Key Hospitalist Clinical Practice Guidelines in 2017

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

January 16, 2018

In This Article

Patient Blood Management for Cardiac Surgery

European Association for Cardio-Thoracic Surgery and the European Association of Cardiothoracic Anaesthesiology

Preoperative fibrinogen levels may be considered to identify patients at high risk of bleeding.

In patients undergoing coronary artery bypass grafting (CABG), acetylsalicylic acid (ASA) should be continued throughout the preoperative period.

In patients taking dual antiplatelet therapy (DAPT) who need to have nonemergent cardiac surgery, postponing surgery for at least 3 days after discontinuation of tacagrelor, 5 days after clopidogrel, and 7 days after prasugrel should be considered.

Recommend that GPIIb/IIIa inhibitors be discontinued at least 4 hours before surgery.

Recommend that prophylactic low-molecular-weight heparin (LMWH) be discontinued 12 hours before surgery and fondaparinux 24 hours before surgery.

Oral or IV iron alone before cardiac surgery may be considered in mildly anemic patients (women, Hb 100-120 g/L; men, Hb 100-130 g/L) or in severely anemic patients (both genders, Hb <100 g/L) to improve erythropoiesis.

Erythropoietin (EPO) with or without iron supplementation should be considered in patients with non-iron deficiency anemia undergoing elective surgery to reduce postoperative transfusions.

Off-pump CABG surgery may be considered in selected patients to reduce perioperative infusions.

The routine use of topical sealants in cardiac surgery is not recommended and may only be considered in cases of persistent bleeding where the bleeding is localized.

The routine use of cell salvage should be considered to prevent transfusions, but the retransfusion of large volumes of cell salvaged blood (>1000 ml) may impair coagulation. Overall, postoperative cell salvage and reinfusion of washed erythrocytes may be considered to reduce transfusions in patients with bleeding.

Heparin level–guided heparin management should be considered over activated clotting time (ACT)–guided heparin management to reduce bleeding, especially in patients who are resistant to heparin.

Limitation of hemodilution is recommended as part of a blood conservation strategy to reduce bleeding and transfusions.

Based on the current evidence, preoperative autologous blood donation in patients without severe aortic stenosis, Canadian Cardiovascular Society (CCS) grade 3–4 angina, or ACS <4 weeks and with high Hb levels (>110 g/L) who are having elective surgery may be considered to reduce the number of postoperative transfusions.

In patients in whom bleeding is related to coagulation factor deficiency, prothrombin complex concentrate (PCC) or fresh-frozen plasma (FFP) administration should be used to reduce bleeding and transfusions. PCC may be preferred over FFP when rapid normalization of coagulation factors is needed.

Recommend the use of packed red blood cells (PRBCs) of all ages, because the storage time of the PRBCs does not affect outcomes. In an attempt to reduce infectious complications, the use of leukocyte-depleted PRBCs is recommended; in contrast, the pooled solvent-detergent FFP may be preferred over standard FFP to reduce the risk for transfusion-related acute lung injury (TRALI).

Reference

  • Pagano D, Milojevic M, Meesters MI, et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery: The Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA). Eur J Cardiothorac Surg. 2017 Oct 3.

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