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Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022
Kietaibl, S., Ahmed, A., Afshari, A., Albaladejo, P., Aldecoa, C., Barauskas, G., De Robertis, E., Faraoni, D., Filipescu, D. C., Fries, D., et al
European Journal of Anaesthesiology. 2023;40(4):226-304
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Optimizing Safety and Success: The Advantages of Bloodless Cardiac Surgery. A Systematic Review and Meta-Analysis of Outcomes in Jehovah's Witnesses
Gemelli, M., Italiano, E. G., Geatti, V., Addonizio, M., Cao, I., Dimagli, A., Dokollari, A., Tarzia, V., Gallo, M., Ferrari, E., et al
Current problems in cardiology. 2023;:102078
Abstract
OBJECTIVE Transfusions are extremely frequent after cardiac surgery, and they have a considerable economic burden and impact on outcomes. Optimal patient blood management (PBM) could play a fundamental role in reducing the rate of transfusion and Jehovah's Witnesses (JW) represent the ideal surrogate study population. This meta-analysis compares outcomes of JWs and non-JWs' patients undergoing cardiac surgery, assessing the safety of a bloodless cardiac surgery. METHODS A scoping review was conducted using a search strategy for studies assessing outcomes of JW undergoing cardiac surgery. The primary outcome was perioperative mortality, and a random-effects meta-analysis was performed. RESULTS Ten studies were included in our meta-analysis, involving 780 JW patients refusing any type of transfusion ("JW") and 1182 patients accepting transfusion if needed ("non-JW"). 86% of non-JW patients received at least 1 transfusion. There was no significant difference in terms of perioperative mortality (OR 0.91; 95% CI 0.55 - 1.52; p = 0.72). The volume blood loss was significantly less in the JW (p = 0.001), while the rate of reoperation for bleeding was also lower, but not statistically significative, in the JW (p = 0.16). Both pre-operative and post-operative hemoglobin and hematocrit were significantly higher in the JW. CONCLUSIONS Bloodless cardiac surgery is safe and early outcomes are similar between JW and non-JW patients: optimal patient blood management is fundamental in guarantying these results. Further studies are needed to assess if a limitation of transfusion could have a positive long-term impact on outcomes.
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Systematic review highlights high risk of bias of clinical prediction models for blood transfusion in patients undergoing elective surgery
Dhiman P, Ma J, Gibbs VN, Rampotas A, Kamal H, Arshad SS, Kirtley S, Doree C, Murphy MF, Collins GS, et al
Journal of clinical epidemiology. 2023
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Abstract
BACKGROUND Blood transfusion can be a lifesaving intervention after perioperative blood loss. Many prediction models have been developed to identify patients most likely to require blood transfusion during elective surgery, but it is unclear whether any are suitable for clinical practice. STUDY DESIGN AND SETTING We conducted a systematic review, searching MEDLINE, Embase, PubMed, The Cochrane Library, Transfusion Evidence Library, Scopus, and Web of Science databases for studies reporting the development or validation of a blood transfusion prediction model in elective surgery patients between 01/01/2000 to 30/06/2021. We extracted study characteristics, discrimination performance (c-statistics) of final models and data which we used to perform risk of bias assessment using the Prediction model Risk Of Bias ASsessment Tool (PROBAST). RESULTS We reviewed 66 studies (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes. CONCLUSION Most blood transfusion prediction models are at high risk of bias and suffer from poor reporting and methodological quality, which must be addressed before they can be safely used in clinical practice.
PICO Summary
Population
Patients undergoing elective surgery (66 studies).
Intervention
Blood transfusion prediction models used perioperatively.
Comparison
Outcome
This systematic review appraised 120 prediction models developed or validated for predicting blood transfusion in elective surgery (72 developed and 48 externally validated models). Pooled c-statistics of externally validated models ranged from 0.67 to 0.78. Most developed and validated models were at high risk of bias due to handling of predictors, validation methods, and too small sample sizes.
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Platelet Function Testing Using Sonoclot and TEG6s as a Platelet Transfusion Prediction Tool in Open Heart Surgery
Sato, T., Edanaga, M., Yamakage, M., Harada, R., Kawaharada, N.
