A review of European guidelines for patient blood management with a particular emphasis on antifibrinolytic drug administration for cardiac surgery

https://doi.org/10.1016/j.jclinane.2022.110654Get rights and content
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Highlights

  • PBM practices are increasingly used but national guidelines in Europe are uncommon.

  • Currently available PBM guidelines are heterogeneous in form and content.

  • Very few PBM guidelines are specific for cardiac surgery.

  • Antifibrinolytics are essential to limit blood loss during cardiac surgery.

  • Practical details for administering antifibrinolytics are not detailed in current guidelines.

Abstract

The concept of patient blood management (PBM) was introduced by the World Health Organization in 2011 and is defined as a “patient-focused, evidence-based and systematic approach for optimizing the management of patients and transfusion of blood products to ensure high quality and effective patient care”. Patient blood management is a multimodal approach based on three pillars: optimization of blood mass, minimization of blood loss and optimization of patient tolerance to anaemia.

Antifibrinolytics play a major role in cardiac surgery, where the risk of perioperative bleeding is high and affects a majority of patients, by effectively reducing bleeding, transfusions, re-operations, as well as their associated morbidity and mortality. They represent an essential part of the pharmacological arsenal of patient blood management.

However, despite the trend towards high-level PBM practices, currently very few European countries have national PBM guidelines and these guidelines, taken as a whole, are heterogeneous in form and content. In particular, the use of antifibrinolytics in cardiac surgery is often not discussed in detail beyond general prophylactic use and any recommendations lack detail including choice of drug, dosing, and mode of administration.

Thus, the implementation of PBM programs in Europe is still challenging.

In 2021, the WHO published a new document highlighting the urgent need to close the gap in PBM awareness and implementation and announced their upcoming initiative to develop specific PBM implementation guidelines.

This review aims first, to summarize the role played by fibrinolysis in haemostatic disorders; second, to give an overview of the current available guidelines in Europe detailing PBM implementation in cardiac surgery; and third, to analyse the place and use of antifibrinolytics in these guidelines.

Keywords

Patient blood management
European guidelines
Antifibrinolytics
Aprotinin
Tranexamic acid
Cardiac surgery
Blood transfusion

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