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Bratt S, Zindovic I, Ede J, Geirsson A, Gunn J, Hansson EC, Jeppsson A, Mennander A, Olsson C, Tang M, Uimonen M, Wickbom A, Gudbjartsson T, Dalén M. Bleeding is associated with severely impaired outcomes in surgery for acute type a aortic dissection. SCAND CARDIOVASC J 2024; 58:2382477. [PMID: 39087759 DOI: 10.1080/14017431.2024.2382477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 06/07/2024] [Accepted: 07/16/2024] [Indexed: 08/02/2024]
Abstract
Background. Surgery for acute type A aortic dissection confers a risk for significant bleeding. We analyzed the impact of massive bleeding on complications after surgery for acute type A aortic dissection. Methods. Patients undergoing surgery for acute type A aortic dissection from the retrospective multicenter Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) database 2005-2014 were eligible. Massive bleeding was defined according to the Universal Definition of Perioperative Bleeding. The primary outcome measure was early mortality and secondary outcome measures were perioperative stroke, mechanical ventilation more than 48 h, new-onset dialysis, and intensive care unit stay. Propensity score matching was performed to adjust for differences in covariates. Results. Nine hundred ninety-seven patients were included, of whom 403 (40.4%) had massive bleeding. In the propensity score-matched cohort (344 pairs), patients with massive bleeding had higher 30-day mortality (17.2 versus 7.6%, p < .001), mechanical ventilation more than 48 h (52.8 versus 22.6%, p < .001), perioperative stroke (24.3 versus 14.8%, p = .002), new-onset dialysis (22.5 versus 4.9%, p < .001), and longer intensive care unit stay (6 versus 3 days, p < .001), compared with patients without massive bleeding. Risk factors for massive bleeding were previous cardiac surgery, preoperative clopidogrel or ticagrelor therapy, DeBakey type I dissection, and localized or generalized malperfusion. Conclusions. Massive bleeding in surgery for acute type A aortic dissection is associated with a markedly increased risk for severe complications as well as early death. Further improvement of surgical technique and pharmacological optimization of coagulation is paramount to possibly improve outcomes in acute type A aortic dissection repair.
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Affiliation(s)
- Sorosh Bratt
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Jacob Ede
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jarmo Gunn
- Department of Surgery, Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Emma C Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ari Mennander
- Department of Cardiothoracic Surgery, Heart Center Tampere University Hospital, Tampere, Finland
| | - Christian Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mariann Tang
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Skejby, Denmark
| | - Mikko Uimonen
- Department of Cardiothoracic Surgery, Heart Center Tampere University Hospital, Tampere, Finland
| | - Anders Wickbom
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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Charbonneau H, Savy S, Savy N, Pasquié M, Mayeur N, Angles O, Balech V, Berthelot AL, Croute-Bayle M, Decramer I, Duterque D, Julien V, Mallet L, M'rini M, Quedreux JF, Richard B, Sidobre L, Taillefer L, Thibaud A, Abouliatim I, Berthoumieu P, Garcia O, Soula P, Vahdat O, Breil C, Brunel P, Sciacca G. Comprehensive perioperative blood management in patients undergoing elective bypass cardiac surgery: Benefit effect of health care education and systematic correction of iron deficiency and anemia on red blood cell transfusion. J Clin Anesth 2024; 98:111560. [PMID: 39146724 DOI: 10.1016/j.jclinane.2024.111560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 07/09/2024] [Accepted: 07/17/2024] [Indexed: 08/17/2024]
Abstract
STUDY OBJECTIVE The aim of this study was to investigate the efficacy of a two-step patient blood management (PBM) program in red blood cell (RBC) transfusion requirements among patients undergoing elective cardiopulmonary bypass (CPB) surgery. DESIGN Prospective, non-randomized, two-step protocol design. SETTING Cardiac surgery department of Clinique Pasteur, Toulouse, France. PATIENTS 897 patients undergoing for elective CPB surgery. INTERVENTIONS We conducted a two-steps protocol: PBMe and PBMc. PBMe involved a short quality improvement program for health care workers, while PBMc introduced a systematic approach to pre- and postoperative correction of deficiencies, incorporating iron injections, oral vitamins, and erythropoiesis-stimulating agents. MEASUREMENTS The PBM program's effectiveness was evaluated through comparison with a pre-PBM retrospective cohort after propensity score matching. The primary objective was the proportion of patients requiring RBC transfusions during their hospital stay. Secondary objectives were also analyzed. MAIN RESULTS After matching, 343 patients were included in each group. Primary outcomes were observed in 35.7% (pre-PBM), 26.7% (PBMe), and 21.1% (PBMc) of patients, resulting in a significant reduction (40.6%) in the overall RBC transfusion rate. Both the PBMe and PBMc groups exhibited significantly lower risks of RBC transfusion compared to the pre-PBM group, with adjusted odds ratios of 0.59 [95% CI 0.44-0.79] and 0.44 [95% CI 0.32-0.60], respectively. Secondary endpoints included reductions in transfusions exceeding 2 units, total RBC units transfused, administration of allogeneic blood products, and total bleeding volume recorded on Day 1. There were no significant differences noted in mortality rates or the duration of hospital stays. CONCLUSIONS This study suggests that health care education and systematic deficiency correction are associated with reduced RBC transfusion rates in elective CPB surgery. However, further randomized, controlled studies are needed to validate these findings and refine their clinical application.
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Affiliation(s)
- Hélène Charbonneau
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Stéphanie Savy
- Clinical Research Committee, Clinique Pasteur, Toulouse, France.
| | - Nicolas Savy
- Toulouse Institute of Mathematics, UMR5219 - University of Toulouse; CNRS - UPS IMT, Toulouse, France.
| | - Marie Pasquié
- Clinical Research Committee, Clinique Pasteur, Toulouse, France.
| | - Nicolas Mayeur
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Olivier Angles
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Vincent Balech
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Anne-Laure Berthelot
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Madeleine Croute-Bayle
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Isabelle Decramer
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - David Duterque
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Valerie Julien
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Laurent Mallet
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Mimoun M'rini
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Jean-François Quedreux
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Benoit Richard
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Laurent Sidobre
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Laurence Taillefer
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Adrien Thibaud
- Department of Anesthesiology and Intensive Care Unit, Clinique Pasteur, Toulouse, France.
| | - Issam Abouliatim
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Pierre Berthoumieu
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Olivier Garcia
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Philippe Soula
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Olivier Vahdat
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Claude Breil
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Pierre Brunel
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
| | - Giovanni Sciacca
- Department of Cardiothoracic and Vascular Surgery, Clinique Pasteur, Toulouse, France.
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He J, Liu X, Zhou L, Chen C, Liu J, Yan M, Ming Y, Wu Z, Guo Y, Liu J, Du L. Association between perioperative hemoglobin decrease and outcomes of transfusion in patients undergoing on-pump cardiac surgery: An observational study from two Chinese heart centers. Heliyon 2024; 10:e37843. [PMID: 39347435 PMCID: PMC11437932 DOI: 10.1016/j.heliyon.2024.e37843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/31/2024] [Accepted: 09/11/2024] [Indexed: 10/01/2024] Open
Abstract
Background It is unclear how perioperative hemoglobin decrease (ΔHb) influences the balance between risks and benefits of red blood cell transfusion after cardiac surgery. Methods We retrospectively analyzed data on 8186 adults who underwent valve surgery and/or coronary artery bypass grafting under cardiopulmonary bypass at two large cardiology centers. We explored the potential association of ΔHb, defined relative to the preoperative level and postoperative nadir, with a composite outcome of in-hospital mortality, myocardial infarction, stroke, and acute kidney injury using multivariable logistic regression, restricted cubic spline, and piecewise-linear models. Results Among 6316 patients without preoperative anemia, ΔHb ≥ 50 % was associated with an elevated risk of the composite outcome [adjusted odds ratio (aOR) 1.95, 95 % confidence interval (CI) 1.81-2.35]. Among 869 patients without preoperative anemia and with ΔHb ≥ 50 %, postoperative transfusion of no more than four units of red blood cell appeared to decrease the risk of the composite outcome, whereas transfusion of more than six units increased risk. Among 5447 patients without preoperative anemia and with ΔHb < 50 %, postoperative transfusion appeared not to decrease the risk of the composite outcome. Among 1870 patients with preoperative anemia, ΔHb ≥ 30 % significantly increased the risk of the composite outcome (aOR 1.61, 95 % CI 1.23-2.10), and this risk might be moderated by postoperative transfusion of no more than four units of red blood cell, but increased by transfusion of more than six units. Conclusions ΔHb may influence the balance between risks and benefits of red blood cell transfusion after cardiac surgery.
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Affiliation(s)
- Junhui He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xinhao Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Changwei Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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4
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Liu S, Su L, Jiang H, Wei Z, Yang B, Xie J, Guo A, He H, Zhu W, Long Y. Full connected layer model with self-attention to hourly predict heparin dosage for perioperative cardiac surgery patients. Comput Biol Med 2024; 182:109085. [PMID: 39244960 DOI: 10.1016/j.compbiomed.2024.109085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 07/04/2024] [Accepted: 08/28/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Anticoagulant therapy for patients who underwent cardiac surgery is a challenge. Both inadequate and excessive anticoagulation can cause fatal complications. Previous studies failed to provide real-time guidance for heparin pump speed adjustment. This study intended to provide a quantitative prediction model to optimize heparin dosage for cardiac surgery patients based on machine learning method. METHODS Patients who underwent cardiac surgery and admitted to intensive care unit in Peking Union Medical College Hospital (PUMCH) from January 2013 to December 2023 were retrospectively analyzed. In order to reach target activated partial thromboplastin time (aPTT), linear regression, SVM, XGBoost, LSTM, GRU, FC (Full Connected Layer) and FC + self-attention models were used to make hourly adjustment recommendation for administrations of heparin pump speed. Mean absolute square, and absolute percentage errors were used to evaluate the reliability of the models. SHAP method and feature cumulative effect were used to interpret the features of the FC + self-attention model. Safety and economic evaluation based on clinical compliance of this real-world data-oriented model was further analyzed. RESULTS A total of 1080 patients including 112,554 heparin pump administrations were included in this study. Among seven candidate models, FC + self-attention model yielded the lowest mean absolute error of 0.9388 and 1.1325 in test and validation cohort. Gap to target aPTT, thrombin time, history of coronary heart disease, previous duration of arterial fibrillation and prothrombin activity were identified as important features affecting heparin adjustment. High compliance to FC + self-attention model may increase percentage of normal therapeutic time and decrease supratherapeutic therapeutic time and reducing blood draw until two consecutive normal therapeutic stabilization of aPTT. CONCLUSIONS This FC + self-attention model is potentially applicable for giving recommendation for healthcare providers to optimize heparin dosage for cardiac surgery patients.
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Affiliation(s)
- Shengjun Liu
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Huizhen Jiang
- Department of Information Center, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Zhenhao Wei
- Goodwill Hessian Health Technology Co. Ltd, Beijing, China
| | - Bingqing Yang
- Goodwill Hessian Health Technology Co. Ltd, Beijing, China
| | - Jiatong Xie
- Goodwill Hessian Health Technology Co. Ltd, Beijing, China
| | - Anhui Guo
- Department of General Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China
| | - Weiguo Zhu
- Department of General Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China.
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, China.
