Getting it right: optimizing transfusion management during the procedure.

There is little doubt that blood transfusions have saved many lives in cases of acute hypovolemia and anemia, but both the literature and practitioners still do not agree as to what the appropriate indicators for transfusion are in a cardiac surgical patient. Furthermore, there are those who claim that the benefit of blood transfusions has never been conclusively demonstrated, and evidence of transfusion related harm continues to accumulate. Cardiac surgical patients may be transfused not only because of bleeding but also due to hemodilution from preoperative and intraoperative intravenous fluids and pump primes in conjunction with a possible preoperative anemia. Getting transfusion right to improve our practice has to be approached multifactorially. The use of prophylactic dosing of blood products has been suggested to be ineffective in reducing blood loss. There are many factors that impact transfusion rates including determining the optimal hematocrit where it is highly unlikely that one figure will be applicable to all patients. The formulation of transfusion guidelines and algorithms that have been agreed upon by all practitioners involved in the care of cardiac surgical patients may have a positive effect-if everyone agrees to transfuse patients via the formulated guidelines or algorithms. Importantly, no one individual should be able make the decision on whether a patient requires a blood transfusion-it must at all times be a team decision, whether in the operating room or intensive care unit.