Two international patient blood management guidelines for patients undergoing non-cardiac surgery

The European Society of Cardiology (ESC) updated ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery details evidence-based recommendations that aim to standardise patient management. They place an emphasis on the combined risk assessment of the patient with the inherent risk of the surgical procedure.

The guidelines follow the three-pillar concept of patient blood management (PBM), with evidence-based recommendations on:

1. Preoperative anaemia - diagnosis and treatment (Pillar one – preoperative haemoglobin optimisation).
2. Bleeding and reduction of iatrogenic diagnostic and surgery related blood loss (Pillar two – minimise iatrogenic blood loss and bleeding).
3. Optimal blood component use with patient-centred clinical decision support (Pillar three - harness tolerance to anaemia in an effort to improve patient outcome).

Dr John Casey, Transfusion Medicine Specialist and National Clinical Lead for Pathology and Clinical Governance at Lifeblood notes that “many of the recommendations in the ESC guidelines are consistent with Australia’s Patient Blood Management Guidelines: Module 2 – Perioperative, which is currently under review”.

In contrast to the ESC guidelines, the Ottawa Intraoperative Transfusion Consensus focuses on the intraoperative period, which “remains a source of high variability in terms of transfusion practice and blood conservation strategies”.

A multidisciplinary expert panel participated in a Delphi consensus survey to recommend strategies in the preoperative, intraoperative, and postoperative periods with the aim to minimise variability in intraoperative red blood cell (RBC) transfusion. 

Overall, 34 statements achieved consensus and resulted in recommendations under the following headings:

• Interprofessional communication
• Haemoglobin measurement
• Procedural considerations and audits
• Restrictive transfusion strategies
• Patient-centred considerations
• Research considerations

“The Ottawa consensus-based recommendations are an important contribution to PBM guidelines and strategies. As the authors state, variations in patient care can be influenced by clinician and institutional factors. Their guidance for informed and shared intraoperative transfusion decision-making is a great example of translating evidence-based guidelines into clinical practice.

“The detail around patient-centred considerations is a welcome addition to highlight the core focus of patient safety and empowerment in any PBM strategy,” says Dr Casey.

Consistent recommendations across both guidelines included:

• Preoperative haemoglobin measurement
• Use of point of care diagnostics to guide blood component therapy
• Use of systems to guide and monitor transfusion appropriateness
• Requirement of informed consent of benefits and risks of transfusion

The full list of recommendations can be found in the publications.

Reference:  

Halvorsen S, Mehilli J, Choorapoikayil S, Zacharowski K. Extract from the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery - Patient Blood Management. Blood Transfus. 2024;22(2):122-129. doi:10.2450/BloodTransfus.708

Lenet T, McIsaac DI, Hallet JH, et al. Intraoperative Blood Management Strategies for Patients Undergoing Noncardiac Surgery: The Ottawa Intraoperative Transfusion Consensus. JAMA Netw Open. 2023;6(12):e2349559. doi:10.1001/jamanetworkopen.2023.49559