CV Surgery Societies Urge Shift to ‘Blood Management’

A shift in clinical thinking from “blood conservation” to the broader idea of “blood management” is the primary focus of updated cardiothoracic guidelines published today collaboratively by four professional societies.

“Patient blood management (PBM) is the treatment of the whole patient considering blood as a liquid vital organ and treating it as such instead of simply deciding when to transfuse,” lead author Pierre Tibi, MD (Yavapai Regional Medical Center, Prescott, AZ), said to TCTMD. He explained that the four tenets of this practice include managing anemia, optimizing coagulation, fostering interdisciplinary blood management therapies throughout the surgical process, and making the patient the center of decision-making all with the goal of reducing allogenic blood transfusions.

“Many times, patients might get a transfusion because they are severely anemic,” he continued. “But if you treat the anemia as opposed to transfusing, then not only are you treating the problem of the blood, but also you're decreasing the risks for patients undergoing transfusions, especially if they are having something invasive done like surgery.”

Tibi noted this is especially important at present given that heart surgeries have been canceled due to a lack of adequate blood stores.

The statement, published online today in the Annals of Thoracic Surgery, updates the 2011 guidelines and is co-sponsored by the Society of Thoracic Surgeons, Society of Cardiovascular Anesthesiologists, American Society of ExtraCorporeal Technology, and Society for the Advancement of Patient Blood Management.

“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,” senior author Susan D. Moffatt-Bruce, MD, PhD, MBA (Royal College of Physicians and Surgeons of Canada, Ottawa), said in a press release. “These recommendations are really centered on the patient and how they would want to be treated during complex cardiothoracic procedures.”

Highlights of the document include details on the assessment, prevention, and treatment of anemia “throughout the entire operative state,” Tibi said. This is especially important for the cardiac surgical population where anemia is prevalent, especially in older patients and those with other diseases, and has been tied to a greater likelihood of blood transfusions.

Also, “for the first time we discussed how informed consent should be obtained with patients who especially who have objections to transfusion therapy,” he said.

The statement also provides recommendations regarding several new antiplatelet and anticoagulant agents on the market that weren’t available a decade ago. Additionally, it outlines various perfusion interventions and techniques that have come to be more prominent, like retrograde autologous priming, acute normovolemic hemodilution, and modified ultrafiltration, as well as transfusion algorithms, Tibi noted.

Open questions to be considered include “exactly what the accurate trigger points for transfusions in various patients ought to be, the best way of treating anemia, [and how to] get the government and insurance companies to pay for the treatment of anemia before surgery,” he concluded. “The thing is that whenever we dive into the literature and look to answer questions, more and more questions come up.”