Patient Blood Management in Cardiac Surgery in Turkiye

Patient blood management (PBM) is defined as "the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize haemostasis and minimize blood loss in an effort to improve patient's outcome" (1,2). Patient blood management has recently been introduced in several areas where blood transfusions are important, such as anaesthesiology, cardiac surgery, orthopedic surgery, or traumatology (3).

Its adoption has been recommended by the WHO since 2010, as well as by national health regulation agencies, international professional societies, and the European Commission (4-7). In literature, there is mounting evidence that multimodal PBM programs can be effective at improving postoperative outcomes and reducing perioperative blood transfusions and costs (8).

Turkish Society of Anaesthesiology and Reanimation (TARD) PBM Task Force has been working on this subject and studied transfusion practices in major surgery patients and the prevalence of perioperative anemia (9). In the TULIP study, unfortunately, high usage of transfusions in major surgical patients in Turkey was documented. As demonstrated in the TULIP study, one of the surgeries that had high transfusion use, was cardiac surgery. Specific procedures with the highest RBC use were also coronary artery bypass grafting (16.9% of all units). Low hemoglobin concentration was the most common indication for intra-operative RBC transfusion (57%).

Preoperative anemia is common in cardiac surgery, with a prevalence between 10% and 50% (depending on the applied definition). Using the standard World Health Organization definition, the prevalence of anemia in the adult cardiac surgery population seems to be around 20% to 30% (10). Preoperative anemia is an independent risk factor for the transfusion of RBC, postoperative morbidity, and mortality (11, 12). An analysis of 9,144 cardiac surgery patients demonstrated that patients with low hematocrit values (<25%) during surgery who were exposed to RBC transfusion had an increased morbidity (cardiac and renal) and hospital mortality (13). Preoperative anemia is mostly the result of inadequate erythropoiesis owing to iron deficiency, malnutrition, malabsorption, inflammation, bone marrow disorders, or chronic blood loss. Importantly, anemic patients with iron deficiency need to be identified as early as possible by the cardiologist, surgeon, or anesthesiologist. With the introduction of a special PBM anemia walk-in clinic, anemia management can be initiated at an early stage. This would allow for timely optimization of iron stores to compensate for iron deficiency (14) or other treatable forms of anemia. Diagnosis and treatment of preoperative anemia are currently not part of standard care but are a core element of PBM to increase Hb values in cardiac surgery patients. In recent years, many studies investigated preoperative anemia and its effects on the outcome of adult cardiac surgery patients (Table 1).

Table 1. Preoperative anemia and its effects on the outcome of adult cardiac surgery patients