Skip to main content

Advertisement

SpringerLink
Log in

Patient Blood Management in Cardiac Surgery

  • Cardiovascular Anesthesia (J Fassl, Section Editor)
  • Published:
Current Anesthesiology Reports Aims and scope Submit manuscript

Abstract

Purpose of the Review

Recently, several large randomized studies and recommendations regarding patient blood management (PBM) in cardiac surgery were published. This review summarizes the current evidence relating to modern strategies in PBM from the perspective of the cardiovascular anesthesiologist.

Recent Findings

Preoperative anemia should be early detected and adequately managed. In patients with intake of anticoagulants or platelet inhibitors, timely and specific stopping should be respected. Specific modification of cardiopulmonary bypass (CPB) systems aiming to reduce hemodilution and conserve patients’ blood reserve have been described. In combination with the use of cell-saving systems, such modifications might reduce the need for blood transfusion. Applying the restrictive transfusion thresholds for red blood cells (hemoglobin threshold close to 70 g/L) is not inferior to a liberal strategy (threshold close to 100 g/L) regarding 30-day mortality, and important outcomes including myocardial infarction, stroke, renal failure, infections, or arrhythmia. Finally, timely diagnosis and adequate treatment of hemostatic abnormalities by specific procoagulant interventions should be considered.

Summary

To optimize the risk-benefit ratio of allogeneic blood transfusion and to reduce associated costs, the implementation of PBM programs compromising a multidisciplinary and multifactorial approach including interventions before, during, and after surgery is suggested.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Althoff FC, Neb H, Herrmann E, et al. Multimodal patient blood management program based on a three-pillar strategy: a systematic review and meta-analysis. Ann Surg. 2019;269:794–804. Recent meta-analysis on the benefit of PBM programs.

    PubMed  Google Scholar 

  2. •• Boer C, Meesters MI, Milojevic M, et al. 2017 EACTS/EACTA guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth. 2018;32:88–120. Recent guidelines on patient blood management in cardiac surgery based on a systematic review.

    CAS  PubMed  Google Scholar 

  3. Karkouti K, Wijeysundera DN, Yau TM, et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion. 2004;44:1453–62.

    PubMed  Google Scholar 

  4. Ranucci M, Bozzetti G, Ditta A, Cotza M, Carboni G, Ballotta A. Surgical reexploration after cardiac operations: why a worse outcome? Ann Thorac Surg. 2008;86:1557–62.

    PubMed  Google Scholar 

  5. Spence RK, Erhard J. History of patient blood management. Best Pract Res Clin Anaesthesiol. 2013;27:11–5.

    PubMed  Google Scholar 

  6. Meybohm P, Richards T, Isbister J, et al. Patient blood management bundles to facilitate implementation. Transfus Med Rev. 2017;31:62–71.

    PubMed  Google Scholar 

  7. • Carson JL, Triulzi DJ, Ness PM. Indications for and adverse effects of red-cell transfusion. N Engl J Med. 2017;377:1261–72. Recent excellent review on the risk of adverse events with RBC transfusion.

    PubMed  Google Scholar 

  8. • Bolliger D, Buser A, Tanaka K. Transfusion requirements in anesthesia and intensive care. Curr Anesthesiol Rep. 2019;9:194–201. Recent narrative review on the benefits, risks, and indication of allogeneic blood transfusion in surgical and critically ill patients.

    Google Scholar 

  9. Gilliss BM, Looney MR, Gropper MA. Reducing noninfectious risks of blood transfusion. Anesthesiology. 2011;115:635–49.

    PubMed  PubMed Central  Google Scholar 

  10. Silliman CC, Fung YL, Ball JB, Khan SY. Transfusion-related acute lung injury (TRALI): current concepts and misconceptions. Blood Rev. 2009;23:245–55.

