REVIEW
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Blood Res (2024) 59:21
Published online June 7, 2024
https://doi.org/10.1007/s44313-024-00021-x
© The Korean Society of Hematology
Preoperative consultation for determining the appropriate transfusion strategy
Correspondence to : *Ka‑Won Kang
ggm1018@gmail.com
© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Abstract
Surgical patients are at risk of postoperative complications and mortality, necessitating preoperative patient optimization through the identification and correction of modifiable risk factors. Although preoperative platelet transfusions aim to reduce the risk of bleeding, their efficacy remains uncertain. Similarly, red blood cell transfusion in patients with anemia does not reduce the risk of postoperative mortality and may exacerbate complications. Therefore, developing individualized strategies that focus on correcting preoperative complete blood count abnormalities and minimizing transfusion requirements are essential. This review aimed to examine complete blood count abnormalities and appropriate transfusion strategies to minimize postoperative complications.
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Keywords: Preoperative care, Anemia, Thrombocytopenia, Blood transfusion, Patient blood management
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REVIEW
Blood Res 2024; 59():
Published online June 7, 2024 https://doi.org/10.1007/s44313-024-00021-x
Copyright © The Korean Society of Hematology.
Preoperative consultation for determining the appropriate transfusion strategy
Ka‑Won Kang1*
1Department of Internal Medicine, Division of Hematology-Oncology, Korea University College of Medicine, 73, Goryeodae‑ro, Seongbuk‑gu, Seoul 02841, the Republic of Korea
Correspondence to:*Ka‑Won Kang
ggm1018@gmail.com
© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Abstract
Surgical patients are at risk of postoperative complications and mortality, necessitating preoperative patient optimization through the identification and correction of modifiable risk factors. Although preoperative platelet transfusions aim to reduce the risk of bleeding, their efficacy remains uncertain. Similarly, red blood cell transfusion in patients with anemia does not reduce the risk of postoperative mortality and may exacerbate complications. Therefore, developing individualized strategies that focus on correcting preoperative complete blood count abnormalities and minimizing transfusion requirements are essential. This review aimed to examine complete blood count abnormalities and appropriate transfusion strategies to minimize postoperative complications.
Keywords: Preoperative care, Anemia, Thrombocytopenia, Blood transfusion, Patient blood management
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Appropriate inquiry for screening possible abnormal hemostasis.
Has there been any history of bleeding disorders in your family, such as excessive bleeding tendencies or abnormal bleeding incidents?.
Have you experienced any episodes of prolonged bleeding following surgical procedures or childbirth?.
In the past, have healthcare professionals needed to revisit a surgical site due to excessive bleeding, or have you ever had to return to the operating room for hemorrhage management?.
Have you ever encountered unusually heavy menstrual periods?.
Do you notice frequent or excessive bruising? If so, are these bruises widespread, or are they primarily localized to specific areas prone to trauma?.
Have you experienced recurrent nosebleeds, either currently or at any point in your life?.
Have you ever undergone a blood or plasma transfusion? If yes, could you provide details regarding the circumstances that necessitated this procedure?.
Have you ever sustained bruising or bleeding as a result of trauma, such as car accidents, falls, sports injuries, altercations, or other violent incidents?.
These contents were adapted from Consultative Hemostasis and Thrombosis (Fourth Edition) [14].
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Schema for preoperative hemostatic evaluation.
Level of Riska Screening History Proposed Surgery Recommended Tests Minimal Negative ± prior surgery and Minor None Low Negative with prior surgery and Major Platelet count, PTT, or none Moderate Possible bleeding disorder or CNS, CPB, or prostatectomy Above tests plus BT (or PFA),b PT High Highly suspicious or documented bleeding disorder and Major or minor Above tests plus factors VIII, IX, and XI levels, TT. If these are negative, pursue diagnosis These contents were adapted from Consultative Hemostasis and Thrombosis (Fourth Edition) [14]..
Abbreviation: BT bleeding time, CNS central nervous system, CPB cardiopulmonary bypass, PFA platelet function assay, PTT partial thromboplastin time, PT prothrombin time, TT thrombin time.
a Estimated by the product of the risk of bleeding times the clinical consequence of bleeding..
b The bleeding time may be replaced by PFA.
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Transfusion guideline recommendations for prophylactic PLT transfusions.
Society/recommendations Strength of recommendation/Quality of evidence European Society of Intensive Care Medicine 2020 [17] We suggest refraining from platelet transfusions to treat thrombocytopenia unless the platelet count falls below 10 × 10^9/L. Conditional/Very low We make no recommendation regarding prophylactic platelet transfusion before invasive procedures for platelet counts between 10 × 10^9/L and 50 × 10^9/L. Research recommendation/- We suggest refraining from prophylactic platelet transfusion before percutaneous tracheostomy or central venous catheter insertion for platelet counts between 50 × 10^9/L and 100 × 10^9/L. Conditional/Very low Society of Interventional Radiology 2019 [18] Consider platelet transfusion if the platelet count is <20 × 10^9/L for procedures with low bleeding risk (e.g., central venous access, including PICC placement, dialysis access, lumbar puncture, paracentesis, thoracentesis, transjugular liver biopsy, or superficial abscess drainage). Weak/Limited(evidence level D) Consider platelet transfusion if the platelet count is <50 × 10^9/L for procedures with high bleeding risk (e.g., deep abscess drainage, solid organ biopsies, arterial intervention <7 French sheath, gastrostomy, urinary tract interventions [nephrostomy, stone removal], or transjugular intrahepatic portosystemic shunt). Weak/Limited(evidence level D) British Society for Haematology 2017 [19] Consider performing the following procedures above the platelet count threshold indicated: Central venous lines, >20 × 10^9/L (using ultrasound). Strong/Moderate Major surgery, >50 × 10^9/L. Strong/Low Lumbar puncture, ≥40 × 10^9/L. Weak/Low Insertion/removal of an epidural catheter, ≥80 × 10^9/L. Weak/Low Neurosurgery or posterior segment ophthalmic surgery, >100 × 10^9/L. Strong/Low Percutaneous liver biopsy, >50 × 10^9/L (consider transjugular biopsy if platelet count is lower). Weak/Moderate Provide prophylactic platelet transfusions (platelet transfusions to patients who do not have clinically significant bleeding and do not require a procedure) to patients with reversible bone marrow failure (e.g., general critical illness, receiving intensive chemotherapy, or undergoing hematopoietic stem cell transplantation) at or above 10 × 10^9/L. Strong/Moderate Consider increasing the threshold for prophylactic platelet transfusion to between 10 × 10^9/L and 20 × 10^9/L in patients judged to have additional risk factors for bleeding (e.g., sepsis). Weak/Low American Association of Blood Banks (AABB) 2015 [20] Suggest prophylactic platelet transfusion for patients having elective central venous catheter placement with a platelet count <20 × 10^9/L. Weak/Low Suggest prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with a platelet count <50 × 10^9/L. Weak/Very low Suggest prophylactic platelet transfusion for patients having elective neuraxial anesthesia with a platelet count <50 × 10^9/L. Weak/Very low Recommends against routine prophylactic platelet transfusion for patients who are nonthrombocytopenic and have cardiac surgery with cardiopulmonary bypass. Weak/Very low Recommends transfusing hospitalized patients with a platelet count <10 × 10^9/L to reduce the risk of spontaneous bleeding. Strong/Moderate These contents were adapted from "How I use platelet transfusions [22].
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