Blood Conservation
Publication Date: March 1, 2011
Last Updated: March 14, 2022
Recommendations
Preoperative interventions
New and Revised in 2011
Drugs that inhibit the platelet P2Y12 receptor should be discontinued before operative coronary revascularization (either on pump or off pump), if possible. The interval between drug discontinuation and operation varies depending on the drug pharmacodynamics, but may be as short as 3 days for irreversible inhibitors of the P2Y12 platelet receptor. (B, Class I)
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Point-of-care testing for platelet adenosine diphosphate responsiveness might be reasonable to identify clopidogrel nonresponders who are candidates for early operative coronary revascularization and who may not require a preoperative waiting period after clopidogrel discontinuation. (C, Class IIb)
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Routine addition of P2Y12 inhibitors to aspirin therapy early after coronary artery bypass graft (CABG) may increase the risk of reexploration and subsequent operation and is not indicated based on available evidence except in those patients who satisfy criteria for ACC/AHA guideline-recommended dual antiplatelet therapy (eg, patients presenting with acute coronary syndromes or those receiving recent drug eluting coronary stents). (B, Class III)
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It is reasonable to use preoperative erythropoietin (EPO) plus iron, given several days before cardiac operation, to increase red cell mass in patients with preoperative anemia, in candidates for operation who refuse transfusion (eg, Jehovah’s Witness), or in patients who are at high risk for postoperative anemia. However, chronic use of EPO is associated with thrombotic cardiovascular events in renal failure patients suggesting caution for this therapy in individuals at risk for such events (eg, coronary revascularization patients with unstable symptoms). (B, Class IIa)
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Recombinant human erythropoietin (EPO) may be considered to restore red blood cell volume in patients also undergoing autologous preoperative blood donation before cardiac procedures. However, no largescale safety studies for use of this agent in cardiac surgical patients are available, and must be balanced with the potential risk of thrombotic cardiovascular events (eg, coronary revascularization patients with unstable symptoms). (A, Class IIb)
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Guidelines from 2007 With Persistent Support
Preoperative identification of high-risk patients (advanced age, preoperative anemia, small body size, noncoronary artery bypass graft or urgent operation, preoperative antithrombotic drugs, acquired or congenital coagulation/clotting abnormalities and multiple patient comorbidities) should be performed, and all available preoperative and perioperative measures of blood conservation should be undertaken in this group as they account for the majority of blood products transfused. (A, Class I)
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Preoperative hematocrit and platelet count are indicated for risk prediction and abnormalities in these variables are amenable to intervention (A, Class I)
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Preoperative screening of the intrinsic coagulation system is not recommended unless there is a clinical history of bleeding diathesis. (B, Class III)
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Patients who have thrombocytopenia (50,000/mm2), who are hyperresponsive to aspirin or other antiplatelet drugs as manifested by abnormal platelet function tests or prolonged bleeding time, or who have known qualitative platelet defects represent a high-risk group for bleeding. Maximum blood conservation interventions during cardiac procedures are reasonable in these high-risk patients. (B, Class IIa)
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It is reasonable to discontinue low-intensity antiplatelet drugs (eg, aspirin) only in purely elective patients without acute coronary syndromes before operation with the expectation that blood transfusion will be reduced. (A, Class IIa)
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Most high-intensity antithrombotic and antiplatelet drugs (including adenosine diphosphate-receptor inhibitors, direct thrombin inhibitors, low molecular weight heparins, platelet glycoprotein inhibitors, tissue-type plasminogen activator, streptokinase) are associated with increased bleeding after cardiac operations. Discontinuation of these medications before operation may be considered to decrease minor and major bleeding events. The timing of discontinuation depends on the pharmacodynamic half-life for each agent as well as the potential lack of reversibility. Unfractionated heparin is the notable exception to this recommendation and is the only agent which either requires discontinuation shortly before operation or not at all. (C, Class IIb)
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Alternatives to laboratory blood sampling (eg, oximetry instead of arterial blood gasses) are reasonable means of blood conservation before operation. (B, Class IIa)
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Screening preoperative bleeding time may be considered in high-risk patients, especially those who receive preoperative antiplatelet drugs. (B, Class IIb)
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Devices aimed at obtaining direct hemostasis at catheterization access sites may be considered for blood conservation if operation is planned within 24 hours. (C, Class IIb)
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Transfusion triggers
Guidelines from 2007 With Persistent Support
Given that the risk of transmission of known viral diseases with blood transfusion is currently rare, fears of viral disease transmission should not limit administration of INDICATED blood products. (This recommendation only applies to countries/blood banks where careful blood screening exists.) (C, Class IIa)
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Transfusion is unlikely to improve oxygen transport when the hemoglobin concentration is greater than 10 g/dL and is not recommended. (C, Class III)
