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Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KYDepartment of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KYCenter for Integrative Environmental Health Sciences, University of Louisville, Louisville, KYDepartment of Pharmacology & Toxicology, University of Louisville, Louisville, KYDepartment of Medicine, University of Louisville, Louisville, KY
THE COLLABORATION of the Society of Thoracic Surgeons (STS), Society of Cardiovascular Anesthesiologists (SCA), the American Society of ExtraCorporeal Technology (AmSECT), and the Society for the Advancement of Patient Blood Management (SABM) produced the updated 2021 Clinical Practice Guidelines on Patient Blood Management in Cardiac Surgery in the September 2021 issue of JCVA.
This new guideline provides the most comprehensive recommendations to date and encompasses the time period from preoperative interventions, including management of antiplatelet and anticoagulant medication, to postoperative blood and fluid management. Recommendations cover the perioperative administration of pharmacologic agents, blood products and derivatives, as well as perfusion interventions, blood salvage techniques, and the use of transfusion algorithms, with an eye toward resource management in cardiac surgery. Patient blood management focuses on managing anemia, optimizing coagulation, interdisciplinary blood conservation modalities, and patient-centered decision-making, in order to achieve improved patient outcomes. In many aspects, cardiac anesthesiologists are involved directly and ideally positioned to take on leadership roles to ensure compliance and success. Pertinent key points are highlighted in Figure 1. The following narrative summarizes the key points from the current Guidelines that are either new or modified from the 2011 publication, or are unchanged but felt to be high priority patient blood management activities.
Fig 12021 Clinical Practice Guidelines on Patient Blood Management in Cardiac Surgery for Anesthesiologists.
One of the most significant determinants of patients requiring a perioperative blood transfusion is preoperative anemia. In patients who have preoperative anemia, in those who refuse blood transfusion, or in those who are deemed highrisk for postoperative anemia, it is reasonable to administer preoperative erythropoietin-stimulating agents and iron supplementation several days before cardiac surgery to increase red cell mass (class IIA, level B-R).
A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: Results of a prospective single-blind randomized controlled trial.
Nonvitamin-K antagonist oral anticoagulants (NOACs) (dabigatran [thrombin inhibitor], apixaban, betrixaban, edoxaban, and rivaroxaban [factor Xa inhibitors]) are a new subgroup of pharmacologic agents that have achieved widespread use since the 2011 publication of these guidelines. They currently are a preferred alternative to the vitamin K antagonist, warfarin, for stroke prevention in nonvalvular atrial fibrillation as well as in the treatment of venous thromboembolism.
In patients in need of emergent cardiac surgery with recent ingestion of a NOAC or laboratory evidence of a NOAC effect, administration of the reversal antidote specific to that NOAC is recommended (ie, administer idarucizumab for dabigatran at the appropriate dose or administer andexanet-alpha for either apixaban or rivaroxaban at the appropriate dose). If the antidote for the specified NOAC is not available, prothrombin complex concentrate is recommended, recognizing that the effective response may be variable (class IIA, level C-LD).
However, an advantage of administration of prothrombin complex concentrate is that it provides for rapid restoration of vitamin K-dependent coagulation factor levels without exposure to allogeneic blood and without the deleterious effects of volume overload that may accompany an equipotent dose of plasma.
Dual-antiplatelet therapy, with a P2Y12 inhibitor and aspirin, is well-demonstrated to decrease ischemic risk and thrombotic complications in patients with acute coronary syndromes. The most commonly used P2Y12 inhibitors in the setting of acute coronary syndromes and percutaneous coronary interventions have been clopidogrel, prasugrel, and ticagrelor. In order to reduce bleeding in patients requiring elective cardiac surgery, ticagrelor should be withdrawn preoperatively for a minimum of three days,
Antifibrinolytic agents currently used in patients undergoing cardiac surgery include the synthetic lysine analogs, tranexamic acid and epsilon aminocaproic acid. Use of these synthetic antifibrinolytic agents reduces blood loss and blood transfusion during cardiac procedures, and their use is indicated for blood conservation
(class I, level A). Tranexamic acid reduces bleeding and total transfusion during off-pump coronary artery bypass grafting surgery (class IIA, level B-R).
Topical application of antifibrinolytic agents to the surgical site after cardiopulmonary bypass (CPB) is reasonable to limit chest tube drainage and transfusion requirements after cardiac surgery, although no single topical preparation emerges as the agent of choice for localized bleeding that is difficult to control (class IIA, level B-R).
