Patient blood management during cardiac surgery: Do we have enough evidence for clinical practice?

Abstract

endorsed by the European Association of Cardiothoracic Anaesthesiologists (EACTA) Transfusion of allogeneic blood products during and after cardiac operations is common. When the degree of anemia and the consequent decrease in oxygen delivery lead to organ ischemia, there is little doubt that red blood cell (RBC) transfusion is necessary. In addition, treatment with fresh-frozen plasma and platelets may be necessary to support coagulation. Treatment with blood products may also aim to prevent hemodynamic instability from excessive postoperative blood loss. A large body of evidence, however, indicates that transfusion of blood products per se may be associated with increased morbidity and mortality after cardiac operations. [1][2][3][4] It is therefore important to assess the real versus perceived need for the transfusion of allogeneic RBCs and other blood From the Department of Cardiothoracic-vascular Anesthesia and Intensive Care, a

Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis

“…Such uncertainty with respect to an expensive pharmacological intervention would be unthinkable. The results of RCTs in non-cardiac surgery patients may not be transferrable to a population with symptomatic cardiac disease and it is of concern that these, as well as the results of observational studies, which we have concluded are unable to guide transfusion practice, form the basis of national and international blood conservation guidelines 4,5,84 . Such guidelines urge clinicians to adopt restrictive transfusion practices due to the adverse outcomes demonstrated in these studies 4,5 .…”

Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials

“…However, there is clinical uncertainty as to how these conditions should be managed clinically because of our limited understanding of the underlying mechanisms and the lack of clinical efficacy for most blood management interventions that have been evaluated in clinical trials. 7 This has led to significant variability in care.…”

Haemostatic management of cardiac surgical haemorrhage

“…Even when more than one aggregation response assessment is performed (e.g. collagen, aspirin, ADP, thrombin receptor agonist peptide), interpretation becomes more and more difficult given the complex nature of post-CPB coagulopathy [5,52,53]. Treatment is still transfusion of platelet concentrate, whatever the defect, with a trend to consider double dose platelets or downward adjustment of the platelet transfusion threshold to compensate for reduced function.…”

“…Tranexamic acid (TXA), used almost ubiquitously in UK cardiac surgical practice, and epsilon aminocaproic acid (EACA), are synthetic lysine-analogues that reversibly block the lysine binding site of plasminogen which inhibits the lysis of polymerised fibrin. They have a plasma half-life of around 2 h, and are excreted in the urine in high concentrations [53]. The optimum dose of TXA is unknown despite its widespread international use, with 10 mg.kg À1 bolus followed by 1 mg.kg À1 .h À1 as a continuous infusion being the most commonly used regimen, with little evidence for higher doses [57].…”