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With hemoglobin levels below 6 g/dL, red blood cell transfusion is reasonable since this can be life-saving. Transfusion is reasonable in most postoperative patients whose hemoglobin is less than 7 g/dL but no high level evidence supports this recommendation. (C, Class IIa)
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It is reasonable to transfuse nonred-cell hemostatic blood products based on clinical evidence of bleeding and preferably guided by point-of-care tests that assess hemostatic function in a timely and accurate manner. (C, Class IIa)
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During cardiopulmonary bypass (CPB) with moderate hypothermia, transfusion of red cells for hemoglobin 6 g/dL is reasonable except in patients at risk for decreased cerebral oxygen delivery (ie, history of cerebrovascular attack, diabetes, cerebrovascular disease, carotid stenosis) where higher hemoglobin levels may be justified. (C, Class IIa)
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In the setting of hemoglobin values exceeding 6 g/dL while on CPB, it is reasonable to transfuse red cells based on the patient’s clinical situation, and this should be considered as the most important component of the decision making process. Indications for transfusion of red blood cells in this setting are multifactorial and should be guided by patient-related factors (ie, age, severity of illness, cardiac function, or risk for critical end-organ ischemia), the clinical setting (massive or active blood loss), and laboratory or clinical parameters (eg, hematocrit, SVO2, electrocardiogram, or echocardiographic evidence of myocardial ischemia etc.). (C, Class IIa)
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It is reasonable to transfuse nonred-cell hemostatic blood products based on clinical evidence of bleeding and preferably guided by specific point-of-care tests that assess hemostatic function in a timely and accurate manner. (C, Class IIa)
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It may be reasonable to transfuse red cells in certain patients with critical noncardiac end-organ ischemia (eg, central nervous system and gut) whose hemoglobin levels are as high as 10 g/dL but more evidence to support this recommendation is required. (C, Class IIb)
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In patients on CPB with risk for critical end-organ ischemia/injury, transfusion to keep the hemoglobin 7 g/dL may be considered. (C, Class IIb)
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Drugs used for intraoperative blood management
New and Revised in 2011
Lysine analogues—epsilon-aminocaproic acid (Amicar) and tranexamic acid (Cyklokapron)—reduce total blood loss and decrease the number of patients who require blood transfusion during cardiac procedures and are indicated for blood conservation. (A, Class I)
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High-dose (Trasylol, 6 million KIU) and low-dose (Trasylol, 1 million KIU) aprotinin reduce the number of adult patients requiring blood transfusion, total blood loss, and reexploration in patients undergoing cardiac surgery but are not indicated for routine blood conservation because the risks outweigh the benefits. High-dose aprotinin administration is associated with a 49% to 53% increased risk of 30-day death and 47% increased risk of renal dysfunction in adult patients. No similar controlled data are available for younger patient populations including infants and children. (A, Class III)
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Guidelines from 2007 With Persistent Support
Use of 1-deamino-8-D-arginine vasopressin (DDAVP) may be reasonable to attenuate excessive bleeding and transfusion in certain patients with demonstrable and specific platelet dysfunction known to respond to this agent (eg, uremic or CPB-induced platelet dysfunction, type I von Willebrand’s disease). (B, Class IIb)
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Routine prophylactic use of DDAVP is not recommended to reduce bleeding or blood transfusion after cardiac operations using CPB. (A, Class III)
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Dipyridamole is not indicated to reduce postoperative bleeding, is unnecessary to prevent graft occlusion after coronary artery bypass grafting, and may increase bleeding risk unnecessarily. (B, Class III)
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Blood derivatives used in blood management
Plasma transfusion is reasonable in patients with serious bleeding in context of multiple or single coagulation factor deficiencies when safer fractionated products are not available. (B, Class IIa)
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For urgent warfarin reversal, administration of prothrombin complex concentrate (PCC) is preferred but plasma transfusion is reasonable when adequate levels of factor VII are not present in PCC. (B, Class IIa)
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Transfusion of plasma may be considered as part of a massive transfusion algorithm in bleeding patients requiring substantial amounts of red-blood cells. (B, Class IIb)
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Prophylactic use of plasma in cardiac operations in the absence of coagulopathy is not indicated, does not reduce blood loss and exposes patients to unnecessary risks and complications of allogeneic blood component transfusion. (A, Class III)
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Use of factor XIII may be considered for clot stabilization after cardiac procedures requiring cardiopulmonary bypass when other routine blood conservation measures prove unsatisfactory in bleeding patients. (C, Class IIb)
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When allogeneic blood transfusion is needed, it is reasonable to use leukoreduced donor blood, if available. Benefits of leukoreduction may be more pronounced in patients undergoing cardiac procedures. (B, Class IIa)
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Use of intraoperative platelet plasmapheresis is reasonable to assist with blood conservation strategies as part of a multimodality program in high-risk patients if an adequate platelet yield can be reliably obtained.
