Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies

Abstract

Developed by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies: Gregory A. Nuttall, M.D. (Chair), Rochester, Minnesota; Brian C. Brost, M.D., Rochester, Minnesota; Richard T. Connis, Ph.D., Woodinville, Washington; James S. Gessner, M.D., Chestnut Hill, Massachusetts; Chantal R. Harrison M.D., San Antonio, Texas; Ronald D. Miller, M.D., San Francisco, California; David G. Nickinovich, Ph.D., Bellevue, Washington; Nancy A. Nussmeier, M.D., Houston, Texas; Andrew D. Rosenberg, M.D., Roslyn Heights, New York; Richard Spence, M.D., Baltimore, Maryland.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints.Practice guidelines are not intended as standards or absolute requirements. The use of practice guidelines cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion, open forum commentary, and clinical feasibility data.This update includes data published since the “Practice Guidelines for Blood Component Therapy” were adopted by the American Society of Anesthesiologists (ASA) in 1995; it also includes data and recommendations for a wider range of techniques than was previously addressed.Blood transfusion refers to the perioperative administration of blood and blood components (e.g. , autologous blood, allogeneic whole blood, red blood cells, fresh frozen plasma [FFP], platelets, and cryoprecipitate). Adjuvant therapies refer to drugs and techniques to reduce or prevent blood loss and the need for transfusion of allogeneic blood.The purposes of these Guidelines are to improve the perioperative management of blood transfusion and adjuvant therapies and to reduce the risk of adverse outcomes associated with transfusions, bleeding, or anemia. In addition, these Guidelines provide an update on the relative risks that cause morbidity and mortality associated with blood transfusion and adjuvant therapies.These Guidelines focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. This includes but is not limited to (1) patients undergoing cardiopulmonary bypass or cardiac surgery, urgent or emergent procedures, obstetric procedures, organ transplantation, and major noncardiac surgery; (2) patients with preexisting blood disorders or acquired deficiency secondary to massive bleeding; (3) critically ill patients; and (4) patients who elect not to undergo transfusion. Excluded from the focus of these Guidelines are neonates, infants, children weighing less than 35 kg, and nonsurgical patients.These Guidelines apply to both inpatient and outpatient surgical settings and to procedures performed in operating rooms as well as in other locations (e.g. , interventional radiology, critical care units) where blood transfusion or other adjuvant therapy is indicated. They are directly applicable to care administered by anesthesiologists and individuals who deliver care under the medical direction or supervision of an anesthesiologist. They are also intended to serve as a resource for other physicians and patient care personnel who are involved in the perioperative care of these patients.The ASA appointed a Task Force of 10 members to (1) review the published evidence, (2) obtain the opinion of a panel of consultants including anesthesiologists and nonanesthesiologist physicians concerned with perioperative blood transfusion, and (3) obtain opinions from practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States, a surgeon, a pathologist specializing in transfusion medicine, an obstetrician, and two consulting methodologists from the ASA Committee on Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence of effective blood transfusion and adjuvant therapies. Second, original published research studies from peer-reviewed journals relevant to the perioperative management of patients undergoing blood transfusions were reviewed. Third, the panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various perioperative management strategies and (2) review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guideline recommendations were solicited from random samples of active members of the ASA. Fifth, the Task Force held open forums at two major national meetings to solicit input on its draft recommendations. National organizations representing specialties whose members typically care for patients undergoing perioperative transfusion were invited to participate in the open forums. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines.Preparation of these Guidelines followed a rigorous methodologic process. To convey the findings in a concise and easy-to-understand fashion, these Guidelines use several descriptive terms.When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.The lack of scientific evidence in the literature is described by the following terms.Formal survey information is collected from consultants and members of the ASA. The following terms describe survey responses for any specified issue. Responses are solicited on a five-point scale; ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being equivocal. Survey responses are summarized based on median values as follows:Preoperative evaluation of a patient for blood transfusion and adjuvant therapies includes (1) reviewing previous medical records, (2) conducting a patient or family interview, and (3) reviewing laboratory test results. Although comparative studies are insufficient to evaluate the perioperative impact of reviewing medical records or conducting a patient interview, the literature reports certain patient characteristics that may be associated with blood transfusion complications. These characteristics include, but are not limited to, congenital or acquired conditions such as factor VIII deficiency, sickle cell anemia, idiopathic thrombocytopenic purpura, and liver disease. In addition, the literature suggests that some preoperative laboratory tests (e.g. , hemoglobin, hematocrit, coagulation profile) may predict the need for blood transfusion or excessive blood loss. The consultants and ASA members strongly agree that reviewing previous medical records, interviewing the patient, and reviewing hemoglobin/hematocrit test results should be part of a preoperative evaluation.