    PubMed  PubMed Central  Google Scholar 

  11. Toy P, Gajic O, Bacchetti P, et al. Transfusion-related acute lung injury: incidence and risk factors. Blood. 2012;119:1757–67.

    CAS  PubMed  PubMed Central  Google Scholar 

  12. Mazzeffi M, Chriss E, Tanaka K. Time for a fresh approach to examining factors associated with red blood cell transfusion outcome. Anesth Analg. 2018;127:1271–4.

    PubMed  Google Scholar 

  13. Agudelo-Jimenez RD, Heatter JA, Cata JP. Transfusion therapy: is there a link with cancer recurrence? Curr Anesthesiol Rep. 2018;8:426–38.

    Google Scholar 

  14. Spitalnik SL. Stored red blood cell transfusions: iron, inflammation, immunity, and infection. Transfusion. 2014;54:2365–71.

    PubMed  PubMed Central  Google Scholar 

  15. Carson JL, Sieber F, Cook DR, et al. Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet. 2015;385:1183–9.

    PubMed  Google Scholar 

  16. Blome M, Isgro F, Kiessling AH, et al. Relationship between factor XIII activity, fibrinogen, haemostasis screening tests and postoperative bleeding in cardiopulmonary bypass surgery. Thromb Haemost. 2005;93:1101–7.

    CAS  PubMed  Google Scholar 

  17. • Bolliger D, Gorlinger K, Tanaka KA. Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology. 2010;113:1205–19. A recent review on coagulopathy and therapeutic options in bleeding patients during major surgery.

    PubMed  Google Scholar 

  18. Bolliger D, Mauermann E, Tanaka KA. Thresholds for perioperative administration of hemostatic blood components and coagulation factor concentrates: an unmet medical need. J Cardiothorac Vasc Anesth. 2015;29:768–76.

    PubMed  Google Scholar 

  19. Ranucci M, Jeppsson A, Baryshnikova E. Pre-operative fibrinogen supplementation in cardiac surgery patients: an evaluation of different trigger values. Acta Anaesthesiol Scand. 2015;59:427–33.

    CAS  PubMed  Google Scholar 

  20. Meesters MI, Burtman D, van de Ven PM, Boer C. Prediction of postoperative blood loss using thromboelastometry in adult cardiac surgery: cohort study and systematic review. J Cardiothorac Vasc Anesth. 2018;32:141–50.

    PubMed  Google Scholar 

  21. Mahla E, Suarez TA, Bliden KP, et al. Platelet function measurement-based strategy to reduce bleeding and waiting time in clopidogrel-treated patients undergoing coronary artery bypass graft surgery: the timing based on platelet function strategy to reduce clopidogrel-associated bleeding related to CABG (TARGET-CABG) study. Circ Cardiovasc Interv. 2012;5:261–9.

    CAS  PubMed  Google Scholar 

  22. •• Myles PS, Smith JA, Forbes A, et al. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med. 2017;376:136–48. The largest RCT on the effectiveness of tranexamic acid on transfusion requriments after coronary artery surgery.

    CAS  PubMed  Google Scholar 

  23. Shi J, Ji H, Ren F, et al. Protective effects of tranexamic acid on clopidogrel before coronary artery bypass grafting: a multicenter randomized trial. JAMA Surg. 2013;148:538–47.

    CAS  PubMed  Google Scholar 

  24. Drews S, Bolliger D, Kaiser C, et al. Prasugrel increases the need for platelet transfusions and surgical reexploration rates compared with clopidogrel in coronary artery bypass surgery. Thorac Cardiovasc Surg. 2015;63:28–35.

    PubMed  Google Scholar 

  25. Bertling A, Fender AC, Schungel L, et al. Reversibility of platelet P2Y12 inhibition by platelet supplementation: ex vivo and in vitro comparisons of prasugrel, clopidogrel and ticagrelor. J Thromb Haemost. 2018;16:1089–98.

