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Hariri G, Collet L, Duarte L, Martin GL, Resche-Rigon M, Lebreton G, Bouglé A, Dechartres A. Prevention of cardiac surgery-associated acute kidney injury: a systematic review and meta-analysis of non-pharmacological interventions. Crit Care 2023; 27:354. [PMID: 37700297 PMCID: PMC10498585 DOI: 10.1186/s13054-023-04640-1] [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: 07/17/2023] [Accepted: 09/06/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (CSA-AKI) is frequent. While two network meta-analyses assessed the impact of pharmacological interventions to prevent CSA-AKI, none focused on non-pharmacological interventions. We aim to assess the effectiveness of non-pharmacological interventions to reduce the incidence of CSA-AKI. METHODS We searched PubMed, Embase, Central and clinical trial registries from January 1, 2004 (first consensus definition of AKI) to July 1, 2023. Additionally, we conducted manual screening of abstracts of major anesthesia and intensive care conferences over the last 5 years and reference lists of relevant studies. We selected all randomized controlled trials (RCTs) assessing a non-pharmacological intervention to reduce the incidence of CSA-AKI, without language restriction. We excluded RCTs of heart transplantation or involving a pediatric population. The primary outcome variable was CSA-AKI. Two reviewers independently identified trials, extracted data and assessed risk of bias. Random-effects meta-analyses were conducted to calculate risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation to assess the quality of evidence. RESULTS We included 86 trials (25,855 patients) evaluating 10 non-pharmacological interventions to reduce the incidence of CSA-AKI. No intervention had high-quality evidence to reduce CSA-AKI. Two interventions were associated with a significant reduction in CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion (RR, 0.55 [95% CI 0.40-0.76], I2 = 0%; Phet = 0.44) and remote ischemic preconditioning (RR, 0.86 [0.78-0.95]; I2 = 23%; Phet = 0.07). Pulsatile flow during cardiopulmonary bypass was associated with a significant reduction in CSA-AKI incidence but with very low quality of evidence (RR = 0.69 [0.48; 0.99]; I2 = 53%; Phet < 0.01). We found high quality of evidence for lack of effect of restrictive transfusion strategy (RR, 1.02 [95% CI 0.92; 1.12; Phet = 0.67; I2 = 3%) and tight glycemic control (RR, 0.86 [95% CI 0.55; 1.35]; Phet = 0.25; I2 = 26%). CONCLUSIONS Two non-pharmacological interventions are likely to reduce CSA-AKI incidence, with moderate quality of evidence: goal-directed perfusion and remote ischemic preconditioning.
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Affiliation(s)
- Geoffroy Hariri
- Département de Santé Publique, UMR-S 1136, AP-HP, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France.
- Département d'anesthésie et réanimation, GRC 29, DMU DREAM, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Sorbonne Université, 75013, Paris, France.
| | - Lucie Collet
- Département de Santé Publique, UMR-S 1136, AP-HP, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Lucie Duarte
- Département d'anesthésie et réanimation, GRC 29, DMU DREAM, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Sorbonne Université, 75013, Paris, France
| | - Guillaume L Martin
- Département de Santé Publique, UMR-S 1136, AP-HP, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | - Matthieu Resche-Rigon
- ECSTRRA - CRESS UMR1153, INSERM and SBIM, AP-HP, Hôpital Saint-Louis, Université de Paris, Paris, France
| | - Guillaume Lebreton
- AP-HP, Service de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital La Pitié-Salpêtrière, Sorbonne Université, 75013, Paris, France
| | - Adrien Bouglé
- Département d'anesthésie et réanimation, GRC 29, DMU DREAM, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital La Pitié-Salpêtrière, Sorbonne Université, 75013, Paris, France
| | - Agnès Dechartres
- Département de Santé Publique, UMR-S 1136, AP-HP, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
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Roy A, Sargant N, Bell J, Stanford S, Solomon C, Kruzhkova I, Knaub S, Mohamed F. Comparison of coagulation parameters associated with fibrinogen concentrate and cryoprecipitate for treatment of bleeding in patients undergoing cytoreductive surgery for pseudomyxoma peritonei: Subanalysis from a randomized, controlled phase 2 study. Health Sci Rep 2023; 6:e1558. [PMID: 37766781 PMCID: PMC10521228 DOI: 10.1002/hsr2.1558] [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: 01/24/2023] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
Background and Aims The FORMA-05 study compared the efficacy and safety of human fibrinogen concentrate (HFC) versus cryoprecipitate for hemostasis in bleeding patients undergoing cytoreductive surgery for pseudomyxoma peritonei (PMP). This subanalysis explores coagulation parameters in the FORMA-05 patients, with a focus on the seven patients who developed thromboembolic events (TEEs). Methods FORMA-05 was a prospective, randomized, controlled phase 2 study in which patients with predicted blood loss ≥2 L received HFC (4 g) or cryoprecipitate (two pools of five units), repeated as needed. Plasma fibrinogen, platelet count, factor (F) XIII, FVIII, von Willebrand Factor (VWF) antigen and ristocetin cofactor activity levels, EXTEM A20, FIBTEM A20, and endogenous thrombin potential (ETP) were measured perioperatively. Results Fibrinogen, platelet count, EXTEM and FIBTEM A20, FXIII, FVIII, VWF levels, and ETP were maintained throughout surgery in both the HFC group (N = 21) and the cryoprecipitate group (N = 23). Seven TEEs were observed in the cryoprecipitate group. The two patients developing deep vein thromboses (DVT) appeared to have a procoagulant status preoperatively, with distinctively higher fibrinogen level, FIBTEM A20, and platelet levels, all of which persisted perioperatively. The five patients developing pulmonary embolism (PE) had slightly higher VWF levels preoperatively, with a disproportionate increase intraoperatively (postcryoprecipitate administration) and postoperatively. Conclusions Patients treated with HFC versus cryoprecipitate showed broad overlaps in coagulation parameters. Patients with PE experienced a disproportionate VWF rise following cryoprecipitate administration, whereas patients developing DVT displayed a procoagulant status before and following surgery. Preoperative testing may allow these patients to be identified.
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Affiliation(s)
- Ashok Roy
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | - Nigel Sargant
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | - John Bell
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | - Sophia Stanford
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
| | | | | | | | - Faheez Mohamed
- Peritoneal Malignancy InstituteBasingstoke and North Hampshire HospitalHampshireUK
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53
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Quader M, Akande O, Cholyway R, Lesnefsky EJ, Toldo S, Chen Q. Infarct Size With Incremental Global Myocardial Ischemia Times: Cyclosporine A in Donation After Circulatory Death Rat Hearts. Transplant Proc 2023; 55:1495-1503. [PMID: 37422374 DOI: 10.1016/j.transproceed.2023.03.088] [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: 12/13/2022] [Revised: 03/03/2023] [Accepted: 03/30/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND We quantified the myocardial infarct size with varying global ischemia durations and studied the benefits of Cyclosporine A (CyA) in reducing cardiac injury in ex vivo and transplanted rat hearts. METHODS Infarct size was measured after 15, 20, 25, 30, and 35 minutes of in vivo global ischemia (n = 34) and compared with control beating-heart donor (CBD) hearts (n = 10). For heart function assessment, donation after circulatory death (DCD) rat hearts (n = 20) were procured after 25 minutes of in vivo ischemia and reanimated ex vivo for 90 minutes. Half of the DCD hearts received CyA (0.5 mM) at reanimation. The CBD hearts (n = 10) served as controls. A separate group of CBD and DCD (with or without CyA treatment) hearts underwent heterotopic heart transplantation; heart function was measured at 48 hours. RESULTS Infarct size was 25% with 25 minutes of ischemia and increased significantly with 30 and 35 minutes to 32% and 41%, respectively. CyA treatment decreased infarct size in DCD hearts (15% vs 25%). Heart function in the transplanted DCD hearts was significantly better with CyA treatment and was comparable to CBD hearts. CONCLUSIONS CyA administered at reperfusion limited infarct size in DCD hearts and improved their function in transplanted hearts.
