Special report: STS workforce on evidence based surgery2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines*
Section snippets
Introduction—Statement of the Problem
In the United States, surgical procedures account for transfusion of almost 15 million units of packed red blood cells (PRBC) every year. Despite intense interest in blood conservation and minimizing blood transfusion, the number of yearly transfusions is increasing [1]. At the same time, the blood donor pool is stable or slightly decreased [1, 2]. Donor blood is viewed as a scarce resource that is associated with increased cost of health care and significant risk to patients (//www.hhs.gov/ophs/bloodsafety/2007nbcus_survey.pdf
2) Methods Used to Survey Published Literature
The search methods used to survey the published literature changed in the current version compared with the previously published guideline. In the interest of transparency, literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical “OR” connector: extracorporeal circulation (MeSH number E04.292
a) Risk Assessment
Not all patients undergoing cardiac procedures have equal risk of bleeding or blood transfusion. An important part of blood resource management is recognition of patients' risk of bleeding and subsequent blood transfusion. In the STS 2007 blood conservation guideline, an extensive review of the literature revealed three broad risk categories for perioperative bleeding or blood transfusion: (1) advanced age, (2) decreased preoperative red blood cell volume (small body size or preoperative anemia
4) Major Changes or Additions
Certain features of blood conservation and management of blood resources stand out based on recently available evidence. Preoperative risk assessment is a necessary starting point. Of the three major preoperative patient risk factors listed above, the patients who are easiest to address are those with low red blood cell volume, either from preoperative anemia or from small body size. Two persistent features of perioperative blood conservation are the need for minimization of hemodilution during
Class I
- 1
Drugs that inhibit the platelet P2Y12 receptor should be discontinued before operative coronary revascularization (either on-pump or off-pump), if possible. The interval between drug discontinuation and operation varies depending on the drug pharmacodynamics, but may be as short as 3 days for irreversible inhibitors of the P2Y12 platelet receptor. (Level of evidence B)
Class IIb
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Point-of-care testing for platelet ADP responsiveness might be reasonable to identify clopidogrel nonresponders who are
7) Summary of Recommendations
A starting point for blood management in patients having cardiac operations is risk assessment. An exhaustive review of the literature suggests three important preoperative risk factors are linked to bleeding and blood transfusion: (1) advanced age (age ≥70 years); (2) low RBC volume either from preoperative anemia or from small body size of from both; and (3) urgent or complex operations usually associated with prolonged CPB time and non-CABG procedures.
Unfortunately, the literature does not
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The Society of Thoracic Surgeons Clinical Practice Guidelines are intended to assist physicians and other health care providers in clinical decision-making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.
For the full text of this and other STS Practice Guidelines, visit http://www.sts.org/resources-publications at the official STS Web site (www.sts.org).
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The International Consortium for Evidence Based Perfusion formally endorses these guidelines.