Cureus. 2023;15(11):e49131
Abstract
Introduction The point-of-care test (POCT) is useful for blood coagulation management during cardiovascular surgery. Although thromboelastography (TEG6s) has been reported to have targeted benefits for blood transfusion in cardiac surgery, Sonoclot analysis has not yet been fully validated. In this study, we evaluated the accuracy of Sonoclot, especially platelet function (PF) as a platelet concentrate (PC) transfusion parameter, compared to TEG6s in cardiovascular surgery. Methods This single-center, prospective, randomised trial was conducted at a university hospital. Forty-two adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass were included in this study between 2017 and 2021. The participants were randomly assigned to the Sonoclot (S) or Sonoclot and TEG6s (ST) groups. The amount of intraoperative PC was determined according to the POCT parameter values at the time of protamine administration. In addition, we investigated the correlation between PF parameters of POCT and platelet count at the end of surgery. Results There was no statistically significant difference in the intraoperative PC volume between the two groups. The Sonoclot PF parameter, PF, was moderately correlated with platelet count at the end of surgery (r=0.5449, p=0.009), and the TEG6s PF parameter showed a strong correlation with platelet count at the end of surgery (r=0.7744, p<0.001). Conclusion There was no statistically significant difference in platelet transfusion volume between the Sonoclot and TEG6s in this study. The correlation between the PF of the Sonoclot and platelet count was moderate. This study suggests that PF of Sonoclot may be a potentiating indicator of PF.
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Noninvasive hemoglobin monitoring for maintaining hemoglobin concentration within the target range during major noncardiac surgery: A randomized controlled trial
Park, S. K., Hur, C., Kim, Y. W., Yoo, S., Lim, Y. J., Kim, J. T.
Journal of clinical anesthesia. 2023;93:111326
Abstract
STUDY OBJECTIVE The effect of noninvasive CO-oximetry hemoglobin (SpHb) monitoring on the clinical outcomes of patients undergoing surgery remains unclear. This trial aimed to evaluate whether SpHb monitoring helps maintain hemoglobin levels within a predefined target range during major noncardiac surgeries with a potential risk of intraoperative hemorrhage. DESIGN A single-center, prospective, randomized controlled trial. SETTING University hospital. PATIENTS One hundred and thirty patients undergoing elective noncardiac surgery with a potential risk of hemorrhage. INTERVENTIONS Patients were randomly allocated to undergo either SpHb-guided management (SpHb group) or usual care (control group). MEASUREMENTS The primary outcome was the rate of deviation of the total hemoglobin concentration (determined from laboratory testing) from a pre-specified target range (8-14 g/dL). This was defined as the number of laboratory tests revealing such deviations divided by the total number of laboratory tests performed during the surgery. MAIN RESULTS The primary outcome occurred significantly less frequently in the SpHb group as compared to that in the control group (15/555 [2.7%]) vs. 68/598 [11.4%]; relative risk, 0.24; 95% confidence interval, 0.13-0.41; P < 0.001). Fewer point-of-care blood tests were performed in the SpHb group than in the control group (median [interquartile range], 2 [1-4] vs. 4 [2-5]; P < 0.001). There were no significant intergroup differences in the number of patients who received red blood cell transfusions during surgery (SpHb vs. control, 33.8% vs. 46.2%; P = 0.201). The incidence of unnecessary red blood cell preparation (>2 units) was lower in the SpHb group than in the control group (3.1% vs. 16.9%; P = 0.024). CONCLUSIONS Compared with routine care, SpHb-guided management resulted in significantly lower rates of hemoglobin deviation outside the target range intraoperatively in patients undergoing major noncardiac surgeries with a potential risk of hemorrhage. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (identifier: NCT03816514).
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Preoperative fibrinogen level and blood transfusions in liver transplantation: A systematic review
Thibeault, F., Plourde, G., Fellouah, M., Ziegler, D., Carrier, F. M.
