Executive summary

Summary of recommendations and practice points

The CRG developed recommendations (given below) where sufficient evidence was available from the systematic review of the literature. The recommendations have been carefully worded to reflect the strength of the body of evidence. Each recommendation has been given a grade, using the following definitions, which were set by the NHMRC:

Grade A	Body of evidence can be trusted to guide practice
Grade B	Body of evidence can be trusted to guide practice in most situations
Grade C	Body of evidence provides some support for recommendation(s) but care should be taken in its application
Grade D	Body of evidence is weak and recommendations must be applied with caution.

The CRG developed practice points where the systematic review found insufficient high-quality data to produce evidence-based recommendations, but the CRG felt that clinicians require guidance to ensure good clinical practice. These points are based on consensus among the members of the committee.

A full list of recommendations and practice points, in numerical order, is given in Appendix G. This section summarises the recommendations and practice points in a sequence that reflects clinical practice. The table below lists the elements of patient blood management; for each element, it shows the relevant recommendations, practice points and section of the document. It is followed by a series of tables giving the full recommendations and practice points for each component.

ELEMENT OF PATIENT BLOOD MANAGEMENT	RECOMMENDATION	PRACTICE POINT	RELEVANT SECTION OF DOCUMENT
Patient blood management program
Establishment	R1		3.1
Implementation	R1		3.3
Procedural guidelines		PP12–13	3.6.5, 3.6.6
Anaemia and haemostasis management
Preoperative anaemia assessment	R2–3	PP1, PP4–5	3.3, 3.4
Iron and ESA therapy	R4-6	PP6–7	3.4
Haemostasis management	R7–10	PP8–10	3.5
Blood conservation strategies
Preoperative
Preoperative autologous donation	R11		3.6.1
Intraoperative
Surgical haemostasis	R11		3.6
Prevention of hypothermia	R12		3.6.2
Appropriate patient positioning		PP11	3.6.3
Deliberate induced hypotension	R13		3.6.4
Acute normovolemic haemodilution	R14	PP12	3.6.5
Intraoperative cell salvage	R15	PP13	3.6.6
Haemostasis analysis	R16		3.6.8
Medications	R17–19	PP14–16	3.6.9
Postoperative
Postoperative cell salvage	R20		3.6.10
Appropriate transfusion practices
Triggers for component transfusion		PP2–3, 17–18	3.3, 3.7
Fresh frozen plasma	R21		3.8
Platelets		PP19	3.8
Recombinant activated factor VII	R22	PP20	3.9

Patient blood management program

RECOMMENDATION – establishment

R1 Grade C	Health-care services should establish a multidisciplinary, multimodal perioperative patient blood management program (Grade C). This should include preoperative optimisation of red cell mass and coagulation status; minimisation of perioperative blood loss, including meticulous attention to surgical haemostasis; and tolerance of postoperative anaemia.

PRACTICE POINT – implementation

PP1	To implement the above recommendations, a multimodal, multidisciplinary patient blood management program is required. All surgical patients should be evaluated as early as possible to coordinate scheduling of surgery with optimisation of the patient’s haemoglobin and iron stores.

PRACTICE POINTS – procedural guidelines

PP12	ANH requires a local procedural guideline that addresses patient selection, vascular access, volume of blood withdrawn, choice of replacement fluid, blood storage and handling, and timing of reinfusion.
PP13	Intraoperative cell salvage requires a local procedural guideline that should include patient selection, use of equipment and reinfusion. All staff operating cell salvage devices should receive appropriate training, to ensure knowledge of the technique and proficiency in using it.

ANH, acute normovolemic haemodilution

RECOMMENDATIONS – preoperative anaemia assessment

R2 Grade C	In patients undergoing cardiac surgery, preoperative anaemia should be identified, evaluated and managed to minimise RBC transfusion, which may be associated with an increased risk of morbidity, mortality, ICU length of stay and hospital length of stay (Grade C).
R3 Grade C	In patients undergoing noncardiac surgery, preoperative anaemia should be identified, evaluated and managed to minimise RBC transfusion, which may be associated with an increased risk of morbidity, mortality, ICU length of stay and hospital length of stay (Grade C).

PRACTICE POINTS – preoperative anaemia assessment

PP1	To implement the above recommendations, a multimodal, multidisciplinary patient blood management program is required. All surgical patients should be evaluated as early as possible to coordinate scheduling of surgery with optimisation of the patient’s haemoglobin and iron stores.
PP4	All surgical patients should be evaluated as early as possible to manage and optimise haemoglobin and iron stores
PP5	Elective surgery should be scheduled to allow optimisation of patients’ haemoglobin and iron stores.

