Preoperative evaluation and perioperative strategies to minimize blood transfusion
- Thomas J Graetz, MD
Thomas J Graetz, MD
- Assistant Professor of Anesthesiology and Surgery (Cardiothoracic)
- Washington University in St. Louis School of Medicine
- Gregory Nuttall, MD
Gregory Nuttall, MD
- Professor of Anesthesiology
- Mayo Clinic College of Medicine
- Section Editors
- Michael Avidan, MD
Michael Avidan, MD
- Section Editor — Surgical Critical Care
- Professor of Anesthesiology and Surgery
- Washington University School of Medicine
- Steven Kleinman, MD
Steven Kleinman, MD
- Section Editor — Transfusion Medicine
- Clinical Professor of Pathology
- University of British Columbia, Vancouver
This topic will review perioperative strategies to avoid or minimize transfusion of blood products during surgery and other interventional procedures. General principles guiding intraoperative transfusion decisions as well as indications and risks associated with transfusion of specific blood components in that setting are discussed separately. (See "Intraoperative transfusion of blood products in adults".)
The preanesthetic consultation provides an opportunity to assess and minimize risks for bleeding and transfusion. Certain medications, diseases, and surgical procedures are associated with increased risks for transfusion . It may be appropriate to postpone an elective procedure if consultation with the surgeon and/or hematologist determines that the benefit of optimizing hemostasis or hemoglobin level outweighs the risks of postponing the surgery. (See "Preoperative assessment of hemostasis", section on 'Medical and hematologic consultations'.)
Selective laboratory testing — A baseline hemoglobin measurement is suggested for patients ≥65 years old who are undergoing major elective surgery and for any patient undergoing a procedure expected to result in significant blood loss. In contrast, hemoglobin measurement is unnecessary for healthy adults undergoing minor surgery unless the history suggests anemia. (See "Preoperative medical evaluation of the adult healthy patient", section on 'Complete blood count'.)
No additional laboratory testing is required unless a bleeding disorder is suspected. This practice is consistent with the American Society of Anesthesiologists (ASA) , the British Committee for Standards in Hematology (BCSH) , and the European Society of Anaesthesia (ESA) .
If the patient or family history or the physical examination suggests the presence of a bleeding disorder, appropriate screening tests should be performed, including prothrombin time (PT) with international normalized ratio (INR), activated partial thromboplastin time (aPTT), and platelet count. A hematology consultation and additional testing are typically necessary to establish a diagnosis and treatment plan. In some cases such as those with significant prior bleeding (eg, drop in hemoglobin level, need for transfusions) it may be appropriate to pursue consultation even when screening tests are normal. (See "Preoperative assessment of hemostasis", section on 'Laboratory testing' and "Preoperative assessment of hemostasis", section on 'Medical and hematologic consultations'.)
- American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology 2015; 122:241.
- Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2012; 116:522.
- Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures. British Committee for Standards in Haematology. Br J Haematol 2008; 140:496.
- De Hert S, Imberger G, Carlisle J, et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28:684.
- Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007; 47:1468.
- Muñoz M, Acheson AG, Auerbach M, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia 2017; 72:233.
- Kotzé A, Harris A, Baker C, et al. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Br J Haematol 2015; 171:322.
- Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944.
- Froessler B, Palm P, Weber I, et al. The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial. Ann Surg 2016; 264:41.
- Zeidler K, Arn K, Senn O, et al. Optimal preprocedural platelet transfusion threshold for central venous catheter insertions in patients with thrombocytopenia. Transfusion 2011; 51:2269.
- Leffell MS, Kim D, Vega RM, et al. Red blood cell transfusions and the risk of allosensitization in patients awaiting primary kidney transplantation. Transplantation 2014; 97:525.
- Jalal DI, Chonchol M, Targher G. Disorders of hemostasis associated with chronic kidney disease. Semin Thromb Hemost 2010; 36:34.
- Shah NL, Intagliata NM, Northup PG, et al. Procoagulant therapeutics in liver disease: a critique and clinical rationale. Nat Rev Gastroenterol Hepatol 2014; 11:675.
- Bouchard D, Marcheix B, Al-Shamary S, et al. Preoperative autologous blood donation reduces the need for allogeneic blood products: a prospective randomized study. Can J Surg 2008; 51:422.
- Billote DB, Glisson SN, Green D, Wixson RL. A prospective, randomized study of preoperative autologous donation for hip replacement surgery. J Bone Joint Surg Am 2002; 84-A:1299.
- Kanter MH, van Maanen D, Anders KH, et al. Preoperative autologous blood donations before elective hysterectomy. JAMA 1996; 276:798.
- Wolberg AS, Meng ZH, Monroe DM 3rd, Hoffman M. A systematic evaluation of the effect of temperature on coagulation enzyme activity and platelet function. J Trauma 2004; 56:1221.
