!"#$%&'()*&+,-+%."%((#(/&"".(*#"&0#(&1-).(%"(1&*/%.12%*-*3%&((

4!(567879:;<97((=74(=!99<(

679!47(!>?@<A!

"#$%&'!((!$&)%*+,%!-.(.!

/01&2%34!54,64780!9%,)060&!:0!;$%<=%<04!%!>%,4?04!@$=%$<0)4!"4,:0&)4<1&24,%!

!  “! 50% of patients undergoing cardiac procedures receive no allogenic blood transfusion. !  patients who receiv more than 10 donor units of blood products are in the 90° percentile of the patient transfusion profile. !  10-20% of patients consume about 80% of the total blood products trasfusions in this population.

!  THERE IS A HIGH-RISK SUBSET OF PATIENTS WHO REQUIRE LARGE AMOUNTS OF BLOOD PRODUCTS DURING THEIR CARDIAC PROCEDURES.”

Sindromi CardioRenali: Les Liaisons Dangereuses 2009

CRS_TYPE 1: !  Shock cardiogeno !  Sindrome coronarica acuta

INCIDENZA: 27-40%

CRS_TYPE 2: !  Scompenso cardiaco cronico !  Deterioramento acuto in SC_cr

INCIDENZA: >60%

CRS_TYPE 3: “CS-associated AKI”

INCIDENZA: 0.3-29.7% “ the challange in understanding the epidemiology of type 3 CRS is that its incidence and associated risk factors fail to consider the inciting event for CSA_AKI as either primarily AKI-related or heart-related.”

Sindromi CardioRenali: Les Liaisons Dangereuses 2009

CRS_TYPE 1: !  Shock cardiogeno !  Sindrome coronarica acuta

INCIDENZA: 27-40%

CRS_TYPE 2: !  Scompenso cardiaco cronico !  Deterioramento acuto in SC_cr

INCIDENZA: >60%

CRS_TYPE 3: “CS-associated AKI”

INCIDENZA: 0.3-29.7% “ the challange in understanding the epidemiology of type 3 CRS is that its incidence and associated risk factors fail to consider the inciting event for CSA_AKI as either primarily AKI-related or heart-related.”

ANEMIA EMODILUIZIONE TRANSFUSION ?

Secondo la WHO, una concentrazione di Hb ! 12 g/dl nei soggetti di sesso femminile e ! 13 g/dl nei soggetti di sesso maschile definisce l’ “ANEMIA”

Incidence: 28.1% of male and 35.9% of female CABG_pts

Preoperative anemia is an early marker of other disease

Low preperative Hb level was found to be an independent risk factor for postoperative renal complications.

ADJUSTING FOR ANEMIA IN CONFOUNDERS PROVED AN INDEPENDENT PREDICTOR OF AKI (OR 2.06; 95%CI 1.14- 3.7)

[28%]

Preoperative_Hemoglobin (g/dl)

Retrospective study: 10,025 CABG_pts (1998-2007)

"  Multivariate logistic regression analysis revealed anemia to be an independent risk factor for higher early (! 30 days) mortality.

"  Cox regression analysis revealed low preoperative hb level to be an independent risk factor for higher late (> 30 days) mortality.

(BC(DE(!(FBCG(3H/0(,.*($#"'(!(FICG(3H/0(,.*(J.$#"(IC(DE(!(FI(3H/0(,.*($#"'(! FK(3H/0(,.*(J.$#"(KC(DE(!(FK(3H/0(,.*($#"'(!(FF(3H/0(,.*(J.$#"(FC(DE(LFK(3H/0(,.*($#"'(L(FF(3H/0(,.*(J.$#"((

LADDOVE POSSIBILE , È IMPORTANTE EVITARE CHE I PAZIENTI

GIUNGANO ANEMICI ALLA CHIRURGIA

1. GESTIONI “CONSAPEVOLI” IN EMODINAMICA

" Hb = -4 g/dl

Access site complications occur 1% to 9% of patients and !5% of patients will require a transfusion after catheterization.