RECOMMENDATIONS – iron and erythropoiesis-stimulating agents

R4 Grade B	In surgical patients with, or at risk of, iron-deficiency anaemia, preoperative oral iron therapy is recommended (Grade B). Refer to the preoperative haemoglobin assessment and optimisation template [Appendix F] for further information on the optimal dosing strategy.
R5 Grade A	In patients with preoperative anaemia, where an ESA is indicated, it must be combined with iron therapy (Grade A).
R6 Grade B	In patients with postoperative anaemia, early oral iron therapy is not clinically effective; its routine use in this setting is not recommended (Grade B).

PRACTICE POINTS – iron and erythropoiesis-stimulating agents

PP6

Surgical patients with suboptimal iron stores (as defined by a ferritin level <100 μg/L) in whom substantial blood loss (blood loss of a volume great enough to induce anaemia that would require therapy) is anticipated, should be treated with preoperative iron therapy. Refer to the preoperative haemoglobin assessment and optimisation template [Appendix F] for further information on the evaluation and management of preoperative patients.

PP7

In patients with preoperative iron-deficiency anaemia or depleted iron stores, treatment should be with iron alone. In patients with anaemia of chronic disease (also known as anaemia of inflammation), ESAs may be indicated. Refer to the preoperative haemoglobin assessment and optimisation template [Appendix F] for further information on the evaluation and management of preoperative patients.

ESA, erythropoiesis-stimulating agent

RECOMMENDATIONS – haemostasis management

R7 Grade C	In patients undergoing CABG either with or without CPB (OPCAB), clopidogrel therapy should be stopped, where possible, at least 5 days before surgery (Grade C).
R8 Grade C	In patients undergoing noncardiac surgery, it is reasonable to continue low dose aspirin therapy. This may require specific evaluation in neurosurgery and intraocular surgery (Grade C).
R9 Grade C	In patients undergoing elective orthopaedic surgery, NSAID therapy should be ceased preoperatively to reduce blood loss and transfusion (Grade C). The timing of the cessation should reflect the agent’s pharmacology.
R10 Grade C	In patients undergoing minor dental procedures, arthrocentesis, cataract surgery, upper gastrointestinal endoscopy without biopsy or colonoscopy without biopsy, warfarin may be continued (Grade B).

PRACTICE POINTS – haemostasis management

PP8	In patients undergoing cardiac surgery, aspirin may be continued until the time of surgery.
PP9	In patients receiving clopidogrel who are scheduled for elective noncardiac surgery or other invasive procedures, a multidisciplinary approach should be used to decide whether to cease therapy or defer surgery, balancing the risk of bleeding and thrombotic events. Specific evaluation is required for patients who had a recent stroke, or received a drug-eluting stent within the last 12 months or a bare metal stent within the last 6 weeks. If a decision is made to cease therapy preoperatively, this should occur 7–10 days before surgery.
PP10	In patients receiving warfarin who are scheduled for elective noncardiac surgery or other invasive procedures (excluding minor procedures—see Recommendation 10); specific management according to current guidelines is required (e.g. guidelines from the American College of Chest Physicians6 and the Australasian Society of Thrombosis and Haemostasis). 7

CABG, coronary artery bypass surgery; CPB, cardiopulmonary bypass; NSAID, nonsteroidal anti-inflammatory drug; OPCAB, off-pump coronary artery bypass

Blood conservation strategies

Preoperative

RECOMMENDATION – preoperative autologous donation

R11 Grade C	The routine use of PAD is not recommended because, although it reduces the risk of allogeneic RBC transfusion, it increases the risk of receiving any RBC transfusion (allogeneic and autologous) (Grade C).

PAD, preoperative autologous donation; RBC, red blood cell

Intraoperative

RECOMMENDATION – prevention of hypothermia

R12 Grade A	In patients undergoing surgery, measures to prevent hypothermia should be used (Grade A).

PRACTICE POINT – appropriate patient positioning

PP11	Excessive venous pressure at the site of surgery should be avoided by appropriate patient positioning, both during and after the procedure.

RECOMMENDATION – deliberate induced hypotension

R13 Grade C	In patients undergoing radical prostatectomy or major joint replacement, if substantial blood loss (blood loss of a volume great enough to induce anaemia that would require therapy) is anticipated, deliberate induced hypotension (MAP 50–60 mmHg) should be considered, balancing the risk of blood loss and the preservation of vital organ perfusion (Grade C).
R14 Grade C	In adult patients undergoing surgery in which substantial blood loss (blood loss of a volume great enough to induce anaemia that would require therapy) is anticipated, the use of ANH should be considered (Grade C).

