Bleeding perioperative bleeding anemia management

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

2013 ESA Guidelines for the Management of Severe Perioperative Bleeding (DO NOT EDIT)

Preoperative Correction of Anemia

Class 1

"1. We recommend that patients at risk of bleeding are assessed for anemia 4–8 weeks before surgery. (Level of Evidence: C) "

"2. If anemia is present, we recommend identifying the cause (iron deficiency, renal deficiency or inflammation). (Level of Evidence: C) "

"3. We recommend treating iron deficiency with iron supplementation (oral or intravenous). (Level of Evidence: B) "

Class 2

"1. If iron deficiency has been ruled out, we suggest treating anemia patients with erythropoietin-stimulating agents. (Level of Evidence: A) "

"2. If autologous blood donation is performed, we suggest treatment with erythropoietin-stimulating agents in order to avoid preoperative anemia and increased overall transfusion rates. (Level of Evidence: B) "

Optimizing Macrocirculation

Class 1

"1. We recommend aggressive and timely stabilization of cardiac preload throughout the surgical procedure, as this appears beneficial to the patient. (Level of Evidence: B) "

"2. We recommend the avoidance of hypervolemia with crystalloids or colloids to a level exceeding the interstitial space in steady state, and beyond an optimal cardiac preload. (Level of Evidence: B) "

"3. We recommend against the use of central venous pressure and pulmonary artery occlusion pressure as the only variables to guide fluid therapy and optimize preload during severe bleeding; dynamic assessment of fluid responsiveness and non-invasive measurement of cardiac output should be considered instead. (Level of Evidence: B) "

Class 2

"1. We suggest the replacement of extracellular fluid losses with isotonic crystalloids in a timely and protocol-based manner. (Level of Evidence: C) "

"2. We suggest the use of balanced solutions for crystalloids and as a basic solute for iso-oncotic preparations. (Level of Evidence: C) "

Transfusion Triggers

Class 1

"1. We recommend a target hemoglobin concentration of 7–9 g/dl during active bleeding. (Level of Evidence: C) "

Oxygen Fraction

Class 1

"1. We recommend that inspiratory oxygen fraction should be high enough to prevent arterial hypoxemia in bleeding patients, while avoiding extensive hyperoxia (PaO2 >26.7 kPa [200 mm Hg]). (Level of Evidence: C) "

Monitoring Tissue Perfusion

Class 1

"1. We recommend repeated measurements of a combination of hematocrit/hemoglobin, serum lactate, and base deficit in order to monitor tissue perfusion, tissue oxygenation and the dynamics of blood loss during acute bleeding. These parameters can be extended by measurement of cardiac output, dynamic parameters of volume status (e.g. stroke volume variation, pulse pressure variation) and central venous oxygen saturation. (Level of Evidence: C) "

Transfusion of Labile Blood Products

Class 1

"1. We recommend that all countries implement national hemovigilance quality systems. (Level of Evidence: C) "

"2. We recommend a restrictive transfusion strategy which is beneficial in reducing exposure to allogeneic blood products. (Level of Evidence: A) "

"3. We recommend photochemical pathogen inactivation with amotosalen and UVA light for platelets. (Level of Evidence: C) "

"4. We recommend that labile blood components used for transfusion are leukodepleted. (Level of Evidence: B) "

"5. We recommend that blood services implement standard operating procedures for patient identification and that staff be trained in early recognition of, and prompt response to, transfusion reactions. (Level of Evidence: C) "

"6. We recommend that multiparous women be excluded from donating blood for the preparation of FFP and for the suspension of platelets in order to reduce the incidence of transfusion-related acute lung injury. (Level of Evidence: C) "

"7. We recommend that all RBC, platelet and granulocyte donations from first-or second-degree relatives be irradiated even if the recipient is immunocompetent, and all RBC, platelet and that granulocyte products be irradiated before transfusing to at-risk patients. (Level of Evidence: C) "

"8. We recommend the transfusion of leukocyte-reduced RBC components for cardiac surgery patients. (Level of Evidence: A) "

Cell Salvage

Class 1

"1. We recommend the routine use of red cell salvage which is helpful for blood conservation in cardiac operations using CPB. (Level of Evidence: A) "

"2. We recommend against the routine use of intraoperative platelet-rich plasmapheresis for blood conservation during cardiac operations using CPB. (Level of Evidence: A) "

"3. We recommend the use of red cell salvage in major orthopedic surgery because it is useful in reducing exposure to allogenic red blood cell transfusion. (Level of Evidence: A) "

"4. We recommend that intraoperative cell salvage is not contraindicated in bowel surgery, provided that initial evacuation of soiled abdominal contents and additional cell washing are performed, and that broad-spectrum antibiotics are used. (Level of Evidence: C) "

Storage Lesions

Class 1

"1. We recommend that RBCs up to 42 days old should be transfused according to the first-in first-out method in, the blood services to minimise wastage of erythrocytes. (Level of Evidence: C) "

Sources

• 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding