A REVIEW OF EUROPEAN GUIDELINES FOR PATIENT BLOOD MANAGEMENT WITH A PARTICULAR EMPHASIS ON ANTIFIBRINOLYTIC DRUG ADMINISTRATION FOR CARDIAC SURGERY

Abstract

<h3>Introduction</h3> Patient blood management (PBM) is a proactive approach towards improving the quality and appropriateness of care. PBM has been recommended by the World Health Organization (WHO) since 2011. The aim is to manage anaemia and bleeding in surgical patients with the objective to minimise the need for transfusion. AntiVbrinolytics play a major role in cardiac surgery, where the risk of perioperative bleeding is high and affects most patients. AntiVbrinolytics effectively reduce bleeding, transfusions, re-operations, and associated morbidity and mortality. They represent an essential part of the pharmacological arsenal of PBM. The authors compared the current available European guidelines in PBM and analysed the place of different antiVbrinolytics in cardiac surgery, according to these guidelines. <h3>Methods</h3> A literature search on European PBM guidelines was performed in December 2020 and repeated in January 2021 using PubMed, Cochrane Database and Google Scholar databases. <h3>Results</h3> Thirteen documents were identiVed, from 6 countries (France, Germany, Italy, The Netherlands, Romania, UK), provided by European Commission or European and/or national learned societies. Of these 13 articles, 10 mentioned cardiac surgery, with 1 fully dedicated to it, and 8 were actual PBM guidelines. <h3>Discussion</h3> Despite the trend towards high-level PBM practices, and the implementation of PBM programs actively supported by the European Commission, national or international PBM guidelines for European countries appear to be both few and heterogeneous in form and content. At the European level, guidelines on bleeding management were published in 2017 by the ESAIC and those dedicated to cardiac surgery were published in 2018 jointly by the EACTS and the EACTA. All the current available guidelines follow and agree on the deVnition of PBM as deVned by the WHO, supported by three pillars: optimizing blood volume, minimising blood loss and optimizing the patient's tolerance to anaemia. Most of them were divided according to the three main surgical phases: preoperative, perioperative and post-operative. Anaemia management appears as a cornerstone of PBM in all guidelines, followed by limiting blood loss during surgical procedures to reduce transfusions and limit the risk of reoperation for bleeding. In this context, the European and national PBM guidelines all recommend the prophylactic use of antiVbrinolytics to avoid or reduce perioperative bleeding. However, they differ in the type of antiVbrinolytic recommended, when it should be given and how (bolus or infusion or both), including the dose and timing. Indeed, when mentioned, the dosing to be used generally differs from one guideline to another. Most guidelines recommend only the use of tranexamic acid. Aprotinin is rarely mentioned, partly because of its recent reintroduction in Europe (Table 1). The implementation of PBM practices in Europe is still challenging, as there is a real need for more homogenous guidance in PBM and in the use of antiVbrinolytics, especially in cardiac surgery. New clinical data to promote the use of antiVbrinolytics could be of interest to improve, accelerate and deploy PBM implementation at a large scale.