Newly updated multi-society cardiac surgery guidelines have shifted to a comprehensive blood management approach, with no longer simple recommendations on transfusion.
An update to the 2011 recommendations from the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists, now in collaboration with the American Society of ExtraCorporeal Technology, and the Society for the Advancement of Patient Blood Management (SABM), has been put out. It is available online in the Annals of Thoracic Surgery.
Since the last version, there has been so much new evidence that Pierre R. Tibi, MD, of Yavapai Regional Medical Center in Prescott, Arizona, and colleagues revised or added 23 recommendations and scrapped others.
Probably the biggest change is going from ‘blood conservation’ to the broader ‘patient blood management‘ (PBM) approach, Dr Tibi told MedPage Today.
“Basically we’re considering blood as another vital organ,” he said. “Why that is important is because now we look at a patient’s blood system as an organ that needs to be assessed and treated for the sake of that organ and not simply to decide when or when not to transfuse.”
Recommendations range from preoperative assessment of bleeding risk and anaemia to intraoperative perfusion and blood salvage practices to postoperative treatment with human albumin for volume replacement.
“Most hospitals around the U.S. are acutely aware of patient blood management and, to some degree or another, are implementing many of the things we are talking about,” noted Tibi, who is the most recent past president of SABM. Nationwide, the amount of blood transfused in cardiac surgery has dropped 45% in the past 10 to 15 years but still ranges widely across centres.
A broadly endorsed guideline like this emphasising the importance of a whole-patient strategy should hopefully standardize effective practices and move insurers to cover them, he suggested.
The guideline, for example, gives preoperative assessment of anaemia and its treatment with IV iron and erythropoietin-stimulating agents, if there is time, a class IIA endorsement. Anaemia is widespread, with possibly as many as 40% of patients having it, with one in 10 being under the 8 mg/dL haemoglobin threshold.
“There is a distinct correlation between preoperative anemia and worse clinical outcomes in most studies,” the guidelines note. “Usually, the greater the anemia, the more severe the complications.”
However, preoperative anaemia is “very, very underrecognised and undertested,” Dr Tibi said. While there isn’t always time to reverse anaemia that is found before cardiac surgery, he pointed out that “most of the factors in elective heart surgery have to do with insurance and Medicare. … Oftentimes the treatment for anaemia is not covered by various entities and is too expensive for patients to cover themselves.”
Other notable updates included a class IA recommendation for red blood cell salvage with centrifugation when patients are on cardiopulmonary bypass and the addition of recommendations for the assessment and treatment of patients on anticoagulants.
The guideline, for example, says to withdraw ticagrelor (Brilinta) at least 3 days, clopidogrel (Plavix) 5 days, and prasugrel (Effient) 7 days prior to elective cardiac surgery, while other non-vitamin K oral anticoagulants (NOACs) should be stopped at least 2 days in advance.
“Despite their advantages, NOACs present some periprocedural challenges for operations with a high-risk bleeding profile,” the document says. “Available measurement assays to assess anticoagulation for NOACs are imprecise, and the availability of reversal agents is limited.”
If point-of-care testing with thrombin clotting time is available for dabigatran (Pradaxa), or anti-factor Xa assays for apixaban (Eliquis) and rivaroxaban (Xarelto), in the case of emergent surgery, the guidelines recommend their use.
Source: MedPage Today
Journal information: Tibi P, et al “STS/SCA/AmSECT/SABM update to the clinical practice guidelines on patient blood management” Ann Thor Surg 2021; DOI: 10.1016/j.athoracsur.2021.03.033.
