STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management

Tibi, Pierre; McClure, R. Scott; Huang, Jiapeng; Baker, Robert A.; Fitzgerald, David; Mazer, C. David; Stone, Marc E.; Chu, Danny; Stammers, Alfred H.; Dickinson, Tim; Shore‐Lesserson, Linda; Ferraris, Victor A.; Firestone, Scott; Kissoon, Kalie; Moffatt-Bruce, Susan D.

doi:10.1053/j.jvca.2021.03.011

Cited by 84 publications

(138 citation statements)

References 185 publications

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“…According to guidelines and previous research, such indications include INR >1.7, prolonged PT or APTT (>1.5 times baseline), or excessive bleeding observed during the surgery. [22][23][24] In other words, any symptoms reflecting the coagulation factor deficiency or coagulopathic bleeding during the surgery will trigger the transfusion of PCC or FFP.…”

Section: Discussionmentioning

confidence: 99%

“…In this study, the indications of PCC or FFP treatment include INR >1.7 or prolonged PT or APTT (>1.5 times baseline) measured 20 min off-pump (ACT within 130 s), or excessive bleeding observed during the surgery. [22][23][24] In the presence of these conditions, 4-factor PCC (15 IU/ kg) or FFP (10 mL/kg) will be given according to the group assignments, guided by manufacturer's instructions and previous research. 22 Half an hour after transfusion, the re-evaluation will be done and an additional dose will be administered if required.…”

Section: Interventionsmentioning

confidence: 99%

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Efficacy of prothrombin complex concentrate (PCC) versus fresh frozen plasma (FFP) in reducing perioperative blood loss in cardiac surgery: study protocol for a non-inferiority, randomised controlled trial

Pei

Sun

et al. 2022

BMJ Open

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ObjectiveTo explore whether prothrombin complex concentrate (PCC) is not inferior to fresh frozen plasma (FFP) with regard to reducing perioperative blood loss in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB).SettingFu Wai Hospital, and Peking Union Medical College Hospital in China.ParticipantsPatients undergoing elective coronary artery bypass grafting, valve replacement or valvuloplasty under CPB, between 18 and 80 years old, will be included.DesignThis study is a non-inferiority, randomised controlled clinical trial. A total of 594 subjects will be randomly assigned to two groups (group PCC and group FFP) and given corresponding interventions when at least one of the following criteria is met: (1) international normalised ratio >1.7 measured 20 min after CPB, (2) prolonged prothrombin time or activated partial thromboplastin time (>1.5 times baseline) measured 20 min after CPB and (3) excessive bleeding observed. 4-factor PCC (15 IU/kg) and FFP (10 mL/kg) will be given to group PCC and group FFP, respectively. Preoperative management, anaesthetic and surgical techniques will be standardised for both groups.Primary and secondary outcome measuresThe primary outcome is the volume of blood loss during and within 24 hours after surgery. The secondary outcomes include (1) the total units of allogeneic red blood cells transfused during and within 7 days after surgery, (2) re-exploration due to postoperative bleeding within 7 days after surgery, (3) adverse events and serious adverse events within 30 days after surgery and (4) length of intensive care unit stay and hospital stay.Trial registration numberRegistered under NCT04244981 at ClinicalTrials.gov on 28 January 2020, https://clinicaltrials.gov/ct2/show/NCT04244981?cond=NCT04244981&draw=2&rank=1.Ethics and disseminationThis study has been approved by the Institutional Review Board of Peking Union Medical College Hospital (ZS-2242).

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Section: Discussionmentioning

confidence: 99%

Section: Interventionsmentioning

confidence: 99%

Efficacy of prothrombin complex concentrate (PCC) versus fresh frozen plasma (FFP) in reducing perioperative blood loss in cardiac surgery: study protocol for a non-inferiority, randomised controlled trial

Pei

Sun

et al. 2022

BMJ Open

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“…19,20 There is consensus, however, that transfusing anemic patients preoperatively does not mitigate the risk and is not recommended. 9,10 Treatment of preoperative anemia with erythroid-stimulating agents (ESAs) and iron has demonstrated efficacy in raising hemoglobin (Hgb) levels and reducing blood transfusions for anemic patients prior to cardiac surgery. Most of these studies have not, however, shown improved major morbidity or mortality despite fewer transfusions for the treated groups.…”

Section: Preoperative Anemia Treatmentmentioning

confidence: 99%

“…25 Based on these data, ESAs should be considered for treating preoperative anemia in select patients, and this is reflected in current societal guidelines. 9,10,26 Most trials attempting to mitigate preoperative anemia have included iron replacement in the treatment arm. Functional iron deficiency accounts for approximately 50% of the anemia in preoperative cardiac surgery patients.…”

