Blood Management Strategies in Cardiac Surgery Still Hodgepodge of Approaches

Blood management strategies continue to vary widely across institutions, a phenomenon that may lead to less than optimal results.

Investigators at the University of Texas Southwestern Medical Center and members of the Society of Cardiovascular Anesthesiologists’ (SCA) Clinical Practice Improvement Blood Conservation Work Group aim to change that: Results from their survey (released in mid-September) will not only help institutions recognize variances in blood management practices, but also identify common barriers to reducing use and track their progress in translating blood conservation guidelines into clinical practice. [Late-breaking note: the last opportunity to complete the “SCA Blood Conservation and Hemostasis in Cardiac Surgery” survey will be Monday, 11/27, when the survey will be sent out again.]

“Blood utilization has been identified by a number of medical societies as an area of overuse,” said Philip E. Greilich, MD, professor of anesthesiology and pain management and the S.T. “Buddy” Harris Distinguished Chair in Cardiac Anesthesiology at the Dallas institution. One such campaign is “Choosing Wisely,” an initiative of the ABIM Foundation in partnership with Consumer Reports.

“The challenge, then, is determining effective ways of engaging physicians, institutions and health care systems in potentially changing their behaviors and approaches to reducing avoidable transfusions. And surveys are a proven way to measure change.

“A revised survey was pushed out to members of the SCA to promote awareness within and between institutions with respect to local and national variances in blood management practices,” Dr. Greilich said.

The researchers designed a standardized 35-question survey, which was based on previous guidelines published by the Society of Thoracic Surgeons and the SCA (Ann Thorac Surg2007;83:S27-S86).

The survey’s questions focus on eight evidence-based recommendations from the 2011 update to the 2007 guidelines (Ann Thorac Surg 2011;91:944-982). Topics included the use of transfusion algorithms, factor concentrates, management of anemia and massive bleeding, and capacity for quality improvement.

“The questions are meant to help a given center and their team identify where the trouble spots may be and leverage that information to guide their own local effort,” Dr. Greilich said. The pilot survey was then sent to members of the SCA Continuous Process Improvement Blood Conservation Workgroup and selected academic cardiac anesthesiologists; responses and feedback were collected in preparation for development of the more comprehensive survey.

As reported at the 2017 annual meeting of the SCA (abstract SCA228), the alpha phase survey response rate was 77% (18/22). A total of 31 suggestions were collected for improving the survey. Although more than 75% of the respondents were from academic practices, they nevertheless identified significant barriers to transfusion algorithms and notable gaps in quality improvement infrastructure.

Next, the researchers went to the beta testing phase, which garnered 72 responses from academic and private practices. This phase provided some insight into current practice patterns, the most surprising of which was that point-of-care testing was unavailable in the operating room for the majority of respondents. The survey also revealed that:

• the overwhelming majority of respondents use antifibrinolytics to prevent postoperative bleeding;
• the majority of respondents use a hemoglobin trigger on bypass of 6 to 7 g/dL; and
• the hemoglobin target on arrival to the ICU is 8 to 9 g/dL among the majority of respondents.

“I was surprised that the point-of-care testing was not available more widely given its central role in a transfusion algorithm,” Dr. Greilich told Anesthesiology News. “All the recommendations are very clear that if you’re going to have compliance with a transfusion algorithm, you need the testing to be at the point of patient care.”

The survey will be distributed soon to SCA members across the country. “The intention here is to identify the gaps between what the guidelines say and what institutions are doing. That’s just part of the journey of any institution. You have to be able to see the gaps before you can correct them.”

Although Martin J. London, MD, appreciated any efforts to streamline blood conservation guidelines, he also saw the challenges in the process, which he called a “pretty messy area.” Part of this, Dr. London discussed, is a function of the age of existing guidelines and quality of existing data. “The guidelines state that they should be updated every three years and that hasn’t been done,” he noted, a professor of clinical anesthesia at the University of California, San Francisco School of Medicine. “The ASA’s blood guidelines are newer, but not as specific for cardiac surgery.”