patient doesn’t survive, but whether it’s a cancer operation or a cardiac operation or whatever, the long-term outcome is adversely affected by needing blood. So if you get a surgery and you end up getting a transfusion, you want to know that you earned it. You want to know that the physicians and the teams did everything that they could to prevent it because it’s not as good as not getting blood.
Host: You know, I'm curious. Are there patients that bleed more than others? If that is the case, how do you identify those that are at risk prior to surgery and how do you deal with that before their operation?
Dr. Klodell: Yeah. So there are patients that are on medications that can really impact platelet functions. These are some of the anti-platelets agents above and beyond aspirin. Aspirin itself doesn’t bother us too much, but then there are drugs like any of these anticoagulant medicines. If you have to do an emergency surgery with some of these medicines circulating, it becomes a little bit more of an issue. We’re prepared to deal with it, but it becomes a little bit more of an issue.
Now, you said how do you identify them preoperatively. Well, first you start with a good history and physical talk to the patients. Find out what they're taking. In elective surgeries, we stop some of those medications some time interval before surgery depending on how long it’s going to take the body to wash that out. Then secondarily we test the patients blood ahead of time. We do that with some basic coagulation tests. Then we do it with some pretty sophisticated testing like thromboelastography and things like that which really give us an entire picture of the patients coagulation cascade so we can know before we ever go to the operating room where it’s platelets or whether it’s their clotting factors or what it is that’s likely to cause us problems, and then develop the best strategy to mitigate that problem.
Host: Got it. Then you also talked about some of the strategies to concern blood loss during the actual surgery itself. So can you maybe get into a little bit more detail about how that works?
Dr. Klodell: Yeah. It’s all pretty technically nuanced and I don’t want to get you down in it too much. But I will tell you that it starts with meticulous surgical technique and making sure that at every step of the operation that we don’t lose a single red blood cell that we don’t absolutely have to. It starts with—sometimes even before you go to operating room—recognizing that a patient’s blood count is low and giving them some medications to drive that blood count up before their day of surgery. So then instead of going to the operating room with say a hematocrit of 28 or 29, maybe they go in with 37 or 38 because you've given them a couple weeks of a medication to drive it up.
In the operating room for cardiac surgery, if we have to use the heart lung machine, we’re going to try to do what we can to sort of allow the patient’s own blood to prime the pump lines and drain off some of the extra crystalloid or clear fluid that’s in it so that we don’t dilute their hematocrit too much. We’re going to make sure that the end that we have meticulous hemostasis meaning that there's no bleeding when we close the chest. Because it doesn’t do us any good if we come to the ICU after having done a great operation and conserve blood, but then the patient bleeds in the ICU at the chest range. So we make sure all of that is there. The anesthesiologist can do some things where they help take some of the patient’s blood before we give the blood thinners in the OR that we have to give, and they can kind of keep it connected to the patient and then reinfuse at the end almost as like supercharged blood because it didn’t get exposed to some of the heart lung machine and some of those kinds of things.
Host: What about post-operation? What measures are taken to reduce blood loss after a surgery?
Dr. Klodell: So once you're in the ICU, the main ways that people lose blood are first, we draw it out of them. We send the lab guys in there with a rainbow color of tubes and they start drawing blood all the time. So we try and minimize blood draws to only the labs we absolutely need to make sure the patient’s safe. We try to do it in smaller tubes and only fill them partway if needed just enough so that the machines in the lab can run the blood samples. We will give the same medicines that we will give pre-operatively to drive the blood counts up, we’ll give them post-operatively if appropriate. What those medicines basically do is make the patient’s own bone marrow produce more cells. So it just kind of revs it up. It’s just like stepping on the gas peddle in your car. It’s going to make the bone marrow churn out some more cells a little bit faster so that they recover that count a little bit faster and we don’t have to give them someone else’s blood.
Host: Alright Dr. Klodell. I really appreciate your time today. That’s Dr. Charles Klodell, a cardiothoracic surgeon at North Florida Regional Medical Center. Thanks for checking out this episode of Helmet of Health. Head to FLHeartAndLung.com to get connected with a provider. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll see you next time.
Prakash Chandran (Host): During a major procedure like heart surgery, it’s common to lose a substantial amount of blood. But what are the possible complications of blood loss and what can be done to prevent it? Let’s talk about it with Dr. Charles Klodell, a cardiothoracic surgeon at North Florida Regional Medical Center. This is Helmet of Health, the podcast from Florida Heart and Lung Institute. I'm Prakash Chandran. So Dr. Klodell, tell us what kind of heart procedures could actually lead to a lot of heavy bleeding?
Charles Klodell, MD (Guest): Well, I think any time you're having that level of surgery, any of the procedures really could have significant blood loss. I think that it’s imperative that you have meticulous surgical technique and that you’re focused on trying to prevent blood loss. We don’t want patients to get transfusions. One of the things that we’ve put in place is a multifaceted blood conservation strategy, which is really an entire team of people that are focusing on preventing blood loss and preventing transfusions. So it’s a very important part in cardiac surgery today to be very focused on blood utilization.
