Optimal blood management as priority route in cardiac surgery

Abstract

Introduction. Generating manifold publications over decades, research continues assessing the burden of perioperative bleeding, preoperative anaemia and red blood component (RBC) transfusion in cardiac surgical patients. The past decade is witnessing a trend towards limited RBC transfusion. Nevertheless, the risk and justifi cation of a restrictive or liberal transfusion strategy in cardiac surgery remain a matter of debate.Aim — a description of evidence estimating the impact of bleeding, preoperative anaemia, red-cell transfusion and restrictive vs. liberal strategies on the risk of mortality and other adverse events in adults with cardiac surgery.Methods. Relevant evidence was mined in PubMed for the period 2012–2019. The query phrases were: cardiac surgery [кардиохирургия], bleeding [кровотечение], preoperative anaemia [предоперационная анемия], red-cell transfusion [переливание эритроцитов], restrictive and liberal transfusion strategy [рестриктивная и либеральная трансфузионная стратегия]. The review includes 18 studies describing outcomes related to bleeding, preoperative anaemia of varying severity and variant-volume RBC transfusion in patients with cardiac surgery. Nine studies comparatively assessed the cardiac surgical clinical outcomes under restrictive and liberal transfusion strategies. A total of 24 full texts have been analysed, one randomised clinical trial (RCT) summary, one retrospective trial summary and one meta-analysis review. Additional studies of concern to discussion have also been considered.Results. One prospective and four retrospective studies evaluated the effect of perioperative bleeding on the risk of subsequent adverse events in patients with cardiac surgery. Three prospective, fi ve retrospective studies and one RCT revealed the association of red-cell transfusion with adverse outcomes. Five retrospective studies exposed a link between preoperative anaemia and reason for RBC transfusions. Six retrospective studies found an independent association between the risk of postoperative complications and mortality in patients having cardiac surgery and preoperative anaemia. Eight RCTs and one meta-analysis of seven RCTs presented comparative data on clinical outcomes of restrictive and liberal transfusion strategies in patients after heart surgery.Conclusion. Preoperative anaemia, haemorrhage and donated component transfusion independently contribute to the risk of serious postoperative complications and death unifying in the “deadly triad” of cardiac surgery. RBC transfusions are integrally indicative of the aid quality in cardiac surgery reflecting the success of blood management system in the hospital. Leveraging a good patient blood management practice at all treatment steps to involve a multispecialty blood-team approach can significantly improve patient outcomes at a higher cost efficiency.