STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management

InterventionACC/AHA Class and LevelPreoperative identification of high-risk patients should be performed, and all available preoperative and perioperative measures of blood conservation should be undertaken in this group as they account for most blood products transfused. Class I, Level AIt is reasonable to discontinue low-intensity antiplatelet drugs (e.g., aspirin) only in purely elective patients without ACS before operation with the expectation that blood transfusion will be reduced.Class IIA, Level A Minimization of phlebotomy through reduction in blood sampling volumes and frequencies is a reasonable means of blood conservation.Class IIA, Level B-NR (nonrandomized) The addition of a P2Y12 inhibitor to aspirin therapy, if indicated, in the immediate postoperative care of CABG patients before ensuring surgical hemostasis may increase bleeding and the need for surgical reexploration, and is not recommended until the risk of bleeding has abated.Class III: No benefit, Level C-LD (limited data)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 (e.g., uremic or CPB-induced platelet dysfunction, type I von Willebrand disease).Class IIB, Level B-NR Plasma transfusion is reasonable in patients with serious bleeding in the context of multiple or single coagulation factor deficiencies when safer fractionated products are not available.Class IIA, Level B-NR 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. Class III: Harm, Level AWhen allogeneic blood transfusion is needed, it is reasonable to use leukoreduced donor blood, if available.Class IIA, Level B-R (randomized) 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 CPB.Class IIB, Level B-NR Antithrombin III concentrates are indicated to reduce plasma transfusion in patients with antithrombinmediated heparin resistance immediately before CPB. Class I, Level AIn high-risk patients with known malignancy who require CPB, blood salvage using centrifugation of salvaged blood from the operative field may be considered when allogeneic transfusion is required.Class IIB, Level B-NR Centrifugation of pump-salvaged blood is reasonable for minimizing post-CPB allogeneic RBC transfusion.Class IIA, Level A Use of modified ultrafiltration may be reasonable for blood conservation and reducing postoperative blood loss in adult cardiac operations using CPB.Class IIB, Level B-R Routine use of red cell salvage using centrifugation is helpful for blood conservation in cardiac operations using CPB.Class I, Level A Direct reinfusion of shed mediastinal blood from postoperative chest tube drainage is not recommended as a means of blood conservation and may cause harm.Class III: Harm, Level B-NR A comprehensive multimodality blood conservation program led by a multidisciplinary team of healthcare providers should be part of any patient blood management program to limit utilization of blood resources and decrease the risk of bleeding.Class I, Level B-R

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