Bleeding is a common occurrence after Cardiac Surgery (CS) and can adversely affect outcomes. Publications on patient blood management are typically focused on reducing red blood cell transfusions through identification and treatment of preoperative anemia, delineation of safe transfusion thresholds, intraoperative blood scavenging, monitoring of the coagulation system, and data-driven algorithms for appropriate transfusion practices. This has been an area of focus in previously published, large, comprehensive, multidisciplinary, multisociety clinical practice guidelines. The inclusion of all aspects of patient blood management are beyond the scope of these recommendations, although we encourage the incorporation of these existing guidelines within a local ERAS framework. This includes education, audit, and continuous practitioner feedback.
Owing to the near-universal accessibility, low-risk profile, cost-effectiveness, and ease of implementation, we did evaluate antifibrinolytic use with tranexamic acid or epsilon aminocaproic acid. In a large randomized clinical trial of patients undergoing coronary revascularization, total blood products transfused, and major hemorrhage or tamponade requiring reoperation were reduced using tranexamic acid. Higher dosages, however, appear to be associated with seizures. A maximum total dose of 100 mg/kg is recommended. Based on this evidence, tranexamic acid or epsilon aminocaproic acid is recommended during on-pump cardiac surgical procedures (class I, level A).