†The consultants strongly agree and the ASA members agree that a coagulation profile should be reviewed.Preoperative evaluation should include reviewing previous medical records, conducting a physical examination of the patient, and an interview of the patient or family to identify risk factors for (1) organ ischemia (e.g. , cardiorespiratory disease), which may influence the ultimate transfusion trigger for red blood cells (e.g. , hemoglobin level), and (2) coagulopathy (e.g. , use of warfarin, clopidogrel, aspirin), which may influence transfusion of non–red blood cell components. In addition, a preoperative evaluation should include checking for the presence of congenital or acquired blood disorders, the use of vitamins or herbal supplements that may affect coagulation (appendix 2), or previous exposure to drugs (e.g. , aprotinin) that may, upon repeat exposure, cause an allergic reaction. Patients should be informed of the potential risks versus benefits of blood transfusion, and their preferences elicited. Available preoperative laboratory results including, but not limited to, hemoglobin, hematocrit, and coagulation profiles should be reviewed if they are appropriate and available. Additional laboratory tests should be ordered based on a patient's condition (e.g. , clinical coagulopathy) or institutional policy.Preoperative patient preparation includes (1) discontinuation or modification of anticoagulation therapy, (2) the prophylactic administration of drugs to promote coagulation and minimize blood loss (e.g. , aprotinin, ϵ-aminocaproic acid, tranexamic acid), and (3) prevention or reduction of allogeneic transfusion requirements.The impact of discontinuing anticoagulation therapy on blood loss has not been sufficiently addressed in the literature. In addition, the literature is insufficient to address the impact of delaying surgery until the effects of anticoagulation drugs have dissipated. The literature supports the use of aprotinin in reducing blood loss and in reducing the number of patients transfused in major surgical procedures (e.g. , selected cardiac and orthopedic procedures). In addition, the literature is supportive of the use of ϵ-aminocaproic acid and tranexamic acid in reducing blood loss; however, the impact of these drugs on reducing the number of patients transfused is equivocal. The literature is insufficient to evaluate the use of these drugs in a nonprophylactic manner. Some literature has reported adverse outcomes associated with the use of antifibrinolytic drugs such as graft thrombosis or closure and rare massive thrombosis. Severe anaphylactic reactions may occur with aprotinin reexposure.The efficacy of erythropoietin in reducing the volume of allogeneic blood transfused per patient as well as reducing the number of patients requiring such transfusions is supported by the literature in select populations (e.g. , renal insufficiency, anemia of chronic disease, refusal of transfusion). The literature is insufficient to address the effects of vitamin K.The efficacy of preadmission blood collection to reduce the volume of allogeneic blood transfused per patient and to reduce the number of patients requiring such transfusions is supported by the literature. However, the literature indicates that certain adverse outcomes (e.g. , transfusion reaction due to clerical errors, bacterial contamination) may still occur with the use of autologous blood.The consultants agree and the ASA members strongly agree that anticoagulation drugs (e.g. , warfarin, clopidogrel, aspirin) should be discontinued before elective or nonemergent surgery, and both agree that such surgery should be delayed until the anticoagulation effects wear off. They agree that, when significant blood loss is expected, antifibrinolytics should be administered. In addition, the consultants and ASA members agree that erythropoietin may be used to reduce the use of allogeneic blood. They agree that vitamin K should be administered preoperatively for reversal of warfarin to potentially avoid transfusion of FFP. The ASA members agree and the consultants are equivocal that preadmission donation of blood should be offered to patients when transfusion of autologous blood is required or preferred. They disagree that autologous blood should be administered to the patient who donated it if his or her hemoglobin is greater than 10 g/dl.If possible, the preoperative evaluation should be done well enough in advance to correct or plan for the management of risk factors associated with transfusions. For elective surgery, patient preparation should include discontinuing anticoagulation therapy for a sufficient time in advance of surgery, if clinically possible. If sufficient time has not elapsed, surgery should be delayed until the effects of these drugs dissipate. The Task Force notes that the effect of clopidogrel may last for approximately a week, and the effects of warfarin may last for several days depending on patient response and the administration of reversal agents (e.g. , vitamin K, prothrombin complex concentrate, recombinant activated factor VII, or FFP). The risk of thrombosis versus the risk of increased bleeding should be considered when altering anticoagulation status. Assure that blood and blood components are available for patients when significant blood loss or transfusion is expected.Antifibrinolytic therapy should not be routinely administered. However, such therapy may be used for reducing the volume of allogeneic blood transfused for patients at high risk of excessive bleeding (e.g. , repeat cardiac surgery). The risks and benefits of instituting