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


Anesth Analg. 2019;129(5):1209-1221. 

In This Article


The literature search yielded a total of 892 titles that were identified and their abstracts reviewed, from which 213 relevant publications were fully reviewed by the working group. Out of the 213 reviewed publications, a final list of 9 practice guidelines was included for summary in the current publication: (1) "Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline";[26] (2) "2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines";[19] (3) "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines";[45] (4) "Management of Severe Perioperative Bleeding: Guideline from the European Society of Anaesthesiology";[20] (5) The "Management of Severe Perioperative Bleeding: Guideline from the European Society of Anaesthesiology, first update 2016";[21] (6) "Practice Guidelines for Perioperative Blood Management: an Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management";[22] (7) "Platelet Transfusion: a Clinical Practice Guideline from the AABB";[23] (8) "Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage";[24] and (9) "2017 EACTS/EACTA Guidelines on Patient Blood Management for Adult Cardiac Surgery."[25]

Summary of recommendations for common daily practices, including preoperative management of anemia and platelet (PLT) function assessment when indicated, as well as intraoperative monitoring of hemostasis, transfusion of blood products, and administration of pharmacological adjuvants in cardiac surgical patients is presented in Supplemental Digital Content 2, Table 1, This summary is based on the most recent published blood management guidelines. In addition, a graphical best-practice advisory for the practicing clinician that can be used at the POC is also included. This graphical advisory includes a summary statement (Figure 1) and 2 separate practical algorithms: (1) an algorithm based on viscoelastic POC coagulation testing (Figure 2) and (2) an algorithm based on "conventional" laboratory coagulation tests when viscoelastic tests are unavailable (Figure 3).

Figure 1.

SCA Summary Statement on Blood Conservation and Transfusion in Cardiac Surgery. EPO indicates erythropoietin; FFP, fresh-frozen plasma; PCC, prothrombin complex concentrate; ROTEM, rotational thromboelastometry; SCA, Society of Cardiovascular Anesthesiologists; TEG, thromboelastography.

Figure 2.

SCA ROTEM/TEG-based cardiac surgery intraoperative transfusion algorithm. ANH indicates acute normovolemic hemodilution; A10, amplitude at 10 minutes; CT, clotting time; DDAVP, 1-deamino-8-D-arginine vasopressin; ECMO, extra corporeal membrane oxygenation; EXTEM, extrinsic pathway thromboelastometry; FIBTEM, fibrinogen-based thromboelastometry; FF, functional fibrinogen; FFP, fresh-frozen plasma; Hb, hemoglobin; HEPTEM, heparinase thromboelastometry; HIT, heparin-induced thrombocytopenia; hTEG, heparinase thromboelastography; iCA++, ionized calcium; INTEM, intrinsic pathway thromboelastometry; LY30, clot lysis at 30 min; MA, maximum amplitude; ML, maximum lysis; PCC, prothrombin complex concentrate; R, reaction time; ROTEM, rotational thromboelastometry; TEG, thromboelastography.

Figure 3.

SCA non-ROTEM/TEG-based cardiac surgery intraoperative transfusion algorithm. ACT indicates activated clotting time; ANH, acute normovolemic hemodilution; CPB, cardiopulmonary bypass; DDAVP, 1-deamino-8-D-arginine vasopressin; FFP, fresh-frozen plasma; Hb, hemoglobin; iCA++, ionized calcium; INR, international normalized ratio; PCC, prothrombin complex concentrate; PLT, platelets; RBC, red blood cell; rFVIIa, recombinant activated factor VII; RV, right ventricle; T, temperature.