Host: Asking a very basic question, but why is losing so much blood a problem?
Dr. Klodell: Well, it’s actually a really good question in that blood is our essential thing for life. It is what carries our oxygen to our tissues. We’re all meant to walk around with a hemoglobin of 14 or 15, but not many people actually do. most of are a little bit iron deficient. Some of us have one or another health issues that leads to a little bit lower blood count. What we do have is what we’re used to having. So if you get surgery and whatever your blood count is you come out at 80% or 70% of it, it’s not as good as if you had all of it. So we really want to be focused on not reducing the blood counts very much. If you say well why not give everyone a transfusion and make them come out at exactly the same number? Well every study that’s ever been done to my knowledge shows that getting blood really isn’t good for you. Now, it beats the alternative which may be that the patient doesn’t survive, but whether it’s a cancer operation or a cardiac operation or whatever, the long-term outcome is adversely affected by needing blood. So if you get a surgery and you end up getting a transfusion, you want to know that you earned it. You want to know that the physicians and the teams did everything that they could to prevent it because it’s not as good as not getting blood.
Host: You know, I'm curious. Are there patients that bleed more than others? If that is the case, how do you identify those that are at risk prior to surgery and how do you deal with that before their operation?
Dr. Klodell: Yeah. So there are patients that are on medications that can really impact platelet functions. These are some of the anti-platelets agents above and beyond aspirin. Aspirin itself doesn’t bother us too much, but then there are drugs like any of these anticoagulant medicines. If you have to do an emergency surgery with some of these medicines circulating, it becomes a little bit more of an issue. We’re prepared to deal with it, but it becomes a little bit more of an issue.
Now, you said how do you identify them preoperatively. Well, first you start with a good history and physical talk to the patients. Find out what they're taking. In elective surgeries, we stop some of those medications some time interval before surgery depending on how long it’s going to take the body to wash that out. Then secondarily we test the patients blood ahead of time. We do that with some basic coagulation tests. Then we do it with some pretty sophisticated testing like thromboelastography and things like that which really give us an entire picture of the patients coagulation cascade so we can know before we ever go to the operating room where it’s platelets or whether it’s their clotting factors or what it is that’s likely to cause us problems, and then develop the best strategy to mitigate that problem.
Host: Got it. Then you also talked about some of the strategies to concern blood loss during the actual surgery itself. So can you maybe get into a little bit more detail about how that works?
Dr. Klodell: Yeah. It’s all pretty technically nuanced and I don’t want to get you down in it too much. But I will tell you that it starts with meticulous surgical technique and making sure that at every step of the operation that we don’t lose a single red blood cell that we don’t absolutely have to. It starts with—sometimes even before you go to operating room—recognizing that a patient’s blood count is low and giving them some medications to drive that blood count up before their day of surgery. So then instead of going to the operating room with say a hematocrit of 28 or 29, maybe they go in with 37 or 38 because you've given them a couple weeks of a medication to drive it up.
In the operating room for cardiac surgery, if we have to use the heart lung machine, we’re going to try to do what we can to sort of allow the patient’s own blood to prime the pump lines and drain off some of the extra crystalloid or clear fluid that’s in it so that we don’t dilute their hematocrit too much. We’re going to make sure that the end that we have meticulous hemostasis meaning that there's no bleeding when we close the chest. Because it doesn’t do us any good if we come to the ICU after having done a great operation and conserve blood, but then the patient bleeds in the ICU at the chest range. So we make sure all of that is there. The anesthesiologist can do some things where they help take some of the patient’s blood before we give the blood thinners in the OR that we have to give, and they can kind of keep it connected to the patient and then reinfuse at the end almost as like supercharged blood because it didn’t get exposed to some of the heart lung machine and some of those kinds of things.
Host: What about post-operation? What measures are taken to reduce blood loss after a surgery?
Dr. Klodell: So once you're in the ICU, the main ways that people lose blood are first, we draw it out of them. We send the lab guys in there with a rainbow color of tubes and they start drawing blood all the time. So we try and minimize blood draws to only the labs we absolutely need to make sure the patient’s safe. We try to do it in smaller tubes and only fill them partway if needed just enough so that the machines in the lab can run the blood samples. We will give the same medicines that we will give pre-operatively to drive the blood counts up, we’ll give them post-operatively if appropriate. What those medicines basically do is make the patient’s own bone marrow produce more cells. So it just kind of revs it up. It’s just like stepping on the gas peddle in your car. It’s going to make the bone marrow churn out some more cells a little bit faster so that they recover that count a little bit faster and we don’t have to give them someone else’s blood.
Host: Alright Dr. Klodell. I really appreciate your time today. That’s Dr. Charles Klodell, a cardiothoracic surgeon at North Florida Regional Medical Center. Thanks for checking out this episode of Helmet of Health. Head to FLHeartAndLung.com to get connected with a provider. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we’ll see you next time.