HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goodnough, L. T. Articles by Shander, A. Search for Related Content PubMed PubMed Citation Articles by Goodnough, L. T. Articles by Shander, A. Related Collections Coronary disease

Ann Thorac Surg 2004;78:1554-1555
© 2004 The Society of Thoracic Surgeons

INVITED COMMENTARY

^a Department of Pathology and Medicine, Stanford Medical Center, 300 Pasteur Dr H-1402, Stanford, CA 94304-5626, USA

Aryeh Shander, MD, FCCM^b

^b Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Engelwood, NJ, USA

ltgoodno{at}stanford.edu

Being able to identify patients undergoing open-heart surgery who are likely to receive transfusion now extends back over nearly 20 years [1]. Subsequent single center analyses [2, 3], including that by Arora and colleagues in this issue [4], have confirmed or extended our knowledge of predictors. Yet there remains an underutilization of algorithms or strategies that base patient management on these predictors, as evidenced by the continued variability of both blood transfusion outcomes and blood conservation utilization across institutions. The resulting transfusion rates of 23% [4] to 61% [2] in programs without aggressive utilization of blood conservation versus those as low as 10% [1] to 13% [3] at institutions with more aggressive blood conservation [5] illustrates the dilemma. Comprehensive use of all blood conservation modalities with appropriately restrictive use of transfusion thresholds may result in a tighter definition of predictors, as illustrated by other authors [6]. Age, gender, and other variables that are accepted predictors of blood product transfusion may lose their value as more data becomes available on conservation techniques in elective cardiac surgery [3].

What efforts are needed to more effectively use blood in this population, particularly for "elective," uncomplicated cardiac surgery? Emerging data suggest that use of rigorous protocols, especially in the detection and treatment of preoperative anemia and intraoperative real-time coagulation monitoring can reduce the need for blood products [3, 6–9]. Improved survival and reduced morbidity are ultimate goals of good clinical practice, so achieving a low transfusion rate must clearly be related to improvement in morbidity and mortality. Other benefits, including lower costs and savings of blood, a precious resource, are additive. Incorporating appropriate transfusion indications along with blood conservation techniques are the principles driving the Society for the Advancement of Blood Management (SABM; http://www.sabm.org). Disseminating information, recommendations and guidelines, along with supporting and encouraging investigation in these areas are some of SABM's strategic plans that will help clinicians, such as Arora and coworkers, advance the care of their patients.

References

1. Cosgrove DM, Loop FD, Lytle BW, et al. Determinants of blood utilization during myocardial revascularization. Ann Thorac Surg. 1985;40:380–384[Abstract]
2. Magovern JA, Sakert T, Benckart DH, et al. A model for predicting transfusion after coronary artery bypass grafting. Ann Thorac Surg. 1996;61:27–32[Abstract/Free Full Text]
3. Moskowitz DM, Klein JJ, Shander A, et al. Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center. Ann Thorac Surg. 2004;77:626–634[Abstract/Free Full Text]
4. Arora RC, Légaré J-F, Buth KJ, Sullivan JA, Hirsch GM. Identifying patients at risk of intraoperative and postoperative transfusion in isolated CABG: toward selective conservation strategies. Ann Thorac Surg 2004;78:1547–55
5. Goodnough LT. Blood conservation and blood transfusion practices: flipsides of the same coin. Ann Thorac Surg. 1993;56:3–4[Medline]
6. Helm RE, Rosengart TK, Gomez M, et al. Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion. Ann Thorac Surg. 1998;65:125–136[Abstract/Free Full Text]
7. Shore-Lesserson L. Point-of-care coagulation monitoring for cardiovascular patients: past and present. J Cardiothorac Vasc Anesth. 2002;16:99–106[Medline]
8. Nuttall GA, Oliver WC, Ereth MH, Santrach PJ. Coagulation tests predict bleeding after cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 1997;11:815–823[Medline]
9. Despotis GJ, Skubas NJ, Goodnough LT. Optimal management of bleeding and transfusion in patients undergoing cardiac surgery. Semin Thorac Cardiovasc Surg. 1999;11:84–104[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goodnough, L. T. Articles by Shander, A. Search for Related Content PubMed PubMed Citation Articles by Goodnough, L. T. Articles by Shander, A. Related Collections Coronary disease