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Use of recombinant factor VIIa concentrate may be considered for the management of intractable nonsurgical bleeding that is unresponsive to routine hemostatic therapy after cardiac procedures using cardiopulmonary bypass (CPB). (B, Class IIb)
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Antithrombin III (AT) concentrates are indicated to reduce plasma transfusion in patients with AT mediated heparin resistance immediately before cardiopulmonary bypass.
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Administration of antithrombin III concentrates is less well established as part of a multidisciplinary blood management protocol in high-risk patients who may have AT depletion or in some, but not all, patients who are unwilling to accept blood products for religious reasons. (C, Class IIb)
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Use of factor IX concentrates, or combinations of clotting factor complexes that include factor IX, may be considered in patients with hemophilia B or who refuse primary blood component transfusion for religious reasons (eg, Jehovah’s Witness) and who require cardiac operations. (C, Class IIb)
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Blood salvage interventions
New and Revised in 2011
In high-risk patients with known malignancy who require CPB, blood salvage using centrifugation of salvaged blood from the operative field may be considered since substantial data supports benefit in patients without malignancy and new evidence suggests worsened outcome when allogeneic transfusion is required in patients with malignancy. (B, Class IIb)
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Consensus suggests that some form of pump salvage and reinfusion of residual pump blood at the end of CPB is reasonable as part of a blood management program to minimize blood transfusion. (C, Class IIa)
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Centrifugation of pump-salvaged blood, instead of direct infusion, is reasonable for minimizing post-CPB allogeneic red blood cell (RBC) transfusion. (A, Class IIa)
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Guidelines from 2007 With Persistent Support
Routine use of red cell salvage using centrifugation is helpful for blood conservation in cardiac operations using CPB. (A, Class I)
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During CPB, intraoperative autotransfusion, either with blood directly from cardiotomy suction or recycled using centrifugation to concentrate red cells, may be considered as part of a blood conservation program. (C, Class IIb)
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Postoperative mediastinal shed blood reinfusion using mediastinal blood processed by centrifugation may be considered for blood conservation when used in conjunction with other blood conservation interventions. Washing of shed mediastinal blood may decrease lipid emboli, decrease the concentration of inflammatory cytokines, and reinfusion of washed blood may be reasonable to limit blood transfusion as part of a multimodality blood conservation program. (B, Class IIb)
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Direct reinfusion of shed mediastinal blood from postoperative chest tube drainage is not recommended as a means of blood conservation and may cause harm. (B, Class III)
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Minimally invasive procedures
Thoracic endovascular aortic repair (TEVAR) of descending aortic pathology reduces bleeding and blood transfusion compared with open procedures and is indicated in selected patients. (B, Class I)
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Off-pump operative coronary revascularization (OPCABG) is a reasonable means of blood conservation, provided that emergent conversion to on-pump CABG is unlikely and the increased risk of graft closure is considered in weighing risks and benefits. (A, Class IIa)
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Perfusion interventions
New and Revised in 2011
Routine use of a microplegia technique may be considered to minimize the volume of crystalloid cardioplegia administered as part of a multimodality blood conservation program, especially in fluid overload conditions like congestive heart failure. However, compared with 4:1 conventional blood cardioplegia, microplegia does not significantly impact RBC exposure. (B, Class IIb)
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Extracorporeal membrane oxygenation (ECMO) patients with heparin-induced thrombocytopenia should be anticoagulated using alternate nonheparin anticoagulant therapies such as danaparoid or direct thrombin inhibitors (eg, lepirudin, bivalirudin or argatroban). (C, Class I)
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Minicircuits (reduced priming volume in the minimized CPB circuit) reduce hemodilution and are indicated for blood conservation, especially in patients at high risk for adverse effects of hemodilution (eg, pediatric patients and Jehovah’s Witness patients). (A, Class I)
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Vacuum-assisted venous drainage in conjunction with minicircuits may prove useful in limiting bleeding and blood transfusion as part of a multimodality blood conservation program. (C, Class IIb)
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Use of biocompatible CPB circuits may be considered as part of a multimodality program for blood conservation. (A, Class IIb)
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Use of modified ultrafiltration is indicated for blood conservation and reducing postoperative blood loss in adult and pediatric cardiac operations using CPB. (A, Class I)