    CAS  PubMed  Google Scholar 

  26. • Bolliger D, Tanaka KA. Coagulation management in cardiac surgery. Curr Anesthesiol Rep. 2017;7:265–72. A recent narrative review on current strategies of coagulation management in cardiac surgery.

    Google Scholar 

  27. Teng R, Carlson GF, Nylander S, Andersson TL. Effects of autologous platelet transfusion on platelet inhibition in ticagrelor-treated and clopidogrel-treated subjects. J Thromb Haemost. 2016;14:2342–52.

    CAS  PubMed  Google Scholar 

  28. Storey RF, Bliden KP, Ecob R, et al. Earlier recovery of platelet function after discontinuation of treatment with ticagrelor compared with clopidogrel in patients with high antiplatelet responses. J Thromb Haemost. 2011;9:1730–7.

    CAS  PubMed  Google Scholar 

  29. Vuilliomenet T, Gebhard C, Bizzozero C, et al. Discontinuation of dual antiplatelet therapy and bleeding in intensive care in patients undergoing urgent coronary artery bypass grafting: a retrospective analysis. Interact Cardiovasc Thorac Surg. 2018;epub ahead.

  30. Erdoes G, Martinez Lopez De Arroyabe B, Bolliger D, et al. International consensus statement on the peri-operative management of direct oral anticoagulants in cardiac surgery. Anaesthesia. 2018;73:1535–45.

    CAS  PubMed  Google Scholar 

  31. Kassebaum NJ, Jasrasaria R, Naghavi M, et al. A systematic analysis of global anemia burden from 1990 to 2010. Blood. 2014;123:615–24.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Ellermann I, Bueckmann A, Eveslage M, et al. Treating anemia in the preanesthesia assessment clinic: results of a retrospective evaluation. Anesth Analg. 2018;127:1202–10.

    PubMed  Google Scholar 

  33. Shander A, Knight K, Thurer R, Adamson J, Spence R. Prevalence and outcomes of anemia in surgery: a systematic review of the literature. Am J Med. 2004;116(Suppl 7A):58S–69S.

    PubMed  Google Scholar 

  34. Napolitano LM. Anemia and red blood cell transfusion: advances in critical care. Crit Care Clin. 2017;33:345–64.

    PubMed  Google Scholar 

  35. • Peters F, Ellermann I, Steinbicker AU. Intravenous iron for treatment of anemia in the 3 perisurgical phases: a review and analysis of the current literature. Anesth Analg. 2018;126:1268–82. A recent narrative review evaluating the value and benefits of iron therapy at different periperative time points.

    CAS  PubMed  Google Scholar 

  36. Cho BC, Serini J, Zorrilla-Vaca A, et al. Impact of preoperative erythropoietin on allogeneic blood transfusions in surgical patients: results from a systematic review and meta-analysis. Anesth Analg. 2019;128:981–92.

    CAS  PubMed  Google Scholar 

  37. •• Spahn DR, Schoenrath F, Spahn GH, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet. 2019;393:2201–12. The recent randomized controlled trial with a pragmatic concept that might be helpful in daily care of cardiac surgery surgery.

    PubMed  Google Scholar 

  38. Kulier A, Levin J, Moser R, et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation. 2007;116:471–9.

    PubMed  Google Scholar 

  39. Loor G, Rajeswaran J, Li L, et al. The least of 3 evils: exposure to red blood cell transfusion, anemia, or both? J Thorac Cardiovasc Surg. 2013;146:1480–7.

    PubMed  Google Scholar 

  40. Munoz M, Gomez-Ramirez S, Campos A, Ruiz J, Liumbruno GM. Pre-operative anaemia: prevalence, consequences and approaches to management. Blood Transfus. 2015;13:370–9.

    PubMed  PubMed Central  Google Scholar 

  41. von Heymann C, Kaufner L, Sander M, et al. Does the severity of preoperative anemia or blood transfusion have a stronger impact on long-term survival after cardiac surgery? J Thorac Cardiovasc Surg. 2016;152:1412–20.