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5
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Patterson AK, Butt AL, Tanaka KA, Harville LE. Proceed With Caution when Comparing Recombinant Factor VIIa to Prothrombin Complex Concentrate in Cardiac Surgical Patients. J Pharm Pract 2024:8971900241273302. [PMID: 39120523 DOI: 10.1177/08971900241273302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Affiliation(s)
- Amy K Patterson
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Lacy E Harville
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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6
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Moser N, Omar MA, Koshman SL, Lin M, Youngson E, Kent W, Harten C. Direct oral anticoagulants for atrial fibrillation in early postoperative valve repair or bioprosthetic replacement. J Thorac Cardiovasc Surg 2024; 168:523-532.e3. [PMID: 37061910 DOI: 10.1016/j.jtcvs.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/30/2023] [Accepted: 03/07/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE Despite increased use of direct oral anticoagulants (DOACs), limited evidence guides their use in the early postoperative period after bioprosthetic valve implantation in patients with atrial fibrillation. Our objective was to describe the efficacy and safety of DOACs and warfarin in the first 3 months after surgical bioprosthetic valve replacement or repair in patients with atrial fibrillation. METHODS This was a retrospective, registry-informed cohort study of surgical patients who underwent bioprosthetic valve replacement or repair, had concomitant atrial fibrillation and received oral anticoagulation at discharge. The primary efficacy outcome was a composite of death, ischemic stroke, transient ischemic attack, and systemic embolism; the primary safety outcome was a composite of major bleeding. Key secondary outcomes were comparative analyses of primary outcomes, temporal anticoagulation prescribing patterns, and 30-day readmission rates. RESULTS A total of 1743 patients were included. Of the 570 patients in the DOAC group, 17 (2%) met the composite efficacy outcome and 55 (10%) met the composite safety outcome. Of the 1173 patients receiving warfarin, 41 (3%) and 114 (10%) met the composite efficacy and safety outcomes, respectively. Comparative secondary analysis was not statistically significant for either the efficacy (adjusted odds ratio, 0.85; 95% confidence interval, 0.46-1.55, P = .59) or safety (adjusted odds ratio, 0.94; 95% confidence interval, 0.66-1.34, P = .76) outcomes. The 30-day readmission rates were similar between both groups. CONCLUSIONS Our results suggest DOACs may be safe and effective alternatives to warfarin in the early postoperative period after valve repair or surgical bioprosthetic replacement. Confirmation awaits adequately powered prospective studies.
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Affiliation(s)
- Nils Moser
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada.
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - William Kent
- Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Cheryl Harten
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
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Saour M, Blin C, Zeroual N, Mourad M, Amico M, Gaudard P, Picot MC, Colson PH. Impact of a bundle of care (intravenous iron, erythropoietin and transfusion metabolic adjustment) on post-operative transfusion incidence in cardiac surgery: a single-centre, randomised, open-label, parallel-group controlled pilot trial. THE LANCET REGIONAL HEALTH. EUROPE 2024; 43:100966. [PMID: 39022429 PMCID: PMC11254177 DOI: 10.1016/j.lanepe.2024.100966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 07/20/2024]
Abstract
Background Red blood cell (RBC) transfusions are frequent in patients after cardiac surgery. This study assessed whether a bundle of care including pre-operative and post-operative administration of erythropoietin (EPO) with intravenous iron supplementation, and restrictive transfusion adjusted for ScvO2 could result in reduced postoperative transfusions. Methods In this single-centre, randomised, open-label, parallel-group controlled pilot study, patients undergoing elective cardiac surgery with high risk of transfusion in a University Hospital were enrolled by the investigator and the randomisation procedure using a central internet-based system was made by the clinical research assistant. Since the trial was open-label, no masking was used. Patients were assigned (1:1) to either the STOP group (40,000 IU subcutaneous EPO combined with 20 mg/kg intravenous ferric carboxymaltose if Hb < 13 g/dL the day before surgery or at ICU admission, and RBC transfusion if Hb ≤ 8 g/dL and ScvO2 ≤ 65%, or additional EPO dose if 8 < Hb < 13 g/dL) or to the control group (RBC transfusion if Hb ≤ 8 g/dL, or, if 8 < Hb < 13 g/dL, intravenous iron sucrose 200 mg or 300 mg according to weight). Primary outcome was the incidence of postoperative RBC transfusion up to hospital discharge or postoperative day 28. The trial is registered with ClinicalTrials.gov, NCT04141631. Findings Between Jan 20, 2020, and Sept 6, 2022, among 128 patients enrolled, 123 (male, 54.4%, 67/123) were included in the full analysis set: 62 in the STOP group and 61 in the control group. Nine patients (14.5%, 9/62) in the STOP group required RBC transfusion vs 19 (31.2%, 19/61) in the control group (odds ratio 0.37 [95% CI: 0.15-0.91], p = 0.03). The median length of follow up to transfusion was 2.6 days (1.5; 4.6) and 3.3 (1.6; 4.2) in control and STOP groups respectively (p = 0.61). Interpretation The bundle of care may reduce postoperative RBC transfusion. The findings should be taken with caution due to the unblinded and exploratory nature of the study. Funding University of Montpellier Hospital and Vifor Pharma.
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Affiliation(s)
- Marine Saour
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Cinderella Blin
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Norddine Zeroual
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Marc Mourad
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Maïlis Amico
- Clinical Research and Epidemiology Unit, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Philippe Gaudard
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
- University of Montpellier, CNRS (Scientific Research Centre), INSERM, PhyMedExp, Montpellier, France
| | - Marie-Christine Picot
- Clinical Research and Epidemiology Unit, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
| | - Pascal H. Colson
- Anaesthesiology and Critical Care Medicine Department, Arnaud de Villeneuve Hospital, University of Montpellier Hospital Centre, University of Montpellier, Montpellier, France
- University of Montpellier, CNRS (Scientific Research Centre), INSERM, Functional Genome Unit, Montpellier, France
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8
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Kim HJ, Shin HJ, Lee SW, Heo S, Lee SH, Kim JE, Son HS, Jung JS. Improvement of Transfusion Practice in Cardiothoracic Surgery Through Implementing a Patient Blood Management Program. J Chest Surg 2024; 57:390-398. [PMID: 38584377 PMCID: PMC11240097 DOI: 10.5090/jcs.23.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 04/09/2024] Open
Abstract
Background In this study, we examined the impact of a patient blood management (PBM) program on red blood cell (RBC) transfusion practices in cardiothoracic surgery. Methods The PBM program had 3 components: monitoring transfusions through an order communication system checklist, educating the medical team about PBM, and providing feedback to ordering physicians on the appropriateness of transfusion. The retrospective analysis examined changes in the hemoglobin levels triggering transfusion and the proportions of appropriate RBC transfusions before, during, and after PBM implementation. Further analysis was focused on patients undergoing cardiac surgery, with outcomes including 30-day mortality, durations of intensive care unit and hospital stays, and rates of pneumonia, sepsis, and wound complications. Results The study included 2,802 patients admitted for cardiothoracic surgery. After the implementation of PBM, a significant decrease was observed in the hemoglobin threshold for RBC transfusion. This threshold dropped from 8.7 g/dL before PBM to 8.3 g/dL during the PBM education phase and 8.0 g/dL during the PBM feedback period. Additionally, the proportion of appropriate RBC transfusions increased markedly, from 23.9% before PBM to 34.9% and 58.2% during the education and feedback phases, respectively. Among the 381 patients who underwent cardiac surgery, a significant reduction was noted in the length of hospitalization over time (p<0.001). However, other clinical outcomes displayed no significant differences. Conclusion PBM implementation effectively reduced the hemoglobin threshold for RBC transfusion and increased the rate of appropriate transfusion in cardiothoracic surgery. Although transfusion practices improved, clinical outcomes were comparable to those observed before PBM implementation.
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Affiliation(s)
- Hee Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Suk Woo Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seonyeong Heo
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seung Hyong Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ji Eon Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
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9
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Bratt S, Dimberg A, Kastengren M, Lilford RD, Svenarud P, Sartipy U, Franco-Cereceda A, Dalén M. Bleeding in minimally invasive versus conventional aortic valve replacement. J Cardiothorac Surg 2024; 19:349. [PMID: 38907320 PMCID: PMC11191138 DOI: 10.1186/s13019-024-02667-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/20/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Observational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting. METHODS This was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events. RESULTS Out of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition (p = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group (p = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion (p = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding. CONCLUSIONS Minimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy. CLINICAL TRIAL REGISTRATION http://www. CLINICALTRIALS gov . Unique identifier: NCT02272621.
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Affiliation(s)
- Sorosh Bratt
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Axel Dimberg
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Kastengren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Robert D Lilford
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
| | - Peter Svenarud
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, SE-17176, Sweden.
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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10
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Ozawa S, Ozawa-Morriello J, Rock R, Sromoski M, Walbolt S, Hall T, Pearse BL. Patient Blood Management as an Emerging Concept in Quality: The Role of Nurses. J Nurs Care Qual 2024; 39:129-135. [PMID: 37350618 DOI: 10.1097/ncq.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Transfusion of blood components has long been considered lifesaving therapy. While blood transfusion may be clinically indicated as a treatment option for some patients, the benefits of transfusion in asymptomatic, hemodynamically stable patients are questionable. PROBLEM Blood component transfusion is routinely used as a default therapy when not clinically indicated, increasing the risk of poor patient outcomes, adverse events, pressures on blood supply and availability, and increased health care costs. APPROACH Nurses have the responsibility to advocate for patients and reduce/avoid unnecessary blood transfusion through the implementation of patient blood management (PBM). The PBM paradigm includes treatment of anemia, minimizing blood loss and bleeding, optimization of coagulation, and employing true patient-centered decision making. CONCLUSIONS PBM should become the standard of care with the goal of improving health care quality and patient outcomes while using the multidisciplinary team for its implementation. As advocates for their patients, nurses can play a major role in the development, implementation, and promotion of PBM.
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Affiliation(s)
- Sherri Ozawa
- Author Affiliations: Deparment of Patient Blood Management (Mss Ozawa and Hall), Accumen Incorporated, Phoenix, Arizona; Department of Clinical Training and Evaluation Center, The University of Western Australia, Perth, Western Australia (Ms Ozawa); Department of Bloodless Medicine and Patient Blood Management, Englewood Health, Englewood, New Jersey (Ms Ozawa and Mr Ozawa-Morriello); Society for the Advancement of Patient Blood Management (SABM), Mt Royal, New Jersey (Ms Ozawa, Rock, Sromoski, Walbolt, and Hall and Mr Ozawa-Morriello); Department of Patient Blood Management and Center for Bloodless Medicine, Geisinger Health System, Danville, Pennsylvania (Mr Ozawa-Morriello and Ms Sromoski); Departments of Bloodless Medicine and Surgery, and Cardiac Surgery Services, Hackensack University Medical Center, Hackensack, New Jersey (Mr Ozawa-Morriello); Department of Patient Blood Management, Alberta Health Services, Calgary, Alberta, Canada (Ms Rock); Association for the Advancement of Blood & Biotherapies (AABB), Bethesda, Maryland (Ms Sromoski); ProMedica Health System, Toledo, Ohio (Ms Walbolt); Department of Patient Blood Management The Prince Charles Hospital, Brisbane, Queensland, Australia (Dr Pearse); and Department of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia (Dr Pearse)
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11
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Krahn KM, Koshman SL, Wang T, Chen J, Bungard TJ, Zhou JS, Omar MA, Cowley EC. Anticoagulant Prescribing Patterns in New-Onset Atrial Fibrillation After Cardiac Surgery. Ann Thorac Surg 2024; 117:859-865. [PMID: 38081497 DOI: 10.1016/j.athoracsur.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 11/08/2023] [Accepted: 11/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery and is associated with an increased risk of thromboembolic stroke. Recommendations regarding the optimal anticoagulant, timing of initiation, and duration of therapy remain uncertain. METHODS Administrative databases were used to include adult patients who presented with POAF after cardiac surgery between January 1, 2015, and December 31, 2020. Key exclusion criteria included preexisting atrial fibrillation, mechanical valve replacement, or anticoagulant prescription fill within 6 months before the index admission. RESULTS A total of 3214 of patients were included, and 878 (27.3%) were prescribed an oral anticoagulant (OAC) on discharge, with 536 (61%) prescribed warfarin and 342 (39%) prescribed a direct OAC. More than half of the patients (56.1%) stopped their OAC by 6 months. There was no difference in stroke or systemic embolism at 30 days, 3 months, or 6 months between those with and without anticoagulation prescribed. However, those on any OAC had higher rates of any bleeding at all time points. CONCLUSIONS A minority of patients who presented with POAF after cardiac surgery were prescribed OAC, with warfarin being the most common agent. OAC initiation was associated with increased bleeding risk, warranting special consideration when assessing a patient's risk of stroke with the increased risk of bleeding, particularly in the postoperative period.
