Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients

Jacob Raphael, MD; C. David Mazer, MD; Sudhakar Subramani, MD; Andrew Schroeder, MD; Mohamed Abdalla, MD; Renata Ferreira, MD; Philip E. Roman, MD; Nichlesh Patel, MD; Ian Welsby, MBBS; Philip E. Greilich, MD; Reed Harvey, MD; Marco Ranucci, MD; Lori B. Heller, MD; Christa Boer, MD; Andrew Wilkey, MD; Steven E. Hill, MD; Gregory A. Nuttall, MD; Raja R. Palvadi, MD; Prakash A. Patel, MD; Barbara Wilkey, MD; Brantley Gaitan, MD; Shanna S. Hill, MD; Jenny Kwak, MD; John Klick, MD; Bruce A. Bollen, MD; Linda Shore-Lesserson, MD; James Abernathy, MD; Nanette Schwann, MD; W. Travis Lau, MD

Disclosures

Anesth Analg. 2019;129(5):1209-1221. 

In This Article

Abstract and Introduction

Abstract

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

Introduction

Coagulopathy associated with cardiac surgery is a multifactorial serious complication that may result in massive bleeding requiring transfusion of red blood cells (RBCs) and procoagulant products to obtain adequate hemostasis.[1,2]

The importance of blood conservation strategies in cardiac surgery is emphasized by the fact that cardiovascular surgical procedures have among the highest overall rate of RBC transfusion when compared to all other surgeries, accounting for 10%–15% of all RBC transfusions in the United States and the United Kingdom.[3,4] Furthermore, approximately 10% of all cardiac surgery patients suffer from severe or massive blood loss, and up to 5% of all patients having cardiac surgery require emergent reexploration in an attempt to correct ongoing bleeding and establish adequate hemostasis.[2,5]

A significant body of evidence associates allogeneic blood transfusions during cardiac surgery with increased risk of serious postoperative morbidities including infections, atrial fibrillation, respiratory complications, acute kidney injury, and short-term and long-term mortality,[6–15] showing a dose–response relationship where morbidity and mortality are directly proportional to the number of units of RBC transfused.[8,14] Moreover, reduction of perioperative transfusion by initiation of blood management practices has been associated with decrease in major postoperative morbidity and mortality.[16–18]

Despite this evidence base, and the publication of numerous practice guidelines,[19–26] much confusion remains about the optimal management of perioperative bleeding in cardiac surgery patients.[5,27–30]

Data show that only a small fraction of published guidelines is successfully integrated into daily clinical practice.[31,32] As a specific example, publication of the 2011 update to the Society of Thoracic Surgeons (STS)/Society of Cardiovascular Anesthesiologists (SCA) Blood Conservation Guideline[19] did not result in a decrease in blood product utilization in cardiac surgery patients, most probably, due to a low rate of guidelines adoption by practitioners.[4,33] Furthermore, while recent STS reports[34,35] demonstrate a modest decline in blood product utilization in cardiac surgical procedures over the last decade, allogeneic blood transfusions still occur in over 50% of high-risk cardiac surgery patients.[3,4,27,36] In the recently published Transfusion Requirements in Cardiac Surgery (TRICS) III trial, for example, RBC transfusions occurred in 52.3% of the patients in the restrictive transfusion group and in 72.6% of the patients in the liberal transfusion group.[36] It is believed, however, that with the successful adoption and implementation of best-practice point of care (POC)–based transfusion algorithms, at least some of these transfusions could be potentially avoided.[37–41]

In response to recent changes in statutory regulations and to facilitate improvement in blood conservation and transfusion management in cardiac surgery, SCA formed a Continuous Practice Improvement (CPI) subcommittee. This subcommittee appointed a Blood Conservation In Cardiac Surgery Working Group—a panel of experts that was directed to organize and summarize the existing guidelines and consensus statements related to blood conservation in cardiac surgery. Additional information about the SCA CPI initiative and the various focus working groups can be found in a recent article and accompanying editorial by Muehlschlegel et al[42] and Schwann et al,[43] respectively.

The current report is the summary of recommendations for blood management in cardiac surgery, made by the SCA CPI Blood Conservation Working Group. This summary focuses on the perioperative management of adults undergoing cardiovascular surgery in which significant blood loss occurs or is expected. Excluded from this document are neonates, infants, children <18 years old, and adults weighing <40 kg.

The current summary of recommendations is not a set of new guidelines. They may be adopted, modified, or rejected according to clinical and institutional needs and constraints. Furthermore, practitioners will need to consider the clinical situation and exercise judgment in applying the more generalized recommendations contained herein. In addition, the recommendations included here are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome.

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