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Affiliation(s)
- Mohammed Quader
- Division of Cardio-Thoracic Surgery, Virginia Commonwealth University, Richmond, Virginia; Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia.
| | - Oluwatoyin Akande
- Division of Cardio-Thoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Renee Cholyway
- Division of Cardio-Thoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Edward J Lesnefsky
- Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Stefano Toldo
- Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Qun Chen
- Department of Surgery, McGuire Veterans Administration Medical Center and Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia; Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
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Raphael J, Feng X, Shotwell MS, Mazzeffi MA, Bollen BA, Shah AS, Kertai MD. Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery. Ann Surg 2023; 278:e650-e660. [PMID: 36538645 DOI: 10.1097/sla.0000000000005733] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We determined whether intraoperative packed red blood cell (PRBC) transfusion was associated with a higher incidence of hospital-acquired venous thromboembolic (HA-VTE) complications and adverse outcomes after isolated coronary artery bypass grafting (CABG) surgery. BACKGROUND Intraoperative PRBC has been associated with increased risk for postoperative deep venous thrombosis after cardiac surgery, but validation of these findings in a large, multi-institutional, national cohort of cardiac surgery patients has been lacking. METHODS A registry-based cohort study of 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of HA-VTE and adverse outcomes. RESULTS Administration of 1, 2, 3, and ≥4 units of PRBC transfusion was associated with increased odds for HA-VTE [odds ratios (ORs): 1.27 (1.22-1.32), 1.21 (1.16-1.26), 1.93 (1.85-2.00), 1.82 (1.75-1.89)], deep venous thrombosis [ORs: 1.39 (1.33-1.46), 1.38 (1.32-1.44), 2.18 (2.09-2.28), 1.82 (1.74-1.91], operative mortality [ORs: 1.11 (1.08-1.14), 1.16 (1.13-1.19), 1.29 (1.26-1.32), 1.47 (1.43-1.50)], readmission within 30 days [ORs: 1.05 (1.04-1.06), 1.16 (1.13-1.19), 1.29 (1.26-1.32), 1.47 (1.43-1.50)], and a prolonged postoperative length of stay [mean difference in days, 0.23 (0.19-0.27), 0.34 (0.30-0.39), 0.69 (0.64-0.74), 0.77 (0.72-0.820]. The odds of pulmonary venous thromboembolism were lower for patients transfused with 1 or 2 units [ORs: 0.98 (0.91-1.06), 0.75 (0.68-0.81)] of PRBC but remained significantly elevated for those receiving 3 and ≥4 units [ORs: 1.19 (1.09-1.29), 1.35 (1.25-1.48)]. CONCLUSIONS Intraoperative PRBC transfusion was associated with HA-VTE and adverse outcomes after isolated CABG surgery.
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Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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Innerhofer N, Rajsic S, Ronzani M, Breitkopf R, Gollmann Tepeköylü C, Velik-Salchner C, Schlosser L, Fries D, Streif W, Schirmer M, Martini J. Loss or Dilution-A New Diagnostic Method to Assess the Impact of Dilution on Standard Laboratory Parameters. Diagnostics (Basel) 2023; 13:2596. [PMID: 37568959 PMCID: PMC10417005 DOI: 10.3390/diagnostics13152596] [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: 06/28/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Intraoperative fluid therapy is regularly used in patients undergoing cardiac surgery procedures with cardiopulmonary bypass (CPB). Although fluid administration has several advantages, it unavoidably leads to hemodilution. The hemodilution may further influence the interpretation of concentration-based laboratory parameters like hemoglobin (Hgb), platelet count (PLT) or prothrombin time (PT). These all parameters are commonly used to guide blood product substitution. To assess the impact of dilution on these values, we performed a prospective observational study in 174 patients undergoing elective cardiac surgery. We calculated the total blood volume according to Nadler's formula, and fluid therapy was correlated with a newly developed dilution coefficient formula at the end of CPB. Intravenously applied fluids were measured from the beginning of the anesthesia (baseline, T0) and 15 min after the end of protamine infusion (end of CPB, T1). The amount of the administered volume (crystalloids or colloids) was calculated according to the percentage of the intravascular fluid effect, and intraoperative diuresis was further subtracted. The median blood volume increased by 148% in all patients at T1 compared to the calculated total blood volume at T0. This led to a dilution-dependent decrease of 38% in all three parameters (Hgb 24%, corrCoeff = 0.53; PLT 41%, corrCoeff = 0.68; PT 44%, corrCoeff = 0.54). The dilution-correlated decrease was significant for all parameters (p < 0.001), and the effect was independent from the duration of CPB. We conclude that the presented calculation-based approach could provide important information regarding actual laboratory parameters and may help in the guidance of the blood product substitution and potential transfusion thresholds. Further research on the impact of dilution and related decision-making for blood product substitution, including its impact on morbidity and mortality, is warranted.
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Affiliation(s)
- Nicole Innerhofer
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
| | - Sasa Rajsic
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
| | - Marco Ronzani
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
| | - Robert Breitkopf
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
| | - Can Gollmann Tepeköylü
- Department for Cardiac Surgery, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Corinna Velik-Salchner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
| | - Lisa Schlosser
- Department of Mathematics, University of Innsbruck, 6020 Innsbruck, Austria
| | - Dietmar Fries
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
| | - Werner Streif
- Department of Paediatrics, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Michael Schirmer
- Department of Internal Medicine, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Judith Martini
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria; (N.I.); (D.F.)
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Zhang Q, Gao Y, Tian Y, Gao S, Diao X, Ji H, Wang Y, Ji B. A transfusion risk stratification score to facilitate quality management in cardiopulmonary bypass. Transfusion 2023; 63:1495-1505. [PMID: 37458390 DOI: 10.1111/trf.17487] [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: 02/14/2023] [Revised: 05/19/2023] [Accepted: 06/09/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Our previous showed that a blood management program in the cardiopulmonary bypass (CPB) department, reduced red blood cell (RBC) transfusion and complications, but assessing transfusion practice solely based on transfusion rates was insufficient. This study aimed to design a risk stratification score to predict perioperative RBC transfusion to guide targeted measures for on-pump cardiac surgery patients. STUDY DESIGN AND METHODS We analyzed data from 42,435 adult cardiac patients. Eight predictors were entered into the final model including age, sex, anemia, New York Heart Association classification, body surface area, cardiac surgery history, emergency surgery, and surgery type. We then simplified the score to an integer-based system. The area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow goodness-of-fit test, and a calibration curve were used for its performance test. The score was compared to existing scores. RESULTS The final score included eight predictors. The AUC for the model was 0.77 (95% CI, 0.76-0.77) and 0.77 (95% CI, 0.76-0.78) in the training and test set, respectively. The calibration curves showed a good fit. The risk score was finally grouped into low-risk (score of 0-13 points), medium-risk (14-19 points), and high-risk (more than 19 points). The score had better predictive power compared to the other two existing risk scores. DISCUSSION We developed an effective risk stratification score with eight variables to predict perioperative RBC transfusion for on-pump cardiac surgery. It assists perfusionists in proactively preparing blood conservation measures for high-risk patients before surgery.
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Affiliation(s)
- Qiaoni Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Yu Tian
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Xiaolin Diao
- Department of Information Center, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Hongwen Ji
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Yuefu Wang
- Surgery Intensive Care Unit & Center of Anesthesia, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
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Garganeeva AA, Tukish OV, Kuzheleva EA, Fediunina VA, Kozlov BN. [Iron deficiency in cardiac surgery patients and the possibility of its correction at the preoperative stage]. KARDIOLOGIIA 2023; 63:68-76. [PMID: 37522830 DOI: 10.18087/cardio.2023.7.n2471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 08/01/2023]
Abstract
Among cardio-surgical patients, the prevalence of iron deficiency conditions reaches 70 %, and anemia is detected in less than 50% cases. Meanwhile, both anemia and latent iron deficiency are risk factors for adverse outcomes in cardio-surgical patients. These conditions are associated with a high frequency and greater volume of blood transfusions as well as with a longer stay in the hospital. Timely diagnosis and correction of iron deficiency, regardless of the presence of anemia, are mandatory at the stage of preoperative preparation. The use of oral iron medicines is limited by their low efficacy in this category of patients and a high risk of adverse events. Intravenous iron medicines have a high potential for correcting iron deficiency, and their efficacy and safety have been previously demonstrated. Administration of ferric carboxymaltose has proved beneficial in studies on iron deficiency correction in cardiological and cardio-surgical patients. In these patients, ferric carboxymaltose improved the dynamics of ferritin and hemoglobin, reduced the risk of blood transfusion, and decreased the duration of stay in the hospital. Preoperative intravenous administration of ferric carboxymaltose to cardio-surgical patients can improve clinical outcomes and the cost effectiveness of cardiac surgery.
