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Ann Thorac Surg 2007;83:S27-S86
© 2007 The Society of Thoracic Surgeons

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Report From the STS Workforce on Evidence Based Surgery

Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline^_*

^a University of Kentucky Chandler Medical Center, Lexington, Kentucky
^b University of Florida, Jacksonville, Florida
^c University of Pennsylvania Health System, Philadelphia, Pennsylvania
^d Harefield Hospital, London, United Kingdom
^e Rush Presbyterian St. Lukes’ Medical Center, Chicago, Illinois
^f Washington University Medical Center, St. Louis, Missouri
^g Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Lebanon, New Hampshire
^h Virginia Commonwealth University, Richmond, Virginia
ⁱ Montefiore Medical Center, Bronx, New York
^j Duke University Medical Center, Durham, North Carolina
^k Keenan Research Center in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
^l Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts

^_* Address correspondence to Dr Ferraris, Division of Cardiovascular and Thoracic Surgery, University of Kentucky Chandler Medical Center, CTW Bldg, Suite 320, 900 South Limestone, Lexington, KY 40536-0200 (Email: ferraris{at}earthlink.net).

Background: A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes.

Methods: We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme.

Results: Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions.

Conclusions: Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient’s own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.