Blood Management for Cardiothoracic Surgery: Guidelines Update

The Society of Thoracic Surgeons (STS) has updated its clinical practice guidelines on patient blood management for those undergoing cardiac surgery.  

The new recommendations, which were produced in collaboration with Society of Cardiovascular Anesthesiologists, the American Society of ExtraCorporeal Technology, and the Society for the Advancement of Blood Management, represent an update of the 2011 guidelines.

The update has been copublished in The Annals of Thoracic Surgery, the Journal of ExtraCorporeal Technology, and the Journal of Cardiothoracic and Vascular Anesthesia.

“These guidelines have been compiled by four different societies, all with different perspectives, so this was a truly multidisciplinary panel,” coauthor Susan Moffatt-Bruce, MD, FRCSC, told theheart.org | Medscape Cardiology.

Moffatt-Bruce, who is chief executive officer of the Royal College of Physicians and Surgeons of Canada and professor of surgery, University of Ottawa, said: “The key message in these guidelines is that blood transfusion is a critical and life-saving facet of the care for cardiothoracic surgery patients, but there are ways to minimize its risks. By following these evidence-based recommendations we can improve patient outcomes and ensure patient safety.”

“In an ideal world, we wouldn’t need blood transfusions at all. But there will always be some patients for whom this will be required — those in urgent situations, who have long durations of surgery, and in specific clinical scenarios,” she observed.

“We would like to minimize the number of transfusions and the amount of blood used. We can do this by certain interventions preoperatively, intraoperatively, and postoperatively, and this is what these guidelines are addressing.”

“These guidelines also increase focus on patient-centred care to include all the members of the team who take care of the patient,” she added.

The update includes 23 new or updated recommendations, together with all previous recommendations, which address the full spectrum of care for patients undergoing cardiac surgery.

The four major tenets of patient blood management are: managing anemia, optimizing coagulation, interdisciplinary blood conservation modalities, and patient-centered decision making to achieve improved patient outcomes.

Critical to this review and guideline development was an understanding of the patient care paradigm throughout the care continuum, which consists of exploring the informed consent process, preoperative conditioning, current clinical use of antiplatelet agents and preoperative anticoagulants, intraoperative blood management, and postoperative management of patients undergoing cardiopulmonary bypass, the report notes.  

Preoperative Interventions

“Management of patients undergoing cardiac surgery starts well before the surgery, in that we need to really get to know our patient and quantify each individual patient’s risk beforehand. We need to have a conversation with the patient, so they are aware of the risk in advance,” Moffatt-Bruce said.

The guidelines state that preoperative identification of high-risk patients should be performed, and all available preoperative and perioperative measures of blood conservation should be undertaken in this group, as they account for the majority of blood products transfused.

It recommends that assessment of anemia is appropriate in all patients undergoing cardiac surgery. In patients who have preoperative anemia, who refuse blood transfusion, or are deemed high-risk for postoperative anemia, it’s reasonable to administer preoperative erythropoietin-stimulating agents and iron supplementation several days prior to surgery to increase red cell mass. While the use of standardized transfusion protocols to reduce transfusion burden is considered reasonable, the guidelines state that the benefit of preoperative treatment of asymptomatic anemia and thrombocytopenia with transfusion is unclear.

The new recommendations also address the new oral anticoagulants (NOACs) and provide evidence and timing to inform patients on when to stop these medications before surgery.

In patients in need of emergency cardiac surgery who are taking NOACs, administration of the reversal antidote specific to that NOAC is recommended. If the antidote for the specified NOAC is not available, prothrombin concentrate is recommended.

In patients on antiplatelet agents undergoing elective cardiac surgery, ticagrelor should be withdrawn a minimum of 3 days, clopidogrel a minimum of 5 days, and prasugrel a minimum of 7 days before the operation. Laboratory and/or point-of-care measurement of antiplatelet drug effect in patients having received recent dual-antiplatelet therapy can be useful to assess bleeding risk or to guide timing of surgery, the guidelines state.

Intraoperative Recommendations

“During the actual procedure, we need to really focus on blood conservation,” Moffatt-Bruce said.

One of the recommendations states that use of synthetic antifibrinolytic agents, such as epsilon–aminocaproic acid or tranexamic acid, reduces blood loss and blood transfusion during cardiac procedures and is indicated for blood conservation.

But Moffatt-Bruce noted that use of tranexamic acid has been downgraded to a class 2 recommendation. “It used to be that tranexamic acid was routinely used; it was assumed it was always needed. Now it is recommended that this is not automatically given but just used in certain clinical situations.”

The guidelines also recommend point-of-care assessment of hemostasis with viscoelastic devices to guide blood product administration and reduce unnecessary transfusions.

Postoperative Interventions

Among the new postoperative recommendations is the use of albumin to provide intravascular volume replacement and minimize the need for transfusion.

On this, Moffatt-Bruce commented: “Postoperative albumin has been considered for many years, but there is more evidence now that this works well to help patients recover and leads to less blood use. The ultimate goal is to reduce the amount of blood transfused.”

“These new updated guidelines are applicable not just to the surgeons but also to the whole team involved in the surgery, including perfusionists, anaesthesiologists, and ICU doctors caring for patient postoperatively. It really is a multidisciplinary blood conservation program,” she added.

Ann Thorac Surg. Published online June 30, 2021. Abstract

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