Vonk et al. describe the blood-conservation strategies and the overall consumption of red blood cells and haemostatic blood products during cardiac surgery with cardiopulmonary bypass in their institution over a 10-year period. A total of 6026 patients were included in the database covering the period from 2002 to 2011. The authors observed a decrease in 24-hour blood losses and a 28% reduction in overall RBC transfusion despite an increase in lowest intraoperative Hb levels from 8.5 to 10.4 g/dL. There was no change in the use of FFP or platelets over the 10 years. Cessation of aprotinin (pump-prime dose only) in 2008 was followed by an increase in RBC transfusions, but a decrease was seen with the implementation of routine cell salvage.

The authors attribute the decrease in blood losses and transfusions to cell salvage, reduced intraoperative fluid volumes and an increase in nadir intraoperative body temperature. Despite the “large reduction” reported, it must be noted that, in 2011, only 40% of patients avoided transfusions altogether: 60% received RBCs, 50% received FFP and 60% received platelets (approximation from Figure 4). Thus, there is still ample room for improvement.

A reduction in the transfusion trigger (9.7 g/dL in the Netherlands) should be envisaged seriously, would be easy to implement and would be effective immediately. Reintroduction of a blood-sparing drug like aprotinin could possibly be useful, inasmuch as an efficacious dose regimen is used (Hammersmith protocol). Finally, goal-directed haemostatic therapy (TEG or ROTEM based, for example) could contribute to a decrease in the use of haemostatic blood products.

– Jean-François Hardy

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