Transplantation reviews (Orlando, Fla.). 2023;37(4):100797
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is a major surgery often associated with significant bleeding. We conducted a systematic review to explore the association between preoperative fibrinogen level and intraoperative blood products transfusion, blood loss and clinical outcomes in patients undergoing OLT. METHODS We included observational studies conducted in patients undergoing an OLT mostly for end-stage liver disease that reported an association between the preoperative fibrinogen level and our outcomes of interest. Our primary outcome was the intraoperative red blood cell (RBC) transfusion requirements. Our secondary outcomes were intraoperative blood loss, intraoperative transfusion of any blood product, postoperative RBC transfusion, postoperative thrombotic or hemorrhagic complications, and mortality. We used a standardized search strategy. We reported our results mostly descriptively but conducted meta-analyses using random-effect models when judged feasible. RESULTS We selected 24 cohort studies reporting at least one of our outcomes. We found that a high preoperative fibrinogen level was associated with fewer intraoperative RBC and other blood products transfusions, and lower blood loss. We also found a lower overall survival in patients with a higher fibrinogen level (pooled hazard ratio [95% CI] of 1.50 [1.23 to 1.84]; 5 studies, n = 1012, I(2) = 48%). Only one study formally explored a fibrinogen level threshold effect. Overall, reporting was heterogeneous, and risk of bias was variable mostly because of uncontrolled confounding. CONCLUSION A higher preoperative fibrinogen level was associated with fewer intraoperative RBC and other blood products transfusions, lower blood loss, and higher mortality. Further studies may help clarify observed associations and inform guidelines.
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Cardiac surgery in Jehovah's Witnesses patients and association with peri-operative outcomes: a systematic review and meta-analysis
Vitolo M, Mei DA, Cimato P, Bonini N, Imberti JF, Cataldo P, Menozzi M, Filippini T, Vinceti M, Boriani G
Current problems in cardiology. 2023;:101789
Abstract
BACKGROUND Strategies for blood conservation, coupled with a careful preoperative assessment, may be applied to Jehovah's Witnesses (JW) patients who are candidates for cardiac surgery interventions. There is a need to assess clinical outcomes and safety of bloodless surgery in JW patients undergoing cardiac surgery. METHODS We performed a systematic review and meta-analysis of studies comparing JW patients with controls undergoing cardiac surgery. The primary endpoint was short-term mortality (in-hospital or 30-day mortality). Peri-procedural myocardial infarction, re-exploration for bleeding, pre-and post-operative Hb levels and cardiopulmonary bypass (CPB) time were also analyzed. RESULTS A total of 10 studies including 2,302 patients were included. The pooled analysis showed no substantial differences in terms of short-term mortality among the two groups (OR 1.13, 95% CI 0.74-1.73, I(2)=0%). There were no differences in peri-operative outcomes among JW patients and controls (OR 0.97, 95% CI 0.39-2.41, I(2)=18% for myocardial infarction; OR 0.80, 95% CI 0.51-1.25, I(2)=0% for re-exploration for bleeding). JW patients had a higher level of pre-operative Hb (Standardized Mean Difference [SMD] 0.32, 95% CI 0.06-0.57) and a trend toward a higher level of post-operative Hb (SMD 0.44, 95% CI -0.01-0.90). A slightly lower CPB time emerged in JWs compared with controls (SMD -0.11, 95% CI -0.30-0.07). CONCLUSIONS JW patients undergoing cardiac surgery, with avoidance of blood transfusions, did not have substantially different peri-operative outcomes compared with controls, with specific reference to mortality, myocardial infarction, and re-exploration for bleeding. Our results support the safety and feasibility of bloodless cardiac surgery, applying patient blood management strategies.
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Optimisation and Effect Analysis of the Blood Collection Method in Pre-Deposit Autotransfusion Patients Undergoing Thoracotomy Surgery
Jia, L., Wang, Y., Zhang, W., Lin, Y., Chen, F., Wan, Y., Fu, X.
