"As medicine evolves and we learn more, it always is important to review past assumptions, validate new information, and concisely present the best current recommendations," said senior author Susan D. Moffatt-Bruce, MD, PhD, MBA, from the Royal College of Physicians and Surgeons of Canada in Ottawa. "These recommendations are really centered on the patient and how they would want to be treated during complex cardiothoracic procedures."
Since 2011--when the guidelines were last updated--there has been a "remarkable increase" in minimally invasive procedures that has contributed to a favorable shift in blood product utilization and management, according to coauthor Victor A. Ferraris, MD, PhD, from the University of Kentucky College of Medicine in Lexington. As a result, the new practice guideline, which features 23 new or updated recommendations, marks the third iteration and the first in 10 years. "Blood management guidelines are a 'moving target' that change with the advent of new or modified evidence," he said.
It's important to note that in the previous guideline, the term "blood conservation" was used; the new recommendations yield to the broader term "patient blood management" (PBM).
PBM--developed in 2008--is a standard of care designed to optimize patient outcomes by minimizing blood loss, preventing anemia (a lower than normal number of red blood cells, resulting in a decreased capacity of the blood to carry oxygen to the body's tissues), and reducing the need for allogeneic blood transfusions (blood from donors rather than the patients themselves). This approach also places patients at the heart of the decision-making process, ensuring that they are fully informed of the risks and benefits of their treatments and incorporating their values and choices into the treatment pathway. These major tenets of PBM are confirmed in the updated guideline.
"This guideline provides clinicians with a detailed assessment of patient blood management in the cardiac surgical patient--what has been proven to work and what has not--as well as the ability to incorporate these techniques with the most up-to-date evidence," said lead author Pierre R. Tibi, MD, from Yavapai Regional Medical Center in Prescott, Arizona.
Among the most important changes to the practice guideline is the adoption of PBM as a treatment of the whole patient, with blood considered a "liquid organ" or "vital entity" in taking care of the surgical patient, rather than focusing simply on when or when not to transfuse, explained Dr. Tibi.
Blood transfusions--which can be a critical and life-saving facet of cardiothoracic surgery patient care--are generally safe and have saved millions of lives, but they carry the risk of serious side effects, according to Dr. Tibi. Transfused blood has the potential to introduce disease and cause potent immunological reactions or even death; it does not work as well as a patient's own blood.
"Blood transfusions can be harmful to the body. Therefore, unless the proven benefit of blood transfusions outweighs the known risks, it is better to treat patients before, during, and after surgery in ways that decrease the risks of needing blood as much as possible for the best outcomes," he said.
These risks can be lessened through the use of PBM, helping ensure that a patient's own blood is adequate and transfusions are not needed. In fact, some hospital systems in the US have experienced as much as a 45% overall reduction in the rate of transfusions since starting PBM programs.
"Patient safety is well supported in this guideline, as it reduces the risks associated with blood transfusions," said Dr. Moffatt-Bruce.
For example, the guideline includes preoperative interventions related to identifying and managing anemia--a condition that is "extremely prevalent" in the cardiac surgical population, especially in elderly patients or those with other diseases. The most common cause of anemia is iron deficiency, occurring in up to 50% of anemic patients, according to the guideline. Historically, patients with preoperative anemia are more likely to require transfusions, so treating iron-deficiency anemia should be done before surgery. If successful, this can dramatically reduce the need for a blood transfusion.
The new guideline also suggests that in cardiac operations with cardiopulmonary bypass (CPB), the "well-established method" of red cell salvage via centrifugation may be routinely used. In this process, blood that the patient loses during the operation is collected, filtered, and washed by a machine before being reinfused into the patient. Red cell salvage is an important part of the blood conservation aspect of PBM.
Another new addition to the guideline is the recommendation to administer human albumin after cardiac surgery, which also has been shown to minimize the need for transfusion. This medicine typically is used to treat or prevent shock following serious injury, bleeding, or surgery by increasing the volume of blood plasma. Also, priming of the CPB circuit with a patient's own blood (known as "retrograde autologous priming") should be used wherever possible, according to the guideline. This "simple, safe, and effective process" has been shown to decrease transfusion rates, especially for cardiac operations that result in excessive blood loss.
"The guideline has been assembled by experts from different specialties and backgrounds who have reviewed the most recent data," said Dr. Moffatt-Bruce. "This guidance allows clinicians to standardize treatment with the knowledge that they are utilizing the best information while considering all aspects of patient care."