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Affiliation(s)
- Kaitlyn M Krahn
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Sheri L Koshman
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Ting Wang
- Data and Research Services, Alberta Strategy for Patient Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - June Chen
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Tammy J Bungard
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Jian Song Zhou
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada
| | - Emily C Cowley
- Department of Pharmacy, Alberta Health Services, Edmonton, Alberta, Canada.
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12
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Kaserer A, Schöchl H, Spahn DR. Navigating Critical Waters: The Importance of a Systematic Coagulation Algorithm in the Intensive Care Unit. Anesth Analg 2024; 138:496-498. [PMID: 38364241 DOI: 10.1213/ane.0000000000006865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Affiliation(s)
- Alexander Kaserer
- From the Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Herbert Schöchl
- Ludwig Boltzmann Institute for Traumatology, Vienna and Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Donat R Spahn
- Formerly, Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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13
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Ledergerber K, Hollinger A, Zimmermann S, Todorov A, Trutmann M, Gallachi L, Gschwandtner LA, Ryser LA, Gebhard CE, Bolliger D, Buser A, Tsakiris DA, Siegemund M. Impact of Additional Administration of von Willebrand Factor Concentrates to Thrombocyte Transfusion in Perioperative Bleeding in Cardiac Surgery. Transfus Med Hemother 2024; 51:22-31. [PMID: 38314243 PMCID: PMC10836859 DOI: 10.1159/000530810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/16/2023] [Indexed: 02/06/2024] Open
Abstract
Background Von Willebrand factor (vWF) is an important part of blood coagulation since it binds platelets to each other and to endothelial cells. In traumatic and surgical haemorrhage, both blood cells and plasmatic factors are consumed, leading to consumption coagulopathy and fluid resuscitation. This often results in large amounts of crystalloids and blood products being infused. Additional administration of vWF complex and platelets might mitigate this problem. We hypothesize that administration of vWF concentrate additionally to platelet concentrates reduces blood loss and the amount of blood products (platelets, red blood cells [RBC], fresh frozen plasma [FFP]) administered. Methods We conducted a monocentric 6-year retrospective data analysis of cardiac surgery patients. Included were all patients receiving platelet concentrates within 48 h postoperatively. Patients who additionally received vWF concentrates were allocated to the intervention group and all others to the control group. Groups were compared in mixed regression models correcting for known confounders, based on nearest neighbour propensity score matching. Primary endpoints were loss of blood (day one and two) and amount of needed blood products on day one and two (platelets, RBC, FFP). Secondary endpoints were intensive care unit (ICU) and in-hospital length of stay, ICU and in-hospital mortality, and absolute difference of platelet counts before and after treatment. Results Of 497 patients analysed, 168 (34%) received vWF concentrates. 121 patients in both groups were considered for nearest neighbour matching. Patients receiving additional vWF were more likely to receive more blood products (RBC, FFP, platelets) in the first 24 h after surgery and had around 200 mL more blood loss at the same time. Conclusion In this retrospective analysis, no benefit in additional administration of vWF to platelet concentrates on perioperative blood loss, transfusion requirement (platelets, RBC, FFP), length of stay, and mortality could be found. These findings should be verified in a prospective randomized controlled clinical trial (www.clinicaltrials.gov identifier NCT04555785).
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Affiliation(s)
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | | | - Atanas Todorov
- Cardiovascular Gender Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Maren Trutmann
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Laura Gallachi
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | | | | | - Caroline Eva Gebhard
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Daniel Bolliger
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
- Regional Blood Transfusion Service of the Swiss Red Cross, Basel, Switzerland
| | - Dimitrios Athanasios Tsakiris
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Transfusion Medicine and Hematology, Basel University Hospital, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
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14
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Guinn N, Tanaka K, Erdoes G, Kwak J, Henderson R, Mazzeffi M, Fabbro M, Raphael J. The Year in Coagulation and Transfusion: Selected Highlights from 2022. J Cardiothorac Vasc Anesth 2023; 37:2435-2449. [PMID: 37690951 DOI: 10.1053/j.jvca.2023.08.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.
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Affiliation(s)
- Nicole Guinn
- Chief of Neuroanesthesiology, Otolaryngology and Offsite Anesthesia Division, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Jenny Kwak
- Division of Cardiac Anesthesia, Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, Maywood, IL
| | - Reney Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia Medical Center, Charlottesville, VA
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami, Miami, FL
| | - Jacob Raphael
- Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA.
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15
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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16
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Zheng Q, Zhang L, Liu T, Guan D, Feng W, Luo S. Association of prothrombin complexe concentrate with venous thrombosis after cardiac surgery: a case-control study. Front Cardiovasc Med 2023; 10:1237227. [PMID: 37781297 PMCID: PMC10540229 DOI: 10.3389/fcvm.2023.1237227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
Background Prothrombin complex concentrate (PCC) enhances coagulation and controls bleeding. We aimed to assess whether perioperative infusion of PCC is associated with venous thrombosis after cardiac surgery. Methods We conducted a case-control study of patients undergoing cardiac surgery at our hospital in 2021. Multivariate logistic regression was used to assess the correlation between perioperative PCC infusion and postoperative venous thrombosis in cardiac surgery. Stratified analysis was also performed by age, hospitalization days, and whether warfarin, warfarin combined with heparin, warfarin combined with antiplatelet drugs were used postoperatively. Results Data from 161 patients undergoing cardiac surgery were included in the analysis. Of these, 37 (23.0%) patients in the case group developed venous thrombosis, and 124 (77.0%) patients in the control group did not develop venous thrombosis. In the analysis without adjustment for confounders (model 1), perioperative PCC infusion significantly increased the risk of postoperative venous thrombosis (OR: 3.10, 95% CI: 1.26-7.59, P = 0.0135). In the model analysis adjusted for sex, age, and hospitalization days (model 2), perioperative PCC infusion was no longer significantly associated with the risk of postoperative venous thrombosis (OR: 1.76, 95% CI: 0.56-7.59, P = 0.3317). In the fully adjusted model (model 3), there was a marginally significant association between perioperative infusion of PCC and the risk of postoperative venous thrombosis (OR: 0.03, 95% CI: 0.00-1.23, P = 0.0637). Conclusions Our findings show no significant association between perioperative PCC infusion in cardiac surgery and the development of postoperative venous thrombosis. Randomized controlled trials are needed to determine the causal relationship between perioperative PCC infusion and venous thrombosis in cardiac surgery.
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Affiliation(s)
| | | | | | | | | | - Saisai Luo
- Department of Pharmacy, The First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, China
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17
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Vitolo M, Mei DA, Cimato P, Bonini N, Imberti JF, Cataldo P, Menozzi M, Filippini T, Vinceti M, Boriani G. Cardiac Surgery in Jehovah's Witnesses Patients and Association With Peri-Operative Outcomes: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101789. [PMID: 37172869 DOI: 10.1016/j.cpcardiol.2023.101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Strategies for blood conservation, coupled with a careful preoperative assessment, may be applied to Jehovah's Witnesses (JW) patients who are candidates for cardiac surgery interventions. There is a need to assess clinical outcomes and safety of bloodless surgery in JW patients undergoing cardiac surgery. METHODS We performed a systematic review and meta-analysis of studies comparing JW patients with controls undergoing cardiac surgery. The primary endpoint was short-term mortality (in-hospital or 30-day mortality). Peri-procedural myocardial infarction, re-exploration for bleeding, pre-and postoperative Hb levels and cardiopulmonary bypass (CPB) time were also analyzed. RESULTS A total of 10 studies including 2,302 patients were included. The pooled analysis showed no substantial differences in terms of short-term mortality among the two groups (OR 1.13, 95% CI 0.74-1.73, I2=0%). There were no differences in peri-operative outcomes among JW patients and controls (OR 0.97, 95% CI 0.39-2.41, I2=18% for myocardial infarction; OR 0.80, 95% CI 0.51-1.25, I2=0% for re-exploration for bleeding). JW patients had a higher level of preoperative Hb (Standardized Mean Difference [SMD] 0.32, 95% CI 0.06-0.57) and a trend toward a higher level of postoperative Hb (SMD 0.44, 95% CI -0.01-0.90). A slightly lower CPB time emerged in JWs compared with controls (SMD -0.11, 95% CI -0.30-0.07). CONCLUSIONS JW patients undergoing cardiac surgery, with avoidance of blood transfusions, did not have substantially different peri-operative outcomes compared with controls, with specific reference to mortality, myocardial infarction, and re-exploration for bleeding. Our results support the safety and feasibility of bloodless cardiac surgery, applying patient blood management strategies.
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Affiliation(s)
- Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide A Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Paolo Cimato
- Department of Cardiac Surgery, Villa Torri Hospital, GVM Care & Research, Bologna, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Cataldo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Matteo Menozzi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tommaso Filippini
- Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia Modena Italy; School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Marco Vinceti
- Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia Modena Italy; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
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18
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Colson PH, Gaudard P, Meunier C, Seguret F. Impact of Red Blood Cell Transfusion on In-hospital Mortality of Isolated Coronary Artery Bypass Graft Surgery: A Retrospective Observational Study of French Nationwide 3-year Cohort. Ann Surg 2023; 278:e184-e189. [PMID: 35762599 DOI: 10.1097/sla.0000000000005488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the relationship between red blood cell (RBC) transfusion exposure and in-hospital mortality after isolated coronary artery bypass graft (CABG) surgery. BACKGROUND RBC transfusion was commonly used to treat anemia in isolated CABG surgery, but transfusion was found an independent risk factor of postoperative mortality; recent guidelines on patient blood management strategy issued in the last decade may have changed transfusion incidence and related mortality. METHODS A retrospective cohort study was conducted from the National database on patients' hospital discharge reports. Consecutive adult patients who underwent isolated CABG surgery in France from January 1, 2016, to December 31, 2018, were included. The primary outcome was the in-hospital mortality rate. RBC transfusion during the hospital stay was identified by specific codes and ordered as categorical variables (no, moderate, or massive transfusion). RESULTS A total of 37,498 participants were studied [mean (SD) age, 66.5 (9.6) years, 31,587 (84.2%) were men]. In-hospital mortality rate was 1.45% (n=541) and RBC transfusion rate was 9.4% (n=3521). In-hospital deaths were more frequent among transfused patients [1.06% (361) if no transfusion up to 10.2% (n=113) if massive transfusion]. After adjustment for confounding variables, RBC transfusion remained a significant independent factor of in-hospital mortality: odds ratio=1.66 (95% confidence interval: 1.27-2.19, P <0.001) for moderate transfusion, 6.40 (95% confidence interval: 5.07-8.09, P <0.001) if massive. CONCLUSIONS AND RELEVANCE Despite a modest patients' exposure to transfusion, this study suggests that RBC administration is an independent factor of in-hospital mortality in isolated CABG surgery.
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Affiliation(s)
- Pascal H Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
- Montpellier University, INSERM, CNRS, Institute of Functional Genomics, Montpellier, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
- Montpellier University, INSERM, CNRS, PhyMedExp, Montpellier, France
| | - Charles Meunier
- Unit of Evaluation and Epidemiologic Studies on National Hospitalization Activity Databases, Department of Epidemiology, Biostatistics and Medical Information, Montpellier University Hospital, Montpellier, France
| | - Fabienne Seguret
- Unit of Evaluation and Epidemiologic Studies on National Hospitalization Activity Databases, Department of Epidemiology, Biostatistics and Medical Information, Montpellier University Hospital, Montpellier, France
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19
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Gopal R, Md Shakhih MF, Sahalan M, Lee TC, Hermawan H, Sivalingam S, Kadiman S, Saidin S. Immobilization of blood coagulant factor VII on polycaprolactone membrane through polydopamine grafting. Colloids Surf B Biointerfaces 2023; 228:113390. [PMID: 37315506 DOI: 10.1016/j.colsurfb.2023.113390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
Postoperative bleeding following cardiac surgeries is still an issue that deranges the medical resources and cost. The oral and injection administrations of blood coagulation protein, Factor VII (FVII), is effective to stop the bleeding. However, its short half-life has limited the effectiveness of this treatment and frequent FVII intake may distress the patients. Instead, incorporating FVII into synthetic biodegradable polymers such as polycaprolactone (PCL) that is commonly used in drug delivery applications should provide a solution. Therefore, this study aimed to immobilize FVII on PCL membranes through a cross-linkage polydopamine (PDA) grafting as an intermediate layer. These membranes are intended to provide a solution for cardiac bleeding in coagulating blood and sealing the sutured region. The membranes were evaluated in terms of its physio-chemical properties, thermal behavior, FVII release profile and biocompatibility properties. The ATR-FTIR was used to analyze the chemical functionalities of the membranes. Further validation was done with XPS where the appearances of 0.45 ± 0.06% sulfur composition and C-S peak have confirmed the immobilization of FVII on the PCL membranes. The cross-linked FVIIs were viewed in spherical immobilization on the PCL membranes with a size range between 30 and 210 nm. The surface roughness and hydrophilicity of the membranes were enhanced with a slight shift of melting temperature. The PCL-PDA-FVII0.03 and PCL-PDA-FVII0.05 membranes, with wide area of FVII immobilization released approximately only 22% of FVII into the solution within 60 days period and, it is found that the PCL-PDA-FVIIx membranes projected the Higuchi release model with non-Fickian anomalous transport. While the cytotoxic and hemocompatibility analyses showed advance cell viability, identical coagulation time and low hemolysis ratio on the PCL-PDA-FVIIx membranes. The erythrocytes were viewed in polyhedrocyte coagulated structure under SEM visualization. These results validate the biocompatibility of the membranes and its ability to prolong blood coagulation, thus highlighting its potential application as cardiac bleeding sealant.