- Meng ZH, Wolberg AS, Monroe DM 3rd, Hoffman M. The effect of temperature and pH on the activity of factor VIIa: implications for the efficacy of high-dose factor VIIa in hypothermic and acidotic patients. J Trauma 2003; 55:886.
- Lier H, Krep H, Schroeder S, Stuber F. Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma. J Trauma 2008; 65:951.
- Kermode JC, Zheng Q, Milner EP. Marked temperature dependence of the platelet calcium signal induced by human von Willebrand factor. Blood 1999; 94:199.
- John M, Ford J, Harper M. Peri-operative warming devices: performance and clinical application. Anaesthesia 2014; 69:623.
- Perl T, Bräuer A, Quintel M. Prevention of perioperative hypothermia with forced-air warming systems and upper-body blankets. Surg Technol Int 2006; 15:19.
- Madrid E, Urrútia G, Roqué i Figuls M, et al. Active body surface warming systems for preventing complications caused by inadvertent perioperative hypothermia in adults. Cochrane Database Syst Rev 2016; 4:CD009016.
- Sessler DI. Perioperative thermoregulation and heat balance. Lancet 2016; 387:2655.
- Carless PA, Henry DA, Moxey AJ, et al. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2010; :CD001888.
- DeAndrade D, Waters JH, Triulzi DJ, et al. Very low rate of patient-related adverse events associated with the use of intraoperative cell salvage. Transfusion 2016; 56:2768.
- Myles PS, Smith JA, Forbes A, et al. Tranexamic Acid in Patients Undergoing Coronary-Artery Surgery. N Engl J Med 2017; 376:136.
- Lecker I, Wang DS, Whissell PD, et al. Tranexamic acid-associated seizures: Causes and treatment. Ann Neurol 2016; 79:18.
- Raghunathan K, Connelly NR, Kanter GJ. ε-Aminocaproic acid and clinical value in cardiac anesthesia. J Cardiothorac Vasc Anesth 2011; 25:16.
- Koster A, Faraoni D, Levy JH. Antifibrinolytic Therapy for Cardiac Surgery: An Update. Anesthesiology 2015; 123:214.
- Molenaar IQ, Warnaar N, Groen H, et al. Efficacy and safety of antifibrinolytic drugs in liver transplantation: a systematic review and meta-analysis. Am J Transplant 2007; 7:185.
- Poeran J, Rasul R, Suzuki S, et al. Tranexamic acid use and postoperative outcomes in patients undergoing total hip or knee arthroplasty in the United States: retrospective analysis of effectiveness and safety. BMJ 2014; 349:g4829.
- Chen RH, Frazier OH, Cooley DA. Antifibrinolytic therapy in cardiac surgery. Tex Heart Inst J 1995; 22:211.
- Lambert CJ, Marengo-Rowe AJ, Leveson JE, et al. The treatment of postperfusion bleeding using epsilon-aminocaproic acid, cryoprecipitate, fresh-frozen plasma, and protamine sulfate. Ann Thorac Surg 1979; 28:440.
- Parolari A, Mussoni L, Frigerio M, et al. Increased prothrombotic state lasting as long as one month after on-pump and off-pump coronary surgery. J Thorac Cardiovasc Surg 2005; 130:303.
- Barrachina B, Lopez-Picado A, Remon M, et al. Tranexamic Acid Compared with Placebo for Reducing Total Blood Loss in Hip Replacement Surgery: A Randomized Clinical Trial. Anesth Analg 2016; 122:986.
- McCormack PL. Tranexamic acid: a review of its use in the treatment of hyperfibrinolysis. Drugs 2012; 72:585.
- Falana O, Patel G. Efficacy and safety of tranexamic acid versus ϵ-aminocaproic acid in cardiovascular surgery. Ann Pharmacother 2014; 48:1563.
- Zhou ZF, Zhang FJ, Huo YF, et al. Intraoperative tranexamic acid is associated with postoperative stroke in patients undergoing cardiac surgery. PLoS One 2017; 12:e0177011.
- Leebeek FWG, Eikenboom JCJ. Von Willebrand's Disease. N Engl J Med 2017; 376:701.
- Tiede A, Rand JH, Budde U, et al. How I treat the acquired von Willebrand syndrome. Blood 2011; 117:6777.
- Hanke AA, Dellweg C, Kienbaum P, et al. Effects of desmopressin on platelet function under conditions of hypothermia and acidosis: an in vitro study using multiple electrode aggregometry*. Anaesthesia 2010; 65:688.
- Ying CL, Tsang SF, Ng KF. The potential use of desmopressin to correct hypothermia-induced impairment of primary haemostasis--an in vitro study using PFA-100. Resuscitation 2008; 76:129.
- Sheridan DP, Card RT, Pinilla JC, et al. Use of desmopressin acetate to reduce blood transfusion requirements during cardiac surgery in patients with acetylsalicylic-acid-induced platelet dysfunction. Can J Surg 1994; 37:33.
