Patient Blood Management Guidelines: Module 2

Perioperative

Appendix G - List of recommendations and practice points

This appendix lists the recommendations and practice points in numerical order.

RECOMMENDATIONS
No. RECOMMENDATION Relevant section of document

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. 3.1

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). 3.3

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). 3.3

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.

3.4

R5

Grade A
In patients with preoperative anaemia, where an ESA is indicated, it must be combined with iron therapy (Grade A). 3.4

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). 3.4

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). 3.5

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). 3.5

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. 3.5

R10

Grade B
In patients undergoing minor dental procedures, arthrocentesis, cataract surgery, upper gastrointestinal endoscopy without biopsy or colonoscopy without biopsy, warfarin may be continued (Grade B). 3.5

R11

Grade C
The routine use of preoperative autologous donation 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). 3.6

R12

Grade A
In patients undergoing surgery, measures to prevent hypothermia should be used (Grade A). 3.6

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). 3.6

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). 3.6

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). 3.6

R16

Grade C
In adult patients undergoing cardiac surgery, the use of TEG should be considered (Grade C). 3.6

R17

Grade A
In adult patients undergoing cardiac surgery, the use of intravenous tranexamic acid is recommended (Grade A). 3.6

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). 3.6

R19

Grade C
In adult patients undergoing cardiac surgery, the use of intravenous ε-aminocaproic acid is recommended (Grade C). 3.6

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). 3.6

R21

Grade B
The prophylactic use of FFP in cardiac surgery is not recommended (Grade B). 3.8

R22

Grade C
The prophylactic or routine therapeutic use of rFVIIa is not recommended because concerns remain about its safety profile, particularly in relation to thrombotic adverse events (Grade C). 3.9

ANH, acute normovolemic haemodilution; CABG, coronary artery bypass surgery; CPB, cardiopulmonary bypass; ESA, erythropoiesis-stimulating agent; FFP, fresh frozen plasma; ICU, intensive care unit; NSAID, nonsteroidal anti- inflammatory drug; MAP, mean arterial blood pressure; OPCAB, off-pump coronary artery bypass; RBC, red blood cell; rFVIIa, recombinant activated factor VIIa; TEG, thromboelastography

Summary of practice points
No. PRACTICE POINT Relevant Section of Document

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. 3.3

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. 3.3

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. 3.3

PP4

All surgical patients should be evaluated as early as possible to manage and optimise haemoglobin and iron stores. 3.4

PP5

Elective surgery should be scheduled to allow optimisation of patients’ haemoglobin and iron stores. 3.4

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.

3.4

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.

3.4

PP8

In patients undergoing cardiac surgery, aspirin may be continued until the time of surgery. 3.5

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. 3.5

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. 3.5

PP11

Excessive venous pressure at the site of surgery should be avoided by appropriate patient positioning, both during and after the procedure. 3.6

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. 3.6

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. 3.6

PP14

There is evidence for the beneficial effect of intravenous aprotinin on incidence and volume of transfusion, blood loss, and the risk of re-operation 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)

3.6

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. 3.6

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. 3.6

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. 3.7

PP19

The prophylactic use of platelets post cardiac surgery is not supported. 3.8

PP20

The administration of rFVIIa may be considered in the perioperative patient with life-threatening haemorrhage after conventional measures, including surgical haemostasis, use of anti-fibrinolytics, and appropriate blood component therapy have failed. 3.9

ANH, acute normovolemic haemodilution; ESA, erythropoiesis-stimulating agent; INR, international normalised ratio; RBC, red blood cell; rFVIIa, recombinant activated factor VIIa