SUPPLEMENTARE:

•  B12, 5000 MCG/7GG IM

•  Acido folico, 5 mg/die PO NON INDICAZIONE

AL FERRO

NO SI’

FERRO ENDOVENOSO:

FERLIXIT, FIALE DA 62.5 MG # 1 FIALA/100 ML IN 2 ORE A GIORNI ALTERNI

DOSE TOTALE IN MG # (HB DESIDERATA – HB MISURATA) X PESO IN KG X 2.4

NO ANEMIA:

LA FERRITINA E’ > 500 NG/ML?

LA FERRITINA E’ < 100 NG/ML ?

CARDIOCHIRURGIA

malgrado anemia

r-HEPO + FERRO PO, FOLATI PO E VIT B12 A DOSI DI MANTENIMENTO***

FERRO ENDOVENOSO

B12 E FOLATI SONO NEI LIMITI ?

FEMMINE: Hb >13 g/dl

MASCHI: Hb > 14 g/dl ?

(cut-off per anemia )

ANEMIA:

LA CAUSA E’ LA DEPLEZIONE IN FERRO ?

[SIDEREMIA SOTTO CUT-OFF?]

Alla fine del trattamento marziale

Dopo 15 gg di terapia

CCH A EMOPOIESI OTTIMIZZATA

(TESTIMONE DI GEOVA HA QUESTO PERCORSO)

IL PAZIENTE DEVE ESSERE AVVIATO A PRATICHE DI AUTODONAZIONE (ES: IPERIMMUNIZZATO; RIFUITO TRASFUSIONI OMOLOGHE) ?

2. OTTIMIZZARE L’ERITROPIOIESI AL PRERICOVERO

3. TIMING “CONSAPEVOLE” DELLA CHIRURGIA

REVISIONE CHIRURGICA PER SANGUINAMENTO:

!  CABG: 3.1% !  Tutti gli interventi CCH: 4.6% (2-6%)

[ATS 2004; 78: 527-34]

“It is reasonable to DISCONTINUE THIENOPYRIDINES 5 TO 7 DAYS BEFORE CARDIAC PROCEDURES to limit blood loss and transfusion. Failure to discontinue these fdrugs before operation risks increased bleeding and POSSIBLY worse outcome.”

(Class IIa recommendation)

PERCHÉ L’ANEMIA CONFERISCE UN RISCHIO AGGIUNTIVO NEL CARDIOPATICO OPERATO?

DO2

COMPETENZA DEL “CARRIER_O2”

5&<K'(M&<K(

DE(

(><N(((

55(O(P!5Q>85(((

1. Ottimizzare l’emodinamica è una misura efficace per diminuire l’incidenza della disfunzione renale postoperatoria (OR 0.64; CI 0.50-0.83; p=0.0007) …

!  … anche nel paziente ad elevato rischio di mortalità/morbilità

2. Nell’ambito delle possibilità considerate, il timing della ottimizzazione emodinamica (pre o intraoperatorio) non è critico al fine del risultato

3. Nel paziente a rischio elevato il raggiungimento dell’obiettivo emodinamico è raggiunto per lo più con fluidi e inotropi

!  L’impiego del PAC nei pazienti a rischio elevato è una misura importante

4. La DO2 da perseguire per soddisfare l’obiettivo è quella normale !  1000 ml/min

.!

(.!

-.!

A.!

B.!

C.!

D.!

E.!

F.!

G.!

(! -! A! B! C! Rene, corticale

Cuore Fegato Encefalo Rene, midollare

App

orto

di o

ssig

eno

(ml/m

in/1

00 g

) Es

traz

ione

di o

ssig

eno

(%)

Kidney Int 1994

Ria

ssor

bim

ento

del

sod

io

><6@7R(S<K(TU($$(

D3(

L’APPORTO DI O2 NEL RENE: NE RICEVE DI PIÙ CHI NE UTILIZZA DI MENO

P7=?44!(S<K(FU($$(

D3(

Almost 95% of patients admitted to the ICU have an Hb level below normal by ICU day 3. [Chest 2007;131:1583]

Blood samples from ICU patients are routinarily collected via artherial catheters. The volume of blood discarded as part of this method of sampling is nearly 30% of the total blood volume drawn. [Anaesth Intensive Care 2003;31:653]

All ICU patients are exposed to the risk of frequent flebotomy. Some extimates have suggested that we remove nearly 60 ml blood per day from those in the ICU. [Chest 2005;127:702]

MA C’È DI PIÙ ! CARDIOCHIRURGIA E’ …. CEC

CPBP duration (min)

Prob

abili

ty o

f acu

te k

idne

y in

jury

CPBP duration (min)

Prob

abili

ty o

f acu

te k

idne

y in

jury

?

CEC E’ SIRS + EMODILUIZIONE ACUTA

40% CASES

11% CASES

SIRS E’ ….

DANNO D’ORGANO

E IPOTENSIONE

CEC E’ EMODILUIZIONE ACUTA

!!!!!!!!!!!!

;4(8<4?P7(=74(56;P7(7’ !FGUU($0(V(;4(8<4?P7(=744!(>!6=;<547W;!((

((4!(8<47P;!(5!:(7’(TU($0HX3(

(M!<K(>7>(OFUUYN(>;(@7<6;><(O(KCB(0H$%"(Z$K(

(

M7([M!([!MM!(#(D>@([!MM;(7(

=<K(L(8<K(!!!!!!!!!!!!!!!

!!

P%"%\>7>'(9OFUB( M)/\>7>'(9O]UF(

!^;A((

M)&3#(FA(FGUQKUU(#(%"(M\>*(,*.$(E&+#0%"#N((

M)&3#(KA(KUUQIUU(#(%"(M\>*(,*.$(E&+#0%"#N((

M)&3#(IA(_IUU(#(%"(M\>*(,*.$(E&+#0%"#(.*(M\>*`(B($3H/0(.*(>66@((

MASKED CIRCULATORY

SHOCK

=<K(1*%a1&0()2*#+2.0/((%"(&"#+)2#ab#/(2-$&"+A(!(KcUQIUU($0H$%"H$K(

IN ECC …..

FLUSSO DI POMPA X CAO2 = TARGET DO2

"&$=,&2!7,&#?H!!I1=!-CJ!!

9=#:K!7,&#?H!!I1=!-.J!

CI # FINO A 3.8 l/min*m2

N=3003 (2000-2008)

@&*3#)(D1)>7>(_(KcY(S#*($(!^;S.+).S(

(d(D1)(%"(1#1(L(KcY(Q($&("."(0’&"#$%&(

S#*(+#(Q((2&(#e#f.(S*.Q!^;((%"/%S#"/#")#(/&00’#+S.+%b%."#(&(W6>(/&(E&"1&'($#/%&).(/&(=<K(%"&/#3-&)&g((

Hct mediano 25%

Hct > 24%

Hct < 24%

(97h76([4<<=(O(6[>(M@<67=((i<6(L(FB(=!jM(<4=76([4<<=(O(6[>(M@<67=(i<6(_(FB(=!jM(

(

AUTODONAZIONE ? E’ MEGLIO DI NO !

7R5<M?67(@<(F(<6(K(6[>(?9;@M(

IMMUNOMODULAZIONE ASSOCIATA ALLA TRASFUSIONE & SUSCETTIBILITÀ ALLA SEPSI

DANNO AL MICROCIRCOLO DOVUTO ALLA MINORE DEFORMABILITÀ DEI GRC DA BANCA & SUSCETTIBILITÀ ALL’ISCHEMIA ?

@2FA((S*.$.)#(1#00Q

$#/%&)#/(%$$-"#(*#+S."+#(

@2KA((S*.$.)#((2-$.*&0(%$$-"#(*#+S."+#(

(

9OFk((

9O]K(

(

cF(>M\S&a#")+(>M(J%)2(7>>(

(

@*&"+,-+%."A((h[>Q*#/-1#/(6[>(

(

METHODS:

P_R_CLINICAL_NONINFERIORITY_TRIAL (2009-2010)

PATIENTS: 502 ICU patients submitted to CS with ECC

STRATEGY OF BLOOD TRANSFUSION IN CS_ICU: !  Liberal (n=253): target Hct !30% !  Restrictive (n=249): target Hct !24%

