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Perioperative coagulation management and blood conservation in cardiac surgery: a Canadian Survey
Ravi Taneja1, Philip Fernandes, Gulshan Marwaha
1Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, ON, Canada. Ravi.Taneja@lhsc.on.ca
Insights
Canadian cardiac surgery centers rarely use advanced point-of-care tests for anticoagulation management or have clear bleeding protocols. Standardized blood conservation strategies are needed to improve patient outcomes.
Area of Science:
- Anesthesiology
- Cardiovascular Surgery
- Transfusion Medicine
Background:
- Cardiac surgery necessitates meticulous anticoagulation and blood conservation strategies.
- Current practices in Canada for managing anticoagulation and blood loss during cardiac surgery are not well-defined.
- Variability in perioperative blood management may impact patient outcomes.
Purpose of the Study:
- To survey Canadian institutions performing cardiac surgery regarding their current anticoagulation and blood conservation strategies.
- To identify common practices and potential gaps in perioperative blood management.
Main Methods:
- An institutional survey was distributed to all Canadian university hospitals performing cardiac surgery.
- The survey assessed methods for anticoagulation monitoring, antifibrinolytic use, blood conservation techniques, and transfusion guidelines.
- Response rate was 85%.
Main Results:
- Activated coagulation time (ACT) is the predominant method for heparin monitoring; advanced point-of-care tests are infrequently used (<10%).
- Tranexamic acid is widely used (80%), while cell savers are uncommon (29%).
- Over 50% of ICUs lack written guidelines for managing blood products and factor administration; one-third of centers do not regularly audit transfusion practices.
Conclusions:
- Most Canadian cardiac surgery centers rely on ACT for anticoagulation monitoring, with limited use of other point-of-care tests.
- A significant proportion of institutions lack standardized algorithms for bleeding management and do not regularly audit transfusion practices.
- Implementing standardized perioperative blood conservation protocols could benefit cardiac surgery patients in Canada.
Objective:
To determine which strategies are currently used for (anti)coagulation management and blood conservation during cardiac surgery in Canada.
Design:
Institutional survey.
Setting:
University hospital.
Participants:
All sites performing cardiac surgery in Canada.
Interventions:
None.
Measurements And Main Results:
The response rate was 85%. Anticoagulation with heparin is monitored routinely through the activated coagulation time (ACT). Less than 10% of centers use heparin concentrations (Hepcon HMS, Medtronic), thromboelastography, or other point-of-care tests perioperatively. Eighty percent of centers routinely use tranexamic acid as the primary antifibrinolytic agent; however aprotinin until recently, was used more commonly for patients at increased risk for bleeding. Retrograde autologous prime is commonly used (62%); however, cell savers are uncommon for routine patients undergoing cardiac surgery (29%). Although most hospitals use a hematocrit of 20% to 21% for transfusing red blood cells, more than 50% of intensive care units do not have written guidelines for the administration of protamine, fresh frozen plasma, platelets, or factor VIIa. At least one third of centers do not audit their transfusion practices regularly.
Conclusions:
The majority of Canadian institutions do not use point-of-care tests other than ACT. Most institutions do not have algorithms for management of bleeding following cardiac surgery and at least 30% do not monitor their transfusion practice perioperatively. Cardiac surgery patients in Canada may benefit from a standardized approach to blood conservation in the perioperative period.
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