- Despotis GJ, Levine V, Saleem R, et al. Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomised controlled trial. Lancet 1999; 354:106.
- Franchini M, Lippi G. Prothrombin complex concentrates: an update. Blood Transfus 2010; 8:149.
- Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30:270.
- Fries D. The early use of fibrinogen, prothrombin complex concentrate, and recombinant-activated factor VIIa in massive bleeding. Transfusion 2013; 53 Suppl 1:91S.
- Weber CF, Görlinger K, Meininger D, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117:531.
- Ghadimi K, Levy JH, Welsby IJ. Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting. Anesth Analg 2016; 122:1287.
- Sørensen B, Bevan D. A critical evaluation of cryoprecipitate for replacement of fibrinogen. Br J Haematol 2010; 149:834.
- Jensen NH, Stensballe J, Afshari A. Comparing efficacy and safety of fibrinogen concentrate to cryoprecipitate in bleeding patients: a systematic review. Acta Anaesthesiol Scand 2016; 60:1033.
- Rahe-Meyer N, Solomon C, Hanke A, et al. Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery: a randomized, placebo-controlled trial. Anesthesiology 2013; 118:40.
- Wikkelsø A, Lunde J, Johansen M, et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev 2013; :CD008864.
- Schöchl H, Nienaber U, Hofer G, et al. Goal-directed coagulation management of major trauma patients using thromboelastometry (ROTEM)-guided administration of fibrinogen concentrate and prothrombin complex concentrate. Crit Care 2010; 14:R55.
- Holcomb JB, Minei KM, Scerbo ML, et al. Admission rapid thrombelastography can replace conventional coagulation tests in the emergency department: experience with 1974 consecutive trauma patients. Ann Surg 2012; 256:476.
- Fominskiy E, Nepomniashchikh VA, Lomivorotov VV, et al. Efficacy and Safety of Fibrinogen Concentrate in Surgical Patients: A Meta-Analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2016; 30:1196.
- Hiippala ST, Myllylä GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995; 81:360.
- Hedner U. Mechanism of action of factor VIIa in the treatment of coagulopathies. Semin Thromb Hemost 2006; 32 Suppl 1:77.
- Yank V, Tuohy CV, Logan AC, et al. Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 2011; 154:529.
- Levi M, Levy JH, Andersen HF, Truloff D. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010; 363:1791.
- Lin Y, Stanworth S, Birchall J, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2011; :CD005011.
- Simpson E, Lin Y, Stanworth S, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012; :CD005011.
- Brase J, Finger B, He J, et al. Analysis of Outcomes Using Low-Dose and Early Administration of Recombinant Activated Factor VII in Cardiac Surgery. Ann Thorac Surg 2016; 102:35.
- Biss TT, Hanley JP. Use of recombinant factor VIIa (rFVIIa) in the management of intractable haemorrhage: a survey of current UK practice. Br J Haematol 2007; 138:126.
- Alfirevic A, Duncan A, You J, et al. Recombinant factor VII is associated with worse survival in complex cardiac surgical patients. Ann Thorac Surg 2014; 98:618.
- Goodnough LT, Levy JH. The Judicious Use of Recombinant Factor VIIa. Semin Thromb Hemost 2016; 42:125.
- Bodnaruk ZM, Wong CJ, Thomas MJ. Meeting the clinical challenge of care for Jehovah's Witnesses. Transfus Med Rev 2004; 18:105.
- Shander A, Javidroozi M, Naqvi S, et al. An update on mortality and morbidity in patients with very low postoperative hemoglobin levels who decline blood transfusion (CME). Transfusion 2014; 54:2688.
- Shander A, Javidroozi M, Perelman S, et al. From bloodless surgery to patient blood management. Mt Sinai J Med 2012; 79:56.
- PREOPERATIVE STRATEGIES
- Selective laboratory testing
- Management of medications affecting hemostasis
- Correction of anemia or thrombocytopenia
- - Correction of anemia in selected patients
- - Treatment of thrombocytopenia for selected procedures
- Treatment of vitamin K deficiency
- Management of anemia and hemostasis in renal insufficiency
- Management of hemostasis in hepatic insufficiency
- Management of specific hemostatic disorders
- - Inherited conditions
- - Acquired disorders
- Preoperative autologous blood donation
- INTRAOPERATIVE STRATEGIES
- Fluid management
- Temperature management
- Surgical blood conservation techniques
- - Electrosurgery devices
- - Topical hemostatic agents and tissue adhesives
- - Acute normovolemic hemodilution
- - Intraoperative blood salvage
- Selective use of procoagulant products
- - Antifibrinolytics
- - Desmopressin (DDAVP)
- - Prothrombin complex concentrate (PCC)
- - Fibrinogen concentrate
- - Recombinant activated factor VII (rFVIIa)
- REFUSAL OR LIMITED AVAILABILITY OF BLOOD
- SUMMARY AND RECOMMENDATIONS