OUTCOME MEASURE: 30-day all-cause mortality & in-hospital morbidity (CS, ARDS, CRRT)

RESULTS:

PATIENTS EXPOSED TO RBC: 316 (63%) [PO_DAY 0#3]

!  Liberal (n=253): 78% !  Restrictive (n=249): 47%

OUTCOME: COMPARABLE IN THE TWO GROUPS WITH DIFFERENT TRANSFUSION STRATEGY TRANSFUSION OF 5 OR MORE RBC UNITS WAS ASSOCIATED WITH HIGHER MORTALITY. IN A MULTIVARIATE COX REGRESSION ANALYSIS (AGE, SEX, TYPE OF CS, LVEF, REDO_CS, PREOP_HB, POST_CS_HB, LACTATES, SVO2), THE NUMBER OF TRANSFUSED RBC UNITS WAS INDEPENDENTLY ASSOCIATED WITH AN INCREASED RICK OF DEATH AT 30 DAYS IN THE ENTIRE POPULATION (HR, 1.2 [95& , 1.1-1.4; P =.002)

METHODS:

P_R_CLINICAL_NONINFERIORITY_TRIAL (2009-2010)

PATIENTS: 502 ICU patients submitted to CS with ECC

STRATEGY OF BLOOD TRANSFUSION IN CS_ICU: !  Liberal (n=253): target Hct !30% !  Restrictive (n=249): target Hct !24%

OUTCOME MEASURE: 30-day all-cause mortality & in-hospital morbidity (CS, ARDS, CRRT)

RESULTS:

PATIENTS EXPOSED TO RBC: 316 (63%) [PO_DAY 0#3]

!  Liberal (n=253): 78% !  Restrictive (n=249): 47%

OUTCOME: COMPARABLE IN THE TWO GROUPS WITH DIFFERENT TRANSFUSION STRATEGY TRANSFUSION OF 5 OR MORE RBC UNITS WAS ASSOCIATED WITH HIGHER MORTALITY. IN A MULTIVARIATE COX REGRESSION ANALYSIS (AGE, SEX, TYPE OF CS, LVEF, REDO_CS, PREOP_HB, POST_CS_HB, LACTATES, SVO2), THE NUMBER OF TRANSFUSED RBC UNITS WAS INDEPENDENTLY ASSOCIATED WITH AN INCREASED RICK OF DEATH AT 30 DAYS IN THE ENTIRE POPULATION (HR, 1.2 [95& , 1.1-1.4; P =.002)

TRA

SFUSI

ONE

C O N C L U I N O I S

!  NO AUTODONAZIONE DI GRC, [SI DI PFC; FORSE SI DI PLT] !  SET-UP CEC CUSTOMIZZATO SUL PAZIENTE (BASSA BSA) !  IMPIEGO DEGLI ANTIFIBRINOLITICI !  EMOSTASI ACCURATA PRE –CEC !  CHIRURGIA “VELOCE” !  POLITICHE RESTRITTIVE NELL’USO DEI FLUIDI

!  CIRCUITI BIOCOMPATIBILI ($ SIRS) !  CAD: MINI-CEC A CIRCUITO CHIUSO ($ SIRS) [ATS 2009;88:529]

!  CIRCUITI CEC A BASSO PRIME (800 -1000 ML)

!  CANNULAZIONE SCRUPOLOSA !  GESTIONE CEC CHE LIMITA LA DILUIZIONE (LIVELLI) !  GESTIONE FARMACOLOGICA NON VASOPLEGIZZANTE !  UTILIZZO DELL’ULTRAFILTRO SE IPERVOLEMIA !  CARDIOPLEGIA EMATICA VS CRISTALLOIDE [ATS 2010;89:11]

!  SISTEMATICO CALCOLO DELLA DO2 IN CEC E IN TICV [PAC] !  USO DI ALGORITMI TRASFUSIONALI BASATI SUL TEG !  UTILIZZO DI STRATEGIE TRASFUSIONALI RESTRITTIVE !  METODI CHE LIMITANO LO SCARTO DI GRC [VAMP]