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Affiliation(s)
- Rathosivan Gopal
- Department of Biomedical Engineering and Health Sciences, Faculty of Electrical Engineering Universiti Teknologi Malaysia, 81310 UTM Johor Bahru, Johor, Malaysia
| | - Muhammad Faiz Md Shakhih
- Department of Biomedical Engineering and Health Sciences, Faculty of Electrical Engineering Universiti Teknologi Malaysia, 81310 UTM Johor Bahru, Johor, Malaysia
| | - Mariaulpa Sahalan
- Department of Biomedical Engineering and Health Sciences, Faculty of Electrical Engineering Universiti Teknologi Malaysia, 81310 UTM Johor Bahru, Johor, Malaysia
| | - Te Chuan Lee
- Department of Production and Operation Management, Faculty of Technology Management and Business, Universiti Tun Hussein Onn Malaysia, Parit Raja 86400, Batu Pahat, Johor, Malaysia
| | - Hendra Hermawan
- Department of Mining, Metallurgical and Materials Engineering, Laval University, Quebec City G1V 0A6, Canada
| | - Sivakumar Sivalingam
- Department of Cardiothoracic Surgery, Institut Jantung Negara, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Suhaini Kadiman
- Department of Clinical Research, Institut Jantung Negara, 145 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia
| | - Syafiqah Saidin
- Department of Biomedical Engineering and Health Sciences, Faculty of Electrical Engineering Universiti Teknologi Malaysia, 81310 UTM Johor Bahru, Johor, Malaysia; IJN-UTM Cardiovascular Engineering Centre, Institute of Human Centered Engineering, Universiti Teknologi Malaysia, 81310 UTM Johor Bahru, Johor, Malaysia.
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20
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Rozental O, Cushing MM, Shander A, Isbister JP, Lasocki S, Meybohm P, Muñoz M, Spahn DR, Weiniger CF, Trentino KM, Girardi NI. Penny-wise and pound-foolish: the challenges of preoperative anaemia management. Br J Anaesth 2023:S0007-0912(23)00231-3. [PMID: 37244835 DOI: 10.1016/j.bja.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/29/2023] Open
Abstract
The timely correction of anaemia before major surgery is important for optimising perioperative patient outcomes. However, multiple barriers have precluded the global expansion of preoperative anaemia treatment programmes, including misconceptions about the true cost/benefit ratio for patient care and health system economics. Institutional investment and buy-in from stakeholders could lead to significant cost savings through avoided complications of anaemia and red blood cell transfusions, and through containment of direct and variable costs of blood bank laboratories. In some health systems, billing for iron infusions could generate revenue and promote growth of treatment programmes. The aim of this work is to galvanise integrated health systems worldwide to diagnose and treat anaemia before major surgery.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA.
| | - Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, TeamHealth, Englewood Health, Englewood, NJ, USA
| | - James P Isbister
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Angers, Université d'Angers, Angers, France
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Manuel Muñoz
- Peri-operative Transfusion Medicine, Department of Surgical Specialties, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital of Zurich, Zurich, Switzerland
| | - Carolyn F Weiniger
- Department of Anesthesia, Intensive Care and Pain, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kevin M Trentino
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Natalia I Girardi
- Department of Anesthesiology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
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21
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Spadaccio C, Rose D, Nenna A, Taylor R, Bittar MN. Early Re-Exploration versus Conservative Management for Postoperative Bleeding in Stable Patients after Coronary Artery Bypass Grafting: A Propensity Matched Study. J Clin Med 2023; 12:jcm12093327. [PMID: 37176767 PMCID: PMC10179715 DOI: 10.3390/jcm12093327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Postoperative bleeding requiring re-exploration in cardiac surgery has been associated with complications impacting short-term outcomes and perioperative survival. Many aspects of decision-making for re-exploration still remain controversial, especially in hemodynamically stable patients with significant but not acutely cumulating chest drain output. We investigated the impact of re-exploratory surgery on short-term outcomes in a "borderline population" of CABG patients who experienced significant non-acute bleeding, but that were not in critically hemodynamic unstable conditions. METHODS A prospectively collected database of 8287 patients undergoing primary isolated elective CABG was retrospectively interrogated. A population of hemodynamically stable patients experiencing significant non-acute or rapidly cumulating bleeding (>1000 mL of blood loss in 12 h, <200 mL per hour in the first 5 h) with normal platelet and coagulation tests was identified (N = 1642). Patients belonging to this group were re-explored (N = 252) or treated conservatively (N = 1390) based on the decision of the consultant surgeon. Clinical outcomes according to the decision-making strategy were compared using a propensity score matching (PSM) approach. RESULTS After PSM, reoperated patients exhibited significantly higher overall blood product consumption (88.4% vs. 52.6% for red packed cells, p = 0.001). The reoperated group experienced higher rates of respiratory complications (odds ratio 5.8 [4.29-7.86] with p = 0.001 for prolonged ventilation), prolonged stay in intensive care unit (coefficient 1.66 [0.64-2.67] with p = 0.001) and overall length of stay in hospital (coefficient 2.16 [0.42-3.91] with p = 0.015) when compared to conservative management. Reoperated patients had significantly increased risk of multiorgan failure (odds ratio 4.59 [1.37-15.42] with p = 0.014) and a trend towards increased perioperative mortality (odds ratio 3.12 [1.08-8.99] with p = 0.035). CONCLUSIONS Conservative management in hemodynamically stable patients experiencing significant but non-critical or emergency bleeding might be a safe and viable option and might be advantageous in terms of reduction of postoperative morbidities and hospital stay.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - David Rose
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - Antonio Nenna
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rebecca Taylor
- Research and Development, Blackpool Teaching Hospitals, Blackpool FY3 8NR, UK
| | - Mohamad Nidal Bittar
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
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22
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Spahn DR, Kaserer A. Management of severe peri-operative bleeding: A call for action by the ESAIC. Eur J Anaesthesiol 2023; 40:223-225. [PMID: 36855940 DOI: 10.1097/eja.0000000000001804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Affiliation(s)
- Donat R Spahn
- From the Institute of Anesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland (DRS, AK)
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23
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Yao X, Li N, Lu R, Wang X, Zhang Y, Wang S. Development of a nomogram for predicting nosocomial infections among patients after cardiac valve replacement surgery. J Clin Nurs 2023; 32:1466-1475. [PMID: 35988041 DOI: 10.1111/jocn.16489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 07/14/2022] [Accepted: 07/28/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To construct a predictive nomogram of the risk of nosocomial infections among patients after cardiac valve replacement surgery. BACKGROUND Nosocomial infections are a standout challenge that worsens the prognosis of patients after valve replacement surgery. However, studies on the nomogram of nosocomial infections in these patients have remained scarce. DESIGN A retrospective cohort study. METHODS Patients (n = 720) following valve replacement surgery from 2018 to 2019 were selected. LASSO regression and multivariate logistic regression were utilised to ascertain predictors of nosocomial infections. The predictive performance of the nomogram was appraised by calibration and discrimination. Decision and impact curves were used to assess the clinical utility. Internal validation was implemented via 1000 bootstrap samples to mitigate overfitting. TRIPOD guidelines were used in this study. RESULTS One hundred and fifty one patients (20.97%) experienced nosocomial infections following valve replacement surgery. Heart failure, preoperative anaemia, valve material, American Society of Anesthesiologists score ≥ IV, prolonged duration of surgery, duration of mechanical ventilation ≥ 24 h and indwelling nasogastric tube were predictors of nosocomial infections. Using these variables, we developed a predictive nomogram of the occurrence of nosocomial infections and the internal validation results demonstrated good discrimination and calibration of the nomogram. The clinical decision and impact curve revealed significant clinical utility. CONCLUSIONS The present study constructed a nomogram for predicting the risk of nosocomial infections in patients following cardiac valve replacement surgery. This nomogram may strengthen the effective screening of patients at high risk of nosocomial infections. RELEVANCE TO CLINICAL PRACTICE This risk warning tool can assist clinical staff in making decisions and providing individualised infection control measures for patients, which has a significant reference value for clinical practice. NO PATIENT OR PUBLIC CONTRIBUTION The data for this study were obtained from the hospital database, and the entire process of the study did not involve patient participation.
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Affiliation(s)
- Xue Yao
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Na Li
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Ranran Lu
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Xujing Wang
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Yujun Zhang
- School of Nursing and Rehabilitation, Shandong University, Jinan, China.,Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
| | - Shuhui Wang
- Department of Infection Prevention and Control, Qilu Hospital of Shandong University, Jinan, China
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24
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Association of Preoperative Blood Transfusion on Postoperative Outcomes in Emergency General Surgery. J Surg Res 2023; 284:151-163. [PMID: 36571870 DOI: 10.1016/j.jss.2022.11.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Emergency general surgery (EGS) patients often present with anemia, in which preoperative transfusions are performed to mitigate anemia-associated risks. However, transfusions have also been noted to cause worse postoperative outcomes. This study examined how transfusion-associated outcomes vary at different levels of anemia. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2019 was used to identify patients who had undergone any of 12 major EGS procedures using Current Procedural Terminology codes. Patients were divided into two cohorts based on receipt of preoperative transfusion. Cohorts were subdivided into anemia severity levels and propensity score-matched within each using patient demographic and comorbidity variables. We analyzed 30-day postoperative outcomes, including morbidity, mortality, and return to odds ratio (OR), using univariate Chi-squared tests, Wilcoxon signed-rank tests, and multivariate logistic regression analyses. RESULTS 595,407 EGS cases were identified. Receiving preoperative transfusion were 44.45% (n = 3058) of severely anemic, 10.94% (n = 9076) of moderately anemic, 1.34% (n = 1370) of mildly anemic, and 0.174% (n = 704) of no anemia patients. Transfusion resulted in an increased overall morbidity in the severe (OR 1.54), moderate (OR 1.50), mild (OR 1.71), and no anemia (OR 1.85) groups. Mortality increased in the moderate (OR 1.27), mild (OR 1.61), and no anemia (OR 1.76) subgroups. In severe anemia, transfusion status and mortality were not significantly associated. CONCLUSIONS Transfusion is associated with higher morbidity and mortality rates in those with higher hematocrit levels, even after controlling for pre-existing comorbidities. A restrictive transfusion strategy should be considered to avoid risks for those with a hematocrit level more than 24%.
