In cardiac surgical patients it is a complex challenge to find the ideal balance between anticoagulation and hemostasis. Preoperative anemia and perioperative higher transfusion rates are related to increased morbidity and mortality. Patient blood management (PBM) is an evidence based patient specific individualized protocol used in the perioperative setting in order to reduce perioperative bleeding and transfusion rates and to improve patient outcomes. The three pillars of PBM in cardiac surgery consist of optimization of preoperative erythropoiesis and hemostasis, minimizing blood loss, and improving patient specific physiological reserves. This narrative review focuses on the challenges with special emphasis on PBM in the preoperative phase and intraoperative transfusion management and hemostasis in cardiac surgery patients. It is a “must” that PBM is a collaborative effort between anesthesiologists, surgeons, perfusionists, intensivists and transfusion laboratory teams. This review represents an up to date overview over “PBM in cardiac surgery patients”.
Cardiac surgery is associated with perioperative blood loss and a high risk of allogeneic blood transfusion. Patient blood management (PBM) in cardiac surgery contributes to the maintenance of perioperative haemostasis and the minimization of bleeding, which reduce blood transfusion requirements. PBM in cardiac surgery comprises an interaction between the cardiothoracic surgeon, the anaesthesiologist and the clinical perfusionist. The impact of cardiopulmonary bypass distinguishes this discipline from other surgical specialities.In a joint effort, the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA) provide evidence-based recommendations for PBM in adult-acquired cardiac surgery. Literature searches were based on the Population, Intervention, Comparison, Outcome and Time (PICOT) method using standardized Medical Subject Headings (MeSH) terms from the National Library of Medicine, PubMed and Embase database lists of search terms. The PICOT study end points included bleeding, transfusions and reoperations for bleeding. The guideline was reviewed by an external review method and endorsed by the EACTS and the EACTA in collaboration with the editors of the European Journal of Cardio-Thoracic Surgery and the Journal of Cardiothoracic and Vascular Anesthesia.This guideline provides practical recommendations for all clinicians working in the field of PBM in cardiac surgery, with emphasis on preoperative patient optimization and risk reduction, intraoperative maintenance of haemostasis and postoperative treatment for bleeding complications.
https://www.jcvaonline.com/article/S1053-0770(17)30552-9/fulltext
Pediatric cardiac surgery is associated with a substantial risk of bleeding, frequently requiring the administration of allogeneic blood products. Efforts to optimize preoperative hemoglobin, limit blood sampling, improve hemostasis, reduce bleeding, correct coagulopathy, and incorporate blood sparing techniques (including restrictive transfusion practices) are key elements of patient blood management (PBM) programs, and should be applied to the pediatric cardiac surgical population as across other disciplines. Many guidelines for implementation of PBM in adults undergoing cardiac surgery are available, but evidence regarding the implementation of PBM in children is limited to systematic reviews and specific guidelines for the pediatric cardiac population are missing. The objective of the task force from the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA, www.nataonline.com) is to provide evidence-based recommendations regarding anemia management and blood transfusion practices in the perioperative care of neonates and children undergoing cardiac surgery, and to highlight potential areas where additional research is urgently required.
https://pubmed.ncbi.nlm.nih.gov/31076306/
Since the Transfusion Requirements in CriticalCare (TRICC) trial published in 1999 demon-strated equivalent or improved outcomes whenusing a restrictive versus a liberal transfusionthreshold in critically ill patients,1providers and institu-tions have sought to decrease utilization of allogeneicred blood cells by promoting restrictive transfusionpractices. Since that landmark trial, multiple other studiesin different p opulations, including patients undergoingcardiac surgery,2,3elderly patients undergoing hip replace-ment,4medical patients with gastrointestinal bleeds,5andpatients with traumatic brain injury,6have re-demonstrated the equivalence or superiority of restrictiveover liberal transfusion thresholds with regard to patientoutcomes. However, despite a growing body of evidencesupporting this practice, individuals and institutions havefound it surprisingly difficult to adhere to these guidelines.Nonetheless, there remain multiple motivations for reduc-ing superfluous transfusion; blood products are a finiteresource subject to shortage, there are numerous risksassociated with transfusion, and transfusion is an expen-sive endeavor from both direct (acquisition) and indirect(materials, labor , administration) costs.
https://onlinelibrary.wiley.com/doi/epdf/10.1111/trf.14083
Almost 150 years after the first autologous blood transfusion was reported, intraoperative blood salvage has become an important method of blood conservation. The primary goal of autologous transfusion is to reduce or avoid allogeneic red blood cell transfusion and the associated risks and costs. Autologous salvaged blood does not result in immunological challenge and its consequences, provides a higher quality red blood cell that has not been subjected to the adverse effects of blood storage, and can be more cost-effective than allogeneic blood when used for carefully selected surgical patients. Cardiac, orthopaedic and vascular surgery procedures with large anticipated blood loss can clearly benefit from the use of cell salvage. There are safety concerns in cases with gross bacterial contamination. There are theoretical safety concerns in obstetrical and cancer surgery; however, careful cell washing as well as leucoreduction filters makes for a safer autologous transfusion in these circumstances. Further studies are needed to determine whether oncologic outcomes are impacted by transfusing salvaged blood during cancer surgery. In this new era of patient blood management, where multimodal methods of reducing dependence on allogeneic blood are becoming commonplace, autologous blood salvage remains a valuable tool for perioperative blood conservation. Future studies will be needed to best determine how and when cell salvage should be utilized along with newer blood conservation measures.