Journal of multidisciplinary healthcare. 2023;16:2793-2798
Abstract
BACKGROUND AND PURPOSE To explore the feasibility of the modified blood collection method in pre-deposit autotransfusion in patients undergoing thoracotomy surgery. METHODS This double-blinded randomised controlled trial enrolled 92 patients from the cardiothoracic surgery department from February 2019 to October 2020. RESULTS Compared with the conventional blood collection method, the modified blood collection method avoided blood overflow from the oblique plane of the needle (χ(2) = 61.986, P < 0.01) and reduced the diameter of the bruising area after 24 hours (χ(2) = 24.611, P < 0.01). Furthermore, due to optimising the blood collection method, diastolic blood pressure reduced slightly before and after blood collection (t = 2.036, P < 0.05), and patients in the test group had less pain (based on the numerical rating score) (t = 5.556, P < 0.01). Meanwhile, the time required to collect 400 mL of blood was shortened (t = 17.744, p < 0.01). CONCLUSION An improved blood collection method can enhance the blood donation experience, avoid blood spillage, lessen pain and reduce adverse reactions. This may be of great significance in ensuring blood quality and the safety of subsequent transfusions. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov Identifier: NCT05539846.
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What is the optimal management of thromboprophylaxis after liver transplantation regarding prevention of bleeding, hepatic artery or portal vein thrombosis? A systematic review of the literature and expert panel recommendations
Kirchner VA, O'Farrell B, Imber C, McCormack L, Northup PG, Song GW, Spiro M, Raptis DA, Durand F
Clinical transplantation. 2022;:e14629
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Abstract
BACKGROUND A key tenet of clinical management of patients post liver transplantation (LT) is the prevention of thrombotic and bleeding complications. This systematic review investigated the optimal management of thromboprophylaxis after LT regarding portal vein thrombosis (PVT) or hepatic artery thrombosis (HAT) and prevention of bleeding. METHODS Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Seven databases were used to conduct extensive literature searches focusing on the use of anticoagulation in LT and its impact on the following outcomes: PVT, HAT, and bleeding. (CRD42021244288) RESULTS Of the 2,478 articles/abstracts screened, 16 studies were included in the final review. All articles were critically appraised by a panel of independent reviewers. There was wide variation regarding the anticoagulation protocols used. Thromboprophylaxis with therapeutic doses of heparin/Vitamin K antagonist combination did not decrease the risk of de novo or the recurrence of PVT but was associated with an increased risk of bleeding in some studies. Only the use of aspirin resulted in a small but significant decrease in the incidence of HAT post-LT, yet it did not increase the risk of bleeding. CONCLUSIONS Based on existing data and expert opinion, thromboprophylaxis at therapeutic or prophylactic dose is not recommended for prevention of de novo PVT following LT in patients not at high risk. Aspirin should be considered as the standard of care following LT to prevent HAT. Thromboprophylaxis should be strongly considered in recipients at risk of HAT and PVT following LT. This article is protected by copyright. All rights reserved.
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Targeted Bleeding Management Guided by Non-Invasive Haemoglobin Measurement in Surgical Patients
Akdag S, Zengin SU, Cakmak G, Umuroglu T, Aykac ZZ, Saracoglu A
Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2022;32(10):1242-1248
Abstract
OBJECTIVE To assess blood transfusion decisions in blood losses using a continuous total haemoglobin (SpHb) and non-invasive haemoglobin (Hb) device. STUDY DESIGN Double-blinded randomised controlled trial. PLACE AND DURATION OF STUDY Marmara University Hospital, Istanbul, Turkey, from March 2018 to December 2019. METHODOLOGY One hundred and twenty adult patients scheduled for elective major surgery and expected to experience a blood loss greater than 20% of their total blood volume were divided into two groups. These groups were compared for bleeding management with conventional blood gas sampling (Group Hb, the control group) according to Hb monitoring versus SpHb measurement (Group SpHb, the study group). RESULTS In the postoperative measurement, there were fewer red blood cells (RBC) in the SpHb group than in the Hb group (p=0.020). There was a greater change in the amount of RBC from the perioperative to the postoperative period in the SpHb group compared to the Hb group (p<0.001). Postoperative Hb levels of patients in the intensive care unit (ICU) were higher in the SpHb group than in the Hb group (p<0.05). CONCLUSION SpHb can provide effective patient blood management in cases of major surgery. It does not cause a delay in the decision of blood transfusion during surgery. KEY WORDS Haemorrhage, Anaemia, Blood transfusion, General surgery.