MAP, mean arterial blood pressure

PRACTICE POINT – acute normovolemic haemodilution

PP12	ANH requires a local procedural guideline that addresses patient selection, vascular access, volume of blood withdrawn, choice of replacement fluid, blood storage and handling, and timing of reinfusion.

ANH, acute normovolemic haemodilution

RECOMMENDATION – intraoperative cell salvage

R15 Grade C	In adult patients undergoing surgery in which substantial blood loss (blood loss of a volume great enough to induce anaemia that would require therapy) is anticipated, intraoperative cell salvage is recommended (Grade C).

PRACTICE POINT – intraoperative cell salvage

PP13	Intraoperative cell salvage requires a local procedural guideline that should include patient selection, use of equipment and reinfusion. All staff operating cell salvage devices should receive appropriate training, to ensure knowledge of the technique and proficiency in using it.

RECOMMENDATION – haemostasis analysis

R16 Grade C	In adult patients undergoing cardiac surgery, the use of TEG should be considered (Grade C).

TEG, thromboelastography

PRACTICE POINT – medications (aprotinin)

PP14

There is evidence for the beneficial effect of intravenous aprotinin on incidence and volume of transfusion, blood loss, and the risk of reoperation for bleeding. However, the drug has been withdrawn due to concerns that it is less safe than alternative therapies. a a Websites of the Therapeutic Goods Administration (www.tga.gov.au), MedSafe (www.medsafe.govt.nz) and United States Food and Drug Administration (www.fda.gov)

RECOMMENDATIONS – medications (tranexamic acid)

R17 Grade A	In adult patients undergoing cardiac surgery, the use of intravenous tranexamic acid is recommended (Grade A).
R18 Grade B	In adult patients undergoing noncardiac surgery, if substantial blood loss (blood loss of a volume great enough to induce anaemia that would require therapy) is anticipated, the use of intravenous tranexamic acid is recommended (Grade B).

RECOMMENDATION – medications (ε-aminocaproic acid)

R19 Grade C	In adult patients undergoing cardiac surgery, the use of intravenous ε-aminocaproic acid is recommended (Grade C).

PRACTICE POINT – medications (ε-aminocaproic acid)

PP15	There is evidence for the beneficial effect of intravenous ε-aminocaproic acid on reduction of perioperative blood loss and volume of transfusion (Grade C). However, the drug is not marketed in Australia and New Zealand.

PRACTICE POINT – medications (desmopressin)

PP16	In adult patients undergoing surgery in which substantial blood loss (blood loss of a volume great enough to induce anaemia that would require therapy) is anticipated, the routine use of desmopressin is not supported, due to uncertainty about the risk of stroke and mortality.

Postoperative

RECOMMENDATION – postoperative cell salvage

R20 Grade C	In adult patients undergoing cardiac surgery or total knee arthroplasty, in whom significant postoperative blood loss is anticipated, postoperative cell salvage should be considered (Grade C).

Appropriate transfusion practices

PRACTICE POINTS – triggers for blood component transfusion

PP2	RBC transfusion should not be dictated by a haemoglobin ‘trigger’ alone, but should be based on assessment of the patient’s clinical status. In the absence of acute myocardial or cerebrovascular ischaemia, postoperative transfusion may be inappropriate for patients with a haemoglobin level of >80 g/L.
PP3	Patients should not receive a transfusion when the haemoglobin level is ≥100 g/L. In postoperative patients with acute myocardial or cerebrovascular ischaemia and a haemoglobin level of 70–100 g/L, transfusion of a single unit of RBC, followed by reassessment of clinical efficacy, is appropriate.
PP17	In general, patients with a platelet count ≥50 × 109/L or an INR ≤2 can undergo invasive procedures without any serious bleeding; however, lower platelet counts and higher INRs may be tolerated.
PP18	Specialist guidelines or haematology advice should be sought for at-risk patients undergoing intracranial, intraocular and neuraxial procedures, and for patients with severe thrombocytopenia or coagulopathy.

INR, international normalised ratio; RBC, red blood cell

RECOMMENDATION – fresh frozen plasma

R21 Grade B	The prophylactic use of FFP in cardiac surgery is not recommended (Grade B).

FFP, fresh frozen plasma

PRACTICE POINT – recombinant activated factor VII

PP20	The administration of rFVIIa may be considered in the perioperative patient with life- threatening haemorrhage after conventional measures, including surgical haemostasis, use of antifibrinolytics and appropriate blood component therapy have failed.

rFVIIa, recombinant activated factor VII

Preoperative haemoglobin assessment and optimisation template

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