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Affiliation(s)
- A A Garganeeva
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | - O V Tukish
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | - E A Kuzheleva
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
| | | | - B N Kozlov
- Research Institute of Cardiology, Tomsk National Research Medical Center of the Russian Academy of Sciences
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Kim HJ, Kim JE, Lee JY, Lee SH, Jung JS, Son HS. Perioperative Red Blood Cell Transfusion Is Associated With Adverse Cardiovascular Outcomes in Heart Valve Surgery. Anesth Analg 2023; 137:153-161. [PMID: 36730895 DOI: 10.1213/ane.0000000000006245] [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: 02/04/2023]
Abstract
BACKGROUND We examined the relationship between blood transfusion and long-term adverse events to evaluate the clinical impact of red blood cell (RBC) transfusion on patients undergoing cardiac valve surgery. METHODS From the National Health Insurance Service database, individuals undergoing heart valve surgery were verified, including aortic valve (AV), mitral valve (MV), tricuspid valve (TV), and complex valves (more than 2 valve surgeries). The interested outcomes were incidence of death, ischemic stroke, hemorrhagic stroke, and admission for myocardial infarction during follow-up. Associations between perioperative RBC transfusion and long-term cardiovascular events were analyzed with Cox-proportional hazard model. RESULTS Perioperative RBC transfusion (±2 days from the day of surgery) was categorized into 0, 1, 2, and >3 units based on the number of packs transfused. From 2003 to 2019, the data of 58,299 individuals were retrieved (51.6% were male and 58% were aged above 60 years). The median follow-up duration was 5.53 years. Of the total cohort, 86.5% received at least 1 transfusion. In multivariable analysis, adverse cardiovascular event risk proportionally increased with transfusion in a dose-dependent manner. The adjusted hazard ratios and 95% confidence intervals of outcomes after the transfusion of 1, 2, and ≥3 units compared to those with no transfusion were as follows: death, 1.53 (1.41-1.66), 1.97 (1.81-2.14), and 3.03 (2.79-3.29); ischemic stroke, 1.27 (1.16-1.39), 1.31 (1.19-1.44), and 1.51 (1.38-1.66); hemorrhagic stroke, 1.38 (1.16-1.66), 1.71 (1.43-2.05), and 2.31 (1.94-2.76); and myocardial infarction 1.35 (1.13-1.62), 1.60 (1.33-1.91), and 1.99 (1.66-2.38), respectively (all P < .01). CONCLUSIONS In the analysis of the national cohort, perioperative RBC transfusion during heart valve surgery was associated with adverse cardiovascular outcomes correlated with the volume of RBC transfusion.
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Affiliation(s)
- Hee Jung Kim
- From the Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Eon Kim
- From the Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ji Yoon Lee
- Department of Biostatistics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung Hyung Lee
- From the Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Jae Seung Jung
- From the Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ho Sung Son
- From the Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Seoul, Republic of Korea
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Monaco F, Licheri M, Barucco G, De Bonis M, Lapenna E, Pieri M, Zangrillo A, Ortalda A. Four-Factor Prothrombin Complex Concentrate in Left Ventricular Assist Device Implantation: Inverse Propensity Score-Weighted Analysis. ASAIO J 2023; 69:e293-e300. [PMID: 37146590 DOI: 10.1097/mat.0000000000001974] [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: 05/07/2023] Open
Abstract
We compare the effect of intraoperative administration of four-factor prothrombin complex concentrates (PCCs) versus fresh frozen plasma (FFP) on major bleeding, transfusions, and complications. Out of 138 patients undergoing left ventricle assist device (LVAD) implantation, 32 received PCCs as first-line hemostatic agents and 102 FFP (standard group). The crude treatment estimates indicated that, compared with the standard group, the PCC group required more FFP units (odds ratio [OR]: 4.17, 95% confidence interval [CI]: 1.58-11; p = 0.004) intraoperatively, whereas a greater number of patients received FFP at 24 hours (OR: 3.01, 95% CI: 1.19-7.59; p = 0.021) and less packed red blood cells (RBC) at 48 hours (OR: 0.61, 95% CI: 0.01-1.21; p = 0.046). After the inverse probability of treatment weighting (IPTW) adjusted analyses, in the PCC group there was still a higher number of patients who required FFP (OR: 2.9, 95% CI: 1.02-8.25; p = 0.048) or RBC (OR: 6.23, 95% CI: 1.67-23.14; p = 0.007] at 24 hours and RBC at 48 hours (OR: 3.09, 95% CI: 0.89-10.76; p = 0.007). Adverse events and survival were similar before and after the ITPW adjustment. In conclusion, the PCCs, although relatively safe with respect to thrombotic events, were not associated with a reduction of major bleeding and blood product transfusions.
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Affiliation(s)
- Fabrizio Monaco
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Licheri
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaia Barucco
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Ortalda
- From the Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Walsh B, Mueller B, Roche SL, Alonso-Gonzalez R, Somerset E, Sano M, Villagran Schmidt M, Hickey E, Barron D, Heggie J. Impact of a quality improvement initiative with a dedicated anesthesia team on outcomes after surgery for adult congenital heart disease. JTCVS OPEN 2023; 14:188-204. [PMID: 37425473 PMCID: PMC10329027 DOI: 10.1016/j.xjon.2023.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/23/2023] [Accepted: 03/24/2023] [Indexed: 07/11/2023]
Abstract
Objectives A quality improvement initiative was introduced to the adult congenital cardiac surgery program at Toronto General Hospital in January 2016. A dedicated Adult Congenital Anesthesia and intensive care unit team was introduced within the cardiac group. The use of factor concentrates was introduced. The study compares perioperative mortality, adverse events, and transfusion burden before and after this process change. Methods We performed a retrospective analysis of all adult congenital cardiac surgeries from January 2004 to July 2019. Two groups were analyzed: patients undergoing operation before and after 2016. The primary outcome was in-hospital mortality. One-year mortality and prevalence of key morbidities were analyzed as secondary outcomes. A separate analysis looked at patients who had and had not attended an anesthesia-led preassessment clinic. Results In-hospital mortality was significantly reduced in patients undergoing operation after 2016 (1.1% vs 4.3%, P = .003) despite a higher risk profile. One-year mortality (1.3% vs 5.8%, P = .003) and ventilation times (5.5 hours [3.4-13.0] vs 6.3 hours [4.2-16.2], P = .001) were also reduced. The incidence of stroke and renal failure was similar between groups. Blood product exposure was comparable, but the incidence of chest reopening decreased (1.8% vs 4.8%, P = .022), despite more patients with multiple previous chest wall incisions, on anticoagulation, and with more complex cardiac anatomy. There were no significant outcome differences between those who did or did not attend the preassessment clinic. Conclusions Both in-hospital and 1-year mortality were significantly reduced after the introduction of a quality improvement program, despite a higher risk profile. Blood product exposure remained unchanged, but there were less chest reopenings.
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Affiliation(s)
- Bill Walsh
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Brigitte Mueller
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - S. Lucy Roche
- Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Division of Cardiology, Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Emily Somerset
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Minako Sano
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Milca Villagran Schmidt
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
| | - Edward Hickey
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Barron
- Division of Cardiac Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
- Division of Cardiac Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jane Heggie
- Department of Anesthesia and Pain Medicine, Peter Munk Cardiac Centre, Toronto General Hospital, Toronto, Ontario, Canada
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Cohen BG, Chingcuanco F, Zhang J, Reid NM, Lee V, Hong J, Deliargyris EN, Padula WV. Cost-Effectiveness and Budget Impact of a Novel Antithrombotic Drug Removal System to Reduce Bleeding Risk in Patients on Preoperative Ticagrelor Undergoing Cardiac Surgery. Am J Cardiovasc Drugs 2023:10.1007/s40256-023-00587-4. [PMID: 37204675 DOI: 10.1007/s40256-023-00587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Antithrombotic drugs, including the P2Y12 inhibitor ticagrelor, increase the risk of perioperative bleeding in patients requiring urgent cardiac surgery. Perioperative bleeding can lead to increased mortality and prolong intensive care unit and hospital stays. A novel sorbent-filled hemoperfusion cartridge that intraoperatively removes ticagrelor via hemoadsorption can reduce the risk of perioperative bleeding. We estimated the cost-effectiveness and budget impact of using this device versus standard practices to reduce the risk of perioperative bleeding during and after coronary artery bypass grafting from the US healthcare sector perspective. METHODS We used a Markov model to analyze the cost-effectiveness and budget impact of the hemoadsorption device in three cohorts: (1) surgery within 1 day from last ticagrelor dose; (2) surgery between 1 and 2 days from last ticagrelor dose; and (3) a combined cohort. The model analyzed costs and quality-adjusted life years (QALYs). Results were interpreted as both incremental cost-effectiveness ratios and net monetary benefits (NMBs) at a cost-effectiveness threshold of $100,000/QALY. We analyzed parameter uncertainty using deterministic and probabilistic sensitivity analyses. RESULTS The hemoadsorption device was dominant for each cohort. Patients with less than 1 day of washout in the device arm gained 0.017 QALYs at a savings of $1748 (USD), for an NMB of $3434. In patients with 1-2 days of washout, the device arm yielded 0.014 QALYs and a cost savings of $151, for an NMB of $1575. In the combined cohort, device gained 0.016 QALYs and a savings of $950 for an NMB of $2505. Per-member-per-month cost savings associated with device was estimated to be $0.02 for a one-million-member health plan. CONCLUSION This model found the hemoadsorption device to provide better clinical and economic outcomes compared with the standard of care in patients who required surgery within 2 days of ticagrelor discontinuation. Given the increasing use of ticagrelor in patients with acute coronary syndrome, incorporating this novel device may represent an important part of any bundle to save costs and reduce harm.