https://pubmed.ncbi.nlm.nih.gov/28580663/
A cirurgia eletiva é aquela que não se reveste das características de urgência ou emergência, ou seja, quando o doente não está sob o risco de vida, podendo ser efetuada em data programada, desde que essa data não comprometa a eficácia da intervenção.
O conceito de “gestão do sangue do doente” (Patient Blood Management: PBM) corresponde a uma estratégia global de boas práticas de transfusão, que permite a melhor utilização do sangue e dos seus componentes. O PBM é um exemplo de medicina baseada na evidência centrada no doente que, otimizando e conservando o próprio sangue do doente, visa melhorar os seus resultados em saúde.
Existem Recomendações Europeias, publicadas em março de 2017, dirigidas aos Hospitais e Autoridades Nacionais de Saúde, que recomendam o PBM como estratégia a implementar.
https://normas.dgs.min-saude.pt/wp-content/uploads/2019/10/gestao-do-sangue-do-doente-patient-blood-management-pbm-em-cirurgia-eletiva.pdf
Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13773
Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14358
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, and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use 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 a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.
https://pubs.asahq.org/anesthesiology/article/122/2/241/12287/Practice-Guidelines-for-Perioperative-Blood
The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia and to stabilise macrocirculation and microcirculation to optimise the patient's tolerance to bleeding. Finally, targeted interventions should be used to reduce intraoperative and postoperative bleeding, and so prevent subsequent morbidity and mortality. The objective of these updated guidelines is to provide healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline was posted on the European Society of Anaesthesiology website for four weeks for review. All comments were collated and the guidelines were amended as appropriate. This publication reflects the output of this work. pré-operatórios
https://journals.lww.com/ejanaesthesiology/Fulltext/2017/06000/Management_of_severe_perioperative_bleeding__.3.aspx
Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.
https://onlinelibrary.wiley.com/doi/10.1111/ejh.13348
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676023/pdf/kja-19169.pdf
AA presente Norma aborda o diagnóstico e tratamento das deficiências de ferro no adulto. Considera-se como adulto os maiores ou iguais a 18 anos.
A anemia por deficiência de ferro, constitui a deficiência mais prevalente no mundo segundo a OMS que define anemia se: 1) Hemoglobina <13g/dl no homem e <12g/dl na mulher.
A deficiência de ferro vai desde o estado de depleção de ferro sem anemia à anemia ferropénica.
https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0302013-de-31122013-pdf.aspx
Objective To develop a set of evidence-based recommendations for patient blood management (PBM) and for research.
Conclusions and Relevance The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
https://jamanetwork.com/journals/jama/article-abstract/2727453
A transfusão sanguínea é essencial para o desenvolvimento da medicina moderna, e nas últimas décadas vários tratamentos médicos e cirúrgicos não podiam ter sido implementados sem recurso a esta terapêutica de suporte. Como qualquer outra terapêutica, está associada a riscos não negligenciáveis, é de disponibilidade limitada porque é uma terapêutica dependente do altruísmo dos dadores, e tem custos que devem ser conhecidos pelos médicos prescritores. É geralmente um procedimento seguro e eficaz, permite a correcção das deficiências hematológicas, prevenindo as suas consequências e quando corretamente indicada, o seu efeito benéfico ultrapassa largamente os riscos.
A avaliação da eficácia da transfusão e a monitorização dos efeitos adversos imediatos ou tardios, devem ser contemplados numa boa prática para a garantia de segurança adicional. Todos os aspectos da terapêutica transfusional têm sido alvo de investigação clínica e epidemiológica alargada e há inúmeras publicações em que as indicações clínicas dos diferentes componentes sanguíneos são avaliadas e estabelecidas sobre a forma de guias de
orientação ou normas de boas práticas. No entanto, a maioria dos estudos publicados e planeados com a finalidade de estabelecer limites para a transfusão de Concentrado de Eritrócitos, são estudos não randomizados pelo que os resultados devem ser interpretados de forma cautelosa. Assim, a decisão clínica sobre o recurso à terapêutica transfusional apesar de baseada em evidências ou estudos observacionais, será sempre um acto individualizado em
que a avaliação clínica é determinante e as orientações devem ser entendidas como uma ajuda para decisão e revistas sempre que haja novas evidências, ou novas descobertas neste campo do conhecimento.
https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0382012-de-30122012-png.aspx