Goal-directed transfusion algorithms that incorporate point-of-care testing, such as with viscoelastic devices, are recommended to reduce periprocedural bleeding and transfusion in cardiac surgical patients
(class I, level B-R). Point-of-care monitoring of the hemostatic system is critical to provide timely and accurate assessment of the cause of bleeding, with potential to provide targeted therapies.
Prophylactic use of plasma in cardiac surgery in the absence of coagulopathy is not indicated, does not reduce blood loss, and exposes patients to unnecessary risks and complications of allogeneic blood component transfusion (class III: harm, level A).
Routine use of red cell salvage using centrifugation is helpful for blood conservation and minimizes post-CPB allogeneic red blood cell transfusion in cardiac surgery (class I, level A). Direct reinfusion of shed mediastinal blood from postoperative chest tube drainage is not recommended as a means of blood conservation and may cause harm (class III: harm, level B-NR).
Perfusion Interventions
Acute normovolemic hemodilution is a method intended to limit loss of red blood cell mass by sequestration of a portion of the patient's blood volume before CPB. Acute normovolemic hemodilution is a reasonable method to reduce bleeding and transfusion (class IIA, level of evidence A).
Acute normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis of randomized trials.
Retrograde autologous priming of the CPB circuit should be used wherever possible (class I, level B-R). Throughout most recent studies, the volume of clear prime that is displaced is an important criterion contributing to the effectiveness of retrograde autologous priming in reducing blood transfusions.
This is similar to the way in which a reduced priming volume can be effective in reducing blood transfusion. Reduced priming volume in the CPB circuit reduces hemodilution and is indicated for blood conservation (class I, level B-NR).
The adoption of a combined strategy of surgical approach, anesthesia, and perfusion management, along with CPB circuit features designed to minimize hemodilution and optimize biocompatibility, have been termed "minimally invasive extracorporeal circulation" and are reasonable to reduce blood loss and red cell transfusion as part of a combined blood conservation approach (class IIA, level B-R).
Postoperative Management
In patients undergoing cardiac surgery, a restrictive perioperative allogeneic RBC transfusion strategy (transfusion trigger between 7 and 8 g/dL) is recommended in preference to a liberal transfusion strategy (transfusion trigger between 8 and 10 g/dL) for perioperative blood conservation. This restrictive strategy reduces both transfusion rate and units of allogeneic RBCs without increased risk of mortality or morbidity (class I, level A). Allogeneic RBC transfusion is unlikely to improve oxygen transport when the hemoglobin concentration is greater than 10 g/dL and is not recommended (class III: no benefit; level B-R).14 It is reasonable to administer human albumin after cardiac surgery to provide intravascular volume replacement and minimize the need for transfusion (class IIA, level B-R). Hydroxyethyl starch is not recommended as a volume expander in CPB patients, as it may increase the risk of bleeding (class III: no benefit, level B-R).
Conclusions
This 2021 STS/SCA/AmSECT/SABM updated patient blood management guidelines stress the importance of an evidence-based, multimodal, and multidisciplinary approach to preserving a patient's blood and conserving resources so as to optimize outcomes in patients who are at high risk for transfusion. A standardized protocol for evidence-based patient blood management leads to a patient-centered approach to blood conservation in the perioperative setting and favors improved clinical outcomes in cardiopulmonary procedures.
Conflict of Interest
Jiapeng Huang received grant support from the National Center For Advancing Translational Sciences of the National Institutes of Health under Award Number U18TR003787, NIH P30 (P30ES030283) grant, and Gilead Sciences COMMIT COVID-19 RFP Program grant (Gilead IN-United States-983-6063).
References
Tibi P
McClure RS
Huang J
et al.
STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management.
A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: Results of a prospective single-blind randomized controlled trial.
Acute normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery: A systematic review and meta-analysis of randomized trials.
Owing to the constantly evolving nature of the medical literature, The Society of Thoracic Surgeons (STS) clinical practice guidelines periodically undergo evaluation and updating. A multidisciplinary panel of experts was convened by STS, which includes members of the Society of Cardiovascular Anesthesiologists (SCA), the American Society of ExtraCorporeal Technology (AmSECT), and the Society for the Advancement of Blood Management (SABM), to review the latest data on patient blood management and to update the 2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines.
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