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Affiliation(s)
| | | | | | | | | | - Jonathan Hong
- St. Boniface Hospital, University of Manitoba, Winnipeg, MB, Canada
| | | | - William V Padula
- Stage Analytics, Duluth, GA, USA.
- Department of Pharmaceutical and Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA, USA.
- The Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, USC Schaeffer Center, 635 Downey Way (VPD), Los Angeles, CA, 90089, USA.
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Tibi P, Thompson J, Attaran S, Black E. Retrospective study assessing outcomes in cardiac surgery after implementation of Quantra. J Cardiothorac Surg 2023; 18:149. [PMID: 37069685 PMCID: PMC10109219 DOI: 10.1186/s13019-023-02245-x] [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: 08/26/2022] [Accepted: 04/02/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND The Quantra QPlus System is a cartridge-based device with a unique ultrasound technology that can measure the viscoelastic properties of whole blood during coagulation. These viscoelastic properties correlate directly with hemostatic function. The primary objective of this study was to assess blood product utilization in cardiac surgery patients before and after the implementation of the Quantra QPlus System. METHODS Yavapai Regional Medical Center implemented the Quantra QPlus System to aid in their efforts to reduce the transfusion of allogenic blood products and improve outcomes in patients undergoing cardiac surgery. A total of 64 patients were enrolled prior to the utilization of the Quantra (pre-Quantra cohort), and 64 patients were enrolled after (post-Quantra cohort). The pre-Quantra cohort had been managed via standard laboratory assays along with physician discretion for transfusion decisions. The utilization of blood products and frequency of transfusions were compared and analyzed between the two cohorts. (using the Student's t-test) RESULTS: The implementation of the Quantra resulted in a change in the pattern of blood product utilization leading to a demonstrated decrease in the amount of blood products transfused and the associated costs. The amount of FFP transfused was significantly decreased by 97% (P = 0.0004), whereas cryoprecipitate decreased by 67% (P = 0.3134), platelets decreased by 26% (P = 0.4879), and packed red blood cells decreased by 10% (P = 0.8027) however these trends did not reach statistical significance. The acquisition cost of blood products decreased by 41% for total savings of roughly $40,682. CONCLUSIONS Use of the Quantra QPlus System has the potential to improve patient blood management and decrease costs. STUDY REGISTERED AT CLINICALTRIALS.GOV: NCT05501730.
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Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA.
| | - Jess Thompson
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA
| | - Saina Attaran
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA
| | - Elizabeth Black
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA
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Boer W, van Tornout M, Brusseleers M, Strauven M, de Vooght P, Vander Laenen M, Hoste E, Jorens PG. The effects of differing anticoagulant regimes on blood quality after cell salvage in coronary artery bypass grafting (CABG): a pilot study. J Cardiothorac Surg 2023; 18:116. [PMID: 37031168 PMCID: PMC10082980 DOI: 10.1186/s13019-023-02246-w] [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: 08/28/2022] [Accepted: 04/02/2023] [Indexed: 04/10/2023] Open
Abstract
BACKGROUND Cell salvage reduces allogenic blood transfusion requirements in surgery. We present a pilot study exploring the impact of anticoagulant choice, citrate or heparin, on the quality of cell salvaged blood in adults undergoing coronary artery bypass grafting (CABG). MATERIALS AND METHODS Elective on pump CABG patients were randomly allocated to citrate or heparin anticoagulation. We measured red blood cell characteristics and inflammation in both the blood collection reservoir and the washed red blood cell concentrate. Postoperatively, the level of biomarkers and the coagulation profile in the peripheral blood as well as the transfusion requirements of allogenic blood products were studied. RESULTS Thirty eight patients were included, 19 in the citrate group and 19 in the heparin group. Baseline characteristics were similar. In the washed red blood cell concentrate, Mean Hb (g/dl) and Ht (%) were lower in the citrate group [Hb: 18.1 g/dL (SD 1.3) vs. 21.1 (1.6), p < 0.001; Ht: 59.9% (54.7-60.9) vs. 63.7% (62.3-64.8); p < 0.001]; Mean corpuscular volume (MCV, μm 3) was higher [99.1fL (9.4) vs. 88 (4.2), p < 0.001] and mean corpuscular hemoglobin concentration (MCHC, g/dl) lower in the citrate group [31.9 g/dl (29.6-32.4) vs. 33.6 (33.1-34.0) p < 0.001]. Thrombocyte count (1000/μl) was higher in the citrate group [31.0 (26.0-77.0) vs. 13.0 (10.0-39.0); p = 0.006]. There were no differences in the requirement for allogenic blood products' transfusion (intraoperatively and postoperatively) or in the coagulation parameters after washed red blood cell concentrate infusion. Higher IL-10 was found in the citrate group in the blood collection reservoir, higher neutrophil-derived myeloperoxidase (MPO) in the heparin group after washed red blood cell concentrate infusion. CONCLUSION Though red blood cells in washed red blood cell concentrate were more swollen and diluted in the citrate group with more residual thrombocytes, published quality guidelines were met in both groups. Our pilot study suggests that differences in inflammatory markers in the blood collection reservoir and after infusion of washed red blood cell concentrate indicate a possible pro-inflammatory effect of heparin compared to citrate. A larger study is warranted to confirm these results and their possible clinical consequences. Trial registration ClinicalTrials.gov : NCT02674906. Registered 5 February 2016.
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Affiliation(s)
- Willem Boer
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium.
| | - Mathias van Tornout
- Department of Anesthesiology and Intensive Care Medicine, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Maarten Brusseleers
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Maarten Strauven
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Pieter de Vooght
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Margot Vander Laenen
- Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Ziekenhuis Oost Limburg ZOL, Genk, Belgium
| | - Eric Hoste
- Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
- Research Foundation Flanders (FWO), Brussels, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital, University of Antwerp, LEMP, Edegem, Belgium
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Elbayomi M, Weyand M, Nooh E, Harig F. The lost balloon at midnight: a case report reveals the inevitability of heart team existence. J Cardiothorac Surg 2023; 18:102. [PMID: 37024888 PMCID: PMC10080842 DOI: 10.1186/s13019-023-02202-8] [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: 10/14/2022] [Accepted: 03/31/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Dislodgement of a coronary stent-balloon catheter during percutaneous coronary intervention (PCI) is rare but is a life-threatening complication. A 57- year-old male presented with a non-ST elevation myocardial infarction (NSTEMI). Coronary angiography revealed total thrombotic occlusion of the Right coronary artery (RCA). Following the balloon dilatation of the RCA and while trying to retrieve the balloon catheter, the balloon was dislodged from the catheter shaft and entrapped in the coronary vessel. Under cardiopulmonary bypass, with antegrade cardioplegic arrest, the balloon was extracted through a coronary arteriotomy. Right coronary revascularization was done with reversed saphenous vein graft (SVG). DISCUSSION Given the variety of equipment that can be retained in the coronary artery and the multitude of mechanisms by which it may be entrapped, there are no straightforward techniques applicable to all situations. Specific guidelines or recommendations on properly managing these potentially life-threatening complications do not exist. However, the most crucial issue in the management of these cases is the hemodynamic status of the patient as well as the coronary flow in the vessel with entrapped device or stent. In our case, the RCA was retrogradely perfused from the left coronary artery, which provided time to transfer the patient to cardiovascular surgical backup.