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25
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Itagaki Y, Hayakawa M, Takahashi Y, Hirano S, Yamakawa K. Emergency administration of fibrinogen concentrate for haemorrhage: systematic review and meta-analysis. World J Emerg Surg 2023; 18:27. [PMID: 36998084 PMCID: PMC10061696 DOI: 10.1186/s13017-023-00497-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 03/26/2023] [Indexed: 04/01/2023] Open
Abstract
INTRODUCTION The occurrence of massive haemorrhages in various emergency situations increases the need for blood transfusions and increases the risk of mortality. Fibrinogen concentrate (FC) use may increase plasma fibrinogen levels more rapidly than fresh-frozen product or cryoprecipitate use. Previous several systematic reviews and meta-analyses have not effectively demonstrated FC efficacy in significantly improving the risk of mortality and reducing transfusion requirements. In this study, we investigated the use of FC for haemorrhages in emergency situations. METHODS AND ANALYSIS In this systematic review and meta-analysis, we included controlled trials, but excluded randomized controlled trials (RCTs) in elective surgeries. The study population consisted of patients with haemorrhages in emergency situations, and the intervention was emergency supplementation of FC. The control group was administered with ordinal transfusion or placebo. The primary and secondary outcomes were in-hospital mortality and the amount of transfusion and thrombotic events, respectively. The electronic databases searched included MEDLINE (PubMed), Web of Science, and the Cochrane Central Register of Controlled Trials. RESULTS Nine RCTs in the qualitative synthesis with a total of 701 patients were included. Results showed a slight increase in in-hospital mortality with FC treatment (RR 1.24, 95% CI 0.64-2.39, p = 0.52) with very low certainty of the evidence. There was no reduction in the use of red blood cells (RBC) transfusion in the first 24 h after admission with FC treatment (mean difference [MD] 0.0 Unit in the FC group, 95% CI - 0.99-0.98, p = 0.99) with very low certainty of the evidence. However, the use of fresh-frozen plasma (FFP) transfusion significantly increased in the first 24 h after admission with FC treatment (MD 2.61 Unit higher in the FC group, 95% CI 0.07-5.16, p = 0.04). The occurrence of thrombotic events did not significantly differ with FC treatment. CONCLUSIONS The present study indicates that the use of FC may result in a slight increase in in-hospital mortality. While FC did not appear to reduce the use of RBC transfusion, it likely increased the use of FFP transfusion and may result in a large increase in platelet concentrate transfusion. However, the results should be interpreted cautiously due to the unbalanced severity in the patient population, high heterogeneity, and risk of bias.
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Affiliation(s)
- Yuki Itagaki
- Department of Surgery, Kushiro City General Hospital, 1-12 Shunkodai, Kushiro, Hokkaido, 085-0822, Japan.
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yuki Takahashi
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
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26
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Lehr AR, Hébert P, Fergusson D, Sabri E, Lacroix J. Association Between Length of Storage of Transfused Packed RBC Units and Outcome of Surgical Critically Ill Adults: A Subgroup Analysis of the Age of Blood Evaluation Randomized Trial. Crit Care Med 2023; 51:e73-e80. [PMID: 36728823 DOI: 10.1097/ccm.0000000000005775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The Age of Blood Evaluation (ABLE) study reported no clinical benefit in fresher compared with standard delivery RBC units (length of storage: 6.9 ± 4.1 vs 22.0 ± 8.4 d, respectively). Perioperative patients are often anemic, at risk of blood loss, and more exposed to RBC transfusions. We address the question whether fresh RBC units are safer than standard delivery RBC units in perioperative ICU patients. DESIGN Subgroup analysis of surgical nontrauma adults enrolled in the ABLE randomized controlled trial. SETTING ICUs. PATIENTS Three hundred twenty surgical patients among the 2,510 ICU adults recruited in the ABLE study who had a request for a first RBC transfusion in the first week in ICU stay and an anticipated length of mechanical ventilation greater than or equal to 48 hours. We included perioperative patients but excluded elective cardiac surgery and trauma. INTERVENTIONS Surgical participants were allocated to receive either RBC units stored less than or equal to 7 days or standard issue RBC. MEASUREMENTS AND MAIN RESULTS The primary outcome was 90-day all-cause mortality. One hundred seventy-two perioperative patients were allocated to the fresh and 148 to the standard group. Baseline data were similar. The length of storage was 7.2 ± 6.4 in fresh and 20.6 ± 8.4 days in standard group ( p < 0.0001). The 90-day mortality was 29.7% and 28.4%, respectively (absolute risk difference: 0.01; 95% CI -0.09 to 0.11; p = 0.803). No significant differences were observed for all secondary outcomes, including 6-month mortality, even after adjustment for age, country, and Acute Physiology and Chronic Health Evaluation score. CONCLUSIONS There was no evidence that fresh red cells improved outcomes as compared to standard issue red cells in critically ill surgical patients, consistent with other patients enrolled in the ABLE trial.
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Affiliation(s)
- Anab Rebecca Lehr
- Department of Pediatrics, Montreal Children Hospital, McGill University, Montreal, QC, Canada
| | - Paul Hébert
- Department of Medicine, Bruyere Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dean Fergusson
- Ottawa Hospital Research Institute, Department of Clinical Epidemiology Program and University of Ottawa, Ottawa, ON, Canada
- Departments of Medicine, Surgery, Epidemiology and Community Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Department of Clinical Epidemiology Program and University of Ottawa, Ottawa, ON, Canada
| | - Jacques Lacroix
- Centre Hospitalier Universitaire Sainte Justine, Département de Pédiatrie de l'Université de Montréal, Montréal, QC, Canada
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27
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Núñez-Jurado D, Santotoribio JD, Noval-Padillo JÁ. ClotPro Viscoelastometry Evaluation in Cardiac Surgery With Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:392-398. [PMID: 36577633 DOI: 10.1053/j.jvca.2022.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to assess the reproducibility of the new viscoelastic analyzer ClotPro, and compare the parameters this system produces with the ROTEM delta system in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). DESIGN A prospective and observational study. SETTING At a university hospital. PARTICIPANTS Forty adult patients undergoing cardiac surgery with CPB. INTERVENTIONS Correlations were calculated between ClotPro and ROTEM delta parameters. MEASUREMENTS AND MAIN RESULTS The ClotPro showed a high reproducibility in most of the parameters of each test; whereas ROTEM delta, although showing a low coefficient of variation in the parameters related to clot firmness, showed a high variability in the coagulation times. Excellent correlations were observed in most of the parameters of each test between ROTEM delta and ClotPro (≥0.93). However, a moderate correlation was obtained between the clotting time of the EXTEM and the EX-test (0.54). The concordance of amplitudes at different times within each test was almost 100% on both thromboelastometers. Regarding absolute differences in the test results, most of the measurements showed significant differences (p < 0.0001) between both devices. CONCLUSIONS ClotPro can be used as an alternative to ROTEM delta to evaluate coagulation function in cardiac surgery, but specific reference ranges need to be established first.
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Affiliation(s)
- David Núñez-Jurado
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain
| | - José D Santotoribio
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain
| | - José Á Noval-Padillo
- Department of Clinical Biochemistry, Virgen del Rocío University Hospital, Seville, Spain.
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28
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Nanni G, Vitolo M, Imberti JF, Girolami D, Bonini N, Valenti AC, Cimato P, Boriani G. Short and long-term outcomes after cardiac surgery in Jehovah's Witnesses patients: a case-control study. Intern Emerg Med 2023; 18:151-162. [PMID: 36401716 DOI: 10.1007/s11739-022-03142-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/17/2022] [Indexed: 11/21/2022]
Abstract
Cardiac surgery in Jehovah's Witnesses (JW) patients who refuse blood transfusion is challenging requiring dedicated strategies. We aimed to analyze non-selected JW patients undergoing cardiac surgery and to compare with matched controls both perioperative outcomes and long-term survival. We retrospectively analyzed JW patients undergoing cardiac surgery from January 2016 to March 2021 and compared them with matched controls. The primary outcome was a composite of in-hospital perioperative adverse events and in-hospital mortality. The secondary outcome was all-cause mortality at long-term follow-up. A total of 113 JW patients and 113 controls were included. Baseline clinical characteristics, including laboratory parameters were comparable. Overall, there were no statistical differences between JW vs controls in terms of in-hospital mortality (2.7% vs 1.8%, p = 1.00) but mortality was remarkably high (40%) in JW patients with post-op hemoglobin < 8 g/dl. Logistic regression analysis found that the JW group was not associated with a higher occurrence of the composite outcome (adjusted odds ratio 0.91, 95% confidence interval [CI] 0.54-1.57). After a median follow-up of 1397 [IQR 922.7-1723.5] days, JW patients were not associated with a significantly higher all-cause mortality (adjusted hazard ratio 0.77, 95% CI 0.24-2.42). Cardiac surgery can be safely performed in non-anemic JW patients despite the refusal of blood transfusions. Favorable clinical outcomes can be achieved by the use of specific perioperative strategies for bloodless surgery with no differences as compared to control patients except in JW patients with a very low level of post-operative hemoglobin not supported by immediate transfusions.
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Affiliation(s)
- Giulia Nanni
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Denise Girolami
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Anna Chiara Valenti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
| | - Paolo Cimato
- Department of Cardiovascular Surgery, Hesperia Hospital, Modena, Italy.
- Department of Cardiac Surgery, Villa Torri Hospital, GVM Care & Research, Bologna, Italy.
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
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29
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Implementing patient-centred decision making in peri-operative patient blood management. Eur J Anaesthesiol 2023; 40:1-3. [PMID: 36479986 DOI: 10.1097/eja.0000000000001771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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30
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Judd L, Hof L, Beladdale L, Friederich P, Thoma J, Wittmann M, Zacharowski K, Meybohm P, Choorapoikayil S. Prevalence of pre‐operative anaemia in surgical patients: a retrospective, observational, multicentre study in Germany. Anaesthesia 2022; 77:1209-1218. [DOI: 10.1111/anae.15847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2022] [Indexed: 12/01/2022]
Affiliation(s)
- L. Judd
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - L. Hof
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - L. Beladdale
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - P. Friederich
- Department of Anaesthesiology, Surgical Intensive Care Medicine and Pain Therapy Munich Clinic Bogenhausen Munich Germany
| | - J. Thoma
- Department of Anaesthesiology and Intensive Care Medicine Ortenau Clinic Offenburg‐Kehl Germany
| | - M. Wittmann
- Department of Anaesthesiology and Intensive Care Medicine University Hospital Bonn Germany
| | - K. Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
| | - P. Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine University Hospital Wuerzburg Germany
| | - S. Choorapoikayil
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy University Hospital Frankfurt, Goethe University Frankfurt Frankfurt Germany
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Machine learning-based prediction of massive perioperative allogeneic blood transfusion in cardiac surgery. Eur J Anaesthesiol 2022; 39:766-773. [PMID: 35852544 DOI: 10.1097/eja.0000000000001721] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Massive perioperative allogeneic blood transfusion, that is, perioperative transfusion of more than 10 units of packed red blood cells (pRBC), is one of the main contributors to perioperative morbidity and mortality in cardiac surgery. Prediction of perioperative blood transfusion might enable preemptive treatment strategies to reduce risk and improve patient outcomes while reducing resource utilisation. We, therefore, investigated the precision of five different machine learning algorithms to predict the occurrence of massive perioperative allogeneic blood transfusion in cardiac surgery at our centre. OBJECTIVE Is it possible to predict massive perioperative allogeneic blood transfusion using machine learning? DESIGN Retrospective, observational study. SETTING Single adult cardiac surgery centre in Austria between 01 January 2010 and 31 December 2019. PATIENTS Patients undergoing cardiac surgery. MAIN OUTCOME MEASURES Primary outcome measures were the number of patients receiving at least 10 units pRBC, the area under the curve for the receiver operating characteristics curve, the F1 score, and the negative-predictive (NPV) and positive-predictive values (PPV) of the five machine learning algorithms used to predict massive perioperative allogeneic blood transfusion. RESULTS A total of 3782 (1124 female:) patients were enrolled and 139 received at least 10 pRBC units. Using all features available at hospital admission, massive perioperative allogeneic blood transfusion could be excluded rather accurately. The best area under the curve was achieved by Random Forests: 0.810 (0.76 to 0.86) with high NPV of 0.99). This was still true using only the eight most important features [area under the curve 0.800 (0.75 to 0.85)]. CONCLUSION Machine learning models may provide clinical decision support as to which patients to focus on for perioperative preventive treatment in order to preemptively reduce massive perioperative allogeneic blood transfusion by predicting, which patients are not at risk. TRIAL REGISTRATION Johannes Kepler University Ethics Committee Study Number 1091/2021, Clinicaltrials.gov identifier NCT04856618.