Section: Preoperative Anemia Treatmentmentioning

confidence: 99%

“…Common Hgb threshold values include 6 g/dL intraoperatively and 7 g/dL postoperatively. 9,10,19,26,40 The decision to transfuse should not be entirely based upon Hgb concentration; rather, this threshold should trigger a care team discussion regarding the clinical benefits of transfusion in each individual case. Consensus guidelines recommend that physiologic signs of inadequate end-organ oxygen delivery guide the decision to transfuse once the threshold is reached.…”

Section: Use Of An Evidence-based Rbc Transfusion Triggermentioning

confidence: 99%

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The 7 Pillars of Blood Conservation in Cardiac Surgery

Salenger

Mazzeffi

2021

Innovations�(Phila)

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Cost-effectiveness of Fibrinogen Concentrate vs Cryoprecipitate for Treating Acquired Hypofibrinogenemia in Bleeding Adult Cardiac Surgical Patients

et al. 2023

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ImportanceExcessive bleeding requiring fibrinogen replacement is a serious complication of cardiac surgery. However, the relative cost-effectiveness of the 2 available therapies—fibrinogen concentrate and cryoprecipitate—is unknown.ObjectiveTo determine cost-effectiveness of fibrinogen concentrate vs cryoprecipitate for managing active bleeding in adult patients who underwent cardiac surgery.Design, Setting, and ParticipantsA within-trial economic evaluation of the Fibrinogen Replenishment in Surgery (FIBERS) randomized clinical trial (February 2017 to November 2018) that took place at 4 hospitals based in Ontario, Canada, hospitals examined all in-hospital resource utilization costs and allogeneic blood product (ABP) transfusion costs incurred within 28 days of surgery. Participants included a subset of 495 adult patients from the FIBERS trial who underwent cardiac surgery and developed active bleeding and acquired hypofibrinogenemia requiring fibrinogen replacement.InterventionsFibrinogen concentrate (4 g per dose) or cryoprecipitate (10 units per dose) randomized (1:1) up to 24 hours postcardiopulmonary bypass.Main Outcomes and MeasuresEffectiveness outcomes included number of ABPs administered within 24 hours and 7 days of cardiopulmonary bypass. ABP transfusion (7-day) and in-hospital resource utilization (28-day) costs were evaluated and a multivariable net benefit regression model built for the full sample and predefined subgroups.ResultsPatient level costs for 495 patients were evaluated (mean [SD] age 59.2 [15.4] years and 69.3% male.) Consistent with FIBERS, ABP transfusions and adverse events were similar in both treatment groups. Median (IQR) total 7-day ABP cost was CAD $2280 (US dollars [USD] $1697) (CAD $930 [USD $692]-CAD $4970 [USD $3701]) in the fibrinogen concentrate group and CAD $2770 (USD $1690) (IQR, CAD $1140 [USD $849]-CAD $5000 [USD $3723]) in the cryoprecipitate group. Median (interquartile range) total 28-day cost was CAD $38 180 (USD $28 431) $(IQR, CAD $26 350 [USD $19 622]-CAD $65 080 [USD $48 463]) in the fibrinogen concentrate group and CAD $38 790 (USD $28 886) (IQR, CAD $26 180 [USD $19 495]-CAD $70 380 [USD $52 409]) in the cryoprecipitate group. After exclusion of patients who were critically ill before surgery (11%) due to substantial variability in costs, the incremental net benefit of fibrinogen concentrate vs cryoprecipitate was positive (probability of being cost-effective 86% and 97% at $0 and CAD $2000 (USD $1489) willingness-to-pay, respectively). Net benefit was highly uncertain for nonelective and patients with critical illness.Conclusions and RelevanceFibrinogen concentrate is cost-effective when compared with cryoprecipitate in most bleeding adult patients who underwent cardiac surgery with acquired hypofibrinogenemia requiring fibrinogen replacement. The generalizability of these findings outside the Canadian health system needs to be verified.

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STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management

Cited by 84 publications

References 185 publications

Efficacy of prothrombin complex concentrate (PCC) versus fresh frozen plasma (FFP) in reducing perioperative blood loss in cardiac surgery: study protocol for a non-inferiority, randomised controlled trial

Efficacy of prothrombin complex concentrate (PCC) versus fresh frozen plasma (FFP) in reducing perioperative blood loss in cardiac surgery: study protocol for a non-inferiority, randomised controlled trial

The 7 Pillars of Blood Conservation in Cardiac Surgery

Cost-effectiveness of Fibrinogen Concentrate vs Cryoprecipitate for Treating Acquired Hypofibrinogenemia in Bleeding Adult Cardiac Surgical Patients

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