Special report: STS workforce on evidence based surgery
2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines*

https://doi.org/10.1016/j.athoracsur.2010.11.078Get rights and content

Background

Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007.

Methods

The search methods used in the current version differ compared to the previously published guideline. 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), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical ‘AND’ connector.

Results

In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management.

Conclusions

Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.

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

  • 1

    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).

    *

    The International Consortium for Evidence Based Perfusion formally endorses these guidelines.

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