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Hofmann A, Shander A, Blumberg N, Hamdorf JM, Isbister JP, Gross I. Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up? Anesth Analg 2022; 135:511-523. [PMID: 35977361 DOI: 10.1213/ane.0000000000006138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.
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Affiliation(s)
- Axel Hofmann
- From the Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth, Western Australia, Australia.,Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey.,College of Medicine, University of Florida, Gainesville, Florida.,School of Medicine at Mount Sinai, New York, New York.,Rutgers University, Newark, New Jersey
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey M Hamdorf
- From the Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - James P Isbister
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Irwin Gross
- Department of Medicine, Eastern Maine Medical Center, Bangor, Maine
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Lavoie P, Lapierre A, Maheu-Cadotte MA, Rodriguez D, Lavallée A, Mailhot T. Improving the recognition and management of hemorrhage: A scoping review of nursing and midwifery education. NURSE EDUCATION TODAY 2022; 113:105361. [PMID: 35429750 DOI: 10.1016/j.nedt.2022.105361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/16/2022] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hemorrhage is a frequent complication that nurses and midwives must recognize and manage to avoid life-threatening consequences for patients. There is currently no synthesis of evidence on educational interventions in nursing and midwifery regarding hemorrhage, thus limiting the definition of best practices. OBJECTIVE To map the literature on nursing and midwifery education regarding the recognition and management of hemorrhage. DESIGN Scoping review based on the Joanna Briggs Institute guidelines. DATA SOURCES Quantitative studies evaluating the effect of educational interventions with students, nurses, or midwives published in English or French, with no time limit. REVIEW METHODS Study selection, data extraction, and quality assessment were conducted by two independent reviewers. We characterized educational interventions based on the Guideline for Reporting Evidence-Based Practice Educational Interventions and Teaching. We categorized learning outcomes using the New World Kirkpatrick Model. Methodological quality appraisal was performed with tools from the Joanna Briggs Institute. Findings were synthesized using descriptive statistics and graphical methods RESULT: Most of the 38 studies used a single-group design (n = 26, 68%) and were conducted with professionals (n = 28, 74%) in hospital settings (n = 20, 53%). Most were of low (n = 14; 37%) or moderate (n = 18, 47%) methodological quality. Most interventions focused on postpartum hemorrhage (n = 34, 89%) and combined two or more teaching strategies (n = 25, 66%), often pairing an informational segment (e.g., lecture, readings) with a practical session (e.g., workshop, simulation). Learning outcomes related to the management (n = 27; 71%) and recognition of hemorrhage (n = 19, 50%), as well as results for patients and organizations (n = 9, 24%). CONCLUSION Considerable heterogeneity in interventions and learning outcomes precluded conducting a systematic review of effectiveness. High-quality, controlled studies are needed, particularly in surgery and trauma. Reflection on the contribution of nurses and midwives to the detection, monitoring, and management of hemorrhage could enrich the content and expected outcomes of hemorrhage education.
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Affiliation(s)
- Patrick Lavoie
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, Quebec H1T 1C8, Canada.
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada
| | - Marc-André Maheu-Cadotte
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, Quebec H1T 1C8, Canada
| | - Dora Rodriguez
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada
| | - Andréane Lavallée
- Department of Pediatrics, Columbia University Medical Center, 51 Audubon Ave, Suite 100, New York, NY 10032, United States
| | - Tanya Mailhot
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, Quebec H1T 1C8, Canada
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Devine C, Bartoszko J, Callum J, Karkouti K. Weight-adjusted dosing of fibrinogen concentrate and cryoprecipitate in the treatment of hypofibrinogenaemic bleeding adult cardiac surgical patients: a post hoc analysis of the Fibrinogen Replenishment in cardiac surgery randomised controlled trial. BJA OPEN 2022; 2:100016. [PMID: 37588266 PMCID: PMC10430806 DOI: 10.1016/j.bjao.2022.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/27/2022] [Indexed: 08/18/2023]
Abstract
Background Hypofibrinogenaemia is associated with excessive bleeding after cardiac surgery. Our aim was to compare the efficacy and safety of weight-adjusted vs empiric dosing of fibrinogen replacement in cardiac surgery. Methods In the Fibrinogen Replenishment in Cardiac Surgery (FIBRES) RCT, patients (n=735) received fibrinogen concentrate (4 g) or cryoprecipitate (10 units). In this post-hoc analysis, patients were grouped into quartiles based on increasing weight-adjusted dosing. Generalised estimating equations were used to account for hospital site, age, sex, surgical complexity, urgency, and critical preoperative status. The primary outcome was the number of units of red blood cells transfused within 24 h of cardiopulmonary bypass. Secondary outcomes included allogeneic blood components within 24 h, tamponade or major bleeding, and thromboembolic complications, ischaemic complications, or both within 28 days of cardiopulmonary bypass. Results The median weight-adjusted doses were 52 mg kg-1 of fibrinogen concentrate (inter-quartile range [IQR], 45-61; n=372) and 1.30 units per 10 kg of cryoprecipitate (IQR, 1.11-1.54; n=363). When patients were divided into quartiles of lowest to highest weight-adjusted dosing, no differences were seen in the primary outcome of red blood cell units transfused within 24 h of cardiopulmonary bypass between the lowest and highest quartiles in either the fibrinogen group (adjusted relative risk [RR]=0.90; 95% confidence interval [CI], 0.71-1.13; P=0.36) or the cryoprecipitate group (adjusted RR=1.04; 95% CI, 0.76-1.43; P=0.80). Results were similar for all secondary outcomes. Conclusion Outcomes for the lowest and highest weight-adjusted doses of fibrinogen replacement were comparable. Weight-adjusted dosing does not appear to offer advantages over empiric dosing in this context. Clinical trial registration NCT03037424.
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Affiliation(s)
- Cian Devine
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, School of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - the FIBRES Study Investigators
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pathology and Molecular Medicine, School of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
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35
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Klein A, Agarwal S, Cholley B, Fassl J, Griffin M, Kaakinen T, Paulus P, Rex S, Siegemund M, van Saet A. A review of European guidelines for patient blood management with a particular emphasis on antifibrinolytic drug administration for cardiac surgery. J Clin Anesth 2022; 78:110654. [DOI: 10.1016/j.jclinane.2022.110654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
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36
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Leyra F, Jofre C, Peña N, Olmos E, Del Campo JM, Aranzubia M, Moreno I. Prediction of platelet counts with ROTEM-sigma in cardiac surgery. Minerva Anestesiol 2022; 88:573-579. [PMID: 35381835 DOI: 10.23736/s0375-9393.22.15912-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Excessive bleeding is common after cardiac surgery. According to transfusion algorithms based on ROTEM results, platelet transfusion is recommended when FIBTEM amplitude is normal and EXTEM amplitude is reduced. The aim of this study is to evaluate whether ROTEM parameters may predict accurately platelet counts in cardiac surgery patients and to determine which of these parameters is the most useful for predicting platelet counts. METHODS In this retrospective single center study data from 83 patients who underwent cardiac surgery were reviewed. We analysed the results of patients for whom ROTEM and conventional laboratory tests were performed simultaneously. The derived ROTEM parameter PLTEM was used to estimate platelet count, PLTEM is calculated by subtracting FIBTEM from EXTEM. Correlation between ROTEM variables and platelet counts were determined. Logistic regression analyses were performed to predict platelet counts. RESULTS ROTEM A5 values show a high linear correlation with MCF values. PLTEM has a strong linear correlation with platelet counts. According to our results for PLTEM A5 < 32 mm the probability of platelet count < 150 x 109/L is 100%, for PLTEM A5 < 27 mm the probability of platelet count < 100 x 109/L is nearly 80%, and for PLTEM A5 < 22 the probability of platelet count < 75 x 109/L is 70%. CONCLUSIONS This study demonstrates the reliability of considering early ROTEM results and the feasibility of using PLTEM A5 to predict platelet counts and so improve our ability to decide the need of platelet transfusion in cardiac surgery patients.
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Affiliation(s)
- Fernando Leyra
- Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain -
| | - Cristina Jofre
- Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Natalia Peña
- Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Eva Olmos
- Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - José M Del Campo
- Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Montserrat Aranzubia
- Anesthesiology Department, Hospital Universitario Fundación Jimenez Diaz, Madrid, Spain
| | - Isidro Moreno
- Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain
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Spadaccio C, Nenna A, Candura D, Rose D, Moscarelli M, Al-Attar N, Sutherland F. Total arterial coronary artery bypass grafting in patients with preoperative anemia. J Card Surg 2022; 37:1528-1536. [PMID: 35324020 DOI: 10.1111/jocs.16425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Blood transfusions after coronary artery bypass grafting (CABG) has been associated to adverse outcomes, especially in anemic patients. However, little is known about the influence of the modality of revascularization. Total arterial revascularization (TAR) was shown to reduce postoperative transfusion when compared to saphenous vein-based (SV)-CABG (LIMA plus one/more SV grafts). We, therefore, aimed to investigate the impact of TAR-CABG versus SV-CABG on blood products use and perioperative outcomes in patients with preoperative anemia, normally at higher risk for postoperative transfusions. METHODS From a cohort of 936 patients with mild preoperative anemia undergoing primary elective on-pump CABG, 166 matched pairs of patients undergoing either TAR- or SV-CABG were obtained. Anemia was defined as hemoglobin level <13 g/dl for men and <12 g/dl for women. The primary endpoint was the evaluation of red packed cells (RPC) use over the entire hospital stay. RESULTS TAR patients showed significantly reduced RPC usage compared with SV (mean difference 0.45 units). TAR patients had a reduced intubation time (mean difference 7.6 h) and were discharged 1.24 days earlier than SV patients. Pneumonia and acute kidney injury were doubled among SV patients. Adjusted regression showed that TAR technique is a predictor of reduced RPC unit use regardless of age and EuroSCORE II (odds ratio: 0.63, p < .01). CONCLUSION Patients with preoperative anemia might benefit from TAR regardless of age or calculated operative risk. TAR-CABG was associated to reduced postoperative use of blood products and postoperative length of stay in comparison with SV-CABG in this subset of patients.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK.,Cardiac Surgery Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio Nenna
- Cardiac Surgery Department, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Dario Candura
- Cardiac Surgery Department, Leiden University Medical Centrum, Leiden, The Netherlands
| | - David Rose
- Cardiac Surgery Department, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital (GVM), Cotignola, Ravenna, Italy
| | - Nawwar Al-Attar
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK
| | - Fraser Sutherland
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK
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38
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Gaudriot B, Oilleau JF, Kerforne T, Ecoffey C, Huet O, Mansour A, Verhoye JP, Massart N, Nesseler N. The impact of iron store on red blood cell transfusion: a multicentre prospective cohort study in cardiac surgery. BMC Anesthesiol 2022; 22:74. [PMID: 35313823 PMCID: PMC8935744 DOI: 10.1186/s12871-022-01616-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anaemia is common prior to cardiac surgery and contributes to perioperative morbidity. Iron deficiency is the main cause of anaemia but its impact remains controversial in the surgical setting. We aimed to estimate the impact of iron deficiency on in-hospital perioperative red blood cell transfusion for patients undergoing elective and urgent cardiac surgery. Secondary objectives were to identify risk factors associated with in-hospital red blood cell transfusion. METHODS We conducted a prospective multicentre observational study in three university hospitals performing cardiac surgery. We determined iron status prior to surgery and collected all transfusion data to compare iron-deficient and iron-replete patients during hospital stay. We performed a multivariable logistic regression to compare transfusion among groups. RESULTS Five hundred and two patients were included. A trend of low haemoglobin levels associated with iron deficiency persisted until discharge. Red blood cell transfusion was significantly higher in the group of iron deficient patients during surgery (22% vs 13%, p = 0.017), however the incidence during the whole hospital stay was 31% in the iron-deficient group, not significantly different with the non-deficient group (26%, p = 0.28). Iron deficiency was not independently associated with in-hospital red blood cell transfusion (adjusted OR = 0.85 [0.53-1.36], p = 0.49). CONCLUSIONS In-hospital red blood cell transfusion was not significantly higher in iron-deficient patients and iron deficiency was not associated with in-hospital red blood cell transfusion in patients undergoing elective and urgent cardiac surgery. Iron deficiency was the main cause of anaemia and anaemia was a strong driver of red blood cell transfusion. Further studies should identify sub-population of iron-deficient patients which may benefit from preoperative iron deficiency management and explore the long-term impact of lower haemoglobin levels at discharge in the iron deficient population.