antifibrinolytic therapy should be assessed on a case-by-case basis.Erythropoietin should be administered when possible to reduce the need for allogeneic blood in certain selected patient populations (e.g. , renal insufficiency, anemia of chronic disease, refusal of transfusion). The Task Force recognizes that erythropoietin administration is perceived as being expensive and requires time (in weeks) to induce a significant increase in hemoglobin concentration. Vitamin K or another warfarin antagonist should be used for reversal of warfarin to potentially avoid transfusion of FFP.Where autologous blood is required or preferred, the patient may be offered the opportunity to donate blood before admission. However, the Task Force cautions that preoperative anemia may be induced in addition to an increase in autologous or allogeneic transfusions, as well as and include red blood cell transfusion, management of and and of adverse effects of and management of potential or blood loss includes (1) the of blood (2) hemoglobin or hematocrit, (3) for the presence of and of (e.g. , blood blood and (4) transfusion of allogeneic red blood cells or autologous blood , and red blood cell literature is insufficient to evaluate the efficacy of specific or techniques for the presence of or of or as for the transfusion of red blood The literature supports the efficacy of as well as red blood cell in reducing the number of allogeneic transfused per patient in certain appropriate surgical procedures (e.g. , cardiac surgery, liver surgery, orthopedic However, the literature is equivocal the of to reduce the number of patients Although the practice is in the United States, the literature suggests that red blood cell reduce the number of patients a volume of that has been published since the last practice the information to when a blood transfusion should be is not available in the literature. Although have transfusion on patient the literature is insufficient to a transfusion trigger in surgical patients with blood consultants and ASA members strongly agree that a of the surgical and with the surgical should be done to assess the presence of excessive bleeding , The consultants and ASA members strongly agree that for the presence of and of should be They strongly agree that red blood cells should be administered when the hemoglobin is less than and strongly agree that red blood cells are when the is than 10 In addition, the consultants and ASA members agree that, when autologous blood is required or preferred, and or red blood cell are The consultants are equivocal and the ASA members agree that red blood cell is a in or allogeneic transfusion. they agree that and other laboratory may be a of significant blood of the surgical should be to assess the presence of excessive bleeding , for of blood loss (e.g. , and should be (e.g. , blood should be used to assess the of and of should be used when appropriate (e.g. , blood hemoglobin or when blood loss or any of organ ischemia blood cells should be administered when the hemoglobin is (e.g. , less than in a when the anemia is blood cells are when the hemoglobin is than 10 These may be in the presence of blood loss. The of hemoglobin , or red blood cell transfusion should be based on any of organ potential or bleeding and the patient's volume and the patient's risk factors for of These risk factors include a cardiopulmonary and high volume and blood with or until the criteria for red blood cell transfusion are of red blood cells should be transfused to organ or blood and other means to blood loss (e.g. , may be may also be and management of potential or coagulopathy includes (1) of the surgical and laboratory for (2) transfusion of platelets, (3) transfusion of (4) transfusion of administration of drugs to excessive bleeding (e.g. , and recombinant activated factor of the surgical is practice and of the presence of bleeding and the of blood includes or In a bleeding patient, coagulation tests is also and the literature suggests that coagulation test results with perioperative blood depending on the of used for volume The literature supports the use of and to excessive Although are insufficient numbers of published clinical the efficacy of recombinant activated factor in excessive bleeding , reports its efficacy as a when therapy has a volume of that has been published since the last practice the information to when transfusion of a blood should occur is not available in the literature. Although have transfusion on patient and transfusion in cardiac surgery, the literature is insufficient to specific transfusion for coagulopathy in surgical patients with blood consultants and ASA members strongly agree that, in addition to a of the surgical with the surgical should include an of the presence of The consultants and ASA members agree that, in a bleeding patient, should be administered when the is below They also agree that, in a bleeding patient, should be administered when or activated time is and that should be when are less than The consultants agree and the ASA members are equivocal that recombinant activated factor is an appropriate when have been The ASA members agree and the consultants are equivocal that should be administered when excessive bleeding the consultants and ASA members agree that (e.g. , or should be administered for the of excessive of the surgical should be by the and to excessive bleeding , coagulopathy) is for excessive blood loss should also include checking surgical and surgical for coagulopathy should include of prothrombin time or and tests may include of and possible, a should be before transfusion of in a bleeding patient, and a test of should be done in patients with or (e.g. , In surgical or obstetric patients with transfusion is if the is to be greater than and is when the is below in the presence of excessive or procedures associated with limited blood loss may be performed in