Dr. Tibi expects that some clinicians will be surprised by several of the recommendations, especially those that carry a "great deal of evidence" and likely will require changes to routine treatments for their patients undergoing cardiac surgery (e.g., the information related to the preoperative treatment of anemia and the assorted perfusion techniques).
For patients, it's important that their hospitals, surgeons, and care teams are aware of PBM and that they are utilizing the "best, most proven techniques available," Dr. Tibi advises. "Patients should certainly ask, 'What do you do so that my chances of receiving blood are minimized?'"
INFORMATION:
Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, and Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. DOI: 10.1016/ j.athoracsur.2021.03.033.
Link to Guideline: https://www.annalsthoracicsurgery.org/article/S0003-4975(21)00556-7/fulltext
For a copy of The Annals article, contact Jennifer Bagley at 312-202-5865 or jbagley@sts.org.
About STS and The Annals of Thoracic Surgery
Founded in 1964, The Society of Thoracic Surgeons is a not-for-profit organization representing 7,700 cardiothoracic surgeons, researchers, and allied health care professionals worldwide who are dedicated to ensuring the best possible outcomes for surgeries of the heart, lung, and esophagus, as well as other surgical procedures within the chest. The Society's mission is to advance cardiothoracic surgeons' delivery of the highest quality patient care through collaboration, education, research, and advocacy. The Annals of Thoracic Surgery is the official journal of STS and the Southern Thoracic Surgical Association. It has an impact factor of 3.639. For more information, visit http://www.sts.org.
About SCA and the Journal of Cardiothoracic and Vascular Anesthesia
Founded in 1978, the Society of Cardiovascular Anesthesiologists (SCA) is an international organization of physicians that promotes excellence in patient care through education and research in perioperative care for patients undergoing cardiothoracic and vascular procedures. SCA's vision is to be globally recognized by working for cardiovascular and thoracic anesthesiology and perioperative care. This vision is recognized by working toward succinct goals in the area of education, leadership, membership engagement, and research. The Journal of Cardiothoracic and Vascular Anesthesia is primarily aimed at anesthesiologists who deal with patients undergoing cardiac, thoracic, or vascular surgical procedures. For more information, visit http://www.scahq.org.
"This work is a testament to the collaborative dedication among different medical specialty societies in establishing best practices for our cardiac surgery patients," said Jim Pavletich, MHA, CAE, executive director of SCA. "We are convinced that this new guideline will contribute significantly toward improving clinical outcomes in cardiac surgery patients and would like to thank all the involved stakeholders in providing us with such a high-quality publication."
About AmSECT and the Journal of ExtraCorporeal Technology
The American Society of ExtraCorporeal Technology (AmSECT) was founded in 1964 with the belief that members of the then-new allied health field could best serve their profession by sharing their thoughts and experiences. AmSECT has 1,800 members throughout the world and remains dedicated to improving patient care and safety by providing for the continuing education and professional needs of the extracorporeal circulation technology community. AmSECT's Journal of ExtraCorporeal Technology is the premier source of the most current research and information related to extracorporeal technology including cardiopulmonary bypass, extracorporeal life support, mechanical assist devices, and perioperative blood management. The journal is the longest continuously published periodical in the field of perfusion and has served as the official publication of AmSECT since 1967. For more information, visit http://www.amsect.org.
"We are honored to be involved in the collective update of the clinical practice guidelines on patient blood management. It is collaborations like this that lead to improved patient care and ultimately better outcomes," said James Reagor, MPS, CCP, FPP, president of AmSECT. "AmSECT is committed to improving patient care and safety through the continuing education of the extracorporeal community. Our goal is institutional adoption of these guidelines and establishing best practices and standardization across teams and organizations."
About SABM
Founded in 2001, the Society for the Advancement of Patient Blood Management (SABM) was started by a group of dedicated volunteers who saw a need for a new way of thinking. SABM's multidisciplinary, international membership believes that optimal patient blood management ought to be the standard of care for all patients. Improving patient outcomes through anemia management, optimizing coagulation, blood conservation strategies, and patient-centered rather than blood product-centered decision-making remains the mission of the organization. SABM promotes the evidence-based position that PBM is a vital patient quality and safety initiative which aligns with current health care priorities worldwide. For more information, visit http://www.sabm.org.
"The Society for the Advancement of Patient Blood Management is extremely honored to be included in this prestigious group of organizations, all with the aligned goal of improving patient care and outcomes through optimal patient blood management in cardiac surgery," said Sherri Ozawa, RN, president of SABM.