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Benefit of the use of conventional or zero balance ultrafiltration is not well established for blood conservation and reducing postoperative blood loss in adult cardiac operations. (A, Class IIb)
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Available leukocyte filters placed on the CPB circuit for leukocyte depletion are not indicated for perioperative blood conservation and may prove harmful by activating leukocytes during CPB. (B, Class III)
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Guidelines from 2007 With Persistent Support
Open venous reservoir membrane oxygenator systems during cardiopulmonary bypass may be considered for reduction in blood utilization and improved safety. (C, Class IIb)
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All commercially available blood pumps provide acceptable blood conservation during CPB. It may be preferable to use centrifugal pumps because of perfusion safety features. (B, Class IIb)
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In patients requiring longer CPB times (2 to 3 hours), maintenance of higher and/or patient-specific heparin concentrations during CPB may be considered to reduce hemostatic system activation, reduce consumption of platelets and coagulation proteins, and to reduce blood transfusion. (B, Class IIb)
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Use either protamine titration or empiric low dose regimens (eg, 50% of total heparin dose) to lower the total protamine dose and lower the protamine/heparin ratio at the end of CPB may be considered to reduce bleeding and blood transfusion requirements. (B, Class IIb)
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The usefulness of low doses of systemic heparinization (activated clotting time 300 s) is less well established for blood conservation during CPB but the possibility of underheparinization and other safety concerns have not been well studied. (B, Class IIb)
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Acute normovolemic hemodilution may be considered for blood conservation but its usefulness is not well established. It could be used as part of a multipronged approach to blood conservation.
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Retrograde autologous priming of the CPB circuit may be considered for blood conservation. (B, Class IIb)
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Topical hemostatic agents
Topical hemostatic agents that employ localized compression or provide wound sealing may be considered to provide local hemostasis at anastomotic sites as part of a multimodal blood management program. (C, Class IIb)
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Antifibrinolytic agents poured into the surgical wound after CPB are reasonable interventions to limit chest tube drainage and transfusion requirements after cardiac operations using CPB. (B, Class IIa)
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Postoperative care
A trial of therapeutic positive end-expiratory pressure (PEEP) to reduce excessive postoperative bleeding is less well established. (B, Class IIb)
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Use of prophylactic PEEP to reduce bleeding postoperatively is not effective. (B, Class III)
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Management of blood resources
New and Revised in 2011
Creation of multidisciplinary blood management teams (including surgeons, perfusionists, nurses, anesthesiologists, intensive care unit care providers, housestaff, blood bankers, cardiologists, etc.) is a reasonable means of limiting blood transfusion and decreasing perioperative bleeding while maintaining safe outcomes. (B, Class IIa)
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Guidelines from 2007 With Persistent Support
A multidisciplinary approach involving multiple stakeholders, institutional support, enforceable transfusion algorithms supplemented with point-of-care testing, and all of the already mentioned efficacious blood conservation interventions limits blood transfusion and provides optimal blood conservation for cardiac operations. (A, Class I)
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A comprehensive integrated, multimodality blood conservation program, using evidence based interventions in the intensive care unit, is a reasonable means to limit blood transfusion. (B, Class IIa)
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Total quality management, including continuous measurement and analysis of blood conservation interventions as well as assessment of new blood conservation techniques, is reasonable to implement a complete blood conservation program. (B, Class IIa)
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Recommendation Grading
Overview
Title
Blood Conservation
Authoring Organization
Society of Thoracic Surgeons
Publication Month/Year
March 1, 2011
Last Updated Month/Year
June 21, 2023
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This summary is an update of the blood conservation guideline published in 2007.
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Emergency care, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Prevention, Management
Diseases/Conditions (MeSH)
D005112 - Extracorporeal Circulation, D002315 - Cardiopulmonary Bypass
Keywords
perioperative care, blood conservation
Source Citation
2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines*
Ferraris, Victor A. et al.The Annals of Thoracic Surgery, Volume 91, Issue 3, 944 - 982