patients with less than transfusion may be an if is or (e.g. , the presence of cardiopulmonary and of patients with and therapy, including prophylactic therapy, should be based on the potential for or bleeding, and the risk of bleeding a (e.g. , or the cannot be done in a in the presence of excessive bleeding , may be when is is due to increased (e.g. , idiopathic thrombocytopenic purpura, thrombocytopenic prophylactic transfusion is and possible, coagulation tests , or and should be before the administration of in a bleeding Transfusion of is not if and are transfusion is for (1) of excessive bleeding , coagulopathy) in the presence of a greater than or greater than or an greater than (2) of excessive bleeding secondary to coagulation factor deficiency in patients transfused with than blood volume and when or and cannot be in a (3) urgent reversal of warfarin (4) of coagulation factor for which specific are or in a patient requiring is not for of plasma volume or frozen plasma should be in to a of of plasma factor with administration of for urgent reversal of warfarin for which to 1 platelets, or 1 fresh whole a of coagulation factors to that in 1 possible, a should be before the administration of in a bleeding Transfusion of is if is greater than Transfusion of is (1) when the is less than in the presence of excessive bleeding, (2) to correct excessive bleeding in transfused patients when cannot be in a fashion, and (3) for patients with congenital possible, decisions patients with congenital should be in with the patient's The of patients with and therapy should be based on the potential for or bleeding and the risk of bleeding a (e.g. , or patients with should be with specific if available. If are not is indicated. of of it should be that of the of as or such as or should be considered when excessive bleeding for excessive bleeding , coagulopathy) have been recombinant activated factor should be effects of transfusions include, but are not limited to, bacterial of and transfusion of blood platelets, is the cause of from blood transfusions. The increased risk of bacterial is to a of blood are their If a patient a within platelets, from may be a is from of certain a transfusion. and transfusion and are in within and in the may is specific therapy other than transfusion and instituting critical care supportive patients in is of the of transfusion major adverse effect of transfusion therapy is the of For the and deficiency were allogeneic blood These risks are of the major for the in has been the use of acid The and be by this To disease, and cannot be may the of both and transfusion of reactions include and bleeding, but these may be to other in the The of a transfusion reaction in patients include or However, these may not be consultants and ASA members strongly agree that checking for and of a transfusion reaction should be done in the The consultants agree and the ASA members strongly agree that and should be the consultants and ASA members agree that should be assessed to for transfusion for and of bacterial and transfusion including increased and instituting therapy for transfusion the blood transfusion and appropriate scientific of these Guidelines was based on evidence or potential clinical and The below were to assess their impact on a of outcomes to perioperative blood transfusion and adjuvant they are not included in the focus of these areas of research include (1) the use of to improve making and reduce transfusion and (2) or other blood to reduce transfusion requirements. evidence was from research and evidence was from open and other (e.g. , For purposes of literature potentially relevant clinical studies were and of the literature. The and a from than were a of that addressed to the evidence review of the studies not provide evidence and were of reported in a was as an evidence a or equivocal. The results were summarized to obtain a for evidence before conducting a to evidence enough studies with and information sufficient for These were (1) erythropoietin versus (2) preadmission blood donation versus autologous blood (3) antifibrinolytics ϵ-aminocaproic acid tranexamic acid (4) transfusion of autologous blood red blood cell and versus or tests were for and were for tests were as (1) the values based on of the reported values from the and (2) the of the studies by of the by the of the based on the for results was used with was at for of the studies were to the results. were when significant was To for potential a was for studies was and tests for research results were results are reported in To be as significant agree with test results both of data are In the of findings from both the and tests agree with other to be as Task Force members and two methodologists was by a for were as (1) of (2) of (3) evidence and (4) literature for values were (1) (2) of (3) and (4) literature These values to high of was from including (1) survey opinion from consultants who were selected based on their or in perioperative blood transfusion and adjuvant (2) survey opinions from a selected of active members of the (3) from of two held open forums at two national commentary, and Task Force opinion and The survey of was of for and of for of the surveys are reported in and in the of the consultants were asked to if of the evidence their clinical practices if the Guidelines were The of was of The of consultants associated with were as preoperative discontinuation of anticoagulation and of drugs to perioperative drugs to promote coagulation and minimize blood preoperative autologous blood for and for transfusion transfusion of allogeneic red blood transfusion of autologous transfusion of transfusion of transfusion of of excessive and and laboratory for transfusion of the that the Guidelines have effect on the of time on a that be an increase in the of time they on a with the of these Guidelines. The of increased time by these from 5 to 10