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Affiliation(s)
- Baptiste Gaudriot
- Department of Anaesthesia and Critical Care, University Hospital of Rennes, 35000, Rennes, France.
- Service d'Anesthésie-Réanimation CTCV, Centre Cardio-Pneumologique, Hôpital Pontchaillou, 2 rue Henri Le Guilloux, 35033, Cedex 9, Rennes, France.
| | - Jean-Ferreol Oilleau
- Department of Anaesthesia and Critical Care, Brest University Hospital, 29000, Brest, France
| | - Thomas Kerforne
- Department of Anaesthesia and Critical Care, INSERM U-1082, Poitiers University Hospital, 86000, Poitiers, France
| | - Claude Ecoffey
- Department of Anaesthesia and Critical Care, University Hospital of Rennes, 35000, Rennes, France
- Univ Rennes, CHU de Rennes, 35000, Rennes, France
| | - Olivier Huet
- Department of Anaesthesia and Critical Care, Brest University Hospital, 29000, Brest, France
- Brest University, 29000, Brest, France
| | - Alexandre Mansour
- Department of Anaesthesia and Critical Care, University Hospital of Rennes, 35000, Rennes, France
- Univ Rennes, CHU de Rennes, 35000, Rennes, France
| | - Jean-Philippe Verhoye
- Univ Rennes, CHU de Rennes, 35000, Rennes, France
- Thoracic and Cardiovascular Surgery, University Hospital of Rennes, Univ Rennes 1, 35000, Rennes, France
| | - Nicolas Massart
- Intensive Care Unit, Saint-Brieuc Hospital, 22000, Saint-Brieuc, France
| | - Nicolas Nesseler
- Department of Anaesthesia and Critical Care, University Hospital of Rennes, 35000, Rennes, France
- Univ Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, F-35000, Rennes, France
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39
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Shander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, Kor DJ, Faraoni D, Freedman J. A Global Definition of Patient Blood Management. Anesth Analg 2022; 135:476-488. [PMID: 35147598 DOI: 10.1213/ane.0000000000005873] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations, from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at screening for, diagnosing and appropriately treating anemia, minimizing surgical, procedural, and iatrogenic blood losses, managing coagulopathic bleeding throughout the care and supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey.,Society for the Advancement of Patient Blood Management (SABM), Mount Royal, New Jersey
| | - Jean-Francois Hardy
- Department of Anaesthesiology and Pain Medicine, Université de Montréal, Montréal, Quebec, Canada.,Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France
| | - Sherri Ozawa
- Society for the Advancement of Patient Blood Management (SABM), Mount Royal, New Jersey.,Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Health, Englewood, New Jersey
| | - Shannon L Farmer
- Medical School and Division of Surgery, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Department of Haematology, Royal Perth Hospital, Perth, Western Australia, Australia.,International Foundation for Patient Blood Management, Basel, Switzerland.,The Western Australia Patient Blood Management Group, The University of Western Australia, Perth, Western Australia, Australia
| | - Axel Hofmann
- Medical School and Division of Surgery, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,International Foundation for Patient Blood Management, Basel, Switzerland.,Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Steven M Frank
- Department of Anesthesiology, Critical Care Medicine, Johns Hopkins Health System Patient Blood Management Program, The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Michigan.,Patient Blood Management Program, Mayo Clinic, Rochester, Michigan
| | - David Faraoni
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France.,Department of Anesthesiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - John Freedman
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Ontario, Canada.,The Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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40
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Pei L, Sun C, Lv H, Zhang Y, Shi J. Efficacy of prothrombin complex concentrate (PCC) versus fresh frozen plasma (FFP) in reducing perioperative blood loss in cardiac surgery: study protocol for a non-inferiority, randomised controlled trial. BMJ Open 2022; 12:e051072. [PMID: 35144945 PMCID: PMC8845189 DOI: 10.1136/bmjopen-2021-051072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore whether prothrombin complex concentrate (PCC) is not inferior to fresh frozen plasma (FFP) with regard to reducing perioperative blood loss in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). SETTING Fu Wai Hospital, and Peking Union Medical College Hospital in China. PARTICIPANTS Patients undergoing elective coronary artery bypass grafting, valve replacement or valvuloplasty under CPB, between 18 and 80 years old, will be included. DESIGN This study is a non-inferiority, randomised controlled clinical trial. A total of 594 subjects will be randomly assigned to two groups (group PCC and group FFP) and given corresponding interventions when at least one of the following criteria is met: (1) international normalised ratio >1.7 measured 20 min after CPB, (2) prolonged prothrombin time or activated partial thromboplastin time (>1.5 times baseline) measured 20 min after CPB and (3) excessive bleeding observed. 4-factor PCC (15 IU/kg) and FFP (10 mL/kg) will be given to group PCC and group FFP, respectively. Preoperative management, anaesthetic and surgical techniques will be standardised for both groups. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome is the volume of blood loss during and within 24 hours after surgery. The secondary outcomes include (1) the total units of allogeneic red blood cells transfused during and within 7 days after surgery, (2) re-exploration due to postoperative bleeding within 7 days after surgery, (3) adverse events and serious adverse events within 30 days after surgery and (4) length of intensive care unit stay and hospital stay. TRIAL REGISTRATION NUMBER Registered under NCT04244981 at ClinicalTrials.gov on 28 January 2020, https://clinicaltrials.gov/ct2/show/NCT04244981?cond=NCT04244981&draw=2&rank=1. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Board of Peking Union Medical College Hospital (ZS-2242).
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Affiliation(s)
- Lijian Pei
- Department of Anaesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Outcomes Research Consortium, Cleveland, Cleveland, Ohio, USA
| | - Chen Sun
- Department of Anaesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hong Lv
- Department of Anaesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jia Shi
- Department of Anaesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Sharan S, Kapoor PM, Choudhury M, Prakash M, Chowdhury UK, Hote M, Ravi V. Platelet Function Test in Coronary Artery Bypass Grafting: Does It Predict Postoperative Bleeding? JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1742402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased risk of perioperative bleeding and morbidity associated with transfusion as a result of acquired and pharmacologically induced impaired platelet function.
Settings and Design In this a prospective observational study where 52 patients underwent on-pump CABG were analyzed with ROTEM platelet aggregometry.
Materials and Methods Patients were assigned to the “nonexcessive” and “excessive” postoperative bleeding groups according to the postoperative chest tube drainage over 24 hours. Platelet function was assessed by ROTEM platelet using three different activators (arachidonic acid, adenosine diphosphate, and thrombin receptor-activating peptide), at two perioperative time points (T1, before heparinization and T2, 5–10 minutes after protamine administration).
Results There were no differences regarding demographic, pre–cardiopulmonary bypass (CPB) platelet count and antiplatelet therapy. Platelet function was impaired over the time course in all parameters with three different activators. At T2 point, area under the curve (AUC) of all the three platelet indices, that is, TRAPTEM, ARATEM, and ADPTEM, showed significant difference between excessive and nonexcessive groups. At both T1 and T2 points, the amplitude after 6 minutes (A6) and maximum slope (MS) parameters of TRAPTEM, ARATEM, and ADPTEM tests were not significantly different in excessive and nonexcessive groups. At T1 point, AUC was also not significantly different in all three ROTEM platelet tests. Results after protamine administration showed correlation with postoperative chest tube drainage. Cut-off values, as determined by receiver operating characteristics (ROC) analyses, had a consistently weak positive predictive value for all tests at T2 time point, whereas negative predictive values were higher.
Conclusion Platelet function analysis using ROTEM platelet can help to exclude platelet dysfunction as the reason for bleeding after cardiac surgery. Point-of-care platelet function analysis, particularly in combination with viscoelastic testing can reduce perioperative bleeding and transfusion requirements, as well as improve patient outcomes in cardiac surgery.
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Affiliation(s)
- Sandeep Sharan
- Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Minati Choudhury
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Prakash
- Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal K. Chowdhury
- Department of Cardio Thoracic Vascular Surgery (CTVS), All India Institute of Medical Sciences, New Delhi, India
| | - Milind Hote
- Department of Cardio Thoracic Vascular Surgery (CTVS), All India Institute of Medical Sciences, New Delhi, India
| | - Vajala Ravi
- Department of Statistics, Delhi University, Lady Sriram College, New Delhi, India
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Chegini A. Evaluating the Importance of Patient Blood Management During COVID-19 Pandemic. Anesth Pain Med 2022; 11:e112910. [PMID: 35291403 PMCID: PMC8909534 DOI: 10.5812/aapm.112910] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/29/2021] [Accepted: 12/07/2021] [Indexed: 01/28/2023] Open
Abstract
Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients afflicted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as significant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in different countries have made recommendations to the PBM in hospitals.
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Affiliation(s)
- Azita Chegini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
- Corresponding Author: Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran.
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Hoghooghy A, Honarmand A, Bagheri K, Rezaei K. Evaluation of plasma fibrinogen levels before and after coronary artery bypass graft surgery and its association with the need for blood products. Adv Biomed Res 2022; 11:25. [PMID: 35720218 PMCID: PMC9201223 DOI: 10.4103/abr.abr_22_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/12/2022] Open
Abstract
Background: The present study investigated the plasma level of fibrinogen before and after removing the pump in coronary artery bypass graft (CABG) surgery and its relationship with the need for blood products. Materials and Methods: The present study was performed on 60 patients who were candidates for CABG surgery. The fibrinogen level of these patients was assessed and recorded before surgery and immediately after removing the pump. In addition, their hemoglobin level was recorded before the operation and 2 h after. In addition, the number and type of blood products transfusion were recorded intraoperatively and postoperatively and also at the intensive care unit. Results: Patients’ fibrinogen level after removing the pump with the mean of 130.53 ± 122.01 mg/dl decreased significantly compared to before surgery with the mean of mg/dl 224.95 ± 132.88 mg/dl (P < 0.001). In addition, the prognostic value of fibrinogen after removing the pump in determining the postoperative need of blood transfusion showed that the cut-off value of fibrinogen was < 196 mg/dl with a sensitivity of 16.82% and specificity of 80%, but it was not statistically significant (area under the curve [95% confidence interval]: 0.519 [0.350–0.689]; P = 0.825). Conclusion: According to the results of the present study, due to significant changes in fibrinogen levels after removing the pump compared to preoperation, it seems that this factor can play an important role in prognosis of the need to postoperative blood transfusion, although the prognostic value and the critical point mentioned in our study was not significant and it is required to do further studies.
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Sadeghi R, Haji Aghajani M, Miri R, Kachoueian N, Jadbabaei AN, Mahjoob MP, Omidi F, Ghazanfarabadi M, Sarveazad A. Dual antiplatelet therapy before coronary artery bypass grafting in patients with myocardial infarction: a prospective cohort study. BMC Surg 2021; 21:449. [PMID: 34972501 PMCID: PMC8720217 DOI: 10.1186/s12893-021-01436-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dual antiplatelet therapy (DAPT) in patients with MI who are candidates for early coronary artery bypass grafting (CABG) can affect intraoperative and postoperative outcomes. Therefore, the aim of this study was to evaluate the effect of DAPT up to the day before CABG on the outcomes during and after surgery in patients with MI. METHODS In this prospective cohort study, 224 CABG candidate patients with and without MI were divided into two groups: (A) patients without MI who were treated with aspirin 80 mg/day before surgery (noMI-aspirin group; n = 124) and (B) patients with MI who were treated with aspirin 80 mg/day before surgery and clopidogrel (Plavix brand) at a dose of 75 mg/day (MI-DAPT group; n = 120). Dual or mono-antiplatelet therapy continued until the day before surgery. Patients were followed to assess in-hospital and 6-months outcomes. RESULTS The in-hospital mortality in MI-DAPT group was similar with noMI-aspirin group (OR 4.2; 95% CI 0.9-20.5; p = 0.071). The prevalence of CVA (p = 0.098), duration of hospital stay (p = 0.109), postoperative ejection fraction level (p = 0.693), diastolic dysfunction grade (p = 0.651) and postoperative PAP level (p = 0.0364) did not show difference between two groups. No mild or severe bleeding was observed in the patients. Six-month follow up showed that number of readmissions (p = 0.801), number of cases requiring angiography (p = 0.100), cases requiring re-PCI (p = 0.156), need for re-CABG (p > 0.999) and CVA (p > 0.999) did not differ between the two groups. During the 6-month follow-up, out-hospital mortality did not differ significantly between the two groups (p = 0.446). CONCLUSIONS A 6-month follow-up showed that DAPT with aspirin and clopidogrel before CABG in patients with MI has no effect on postoperative outcomes more than mono-APT with aspirin. Therefore, DAPT is recommended in the preoperative period for these patients.
