Patient blood
management
SEYMUR MUSTAFAYEV
Preoperative management
Preoperative measures

management of antithrombotic medication

optimization of haemoglobin (Hb) levels in the context of patient comorbiditiesand
body surface dimensions

the assessment and weighing of patient haemostatic risk factors, including the
presence of congenital disorders.
Management of antithrombotic
medication
•It is reasonable to discontinue low-intensity antiplatelet drugs (eg, aspirin) only in purely elective patients without acute coronary syndromes
before operation with the expectation that blood transfusion will be reduced (Class IIA, Level A).
ASA - Aspirin
•In patients at high risk of bleeding or refusing blood transfusions and undergoing non-coronary cardiac surgery, stopping ASA should be
considered at least 5 days preoperatively (Class IIA, Level A).
•It is recommended that ASA be re(started) as soon as there is no concern over bleeding (within 24 h) after isolated CABG (Class I, Level B).
DAPT – Dual Antiplatelet
Therapy
•In patients taking DAPT who need to
have non-emergent cardiac surgery,
postponing surgery for at least 3 days
after discontinuation of ticagrelor, 5
days after clopidogrel and 7 days
after prasugrel should be considered
(Class IIA, Level B).
LMWH(Low molecular
weight heparin) / UFH
(Unfractionated heparin)
•Preoperative bridging of oral
anticoagulation with UFH/LMWH is
only indicated in patients at high risk
of thrombotic events. It is further
recommended that prophylactic
LMWH be discontinued 12 h and
fondaparinux 24 h before surgery; a
longer interval may be necessary for
patients with impaired renal function
(Class I, Level B).
VKA – Vitamin K
Antogonists
DOACs(Direct Oral
Anticoagulants)
• VKAs are regularly stopped 3–5 days
before surgery to obtain an INR <1.5.
In patients having urgent or
emergency surgery, the effect of VKA
can be completely reversed by
administering prothrombin complex
concentrate (PCC) (Class IIA, Level C).
• DOACs be stopped at least 48 h prior
to surgery in patients having elective
cardiac surgery; a longer interval may
be necessary for patients with
impaired renal function (Class IIA,
Level C).
Optimization of haemoglobin (Hb) levels in
the context of patient comorbidities

Anaemia:

up to 40% of patients presenting to cardiac surgery

mild anaemia (women, Hb 100–120 g/l; men, Hb 100–130 g/l)

severe anaemia (both genders, Hb <100 g/l) of any cause prior to cardiac surgery

Oral or intravenous iron alone prior to cardiac surgery may be considered in mildly anaemic patients (women, Hb 100–120 g/l;
men, Hb 100–130 g/l) or in severely anaemic patients (both genders, Hb <100 g/l) to improve erythropoiesis (Class IIb, Level C)

In patients who have (i) preoperative anemia, (ii) refuse blood transfusion, (iii) or are deemed high-risk for postoperative anemia, it
is reasonable to administer preoperative erythropoietin-stimulating agents and iron supplementation several days prior to cardiac
operations to increase red cell mass. (Class IIA Level B-R)

Minimization of phlebotomy by reduced volume and frequency of blood sampling is a reasonable means of blood
conservation. (Class IIA, Level B-NR)

Ultra-short-term treatment - slow infusion of 20 mg/kg ferric carboxymaltose, 40 000 U subcutaneous erythropoietin alpha, 1 mg
subcutaneous vitamin B12, and 5 mg oral folic acid; Result - fewer RBC units transfused, higher haemoglobin concentration, higher
reticulocyte count, and a higher reticulocyte haemoglobin content during the first 7 days, 73 (30%) versus 79 (33%) serious
adverse events until postoperative day 90 [ https://pubmed.ncbi.nlm.nih.gov/31036337/ ]
Postoperative management

Medication

It is recommended that ASA be re(started) as soon as there is no
concern over bleeding (within 24 h) after isolated CABG. (Class I,
Level B)

The addition of a P2Y12 inhibitor to aspirin therapy, if indicated, in
the immediate postoperative care of coronary artery bypass
grafting patients prior to 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))
Transfusion strategy and fluid
management

In patients undergoing cardiac surgery, a restrictive(7-8 q/dl) perioperative allogeneic RBC
transfusion strategy is recommended in preference to a liberal(> 10 q/dl) transfusion strategy
for perioperative blood conservation, as it reduces both transfusion rate and units of
allogeneic RBCs without increased risk of mortality or morbidity. (Class I, Level A)

Allogeneic RBC transfusion is unlikely to improve oxygen transport when the hemoglobin
concentration is greater than 10 g/dL and is not recommended. (Class III: No Benefit; Level BR)

Allogeneic RBC transfusion is unlikely to improve oxygen transport when the hemoglobin
concentration is greater than 10 g/dL and is not recommended. (Class III: No Benefit; Level BR)

It is reasonable to administer human albumin after cardiac surgery to provide intravascular
volume replacement and minimize the need for transfusion. (Class IIA, Level B-R)
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dəyişikliklər
Real World Applications of Patient Blood
Management in Cardiac Surgery | ERAS Webinar
https://www.ctsnet.org/article/real-worldapplications-patient-blood-management-cardiacsurgery-eras-webinar
https://www.researchgate.net/figure/Managementprotocol-for-bleeding-postoperative-patients-inCardiac-Surgical-Intensive_fig1_323933873