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Affiliation(s)
- Mohamed Elbayomi
- Department of Cardiovascular Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany.
| | - Michael Weyand
- Department of Cardiovascular Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Ehab Nooh
- Department of Cardiovascular Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
| | - Frank Harig
- Department of Cardiovascular Surgery, Friedrich-Alexander-University, Krankenhausstr. 12, 91054, Erlangen, Germany
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Rubino AS, De Santo LS, Montella AP, Golini Petrarcone C, Palmieri L, Galbiati D, Galdieri N, De Feo M. Prognostic Implication of Preoperative Anemia in Redo Cardiac Surgery: A Single-Center Propensity-Matched Analysis. J Cardiovasc Dev Dis 2023; 10:160. [PMID: 37103039 PMCID: PMC10146465 DOI: 10.3390/jcdd10040160] [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: 03/15/2023] [Revised: 04/02/2023] [Accepted: 04/05/2023] [Indexed: 04/08/2023] Open
Abstract
Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known about its prognostic value in the setting of redo procedure. A retrospective, observational cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020. The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. Selection bias was assessed with the propensity-adjustment method. The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and nonanemic groups emerged in the risk for postoperative stroke (0.6% vs. 4.4%, p = 0.023), postoperative renal dysfunction (29.7% vs. 15.6%, p = 0.001), a need for prolonged ventilation (18.1% vs. 7.2%, p = 0.002), and high-dosage inotropes (53.1% vs. 32.9%, p < 0.001) along with both length of ICU and hospital stay (8.2 ± 15.9 vs. 4.3 ± 5.4 days, p = 0.003 and 18.8 ± 17.4 vs. 14.9 ± 11.1, p = 0.012). After propensity matching (145 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke, and the need for high-dosage inotrope cardiac morbidity. Preoperative anemia is significantly associated with acute kidney injury, stroke, and the need for high-dosage inotropes in patients referred for redo procedures.
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Affiliation(s)
- Antonino Salvatore Rubino
- Cardio-Thoraco-Vascular Department, Division of Cardiac Surgery, Papardo Hospital, 98158 Messina, Italy
| | - Luca Salvatore De Santo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Antonio Pio Montella
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Caterina Golini Petrarcone
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Lucrezia Palmieri
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Denise Galbiati
- Cardiovascular Department, Cardiac Surgery Unit of the IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Nicola Galdieri
- Cardiac Intensive Care Unit, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
| | - Marisa De Feo
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Monaldi Hospital, Via Leonardo Bianchi, 80131 Neaples, Italy
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Helwani MA, De Wet CJ, Pennington B, Abdulnabi S, Moon MR. Severe Acute Blood Loss Anemia in Jehovah's Witnesses Undergoing Cardiac Surgery: Single Academic Center Experience. J Cardiothorac Vasc Anesth 2023; 37:513-518. [PMID: 36435723 DOI: 10.1053/j.jvca.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/30/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the effect of severe acute blood loss anemia (ABLA) on postoperative outcomes in Jehovah's Witness (JW) patients undergoing cardiac surgery. DESIGN This was a retrospective cohort study of adult JW patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) between January 1998 and December 2018 at Barnes-Jewish Hospital in St. Louis, Missouri. SETTING At a single tertiary academic center. PARTICIPANTS Patients who were JWs undergoing cardiac surgery requiring CPB. INTERVENTIONS Patients were divided into the following 2 groups: JW patients who developed severe ABLA (defined as postoperative hematocrit level <21), and patients who did not develop severe ABLA. MEASUREMENTS AND MAIN RESULTS A total of 48 JW patients who underwent cardiac surgery between 2008 and 2018 were identified. Of these patients, 9 (18.8%) developed postoperative severe ABLA, and 39 (81.3%) did not. Severe ABLA was associated with increased postoperative mortality at 30-days, 90-days, and 1-year postoperatively, and a trend toward increased hospital length of stay. CONCLUSIONS Severe ABLA after cardiac surgery was associated with higher mortality and a trend toward increased hospital length of stay among JW patients. More data are required to confirm the findings.
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Affiliation(s)
| | - Charl J De Wet
- Department of Anesthesiology, Washington University, St. Louis, MO
| | | | | | - Marc R Moon
- Department of Cardiothoracic Surgery, Texas Heart Institute, Houston, TX
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Tong N, King J, Fomani K. Comparison of computerized provider order entry specific transfusion indications versus the use of "Other". Transfusion 2023; 63:737-744. [PMID: 36789571 DOI: 10.1111/trf.17281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 12/10/2022] [Accepted: 01/13/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Computerized physician order entry (CPOE) systems are one way to reinforce evidence-based transfusion indications for blood products. The new CPOE system that was implemented at our institution allowed healthcare providers to select "Other" as an indication and provide reasons for transfusion outside of accepted guidelines. STUDY DESIGN AND METHODS Transfusion order records for packed red blood cells (RBCs), platelets, and fresh frozen plasma (FFP) from high product-ordering areas of Long Island Jewish Medical Center and Cohen's Children's Medical Center from April 2021, when the new CPOE system was implemented, to November 2021 were reviewed. The percentage of "Other" orders was determined and the reason for each "Other" order was reviewed to identify possible areas for education or valid indications not included in the institutionally recognized indications. RESULTS 9.7% of RBC orders, 1.9% of platelet orders, and 18.2% of FFP orders were placed with "Other" as the indication for transfusion (χ2 2 = 88.5; p < .001). Reasons for "Other" orders were varied, but notable reasons included indications already institutionally accepted such as, bleeding (15.7% of pediatric "Other" RBC orders), hold for OR (14.3% of pediatric and 15.8% of adult "Other" RBC orders), and novel reasons such as FFP for ACE-inhibitor associated angioedema (84.6% of adult "Other" FFP orders). DISCUSSION The findings from our study provide examples of potential difficulties hospitals may encounter when they implement a new computerized physician order entry system. Provider education may play an important role to reduce the number of "Other" orders placed for already recognized indications.
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Affiliation(s)
- Nicholas Tong
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Northwell, Greenvale, New York, USA
| | - Jessica King
- Department of Pathology and Laboratory Medicine: Blood Bank, Long Island Jewish Medical Center, Queens, New York, USA
| | - Katayoun Fomani
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Northwell, Greenvale, New York, USA.,Department of Pathology and Laboratory Medicine: Blood Bank, Long Island Jewish Medical Center, Queens, New York, USA
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Kloeser R, Buser A, Bolliger D. Treatment Strategies in Anemic Patients Before Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:266-275. [PMID: 36328926 DOI: 10.1053/j.jvca.2022.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
Both preoperative anemia and the transfusion of red blood cells have been associated with increased morbidity and mortality after cardiac surgery. To reduce the need for blood transfusion during surgery and improve patient outcomes, patient blood management programs have been developed. A primary focus of patient blood management in the preoperative period is the identification, diagnosis, and treatment of preoperative anemia, as anemia is associated with an increased risk of preoperative blood transfusion. In this narrative review, the authors focus on the laboratory screening of anemia before surgery and the evidence and limitations of different treatment strategies in anemic patients scheduled for cardiac surgery. To accurately correct preoperative anemia, the timely detection and definition of the etiology of anemia before elective cardiac surgery are crucial. Multiple randomized studies have been performed using preoperative iron supplementation and/or administration of erythropoiesis-stimulating agents in patients undergoing cardiac surgery. Although preoperative iron substitution in patients with iron deficiency is recommended, the evidence of its effectiveness is limited. In patients with nonpure iron deficiency anemia, combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended. Combined therapy might effectively reduce the need for red blood cell transfusion, even if applied shortly before cardiac surgery. The therapeutic effect on morbidity and mortality remains unclear. Nonetheless, the timely preoperative assessment of anemia and determination of iron status, eventually leading to targeted therapy, should become a standard of care and might potentially improve patient outcomes.
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Affiliation(s)
- Raphael Kloeser
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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Houry M, Tohme J, Sleilaty G, Jabbour K, Bou Gebrael W, Jebara V, Madi-Jebara S. Effects of ferric carboxymaltose on hemoglobin level after cardiac surgery: A randomized controlled trial. Anaesth Crit Care Pain Med 2023; 42:101171. [PMID: 36375780 DOI: 10.1016/j.accpm.2022.101171] [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: 04/19/2022] [Revised: 09/02/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Perioperative anemia is common in cardiac surgery. Few studies investigated the effect of postoperative intravenous (IV) iron supplementation and were mostly inconclusive. METHODS Design: A randomized single-center, double-blind, placebo-controlled, parallel-group trial. PARTICIPANTS 195 non-anemic patients were recruited from December 2018 to December 2020: 97 patients received 1 g of ferric carboxymaltose (FCM) and 98 patients received 100 mL of physiological serum on postoperative day 1. MEASUREMENTS hemoglobin levels, reticulocyte count, serum iron, serum ferritin, and transferrin saturation were measured at induction of anesthesia, postoperative days 1, 5, and 30. Transfusion rate, duration of mechanical ventilation, critical care unit length of stay, and side effects associated with IV iron administration were measured. The primary outcome was hemoglobin level on day 30. Secondary outcomes included iron balance, transfused red cell packs, and critical care unit length of stay. RESULTS At day 30, the hemoglobine level was higher in the FCM group than in the placebo group (mean 12.9 ± 1.2 vs. 12.1 ± 1.3 g/dL (95%CI 0.41-1.23, p-value <0.001)). Patients in the FCM group received fewer blood units (median 1[0-2] unit vs. 2 [0-3] units, p-value = 0.037) and had significant improvement in iron balance compared to the control group. No side effects associated with FCM administration were reported. CONCLUSION In this randomized controlled trial, administration of FCM on postoperative day 1 in non-anemic patients undergoing cardiac surgery increased hemoglobin levels by 0.8 g/dL on postoperative day 30, leading to reduced transfusion rate, and improved iron levels on postoperative day 5 and 30. CLINICAL TRIAL REGISTRY NUMBER NCT03759964.
