Drug, Devices, Technologies, and Techniques for Blood Management in Minimally Invasive and Conventional Cardiothoracic Surgery: A Consensus Statement From the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011

OBJECTIVE: The objectives of this consensus conference were to evaluate the evidence for the efficacy and safety of perioperative drugs, technologies, and techniques in reducing allogeneic blood transfusion for adults undergoing cardiac surgery and to develop evidence-based recommendations for comprehensive perioperative blood management in cardiac surgery, with emphasis on minimally invasive cardiac surgery.

METHODS: The consensus panel short-listed the potential topics for review from a comprehensive list of potential drugs, devices, technologies, and techniques. The process of short-listing was based on the need to prioritize and focus on the areas of highest importance to surgeons, anesthesiologists, perfusionists, hematologists, and allied health care involved in the management of patients who undergo cardiac surgery whether through the conventional or minimally invasive approach. MEDLINE, Cochrane Library, and Embase databases were searched from their date of inception to May 2011, and supplemental hand searches were also performed. Detailed methodology and search strategies are outlined in each of the subsequently published systematic reviews. In general, all relevant synonyms for drugs (antifibrinolytic, aprotinin, [Latin Small Letter Open E]-aminocaproic acid, tranexamic acid [TA], desmopressin, anticoagulants, heparin, antiplatelets, anti-Xa agents, adenosine diphosphate inhibitors, acetylsalicylic acid [ASA], factor VIIa [FVIIa]), technologies (cell salvage, miniaturized cardiopulmonary bypass (CPB) circuits, biocompatible circuits, ultrafiltration), and techniques (transfusion thresholds, minimally invasive cardiac or aortic surgery) were searched and combined with terms for blood, red blood cells, fresh-frozen plasma, platelets, transfusion, and allogeneic exposure. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of each recommendation.

RESULTS AND RECOMMENDATIONS: Database search identified more than 6900 articles, with 4423 full-text randomized controlled trials assessed for eligibility, and the final 125 systematic reviews and meta-analyses were used in the consensus conference. The results of the consensus conference, including the evidence-based statements and the recommendations, are outlined in the text, with references given for the relevant evidence that formed the basis for the statements and recommendations.

RECOMMENDATIONS FOR ANTIFIBRINOLYTICS: RECOMMENDATIONS FOR TA IN OFF-PUMP CORONARY ARTERY BYPASS: RECOMMENDATIONS FOR DDAVP: RECOMMENDATIONS FOR TOPICAL HEMOSTATICS: RECOMMENDATIONS FOR FVIIA: RECOMMENDATIONS FOR ERYTHROPOIETIN PLUS IRON: RECOMMENDATIONS FOR ANTIPLATELETS BEFORE CARDIAC SURGERY: RECOMMENDATIONS FOR ANTIPLATELETS AFTER CARDIAC SURGERY: RECOMMENDATIONS FOR ACUTE NORMOVOLEMIC HEMODILUTION: RECOMMENDATIONS FOR RETROGRADE AUTOLOGOUS PRIMING: RECOMMENDATIONS FOR CELL SALVAGE: RECOMMENDATIONS: BIOCOMPATIBLE CPB CIRCUITS: RECOMMENDATIONS FOR MINIATURIZED EXTRACORPOREAL CARDIOPULMONARY CIRCUIT VERSUS CONVENTIONAL EXTRACORPOREAL CARDIOPULMONARY CIRCUIT: RECOMMENDATIONS FOR ULTRAFILTRATION (CONTINUOUS OR MODIFIED): RECOMMENDATIONS FOR PLATELET PLASMAPHERESIS: RECOMMENDATIONS FOR POINT-OF-CARE MONITORING: RECOMMENDATIONS FOR SURGICAL TECHNIQUES FOR OPCAB, MINIMALLY INVASIVE STERNOTOMY FOR AORTIC VALVE SURGERY, MINIMALLY INVASIVE STERNOTOMY FOR MITRAL VALVE SURGERY, AND TRANSCATHETER AORTIC VALVE IMPLANTATION: