The imperative integration of patient blood management into ERACS: bridging the gap for optimizing outcomes in cardiac surgery

Abstract

Background

Enhanced Recovery After Surgery (ERAS) in cardiac surgery was designed to improve outcomes, reduce complications, and optimize recovery. Despite these efforts, perioperative anemia, a key modifiable risk factor that affects 20 to 41% of patients, remains under-addressed and is strongly associated with increased transfusion rates, morbidity, and mortality. Patient Blood Management (PBM) has demonstrated efficacy in improving outcomes by optimizing hemoglobin levels, reducing blood loss, and minimizing transfusions, although it is not yet fully integrated into cardiac ERAS pathways.

Main Text

ERAS pathways are patient-centered, multidisciplinary, preventive and evidence-based. Although the principles of PBM align with ERAS, detailed PBM targets are often neglected in ERAS-based line of care. In cardiac surgery, the risks associated with anemia and transfusion are substantially higher than in other surgical specialties. However, perioperative interventions might manage anemia, mitigate bleeding risks, and improve tolerance to anemia in this particularly sensitive population. Implementation challenges include the need for institutional culture shifts and multidisciplinary education maintaining clinical awareness to support individualized recovery trajectories.

Conclusion

Integrating PBM into cardiac ERAS-based pathways addresses a critical gap that could lead to improved patient outcomes, reduced complications, lower transfusion rates, and optimized resource utilization. While healthcare progressively focuses on safety, quality, and value-based care, the convergence of ERAS and PBM offers a comprehensive approach to advancing perioperative medicine in cardiac surgery.

Scenario

Multidisciplinary protocols for outcome optimization are increasing in prominence globally, aiming to improve recovery for patients undergoing surgical interventions. These protocols stand out for their efficiency, emphasis on process quality, and focus on patient experience and satisfaction, which are key aspects in modern medicine and value a patient-centered, value-based approach (Zanotto et al. 2021).

Despite the high prevalence of preoperative anemia and its documented impact on surgical outcomes (Faria et al. 2021), as well as the financial burden on hospitals for cardiac surgeries, patient blood management (PBM) remains undervalued in perioperative optimization protocols. To improve these protocols and achieve better patient outcomes, it might be necessary to integrate PBM strategies into rapid recovery protocols.

Studies have shown that 20% to 41% of patients scheduled for coronary artery bypass grafting present with preoperative anemia (Faria et al. 2021; Schwann et al. 2023; Padmanabhan et al. 2019a; Bolliger et al. 2022), and their transfusion rates range from 9.1% to 32.5% (Fitzgerald et al. 2023; Likosky et al. 2014; Bennett-Guerrero et al. 2010; Hajjar et al. 2010), with a significant financial impact(Kleinerüschkamp et al. 2016, 2019). Perioperative anemia and homologous blood transfusion are widely recognized as risk factors for increased short- and long-term morbidity and mortality, which are proportional to the severity of anemia and the amount of homologous red blood cells transfused (Faria et al. 2021; Schwann et al. 2023; Padmanabhan et al. 2019b; Loor et al. 2013).

In a scenario with a high incidence of anemia in the perioperative period (Faria et al. 2021; Schwann et al. 2023; Meybohm et al. 2020), integrating PBM protocols into perioperative optimization pathway based on ERAS (Mejía et al. 2016; Mejia et al. 2022a, 2022b, 2024, 2021; Engelman et al. 2019) may lead to improved outcomes in cardiac surgery.

PBM and ERAS

PBM focuses on individualized and evidence-based care to manage blood cell counts, minimize blood loss and enhance anemia tolerance (Meybohm et al. 2020; Force and on Patient Blood Management for Adult Cardiac Surgery in Europe Association between cardio-thoracic surgery (EACTS) and the European Association of Cardiothoracic Anesthesiology (EACTA), Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, 2017;) (Fig. 1). Although this concept is gradually being recognized in the literature, it is still not widely incorporated into clinical protocols.

Fig. 1.

Bundles of care for patient blood management during the perioperative period. *Perioperative approach; TIBC: total iron-binding capacity; CPB: cardiopulmonary bypass

The variability in transfusion practices across hospitals was highlighted by Fitzgerald et al. 2023 where the results couldn’t be explained by patient or procedural factors alone and pointing out that variability among hospitals was more common than among surgeons, demonstrating that bridging the gap in ERAS protocols necessitates the adoption of PBM strategies alongside an enhanced institutional culture.

The ERAS framework (Engelman et al. 2019; Ripollés-Melchor et al. 2019), as exemplified by the Totalcor (Mejia et al. 2021) and Tempos Certos (Mejia et al. 2022a) protocols, relies on evidence-based bundled interventions implemented by a multidisciplinary team aligned with institutional culture. They should aim to reduce surgical stress and early mobilization, optimize pain control, and ensure safe hospital discharge.

The ERAS and PBM principles intersect at (1) evidence-based strategies, (2) multidisciplinary approach, (3) preventive and (4) patient-centered interventions. Although the principles of PBM align with ERAS, detailed PBM targets are often neglected in ERAS-based pathways, emphasized by Guinn and Goobie (2022), Salenger (2024) and Grant et. Al (2024). Undoubtedly, incorporating these concepts will demand comprehensive training and may face institutional challenges related to PBM and ERAS implementation routines.

A study in colorectal surgery indicated that preoperative anemia did not reduce the benefits of enhanced recovery (Hardy et al. 2021). Nevertheless, the increased risks of bleeding, anemia and transfusion associated with cardiac surgery have already been established as risk factors for poorer outcomes (Faria et al. 2021; Loor et al. 2013; Meybohm et al. 2020). This highlights the necessity for strategic planning to mitigate these risks.

Cardiac surgery has experienced a historic quality improvement milestone with the establishment of quality units and large databases, which, combined with advances in technical approaches, have elevated specialty outcomes (Mejía et al. 2016). Currently, the growth of specialized center and the systematization of techniques further potentiate this effect, with protocols such ERAS and PBM standing out prominently. However, when applied separately, these care pathways may lose potential synergistic benefits. It is important to emphasize that these recommendations are first and foremost, evidence-based and regularly updated, which makes continuous education essential. Therefore, it is important to form a task force to better disseminate local guidelines from leading centers employing these approaches, fostering a culture of teamwork.

Conclusions

Given the pursuit of enhanced patient experiences and greater healthcare access, alongside the emphasis on safety, quality of care, waste reduction, and value creation, healthcare managers and multidisciplinary teams should integrate PBM concepts into a comprehensive cardiac surgery care pathway as ERAS-bases pathways as a standard of care.

Abbreviations

CPB

Cardiopulmonary bypass

ERAS

Enhanced Recovery After Surgery

TIBC

Total iron-binding capacity;

PBM

Patient Blood Management

Authors’ contributions

G.B.B. and F.A.S.L.J. prepared figures and prepared for submission. O.A.V.M., G.B.B. and F.B.J. idealized the perspective idea. G.B.B., F.A.S.L.J. and O.A.V.M. wrote the main manuscript text. All authors reviewed the manuscript and figures.

Funding

There are not any funding resources supporting this publication.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable,

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.