    Google Scholar 

  42. Russell L, Holst LB, Lange T, Liang X, Ostrowski SR, Perner A. Effects of anemia and blood transfusion on clot formation and platelet function in patients with septic shock: a substudy of the randomized TRISS trial. Transfusion. 2018;58:2807–18.

    CAS  PubMed  Google Scholar 

  43. Hare GM, Freedman J, David Mazer C. Risks of anemia and related management strategies: can perioperative blood management improve patient safety? Can J Anaesth. 2013;60:168–75.

    PubMed  Google Scholar 

  44. Karkouti K, Wijeysundera DN, Beattie WS, et al. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 2008;117:478–84.

    PubMed  Google Scholar 

  45. Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378:370–9.

    PubMed  Google Scholar 

  46. Karkouti K, Wijeysundera DN, Yau TM, et al. Advance targeted transfusion in anemic cardiac surgical patients for kidney protection: an unblinded randomized pilot clinical trial. Anesthesiology. 2012;116:613–21.

    CAS  PubMed  Google Scholar 

  47. •• Shehata N, Mistry N, da Costa BR, et al. Restrictive compared with liberal red cell transfusion strategies in cardiac surgery: a meta-analysis. Eur Heart J. 2019;40:1081–8. The largest meta-analysis on restrictive vs. liberal RBC transfusion in cardiac surgery.

    CAS  PubMed  Google Scholar 

  48. Carson JL, Stanworth SJ, Alexander JH, et al. Clinical trials evaluating red blood cell transfusion thresholds: an updated systematic review and with additional focus on patients with cardiovascular disease. Am Heart J. 2018;200:96–101.

    PubMed  Google Scholar 

  49. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409–17.

    CAS  PubMed  Google Scholar 

  50. Barile L, Fominskiy E, Di Tomasso N, et al. Acute normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis of randomized trials. Anesth Analg. 2017;124:743–52.

    PubMed  Google Scholar 

  51. Burman JF, Westlake AS, Davidson SJ, et al. Study of five cell salvage machines in coronary artery surgery. Transfus Med. 2002;12:173–9.

    CAS  PubMed  Google Scholar 

  52. Severdija EE, Heijmans JH, Theunissen M, Maessen JG, Roekaerts PH, Weerwind PW. Retrograde autologous priming reduces transfusion requirements in coronary artery bypass surgery. Perfusion. 2011;26:315–21.

    CAS  PubMed  Google Scholar 

  53. Ziyaeifard M, Alizadehasl A, Massoumi G. Modified ultrafiltration during cardiopulmonary bypass and postoperative course of pediatric cardiac surgery. Res Cardiovasc Med. 2014;3:e17830.

    PubMed  PubMed Central  Google Scholar 

  54. Carless PA, Henry DA, Moxey AJ, O’Connell DL, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2006:CD001888.

  55. Wang G, Bainbridge D, Martin J, Cheng D. The efficacy of an intraoperative cell saver during cardiac surgery: a meta-analysis of randomized trials. Anesth Analg. 2009;109:320–30.

    CAS  PubMed  Google Scholar 

  56. Rubens FD, Boodhwani M, Mesana T, et al. The cardiotomy trial: a randomized, double-blind study to assess the effect of processing of shed blood during cardiopulmonary bypass on transfusion and neurocognitive function. Circulation. 2007;116:189–97.

    Google Scholar 

  57. Bolliger D, Sreeram G, Duncan A, et al. Prophylactic use of factor IX concentrate in a Jehovah’s Witness patient. Ann Thorac Surg. 2009;88:1666–8.

    PubMed  Google Scholar 

  58. Colli A, Balduzzi S, Ruyra X. The Hemobag: the modern ultrafiltration system for patients undergoing cardiopulmonary bypass. J Cardiothorac Surg. 2012;7:55.

