Safe Application of a Restrictive Transfusion Protocol in Moderate-Risk Patients Undergoing Cardiac Operations

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology

“…Avoiding cardiopulmonary bypass may theoretically improve RV myocardial protection, although no differences were observed in long‐term follow‐up . Liberal transfusion strategies should be avoided to prevent increased RV load and negative outcomes . Maintenance of right atrial contraction and AV synchrony was experimentally shown to be crucial preventing deterioration in RV failure .…”

“…117 Liberal transfusion strategies should be avoided to prevent increased RV load and negative outcomes. 118 Maintenance of right atrial contraction and AV synchrony was experimentally shown to be crucial preventing deterioration in RV failure. 119 Although LVAD ultimately improves RV function, transient disturbances in loading and geometry lead to RV failure that may compromise late outcomes.…”

Methodologic quality assessment of red blood cell transfusion guidelines and the evidence base of more restrictive transfusion thresholds

“…Third, although the use of a Hb level of less than 6 or 6 to 8 g/dL is strongly recommended in six recommendations (perioperative or critical care setting), no supportive evidence from experimental studies (only observational studies or expert opinion) is available. As mentioned in five recent (systematic) reviews or editorials, future high‐quality studies of sufficient power are needed to answer the question “how low can you go?” by comparing a Hb threshold of 7 to 8 g/dL with lower Hb thresholds or to investigate the benefits or harms of restrictive transfusion thresholds in high‐risk populations (patients with cardiovascular disease, severe sepsis) . For example, a recent multicenter RCT in the United Kingdom concluded that a restrictive transfusion threshold (Hb < 7.5 g/dL, n = 1000) after cardiac surgery was equally effective to a liberal transfusion threshold (Hb < 9 g/dL, n = 1003) with respect to morbidity and health care costs but was inferior in terms of survival (4.2% deaths vs. 2.6% deaths [p = 0.045] in the restrictive versus liberal transfusion group, respectively) .…”

“…by comparing a Hb threshold of 7 to 8 g/dL with lower Hb thresholds or to investigate the benefits or harms of restrictive transfusion thresholds in high-risk populations (patients with cardiovascular disease, severe sepsis). 7,[38][39][40][41] For example, a recent multicenter RCT in the United Kingdom concluded that a restrictive transfusion threshold (Hb < 7.5 g/dL, n 5 1000) after cardiac surgery was equally effective to a liberal transfusion threshold (Hb < 9 g/dL, n5 1003) with respect to morbidity and health care costs but was inferior in terms of survival (4.2% deaths vs. 2.6% deaths [p 5 0.045] in the restrictive versus liberal transfusion group, respectively). 42 Subsequently, evidence-based guidelines on blood transfusion strategies in patients after cardiac surgery should include this highquality evidence by explicitly not recommending a transfusion threshold of Hb level of less than 7.5 g/dL (due to the higher mortality rate).…”

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

“…For example, enrolment of a patient cohort at mixed risk of bleeding and transfusion in two recent multicentre cardiac surgery RCTs, one evaluating antifibrinolytics and another recombinant factor XII, is considered to have significantly influenced the results of these trials. 8,162,191 The LVBT risk score described in the current study provides a simple transparent technique for cohort enrichment in clinical trials in cardiac surgery. Our risk score, which is available as an e-calculator, may also be used by clinicians to accurately risk assess individual patients, a class I recommendation in recent cardiac surgery blood management guidelines.…”