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:10.1016/j.athoracsur.2021.03.033

Cited by 126 publications

(98 citation statements)

References 181 publications

(139 reference statements)

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“…The incidence of thrombotic events among 202 patients on dabigatran in the surgical group (not exclusively cardiovascular) was 5%, but there was no control group to compare this outcome with. Based on these data, idarucizumab is recommended in several guidelines to prevent perioperative bleeding in patients on dabigatran ( 4 , 38 , 40 , 41 ).…”

Section: Discussionmentioning

confidence: 99%

“…An optimal hemostatic effect was achieved in 82% of treated patients with this antidote and the incidence of thrombotic events was 10% in a 30-day follow-up period. Interestingly, the Society of Thoracic Surgeons (STS) in their recent Update to the Clinical Practice Guidelines on Patient Blood Management recommended administration of andexanet alfa in patients in need of emergent cardiac surgery with recent ingestion of either apixaban or rivaroxaban, or laboratory evidence of a DOAC effect ( 40 ). This recommendation is given contrary to Direct Healthcare Professional Communication letter issued by the European Medicines Agency that advises against the use of this reversal agent prior to heparinization since it causes unresponsiveness to the anticoagulant effects of heparin ( 46 ).…”

Section: Discussionmentioning

confidence: 99%

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Management of perioperative bleeding risk in patients on antithrombotic medications undergoing cardiac surgery—a systematic review

Matejic-Spasic¹,

Hassan²,

Thielmann³

et al. 2022

J Thorac Dis

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Background: Antithrombotic drugs increase the risk of bleeding, especially in patients who need urgent surgery without an adequate wash-out period. This review aims to evaluate perioperative bleeding complications in patients on dual antiplatelet therapy (DAPT) or direct-acting oral anticoagulants (DOACs) undergoing high-bleeding risk cardiovascular surgery and to present currently available potential solutions to mitigate antithrombotic therapy-related bleeding complications.Methods: As a first step, we searched for relevant articles, over the last 10 years, in Medline (PubMed) and abstracted clinical information based on pre-defined criteria for bleeding complications. In the next step, an additional search evaluating potential solutions to mitigate bleeding complications was performed. The literature screening and selection process followed the principles derived from the PRISMA statement.Results: From all reviewed studies, a total of 19 articles could be included evaluating the risk for bleeding in cardiac surgery related to DAPT or DOACs and 10 papers evaluating antithrombotic drug reversal or removal in the setting of cardiovascular surgery. Reported bleeding rates ranged between 18% and 41%.The variability of the reported data is remarkable. Idarucizumab is reported to provide optimal perioperative hemostasis in up to 93% of patients. It has been observed that andexanet alfa causes unresponsiveness to the anticoagulant effects of heparin. Antithrombotic removal by intraoperative hemoadsorption is found to be associated with a significant decrease in re-thoracotomy rate, overall procedure duration, administered transfusion volumes, chest-tube drainage, and length of hospitalization.Discussion: Bleeding complications in patients treated with DAPT or DOACs in cardiac surgery are high.New costly reversal agents are available but have not been sufficiently tested in the cardio-surgical setting so far. Interestingly, bleeding-related complications seem to be effectively reduced by applying innovative intraoperative hemoadsorption techniques. Expected results from the ongoing trials should provide better insights concerning the efficacy and safety of several potential solutions. Currently, the variability of reports and the deficit of high-quality studies in this specific setting represent the major limitation for the unbiased conclusion of this review.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Management of perioperative bleeding risk in patients on antithrombotic medications undergoing cardiac surgery—a systematic review

Matejic-Spasic¹,

Hassan²,

Thielmann³

et al. 2022

J Thorac Dis

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“…If anaemia and red cell transfusion both increase morbidity, then the argument for avoiding both is crystal clear. Since Isbister [12] proposed the concept of patient blood management (PBM), a multi-modal approach to mitigate preoperative anemia, optimize coagulation, preserve red cells during surgery and tolerate lower transfusion thresholds following surgery has gained broad acceptance [13,14].…”