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Affiliation(s)
- Maha Houry
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Joanna Tohme
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon.
| | - Ghassan Sleilaty
- Department of Cardiovascular and Thoracic Surgery, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon; Clinical Research Center, Faculty of Medicine, Université Saint-Joseph, Beirut, Lebanon
| | - Khalil Jabbour
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Wissam Bou Gebrael
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Victor Jebara
- Department of Cardiovascular and Thoracic Surgery, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
| | - Samia Madi-Jebara
- Department of Anesthesia and Critical Care, Hôtel-Dieu de France hospital, Université Saint-Joseph, Beirut, Lebanon
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Jovanovic M, Zivkovic I, Jovanovic M, Bilbija I, Petrovic M, Markovic J, Radovic I, Dimitrijevic A, Soldatovic I. Economic Justification Analysis of Minimally Invasive versus Conventional Aortic Valve Replacement. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2553. [PMID: 36767915 PMCID: PMC9916198 DOI: 10.3390/ijerph20032553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 01/29/2023] [Indexed: 06/18/2023]
Abstract
There is no definitive consensus about the cost-effectiveness of minimally invasive aortic valve replacement (AVR) (MI-AVR) compared to conventional AVR (C-AVR). The aim of this study was to compare the rate of postoperative complications and total hospital costs of MI-AVR versus C-AVR overall and by the type of aortic prosthesis (biological or mechanical). Our single-center retrospective study included 324 patients over 18 years old who underwent elective isolated primary AVR with standard stented AV prosthesis at the Institute for Cardiovascular Diseases "Dedinje" between January 2019 and December 2019. Reintervention, emergencies, combined surgical interventions, and patients with sutureless valves were excluded. In both MI-AVR and C-AVR, mechanical valve implantation contributed to overall reduction of hospital costs with equal efficacy. The cost-effectiveness ratio indicated that C-AVR is cheaper and yielded a better clinical outcome with mechanical valve implantation (67.17 vs. 69.5). In biological valve implantation, MI-AVR was superior. MI-AVR patients had statistically significantly higher LVEF and a lower Euro SCORE than C-AVR patients (Mann-Whitney U-test, p = 0.002 and p = 0.002, respectively). There is a slight advantage to MI-AVR vs. C-AVR, since it costs EUR 9.44 more to address complications that may arise. Complications (mortality, early reoperation, cerebrovascular insult, pacemaker implantation, atrial fibrillation, AV block, systemic inflammatory response syndrome, wound infection) were less frequent in the MI-AVR, making MI-AVR more economically justified than C-AVR (18% vs. 22.1%).
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Affiliation(s)
- Marko Jovanovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Igor Zivkovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Milos Jovanovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
| | - Ilija Bilbija
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Cardiac Surgery, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Masa Petrovic
- Institute for Cardiovascular Diseases “Dedinje”, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Jovan Markovic
- Faculty of Dental Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Radovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Transfusiology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Ana Dimitrijevic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivan Soldatovic
- Institute of Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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71
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Natour AK, Shepard AD, Nypaver TJ, Rteil A, Corcoran P, Tang X, Kabbani L. Impact of Preoperative Anemia on Hospitalization, Death, and Overall Survival in Patients With Peripheral Artery Disease Undergoing Endovascular Therapy: A Retrospective Cohort Study in the United States and Canada. J Endovasc Ther 2023:15266028221149926. [PMID: 36680405 DOI: 10.1177/15266028221149926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE Preoperative anemia is associated with adverse outcomes after cardiac and noncardiac surgeries, but outcomes after an endovascular peripheral vascular intervention (PVI) are not well established. We aimed to assess the association of preoperative anemia with 30 day death, hospital length of stay (LOS), and overall (long term) survival in patients undergoing an endovascular PVI for peripheral artery disease. MATERIALS AND METHODS In this retrospective, cohort study in the United States and Canada, we queried the national Vascular Quality Initiative database for all endovascular PVIs performed between 2010 and 2019, and outcomes were correlated with patients' hemoglobin (Hb) levels. Anemia was classified as mild (Hb=10-13 g/dL for men and 10-12 g/dL for women), moderate (Hb=8-9.9 g/dL), and severe (Hb<8 g/dL). RESULTS A total of 79 707 adult patients who met study criteria underwent endovascular PVI. The mean age was 68 years, and 59% of patients were male. Anemia was documented in 38 543 patients (48%) and was mild in 27 435 (71%), moderate in 9783 (25%), and severe in 1325 (4%). The median follow-up duration was 4 years (range, 1.25-5.78 years). On univariate analysis, 30 day mortality, total LOS, and overall survival were significantly associated with the level of preoperative anemia. These associations persisted in the multivariate models. Kaplan-Meier survival analysis demonstrated an association of death with degree of anemia (p<0.001). CONCLUSION The presence and degree of preoperative anemia were independently associated with increased 30 day mortality and LOS and decreased overall survival for patients with peripheral artery disease who had undergone endovascular PVI. CLINICAL IMPACT The findings from this study have many implications for how to approach vascular surgery in patients with variable hemoglobin levels. Our findings will strengthen our ability to conduct accurate preoperative risk stratification for patients undergoing peripheral vascular interventions. This may also mitigate healthcare expenditures if findings are applied in a way that can lower patient length of postoperative stay while also maintaining quality of care and patient safety. Our results will also serve as guidance for clinical trials, and future prospective trials should evaluate the effect of preoperative optimization of hemoglobin as a potentially modifiable risk factor for outcomes.
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Affiliation(s)
| | | | | | - Ali Rteil
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Paul Corcoran
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Xiaoqin Tang
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Loay Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
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72
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Ellam S, Räsänen J, Hartikainen J, Selander T, Juutilainen A, Halonen J. Impact of minimal invasive extracorporeal circulation on perioperative intravenous fluid management in coronary artery bypass surgery. Perfusion 2023; 38:135-141. [PMID: 34479461 PMCID: PMC9841459 DOI: 10.1177/02676591211043232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Compare the use of blood products and intravenous fluid management in patients scheduled for coronary artery bypass surgery and randomized to minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC). METHODS A total of 240 patients who were scheduled for their first on-pump CABG, were randomized to MiECC or CECC groups. The study period was the first 84 hours after surgery. Hemoglobin <80 g/l was used as transfusion trigger. RESULTS Red blood cell transfusions intraoperatively were given less often in the MiECC group (23.3% vs 9.2%, p = 0.005) and the total intravenous fluid intake was significantly lower in the MiECC group (3300 ml [2950-4000] vs 4800 ml [4000-5500], p < 0.001). Hemoglobin drop also was lower in the MiECC group (35.5 ± 8.9 g/l vs 50.7 ± 9 g/l, p < 0.001) as was hemoglobin drop percent (25.3 ± 6% vs 35.3 ± 5.9%, p < 0.001). Chest tube drainage output was higher in the MiECC group (645 ml [500-917.5] vs 550 ml [412.5-750], p = 0.001). Particularly, chest tube drainage in up to 600 ml category, was in benefit of CECC group (59.1% vs 40.8%, p = 0.003). ROC curve analysis showed that patients with hemoglobin level below 95 g/l upon arrival to intensive care unit was associated with increased risk of developing postoperative atrial fibrillation (POAF) (p = 0.002, auc = 0.61, cutoff <95, sensitivity = 0.47, positive predictive value = 0.64). CONCLUSION MiECC reduced the intraoperative need for RBC transfusion and intravenous fluids compared to the CECC group, also reducing hemoglobin drop compared to the CECC group in CABG surgery patients. Postoperative hemoglobin drop was a predictor of POAF.