    PubMed  PubMed Central  Google Scholar 

  59. Weber CF, Jambor C, Strasser C, et al. Normovolemic modified ultrafiltration is associated with better preserved platelet function and less postoperative blood loss in patients undergoing complex cardiac surgery: a randomized and controlled study. J Thorac Cardiovasc Surg. 2011;141:1298–304.

    PubMed  Google Scholar 

  60. Deppe AC, Arbash W, Kuhn EW, et al. Current evidence of coronary artery bypass grafting off-pump versus on-pump: a systematic review with meta-analysis of over 16,900 patients investigated in randomized controlled trialsdagger. Eur J Cardiothorac Surg. 2016;49:1031–41.

    PubMed  Google Scholar 

  61. Ide M, Bolliger D, Taketomi T, Tanaka KA. Lessons from the aprotinin saga: current perspective on antifibrinolytic therapy in cardiac surgery. J Anesth. 2010;24:96–106.

    PubMed  Google Scholar 

  62. Sniecinski RM, Chen EP, Makadia SS, Kikura M, Bolliger D, Tanaka KA. Changing from aprotinin to tranexamic acid results in increased use of blood products and recombinant factor VIIa for aortic surgery requiring hypothermic arrest. J Cardiothorac Vasc Anesth. 2010;24:959–63.

    CAS  PubMed  Google Scholar 

  63. Bolliger D, Tanaka KA. Roles of thrombelastography and thromboelastometry for patient blood management in cardiac surgery. Transfus Med Rev. 2013;27:213–20.

    PubMed  Google Scholar 

  64. Weber CF, Gorlinger K, Meininger D, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology. 2012;117:531–47.

    PubMed  Google Scholar 

  65. Shah A, Fisher SA, Wong H, et al. Safety and efficacy of iron therapy on reducing red blood cell transfusion requirements and treating anaemia in critically ill adults: a systematic review with meta-analysis and trial sequential analysis. J Crit Care. 2019;49:162–71.

    CAS  PubMed  Google Scholar 

  66. Johansson PI, Rasmussen AS, Thomsen LL. Intravenous iron isomaltoside 1000 (Monofer(R)) reduces postoperative anaemia in preoperatively non-anaemic patients undergoing elective or subacute coronary artery bypass graft, valve replacement or a combination thereof: a randomized double-blind placebo-controlled clinical trial (the PROTECT trial). Vox Sang. 2015;109:257–66.

    CAS  PubMed  PubMed Central  Google Scholar 

  67. Karkouti K, McCluskey SA, Ghannam M, Salpeter MJ, Quirt I, Yau TM. Intravenous iron and recombinant erythropoietin for the treatment of postoperative anemia. Can J Anaesth. 2006;53:11–9.

    PubMed  Google Scholar 

  68. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20:520–4.

    PubMed  PubMed Central  Google Scholar 

  69. •• Mueller MM, Van Remoortel H, Meybohm P, et al. Patient blood management: recommendations from the 2018 Frankfurt consensus conference. JAMA. 2019;321:983–97. The findings and recommendation of a recent large Concensus Conference on PMB are presented.

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department for Anesthesia, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland

    Daniel Bolliger & Joachim M. Erb

  2. Regional Blood Transfusion Service, Swiss Red Cross, Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland

    Andreas Buser

Authors
  1. Daniel Bolliger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andreas Buser
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joachim M. Erb
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Daniel Bolliger.

Ethics declarations

Conflict of Interest

Daniel Bolliger, Andreas Buser, and Joachim M. Erb declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any unpublished studies or data with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Cardiovascular Anesthesia

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bolliger, D., Buser, A. & Erb, J.M. Patient Blood Management in Cardiac Surgery. Curr Anesthesiol Rep 9, 215–222 (2019). https://doi.org/10.1007/s40140-019-00343-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40140-019-00343-y

Keywords

Search

Navigation