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

Victor A. Ferraris, Suellen P. Ferraris, Sibu P. Saha, Eugene A. Hessel, Constance K. Haan, B. David Royston, Charles R. Bridges, Robert Higgins, George Despotis, Jeremiah R. Brown, Bruce D. Spiess, Linda Shore-Lesserson, Mark Stafford-Smith, C. David Mazer, Elliott Bennett-Guerrero, Steven E. Hill, Simon Body

Research output: Contribution to journalArticle

Abstract

Background: 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. Methods: 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. Results: 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. Conclusions: 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.

Original languageEnglish (US)
JournalAnnals of Thoracic Surgery
Volume83
Issue number5 SUPPL.
DOIs
StatePublished - May 2007
Externally publishedYes

Fingerprint

Practice Guidelines
Blood Transfusion
Thoracic Surgery
Antifibrinolytic Agents
Blood Volume
Pharmaceutical Preparations
Operative Blood Salvage
Hemorrhage
Off-Pump Coronary Artery Bypass
Equipment and Supplies
Hemodilution
Body Size
Erythropoietin
Cell Size
Coronary Artery Bypass
Health Personnel
Comorbidity
Anemia
Emergencies
Randomized Controlled Trials

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery : The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline. / Ferraris, Victor A.; Ferraris, Suellen P.; Saha, Sibu P.; Hessel, Eugene A.; Haan, Constance K.; Royston, B. David; Bridges, Charles R.; Higgins, Robert; Despotis, George; Brown, Jeremiah R.; Spiess, Bruce D.; Shore-Lesserson, Linda; Stafford-Smith, Mark; Mazer, C. David; Bennett-Guerrero, Elliott; Hill, Steven E.; Body, Simon.

In: Annals of Thoracic Surgery, Vol. 83, No. 5 SUPPL., 05.2007.

Research output: Contribution to journalArticle

Ferraris, VA, Ferraris, SP, Saha, SP, Hessel, EA, Haan, CK, Royston, BD, Bridges, CR, Higgins, R, Despotis, G, Brown, JR, Spiess, BD, Shore-Lesserson, L, Stafford-Smith, M, Mazer, CD, Bennett-Guerrero, E, Hill, SE & Body, S 2007, 'Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline', Annals of Thoracic Surgery, vol. 83, no. 5 SUPPL.. https://doi.org/10.1016/j.athoracsur.2007.02.099
Ferraris, Victor A. ; Ferraris, Suellen P. ; Saha, Sibu P. ; Hessel, Eugene A. ; Haan, Constance K. ; Royston, B. David ; Bridges, Charles R. ; Higgins, Robert ; Despotis, George ; Brown, Jeremiah R. ; Spiess, Bruce D. ; Shore-Lesserson, Linda ; Stafford-Smith, Mark ; Mazer, C. David ; Bennett-Guerrero, Elliott ; Hill, Steven E. ; Body, Simon. / Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery : The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline. In: Annals of Thoracic Surgery. 2007 ; Vol. 83, No. 5 SUPPL.
@article{e301c886d69c416f9075f5582500f7a5,
title = "Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline",
abstract = "Background: 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. Methods: 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. Results: 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. Conclusions: 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.",
author = "Ferraris, {Victor A.} and Ferraris, {Suellen P.} and Saha, {Sibu P.} and Hessel, {Eugene A.} and Haan, {Constance K.} and Royston, {B. David} and Bridges, {Charles R.} and Robert Higgins and George Despotis and Brown, {Jeremiah R.} and Spiess, {Bruce D.} and Linda Shore-Lesserson and Mark Stafford-Smith and Mazer, {C. David} and Elliott Bennett-Guerrero and Hill, {Steven E.} and Simon Body",
year = "2007",
month = "5",
doi = "10.1016/j.athoracsur.2007.02.099",
language = "English (US)",
volume = "83",
journal = "Annals of Thoracic Surgery",
issn = "0003-4975",
publisher = "Elsevier USA",
number = "5 SUPPL.",

}

TY - JOUR

T1 - Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery

T2 - The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline

AU - Ferraris, Victor A.

AU - Ferraris, Suellen P.

AU - Saha, Sibu P.

AU - Hessel, Eugene A.

AU - Haan, Constance K.

AU - Royston, B. David

AU - Bridges, Charles R.

AU - Higgins, Robert

AU - Despotis, George

AU - Brown, Jeremiah R.

AU - Spiess, Bruce D.

AU - Shore-Lesserson, Linda

AU - Stafford-Smith, Mark

AU - Mazer, C. David

AU - Bennett-Guerrero, Elliott

AU - Hill, Steven E.

AU - Body, Simon

PY - 2007/5

Y1 - 2007/5

N2 - Background: 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. Methods: 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. Results: 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. Conclusions: 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.

AB - Background: 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. Methods: 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. Results: 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. Conclusions: 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.

UR - http://www.scopus.com/inward/record.url?scp=34247269097&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=34247269097&partnerID=8YFLogxK

U2 - 10.1016/j.athoracsur.2007.02.099

DO - 10.1016/j.athoracsur.2007.02.099

M3 - Article

C2 - 17462454

AN - SCOPUS:34247269097

VL - 83

JO - Annals of Thoracic Surgery

JF - Annals of Thoracic Surgery

SN - 0003-4975

IS - 5 SUPPL.

ER -