Section: Introductionmentioning

confidence: 99%

“…Other effects of red cell transfusion after cardiac surgery include atrial brillation [16] and sepsis [9]. To address this issue, in 2007 the Society of Thoracic Surgeons Blood Conservation Guideline Task Force [17] examined the evidence base for each component of PBM in cardiac surgery, with the guidelines updated in 2021 [13]. The guidelines recommend meticulous attention to hemostasis, the use of anti brinolytics to reduce perioperative bleeding, acute normovolemic hemodilution with post-bypass reinfusion, the use of retrograde autologous priming of the bypass circuit, and routine use of red cell scavenging and reinfusion following centrifugation (but not the direct reinfusion of shed mediastinal blood).…”

Section: Introductionmentioning

confidence: 99%

The pressure field as a methodology for fluid management and red cell preservation during cardiac surgery

Woodford

Butlin

Bai³

et al. 2022

Preprint

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Purpose: Anemia and red cell transfusion contribute to morbidity and mortality of surgery. The concept of patient blood management to mitigate preoperative anemia, optimize coagulation, conserve red cells intraoperatively and accept lower post-operative transfusion thresholds has recently gained widespread acceptance across a range of surgical disciplines. Fluid administration is likely to contribute significantly to perioperative anemia and red-cell transfusion requirements, yet a robust basis for managing fluid administration in this context has not been articulated. There is an urgent need for this. Methods:We developed ‘the pressure field method’ as a novel approach to guiding the administration of fluid and drugs to optimize tissue perfusion. The pressure field method was used for the intraoperative management of 67 patients undergoing semi-elective cardiac surgery. We retrospectively compared intraoperative anemia and transfusion requirements in this cohort with a conventional group of 413 patients undergoing cardiac surgery. Results:In the pressure field group, no patients required transfusion whereas in the conventional group, 16% required transfusion during bypass with an average of 2.4 units of packed red cells (P < 0.0001). The average decrease in hemoglobin in the pressure field group was only 13 g/L, whereas in the conventional group it was 52 g/L (P < 0.0001). 80% of the pressure field group received no intravenous fluid during cardiac surgery, and the average intraoperative fluid load was 160 mL.Conclusion:The pressure field method appears to significantly reduce transfusion requirements due to decreased intraoperative fluid loading.

show abstract

Section: Introductionmentioning

confidence: 99%

The pressure field as a methodology for fluid management and red cell preservation during cardiac surgery

Woodford

Butlin

Bai³

et al. 2022

Preprint

View full text Add to dashboard Cite

Purpose: Anemia and red cell transfusion contribute to morbidity and mortality of surgery. The concept of patient blood management to mitigate preoperative anemia, optimize coagulation, conserve red cells intraoperatively and accept lower post-operative transfusion thresholds has recently gained widespread acceptance across a range of surgical disciplines. Fluid administration is likely to contribute significantly to perioperative anemia and red-cell transfusion requirements, yet a robust basis for managing fluid administration in this context has not been articulated. There is an urgent need for this. Methods: We developed ‘the pressure field method’ as a novel approach to guiding the administration of fluid and drugs to optimize tissue perfusion. The pressure field method was used for the intraoperative management of 67 patients undergoing semi-elective cardiac surgery. We retrospectively compared intraoperative anemia and transfusion requirements in this cohort with a conventional group of 413 patients undergoing cardiac surgery. Results: In the pressure field group, no patients required transfusion whereas in the conventional group, 16% required transfusion during bypass with an average of 2.4 units of packed red cells (P < 0.0001). The average decrease in hemoglobin in the pressure field group was only 13 g/L, whereas in the conventional group it was 52 g/L (P < 0.0001). 80% of the pressure field group received no intravenous fluid during cardiac surgery, and the average intraoperative fluid load was 160 mL. Conclusion: The pressure field method appears to significantly reduce transfusion requirements due to decreased intraoperative fluid loading.

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

Cited by 126 publications

References 181 publications

Management of perioperative bleeding risk in patients on antithrombotic medications undergoing cardiac surgery—a systematic review

Management of perioperative bleeding risk in patients on antithrombotic medications undergoing cardiac surgery—a systematic review

The pressure field as a methodology for fluid management and red cell preservation during cardiac surgery

The pressure field as a methodology for fluid management and red cell preservation during cardiac surgery

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