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Affiliation(s)
- Sten Ellam
- Department of Anesthesiology and
Operative Services, Kuopio University Hospital, Kuopio, Finland,Sten Ellam, Department of Anesthesiology
and Operative Services, Kuopio University Hospital, PO Box 100, Kuopio 70029,
Finland.
| | - Jenni Räsänen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland
| | - Juha Hartikainen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland,Heart Center, Kuopio University
Hospital, Kuopio, Finland
| | - Tuomas Selander
- Research Support Services, Kuopio
University Hospital, Kuopio, Finland
| | - Auni Juutilainen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland
| | - Jari Halonen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland,Heart Center, Kuopio University
Hospital, Kuopio, Finland
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73
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Wang E, Wang Y, Li Y, Hu S, Yuan S. Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study. Front Surg 2023; 10:1117974. [PMID: 36896258 PMCID: PMC9989169 DOI: 10.3389/fsurg.2023.1117974] [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: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
Background More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear. Methods In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death. Results The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026). Conclusion We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Dybas J, Wajda A, Alcicek FC, Kaczmarska M, Bulat K, Szczesny-Malysiak E, Martyna A, Perez-Guaita D, Sacha T, Marzec KM. Label-free testing strategy to evaluate packed red blood cell quality before transfusion to leukemia patients. Sci Rep 2022; 12:21849. [PMID: 36528645 PMCID: PMC9759565 DOI: 10.1038/s41598-022-26309-5] [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: 06/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Patients worldwide require therapeutic transfusions of packed red blood cells (pRBCs), which is applied to the high-risk patients who need periodic transfusions due to leukemia, lymphoma, myeloma and other blood diseases or disorders. Contrary to the general hospital population where the transfusions are carried out mainly for healthy trauma patients, in case of high-risk patients the proper quality of pRBCs is crucial. This leads to an increased demand for efficient technology providing information on the pRBCs alterations deteriorating their quality. Here we present the design of an innovative, label-free, noninvasive, rapid Raman spectroscopy-based method for pRBCs quality evaluation, starting with the description of sample measurement and data analysis, through correlation of spectroscopic results with reference techniques' outcomes, and finishing with methodology verification and its application in clinical conditions. We have shown that Raman spectra collected from the pRBCs supernatant mixture with a proper chemometric analysis conducted for a minimum one ratio of integral intensities of the chosen Raman marker bands within the spectrum allow evaluation of the pRBC quality in a rapid, noninvasive, and free-label manner, without unsealing the pRBCs bag. Subsequently, spectroscopic data were compared with predefined reference values, either from pRBCs expiration or those defining the pRBCs quality, allowing to assess their utility for transfusion to patients with acute myeloid leukemia (AML) and lymphoblastic leukemia (ALL).
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Affiliation(s)
- Jakub Dybas
- grid.5522.00000 0001 2162 9631Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzyskiego St., 30-348 Krakow, Poland
| | - Aleksandra Wajda
- grid.5522.00000 0001 2162 9631Faculty of Chemistry, Jagiellonian University, 2 Gronostajowa St., 30-387 Krakow, Poland
| | - Fatih Celal Alcicek
- grid.5522.00000 0001 2162 9631Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzyskiego St., 30-348 Krakow, Poland
| | - Magdalena Kaczmarska
- grid.5522.00000 0001 2162 9631Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzyskiego St., 30-348 Krakow, Poland
| | - Katarzyna Bulat
- grid.5522.00000 0001 2162 9631Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzyskiego St., 30-348 Krakow, Poland ,grid.424613.60000 0001 2167 3632Lukasiewicz Research Network, Krakow Institute of Technology, 73 Zakopiaska St., 30-418 Krakow, Poland
| | - Ewa Szczesny-Malysiak
- grid.5522.00000 0001 2162 9631Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzyskiego St., 30-348 Krakow, Poland
| | - Agnieszka Martyna
- grid.11866.380000 0001 2259 4135Forensic Chemistry Research Group, University of Silesia in Katowice, 9 Szkolna St., 40-006 Katowice, Poland
| | - David Perez-Guaita
- Department of Analytical Chemistry, University of Valancia, Dr. Moliner 50, Burjassot, Spain
| | - Tomasz Sacha
- grid.5522.00000 0001 2162 9631Chair of Haematology, Faculty of Medicine, Jagiellonian University Medical College, 12 Sw. Anny St., 30-008 Krakow, Poland ,grid.5522.00000 0001 2162 9631Department of Haematology, Jagiellonian University Hospital, 2 Jakubowskiego St., 30-688 Krakow, Poland
| | - Katarzyna M. Marzec
- grid.5522.00000 0001 2162 9631Jagiellonian Center for Experimental Therapeutics, Jagiellonian University, 14 Bobrzyskiego St., 30-348 Krakow, Poland ,grid.424613.60000 0001 2167 3632Lukasiewicz Research Network, Krakow Institute of Technology, 73 Zakopiaska St., 30-418 Krakow, Poland
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75
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O'Shaughnessy S, Tangel V, Chaturvedi R, Javaid A, White R, Hoyler MM. Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018. J Card Surg 2022; 37:5162-5171. [PMID: 36378897 DOI: 10.1111/jocs.17168] [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: 06/24/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIM Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients. METHODS We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed. RESULTS A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001). CONCLUSION Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.
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Affiliation(s)
- Sinead O'Shaughnessy
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Virginia Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Rahul Chaturvedi
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Amal Javaid
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Robert White
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
| | - Marguerite M Hoyler
- Department of Anesthesiology, Weill Cornell Medicine, New York City, New York, USA
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76
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Zhou R, Qian D, Li H, Wang Z, Shi S, Shen F, Cheng L, Yang D, Yu M. Clinical presentation and in-hospital outcomes of intraoperative red blood cell transfusion in non-anemic patients undergoing elective valve replacement. Front Cardiovasc Med 2022; 9:1053209. [DOI: 10.3389/fcvm.2022.1053209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
BackgroundIntraoperative transfusion is associated with adverse clinical outcomes in cardiac surgery. However, few studies have shown the impact of intraoperative red blood cell (RBC) transfusion on non-anemic patients undergoing cardiac surgery. We assessed the in-hospital clinical outcomes of non-anemic patients undergoing isolated valve replacements and investigated the predictors associated with intraoperative RBC transfusion.MethodsWe enrolled 345 non-anemic patients undergoing isolated valve replacements in our department from January 2015 to December 2019. The patients were stratified by the receipt of intraoperative RBC transfusion. Baseline characteristics were compared between groups and multiple logistic regression was used to identify the predictors for intraoperative RBC transfusion. The association between intraoperative RBC transfusion and in-hospital outcomes was also evaluated.ResultsIntraoperative RBC transfusion developed in 84 of the 345 enrolled patients (24.3%). Three independent predictors for intraoperative RBC transfusion of non-anemic patients undergoing isolated valve replacements were identified by multivariate logistic analysis, including female, iron deficiency and hemoglobin level. When the two groups were compared, a significant tendency of higher in-hospital mortality (6.0% vs. 1.1%, P = 0.033) and higher incidence of postoperative hypoxemia (9.5% vs. 2.7%, P = 0.007) were observed in the intraoperative RBC transfusion group. After adjustment, the presence of intraoperative RBC transfusion was associated with an increase in postoperative hypoxemia (OR = 3.36, 95% CI: 1.16–9.71, P = 0.026).ConclusionIntraoperative RBC transfusion was associated with poorer clinical outcomes in non-anemic adults undergoing isolated valve replacements, which significantly increased the risk of postoperative hypoxemia. The independent predictors of intraoperative RBC transfusion, such as iron deficiency and female, were identified, which may be helpful for risk assessment and perioperative management.
