Patient Blood Management

Publication Date: June 29, 2021
Last Updated: November 30, 2023

Recommendations

Preoperative interventions

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. (AI)
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Assessment of anemia and determination of its etiology is appropriate in all patients undergoing cardiac surgery, and it is reasonable to treat with intravenous iron preparations if time permits. (B-RIIa)
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In patients undergoing cardiac operations, it is reasonable to implement standardized transfusion protocols in order to reduce transfusion burden. (B-RIIa)
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In patients who have (i) preoperative anemia, (ii) refuse blood transfusion, (iii) or are deemed high-risk for postoperative anemia, it is reasonable to administer preoperative erythropoietin-stimulating agents and iron supplementation several days prior to cardiac operations to increase red cell mass. (B-RIIa)
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Minimization of phlebotomy by reduced volume and frequency of blood sampling is a reasonable means of blood conservation. (B-NRIIa)
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Preoperative treatment of asymptomatic anemia and thrombocytopenia with transfusion is of uncertain benefit. (B-NRIII (no benefit))
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Preoperative antiplatelet management

In order to reduce bleeding in patients requiring elective cardiac surgery, ticagrelor should be withdrawn preoperatively for a minimum of 3 days, clopidogrel for 5 days, and prasugrel for 7 days. (B-NRI)
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It is reasonable to discontinue low-intensity antiplatelet drugs (eg, aspirin) only in purely elective patients without acute coronary syndromes before operation with the expectation that blood transfusion will be reduced. (AIIa)
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Laboratory and/or point-of-care measurement of antiplatelet drug effect in patients having received recent dualantiplatelet therapy can be useful to assess bleeding risk or to guide timing of surgery. (B-RIIa)
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The addition of a P2Y12 inhibitor to aspirin therapy, if indicated, in the immediate postoperative care of coronary artery bypass grafting patients prior to ensuring surgical hemostasis may increase bleeding and the need for surgical reexploration and is not recommended until the risk of bleeding has abated. (C-LDIII (no benefit))
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Preoperative anticoagulants

In patients in need of emergent cardiac surgery with recent ingestion of a nonvitamin K oral anticoagulant (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 appropriate dose or administer andexanet-a for either apixaban or rivaroxaban at appropriate dose). (C-LDIIa)
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If the antidote for the specified NOAC is not available, prothrombin concentrate is recommended, recognizing that the effective response may be variable. (C-LDIIa)
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Pharmacologic agents

Use of synthetic antifibrinolytic agents such as epsilon-aminocaproic acid (EACA) or tranexamic acid reduce blood loss and blood transfusion during cardiac procedures and are indicated for blood conservation. (AI)
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Tranexamic acid reduces bleeding and total transfusion during off pump coronary artery bypass graft surgery. (B-RIIa)
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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 operations using CPB. (B-RIIa)
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Use of 1-deamino-8-D-arginine vasopressin (DDAVP) may be reasonable to attenuate excessive bleeding and transfusion in certain patients with demonstrable and specific platelet dysfunction known to respond to this agent (eg, uremic or CPB-induced platelet dysfunction, type I von Willebrand disease). (B-NRIIb)
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Blood products and derivatives

Antithrombin III concentrates are indicated to reduce plasma transfusion in patients with antithrombin mediated heparin resistance immediately before cardiopulmonary bypass. (AI)
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When allogeneic blood transfusion is needed, it is reasonable to use leukoreduced donor blood, if available. (B-RIIa)
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Plasma transfusion is reasonable in patients with serious bleeding in the context of multiple or single coagulation factor deficiencies when safer fractionated products are not available. (B-NRIIa)
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Prothrombin concentrate is reasonable to consider over fresh frozen plasma as first-line therapy for refractory coagulopathy in cardiac surgery in select situations to reduce bleeding. (B-NRIIa)
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Use of recombinant factor VIIa concentrate may be considered for the management of intractable nonsurgical bleeding that is unresponsive to routine hemostatic therapy after cardiac procedures using CPB. (B-NRIIb)
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Prophylactic use of plasma in cardiac operations 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. (AIII (harm))
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Perfusion interventions

Retrograde autologous priming of the CPB circuit should be used wherever possible. (B-RI)
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Reduced priming volume in the CPB circuit reduces hemodilution and is indicated for blood conservation, (B-NRI)
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Acute normovolemic hemodilution (ANH) is a reasonable method to reduce bleeding and transfusion. (AIIa)
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Minimally invasive extracorporeal circulation is reasonable to reduce blood loss and red cell transfusion as part of a combined blood conservation approach. (B-RIIa)
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Use of modified ultrafiltration may be reasonable for blood conservation and reducing postoperative blood loss in adult cardiac operations using CPB. (B-RIIb)
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Blood salvage interventions

Routine use of red cell salvage using centrifugation is helpful for blood conservation in cardiac operations using CPB. (AI)
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Centrifugation of pump-salvaged blood is reasonable for minimizing post-CPB allogeneic red blood cell transfusion. (AIIa)
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In high-risk patients with known malignancy who require CPB, blood salvage using centrifugation of salvaged blood from the operative field may be considered when allogeneic transfusion is required. (B-NRIIb)
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Direct reinfusion of shed mediastinal blood from postoperative chest tube drainage is not recommended as a means of blood conservation and may cause harm. (B-NRIII (harm))
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Postoperative fluid management

It is reasonable to administer human albumin after cardiac surgery to provide intravascular volume replacement and minimize the need for transfusion. (B-RIIa)
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Hydroxyethyl starch is not recommended as a volume expander in CPB patients as it may increase the risk of bleeding. (B-RIII (no benefit))
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Transfusion algorithms

In patients undergoing cardiac surgery, a restrictive perioperative allogeneic red blood cell (RBC) transfusion strategy is recommended in preference to a liberal transfusion strategy for perioperative blood conservation, as it reduces both transfusion rate and units of allogeneic RBCs without increased risk for mortality or morbidity. (AI)
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Goal directed transfusion algorithms which incorporate point of care testing, such as with viscoelastic devices, are recommended to reduce periprocedural bleeding and transfusion in cardiac surgical patients. (B-RI)
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Allogeneic RBC transfusion is unlikely to improve oxygen transport when the hemoglobin concentration is greater than 10 g/dL and is not recommended. (B-RIII (no benefit))
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Management of blood resources

A comprehensive multimodality blood conservation program led by a multidisciplinary team of health care providers should be part of any patient blood management program to limit utilization of blood resources and decrease the risk of bleeding. (B-RI)
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Recommendation Grading

Overview

Title

Patient Blood Management

Authoring Organizations

American Society of Extracorporeal Technology

Society of Cardiovascular Anesthesiologists

Society of Thoracic Surgeons

Publication Month/Year

June 29, 2021

Last Updated Month/Year

April 1, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Hospital

Intended Users

Physician, nurse practitioner, nurse, physician assistant

Scope

Management

Diseases/Conditions (MeSH)

D001803 - Blood Transfusion, D001769 - Blood

Keywords

blood transfusions, Clinical Practice Guideline, Patient Blood Management

Source Citation

Tibi, P., McClure, R. S., Huang, J., Baker, R. A., Fitzgerald, D., Mazer, C. D., Stone, M., Chu, D., Stammers, A. H., Dickinson, T., Shore-Lesserson, L., Ferraris, V., Firestone, S., Kissoon, K., & Moffatt-Bruce, S. (2021). STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. The Annals of Thoracic Surgery, 112(3), 981–1004. https://doi.org/10.1016/j.athoracsur.2021.03.033