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What’s New in the Patient Safety World

August 2021

New Blood Management Guidelines for Cardiac Surgery

 

 

 

We’ve done multiple columns on the detrimental effects of red blood cell transfusions and the trend toward more restrictive transfusion guidelines (see list at the end of this column). But most of the recommendations for restricted use of transfusion have applied to non-cardiac surgery.

 

Now 4 specialty societies (the Society of Thoracic Surgeons, the Society of Cardiovascular Anesthesiologists, the American Society of ExtraCorporeal Technology, and the Society for the Advancement of Patient Blood Management) have collaborated to publish an update to “Clinical Practice Guidelines on Patient Blood Management” (Tibi 2021). The guidelines focus on ways to minimize blood loss during cardiac surgery and reduce the need for transfusions.

 

The updated guidelines use the term “patient blood management” (PBM) rather than the term “blood conservation” that had been used in the prior guidelines. PBM includes managing anemia, optimizing coagulation, interdisciplinary blood conservation modalities, and patient-centered decision making in order to achieve improved patient outcomes.

 

The guideline calls for preoperative identification of high-risk patients and use of preoperative and perioperative measures of blood conservation. Assessment of anemia and determination of its etiology is appropriate in all patients undergoing cardiac surgery. Iron deficiency is the most common cause of anemia in this population, occurring in up to 50% of anemic patients. Treating iron-deficiency anemia should be done before surgery if time permits, and can substantially reduce the need for blood transfusion. In patients undergoing cardiac operations, it is reasonable to implement standardized transfusion protocols in order to reduce transfusion burden. Preoperative erythropoietin-stimulating agents and iron supplementation several days prior to cardiac operations to increase red cell mass can be considered in those patients at high risk for postoperative anemia or those who refuse transfusion. Phlebotomy should be minimized by reduced volume and frequency of blood sampling as a reasonable means of blood conservation. The guideline also provides recommendations for preoperative management of any antiplatelet agents or anticoagulants being used, including timing of cessation for individual agents and recommendations regarding reversal agents if needed.

 

It also has recommendations regarding use of antifibrinolytic agents (and also DDAVP in those patients with conditions known to respond to DDAVP). It provides guidance for various blood products and derivatives.

 

Red blood cell salvage is emphasized in patients on cardiopulmonary bypass. Centrifugation of pump-salvaged blood is reasonable for minimizing post- cardiopulmonary bypass allogeneic red blood cell transfusion.

 

Regarding volume replacement, the guideline states it is reasonable to administer human albumin after cardiac surgery to provide intravascular volume replacement and minimize the need for transfusion. But hydroxyethyl starch is not recommended as a volume expander in cardiopulmonary bypass patients because it may increase the risk of bleeding.

 

Another recommendation is to use “retrograde autologous priming”, in which the cardiopulmonary bypass circuit is primed with the patient’s own blood. That technique has been shown to reduce transfusion rates.

 

Regarding transfusion strategies, the guideline states “In patients undergoing cardiac surgery, a restrictive perioperative allogeneic red blood cell (RBC) transfusion strategy is recommended in preference to a liberal transfusion strategy for perioperative blood conservation, as it reduces both transfusion rate and units of allogeneic RBCs without increased risk for mortality or morbidity.” It also notes that allogeneic RBC transfusion is unlikely to improve oxygen transport when the hemoglobin concentration is greater than 10 g/dL and is not recommended.

 

The guideline further recommends that a multidisciplinary team of health care providers should be part of any patient blood management program to limit utilization of blood resources and decrease the risk of bleeding.

 

Read the full guideline to see grading of the evidence for each of the recommendations and good discussions on the rationale for each.

 

 

Prior columns on potential detrimental effects related to red blood cell transfusions:

 

 

References:

 

 

Tibi P, McClure RS, Huang J, et al. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Annals of Thoracic Surgery 2021; Published online: June 30, 2021

https://www.annalsthoracicsurgery.org/article/S0003-4975(21)00556-7/fulltext

(Tibi 2021)

 

 

 

 

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