Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline

The Annals of thoracic surgery (Impact Factor: 3.85). 06/2007; 83(5 Suppl):S27-86. DOI: 10.1016/j.athoracsur.2007.02.099
Source: PubMed


A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes.
We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme.
Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions.
Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.

Download full-text


Available from: Elliott Bennett-Guerrero, Jan 23, 2014
  • Source
    • "In this trial no patients developed adverse drug reactions or thromboembolic conditions. The wide use of tranexamic acid in other surgical procedures affirms the safety of the drug (Robin et al., 2010, Tobias, 2004; Ferraris et al., 2007) especially when compared to its aprotinin counterpart (Wells, 2002). "
    [Show abstract] [Hide abstract]
    ABSTRACT: The aim of this triple blinded randomized clinical trial was to evaluate the efficacy of tranexamic acid when used in conjunction with hypotensive anaesthesia exclusively for Le Fort I osteotomies. 49 patients undergoing Le Fort 1 osteotomy for correction of dentofacial deformity were divided into two groups; Group 1 received a placebo of saline 5ml and Group 2 received 10mg/kg body weight of tranexamic acid. The operating surgeon, anaesthetist and investigator were blinded. The variables of interest recorded in this study included the change in Hb%, PCV, total blood loss, total operating time and quality of the surgical field using Fromme’s Ordinal Scale. Statistically significant differences between the two groups were found between the following variables: post-operative Hb%, drop in Hb%, post-operative PCV, drop in PCV, total surgical blood loss, total operating time and quality of surgical field (P<0.05). Group 2 patients exhibited a smaller drop in Hb% and PCV, with a lower Fromme’s Ordinal Scale value and decreased total blood loss and operating time. In conclusion single preoperative administration of tranexamic acid in the dose of 10mg/kg, when combined with hypotensive anaesthesia is effective in controlling blood loss with regards to single piece Le Fort 1 surgery. Scientific Review Board Reference Number: SRB/SDMDS002MF10 Institutional Human Ethical Committee Reference Number: IHEC/SDMDS002MF10
    Journal of Cranio-Maxillofacial Surgery 10/2014; ᅟ(7). DOI:10.1016/j.jcms.2014.03.003 · 2.93 Impact Factor
  • Source
    • "Our patients recovered the preoperative Hb level of >10 g/dL in postoperative month 3 irrespective of the transfusion amount. We transfused the blood salvaged by cell-saving devices in multiple doses as collected in order to avoid an intraoperative crystalloid fluid overload [10,16]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Conservation of blood during cardiac surgery is important because of the shortage of donor blood, risks associated with transfusion, and the costs of allogeneic blood products. This retrospective study explored the feasibility of off-pump coronary artery bypass (OPCAB) without transfusion. Methods One hundred and two consecutive patients underwent OPCAB from January 2007 to June 2012 at Hallym University Sacred Heart Hospital. Excluding 10 chronic renal failures patients, 102 patients were enrolled. Their characteristics, clinical data, and laboratory data were analyzed. We investigated the success rate of OPCAB without transfusion according to pre-operative hemoglobin (Hb), and the cutoff point of the Hb level and the risk factors for transfusion. We implemented multidisciplinary blood-saving protocols. Results The overall operative mortality and the success rate of OPCAB without transfusion were 2.9% (3/102) and 73.5% (75/102). The success rates in patients with Hb<11, 11 <Hb<14, and 14<Hb were 35.0%, 79.2%, and 89.7% (p=0.01), respectively. The risk factors for transfusion are age>70 years, diagnosis of acute myocardial infarction, preoperative Hb and creatinine levels, and operation time. The events precipitating the need for transfusion were low Hb level in 9 patients and hypotension or excessive bleeding in 18 patients. Conclusion The preoperative Hb level of >11 facilitates OPCAB without transfusion. These results suggest that transfusion-free OPCAB can be performed by modifying the risk factors and correctable causes of transfusion and improving various blood salvage methods.
    Korean Journal of Thoracic and Cardiovascular Surgery 08/2014; 47(4):350-7. DOI:10.5090/kjtcs.2014.47.4.350
    • "At the very least, this puts patients at risk for harm while engendering unnecessary cost for the institution. Dr. Carter et al. undertook an effort to understand why physicians transfuse patients in an ethnographic study and this is being followed by a study looking at decision support systems in the EHR that will help encourage physicians to transfuse according to national[222324] and institutional guidelines. Dr. Carter devoted the majority or her talk to discussing their specific findings which are unpublished data. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Pathologists and informaticians are becoming increasingly interested in electronic clinical decision support for pathology, laboratory medicine and clinical diagnosis. Improved decision support may optimize laboratory test selection, improve test result interpretation and permit the extraction of enhanced diagnostic information from existing laboratory data. Nonetheless, the field of pathology decision support is still developing. To facilitate the exchange of ideas and preliminary studies, we convened a symposium entitled: Pathology data integration and clinical decision support. The symposium was held at the Massachusetts General Hospital, on May 10, 2013. Participants were selected to represent diverse backgrounds and interests and were from nine different institutions in eight different states. The day included 16 plenary talks and three panel discussions, together covering four broad areas. Summaries of each presentation are included in this manuscript. A number of recurrent themes emerged from the symposium. Among the most pervasive was the dichotomy between diagnostic data and diagnostic information, including the opportunities that laboratories may have to use electronic systems and algorithms to convert the data they generate into more useful information. Differences between human talents and computer abilities were described; well-designed symbioses between humans and computers may ultimately optimize diagnosis. Another key theme related to the unique needs and challenges in providing decision support for genomics and other emerging diagnostic modalities. Finally, many talks relayed how the barriers to bringing decision support toward reality are primarily personnel, political, infrastructural and administrative challenges rather than technological limitations.
    01/2014; 5(1):2. DOI:10.4103/2153-3539.126145
Show more