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Affiliation(s)
- Roxana Sadeghi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Haji Aghajani
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Miri
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Naser Kachoueian
- Department of Cardiac Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Amir Nasser Jadbabaei
- Department of Cardiac Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Parsa Mahjoob
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Omidi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahboobeh Ghazanfarabadi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Sarveazad
- Colorectal Research Center, Iran University of Medical Sciences, Tehran, Iran.
- Nursing Care Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Hendrikx J, Timmers M, AlTmimi L, Hoogma DF, De Coster J, Fieuws S, Herijgers P, Rega F, Verbrugghe P, Rex S. Fast-Track Failure After Cardiac Surgery: Risk Factors and Outcome With Long-Term Follow-Up. J Cardiothorac Vasc Anesth 2021; 36:2463-2472. [PMID: 35031218 DOI: 10.1053/j.jvca.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/25/2021] [Accepted: 12/09/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES An important cornerstone of the Enhanced Recovery After Cardiac Surgery initiative is a fast-track cardiac anesthesia management protocol. Fast-track failure has been described to have a detrimental impact on immediate postoperative outcomes. The authors here evaluated risk factors for short- and long-term effects of fast-track failure. DESIGN A retrospective cohort study. SETTING A single academic center. PARTICIPANTS Adult cardiac surgery was performed on 7,064 patients between January 2013 and October 2019. INTERVENTION The inclusion criteria for the fast-track program at the postanesthesia care unit were met by 1,097 patients. MEASUREMENTS AND MAIN RESULTS Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Fast-track failure occurred in 69 (6.3%) patients. These were associated with significant increases in the incidences of coronary revascularization, cardiac tamponade or bleeding requiring surgical intervention, new-onset atrial fibrillation, pneumonia, delirium, and sepsis. Likewise, the postoperative length of stay, and up to 5-year mortality, were significantly higher in the fast-track failure than the nonfailure group. The European System for Cardiac Operative Risk Evaluation II and transfusion of any blood product could be identified as independent risk factors for fast-track failure, with only limited discriminative ability (area under the curve = 0.676; 95% confidence interval, 0.611-0.741). CONCLUSION Fast-track failure is associated with increases in morbidity and long-term mortality, but remains difficult to predict.
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Affiliation(s)
- Jore Hendrikx
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Maxim Timmers
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Layth AlTmimi
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Danny F Hoogma
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Johan De Coster
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Paul Herijgers
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals of Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals of Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.
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Schultz-Lebahn A, Nissen PH, Pedersen TF, Tang M, Hvas AM. Platelet function assessed by ROTEM ® platelet in patients receiving antiplatelet therapy during cardiac and vascular surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 82:18-27. [PMID: 34890293 DOI: 10.1080/00365513.2021.2012820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Patients undergoing coronary artery bypass graft (CABG) surgery or carotid endarterectomy (CEA) continue antiplatelet therapy perioperatively, which may increase bleeding risk. We aimed to investigate whether Rotational thromboelastometry (ROTEM®) platelet, a newly marketed platelet function analysis, would detect antiplatelet therapy in CABG and CEA patients; whether detection of reduced platelet function was associated with increased bleeding; and whether ex vivo desmopressin increased platelet function. We included 20 CABG patients continuing aspirin and 20 CEA patients continuing clopidogrel (n = 1) or clopidogrel and aspirin (n = 19). Platelet function was analyzed with ROTEM® platelet and light transmission aggregometry (LTA). According to the lower reference limit, ROTEM® platelet managed to detect aspirin, but clopidogrel detection was inadequate compared to LTA. Using a previously published cut-off for bleeding risk, 6 (30%) patients receiving aspirin and 4 (21%) patients receiving both clopidogrel and aspirin demonstrated platelet function below this cut-off. One of the four CEA patients below the cut-off died from intracerebral hemorrhage postoperatively. CABG patients below (n = 6) and above (n = 14) the cut-off did not differ in chest tube output (median [range]: 373 ml [250-900] vs. 368 ml [195-820]). Ex vivo addition of desmopressin did not increase platelet function. In conclusion, ROTEM® platelet does reveal aspirin treatment whereas clopidogrel treatment is most often overlooked. Due to low bleeding in the study population, it was not possible to conclude on the association with bleeding risk.
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Affiliation(s)
- Anna Schultz-Lebahn
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Peter H Nissen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Troels Fogh Pedersen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mariann Tang
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Kupryashov AA, Kuksina EV, Kchycheva GA, Haydarov GA. Impact of anemia on outcomes in on-pump coronary artery bypass surgery patients. KARDIOLOGIIA 2021; 61:42-48. [PMID: 34882077 DOI: 10.18087/cardio.2021.11.n1802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
Aim To study the contribution of preoperative anemia to the prognosis of adverse clinical events (mortality, complications, transfusion) in patients with ischemic heart disease (IHD) after myocardial revascularization in the conditions of artificial circulation.Material and methods This retrospective cohort study included 1 133 patients with IHD who had undergone isolated myocardial revascularization in the conditions of artificial circulation in 2019. The primary endpoints were mortality and a composite endpoint that included, in addition to mortality, cases of acute coronary syndrome, heart, respiratory and renal failure, neurological deficit, and infectious complications. The secondary endpoints were duration of artificial ventilation of more than 12 h, duration of stay in the resuscitation and intensive care unit (RICU) of more than one day, and duration of postoperative inpatient treatment of more than 7 days. Results Preoperative anemia was found in 196 (17.3 %) patients. The anemia was not associated with mortality but increased the risk of the composite endpoint, prolonged artificial ventilation, stay in RICU for more than one day, and red blood cell transfusion. Despite the absence of a relationship between red blood cell transfusion and mortality, the use of transfusion was associated with increased risks of the composite endpoint and prolonged stay in the RICU and hospital.Conclusion Preoperative anemia is a risk factor for adverse outcomes of myocardial revascularization in the conditions of artificial circulation. Timely treatment of preoperative anemia may improve outcomes of the treatment.
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Affiliation(s)
- A A Kupryashov
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - E V Kuksina
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - G A Kchycheva
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - G A Haydarov
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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Chiariello GA, Bruno P, Pavone N, Calabrese M, D'Avino S, Ferraro F, Nesta M, Farina P, Cammertoni F, Pasquini A, Montone RA, Montini L, Massetti M. Bleeding Complications in Patients With Perioperative COVID-19 Infection Undergoing Cardiac Surgery: A Single-Center Matched Case-Control Study. J Cardiothorac Vasc Anesth 2021; 36:1919-1926. [PMID: 34906382 PMCID: PMC8590476 DOI: 10.1053/j.jvca.2021.11.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/02/2021] [Accepted: 11/07/2021] [Indexed: 01/14/2023]
Abstract
Objective Previous studies reported a poor outcome in patients with coronavirus 2019 (COVID-19) undergoing cardiac surgery. Complications most frequently described were respiratory failure, renal failure, and thromboembolic events. In their recent experience, the authors observed a very high incidence of bleeding complications. The purpose of the study was to investigate a possible significant correlation between perioperative COVID-19 infection and hemorrhagic complications compared to non-COVID-19 patients. Design Single-center, observational, retrospective, matched case-control (1:2) study involving patients who underwent open-heart cardiac surgery from February 2020 and March 2021 with positive perioperative diagnosis of COVID-19 infection, matched with patients without COVID-19 infection. Setting Cardiac surgery unit and intensive care unit of a university tertiary center in a metropolitan area. Participants In the study period, 773 patients underwent cardiac surgery on cardiopulmonary bypass (CPB). Among them, 23 consecutive patients had perioperative diagnosis of COVID-19 infection (study group). These patients were compared with 46 corresponding controls (control group) that matched for age, sex, body mass index, and Society of Thoracic Surgeons score. Interventions Open-heart cardiac surgery on CPB. Measurements and Main Results In the study group, 2 patients (9%) died in the intensive care unit from severe respiratory failure, shock, and multiple organ failure. In the study group, patients showed a significantly higher incidence of bleeding complications (48% v 2%, p = 0.0001) and cases of surgical reexploration for bleeding (35% v 2%, p = 0.0001), a higher incidence of severe postoperative thrombocytopenia (39% v 6%, p = 0.0007), and a higher need of blood components transfusions (74% v 30%, p = 0.0006). Chest tubes blood loss and surgical hemostasis time were markedly prolonged (p = 0.02 and p = 0.003, respectively). Conclusions A worrisome increased risk of early and late bleeding complications in COVID-19 patients was observed, and it should be considered when assessing the operative risk. CPB-related inflammatory reaction could exacerbate the deleterious effect of COVID-19 on the coagulation system and likely deviate it toward a hemorrhagic pattern.
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Affiliation(s)
- Giovanni A Chiariello
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy.
| | - Piergiorgio Bruno
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Natalia Pavone
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Maria Calabrese
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy
| | - Serena D'Avino
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Francesco Ferraro
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Marialisa Nesta
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Piero Farina
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Federico Cammertoni
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Annalisa Pasquini
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Rocco A Montone
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
| | - Luca Montini
- Catholic University of The Sacred Heart, Rome, Italy; Department of Intensive Care Medicine and Anesthesiology, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy
| | - Massimo Massetti
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy; Catholic University of The Sacred Heart, Rome, Italy
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Liu C, Zhang HT, Yue LJ, Li ZS, Pan K, Chen Z, Gu SP, Pan T, Pan J, Wang DJ. Risk factors for mortality in patients undergoing continuous renal replacement therapy after cardiac surgery. BMC Cardiovasc Disord 2021; 21:509. [PMID: 34674651 PMCID: PMC8529736 DOI: 10.1186/s12872-021-02324-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the risk factors for mortality in patients with acute kidney injury requiring continuous renal replacement therapy (AKI-CRRT) after cardiac surgery. METHODS In this retrospective study, patients who underwent AKI-CRRT after cardiac surgery in our centre from January 2015 to January 2020 were included. Univariable and multivariable analyses were performed to identify the risk factors for in-hospital mortality. RESULTS A total of 412 patients were included in our study. Of these, 174 died after AKI-CRRT, and the remaining 238 were included in the survival control group. Multivariable logistic regression analysis revealed that EuroSCORE > 7 (odds ratio [OR], 3.72; 95% confidence interval [CI], 1.92-7.24; p < 0.01), intraoperative bleeding > 1 L (OR, 2.14; 95% CI, 1.19-3.86; p = 0.01) and mechanical ventilation time > 70 h (OR, 5.03; 95% CI, 2.40-10.54; p < 0.01) were independent risk factors for in-hospital mortality in patients who had undergone AKI-CRRT. Our study also found that the use of furosemide after surgery was a protective factor for such patients (odds ratio, 0.48; 95% confidence interval, 0.25-0.92; p = 0.03). CONCLUSIONS In summary, the mortality of patients with AKI-CRRT after cardiac surgery remains high. The EuroSCORE, intraoperative bleeding and mechanical ventilation time were independent risk factors for in-hospital mortality. Continuous application of furosemide may be associated with a better outcome.
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Affiliation(s)
- Chang Liu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Li-Jun Yue
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Ke Pan
- Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China
| | - Zhong Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Su-Ping Gu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China. .,Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
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