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77
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Pupovac SS, Catalano MA, Hartman AR, Yu P. Factor eight inhibitor bypassing activity for refractory bleeding in coronary artery bypass grafting: A propensity‐matched analysis. Res Pract Thromb Haemost 2022; 6:e12838. [PMID: 36474593 PMCID: PMC9716326 DOI: 10.1002/rth2.12838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/17/2022] [Accepted: 10/04/2022] [Indexed: 12/03/2022] Open
Abstract
Background Perioperative bleeding and transfusion have been associated with major morbidity and mortality after cardiac surgery. As concerns remain regarding potential graft thrombosis following administration of a prothrombin factor concentrate, the use of factor eight inhibitor bypassing activity (FEIBA) in managing refractory postoperative bleeding has never been evaluated in patients undergoing isolated coronary artery bypass grafting (CABG). Objectives We aimed to examine the safety of FEIBA in patients undergoing isolated CABG, with respect to 30-day mortality, perioperative outcomes, and thrombotic complications. Methods A retrospective review was undertaken of all consecutive patients who had undergone isolated on-pump CABG between January 2015 and December 2019 at North Shore University Hospital. Patients requiring intraoperative extracorporeal membrane oxygenator support were excluded. Patients were divided into two groups, dependent upon whether they received FEIBA (n = 63) versus no FEIBA (n = 2493). A 1:5 propensity match analysis was employed, and patients were analyzed with respect to thrombotic complications, reintervention for myocardial ischemia, and short-term clinical outcomes. Results There was no difference in 30-day mortality between the two cohorts. There was also no significant difference in a composite of thrombotic complications (composed of deep vein thrombosis, pulmonary embolism, and stroke) between the two groups. Similarly, there was no significant difference in the requirement for postoperative reintervention for myocardial ischemia between patients who received FEIBA versus those who did not. Conclusions Factor eight inhibitor bypassing activity may be safe when used as rescue therapy for refractory bleeding following isolated CABG.
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Affiliation(s)
- Stevan S. Pupovac
- Department of Cardiovascular and Thoracic Surgery North Shore University Hospital/Northwell Health Manhasset New York USA
| | - Michael A. Catalano
- Department of Cardiovascular and Thoracic Surgery Zucker School of Medicine at Hofstra/Northwell Manhasset New York USA
| | - Alan R. Hartman
- Department of Cardiovascular and Thoracic Surgery North Shore University Hospital/Northwell Health Manhasset New York USA
| | - Pey‐Jen Yu
- Department of Cardiovascular and Thoracic Surgery North Shore University Hospital/Northwell Health Manhasset New York USA
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Lim K, Satkunasivam R, Nipper C, Xu J, Hsu E, Slawin JR, Roy T, Allenson KC, Kim MP, Barber SM, Ellis T, Akinsola O, Klaassen Z, Esnaola N, Ravi B, Jerath A, Wallis CJD. Association between isolated abnormal coagulation profile on transfusion following major surgery: A NSQIP analysis of individuals without bleeding disorders. Transfusion 2022; 62:2223-2234. [PMID: 36250486 DOI: 10.1111/trf.17146] [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: 08/04/2022] [Accepted: 08/28/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Preoperative coagulation screening for patients without bleeding disorders remains controversial. The combinatorial risk of INR, aPTT, and platelet count (PLT) abnormalities leading to bleeding requiring transfusion is not known in these patients. We examined the association between abnormal coagulation profile and the risk of transfusion following common elective surgery in patients without bleeding disorders. STUDY DESIGN AND METHODS We utilized the National Surgical Quality Improvement Program (NSQIP) database from 2004 to 2018 to identify patients without a history of bleeding disorders undergoing common 23 major elective procedures across 10 specialties. Multivariable logistic regression was used to assess the association between coagulation profile and bleeding requiring packed red blood cell transfusion intra-/post-operatively. RESULTS Of the 672,075 patients meeting inclusion criteria, 53.7% presented with normal coagulation profile preoperatively. Overall, 12.2% (n = 82,368) received transfusion. In the setting of normal aPTT/PLT, both Equivocal INR of 1.1-1.5 (aOR 1.41, 95% CI 1.38-1.44) and Abnormal INR of >1.5 (aOR 1.81, 95% CI 1.71-1.93) were significantly associated with an increased risk of transfusion. Equivocal (60-70) and Abnormal (>70) aPTT with normal INR/PLT did not demonstrate a comparable risk of transfusion. We observed a synergistic effect of combinatorial lab abnormalities on the risk of transfusion when both Abnormal INR/aPTT and Low PLT of <100,000 were present (aOR 5.18, 95% CI 3.04-8.84), compared to the effect of Abnormal INR/aPTT and normal/elevated PLT (aOR 1.90, 95% CI 1.48-2.45). DISCUSSION The preoperative presence of abnormal findings in INR or PLT was significantly associated with the risk of bleeding requiring transfusion during intraoperative and postoperative periods.
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Affiliation(s)
- Kelvin Lim
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA.,Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas, USA
| | - Cole Nipper
- Texas A&M Health Science Center College of Medicine, Bryan, Texas, USA
| | - Jiaqiong Xu
- Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas, USA
| | - Enshuo Hsu
- Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas, USA
| | - Jeremy R Slawin
- Department of Urology, Houston Methodist Hospital, Houston, Texas, USA
| | - Trisha Roy
- Department of Vascular Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Kelvin C Allenson
- Department of Surgical Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Min P Kim
- Department of Thoracic Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Sean M Barber
- Department of Spine Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Taryn Ellis
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Olutiwa Akinsola
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | - Nestor Esnaola
- Department of Surgical Oncology, Houston Methodist Hospital, Houston, Texas, USA
| | - Bheeshma Ravi
- Department of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesiology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Christopher J D Wallis
- Department of Urology, University of Toronto, Toronto, Ontario, Canada.,Department of Urology, Mount Sinai Hospital, Toronto, Ontario, Canada
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Matkovic E, Lindholm PF. Role of Viscoelastic and Conventional Coagulation Tests for Management of Blood Product Replacement in the Bleeding Patient. Semin Thromb Hemost 2022; 48:785-795. [PMID: 36174609 DOI: 10.1055/s-0042-1756192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
An important aim of viscoelastic testing (VET) is to implement transfusion algorithms based on coagulation test results to help reduce transfusion rates and improve patient outcomes. Establishing a rapid diagnosis and providing timely treatment of coagulopathy is the cornerstone of management of severely bleeding patients in trauma, postpartum hemorrhage, and major surgery. As the nature of acute bleeding and trauma leads to an unstable and tenuous physiologic state, conventional coagulation tests (CCTs) are too slow to diagnose, manage, and also course correct any hemostatic abnormalities that accompany an acute critical illness. Viscoelastic point-of-care tests strongly correlate with results from standard laboratory tests but are designed to enable clinicians to make timely, informed bleeding management decisions when time to intervene is critical. These assays provide an individualized and goal-oriented approach to patient blood management and are increasingly becoming involved in transfusion algorithms. The scope of this review aims to evaluate the current literature on VETs and their impact on actionable outputs in clinical decision making and their relationship to CCT.
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Affiliation(s)
- Eduard Matkovic
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul F Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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81
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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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Mazzeffi MA, Holmes SD, Taylor B, Ghoreishi M, McNeil JS, Kertai MD, Bollen BA, Tanaka K, Raphael J, Glance L. Red Blood Cell Transfusion and Postoperative Infection in Patients Having Coronary Artery Bypass Grafting Surgery: An Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Anesth Analg 2022; 135:558-566. [PMID: 35977365 DOI: 10.1213/ane.0000000000005920] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure in the world and up to one-third of patients are transfused red blood cells (RBCs). RBC transfusion may increase the risk for health care-associated infection (HAI) after CABG, but previous studies have shown conflicting results and many did not establish exposure temporality. Our objective was to explore whether intraoperative RBC transfusion is associated with increased odds of postoperative HAI. We hypothesized that intraoperative RBC transfusion would be associated with increased odds of postoperative HAI. METHODS We performed an observational cohort study of isolated CABG patients in the Society of Thoracic Surgeons adult cardiac surgery database from July 1, 2017, to June 30, 2019. The exposure was intraoperative RBC transfusion modeled as 0, 1, 2, 3, or 4+ units. The authors focused on intraoperative RBC transfusion as a risk factor, because it has a definite temporal relationship before postoperative HAI. The study's primary outcome was a composite HAI variable that included sepsis, pneumonia, and surgical site infection (both deep and superficial). Mixed-effects modeling, which controlled for hospital as a clustering variable, was used to explore the relationship between intraoperative RBC transfusion and postoperative HAI. RESULTS Among 362,954 CABG patients from 1076 hospitals included in our analysis, 59,578 patients (16.4%) received intraoperative RBCs and 116,186 (32.0%) received either intraoperative or postoperative RBCs. Risk-adjusted odds ratios for HAI in patients who received 1, 2, 3, and 4+ intraoperative RBCs were 1.11 (95% confidence interval [CI], 1.03-1.20; P = .005), 1.13 (95% CI, 1.05-1.21; P = .001), 1.15 (95% CI, 1.04-1.27; P = .008), and 1.14 (95% CI, 1.02-1.27; P = .02) compared to patients who received no RBCs. CONCLUSIONS Intraoperative RBC transfusion is associated with a small increase in odds of HAI in CABG patients. Future studies should explore whether reductions in RBC transfusion can also reduce HAIs.
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Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sari D Holmes
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bradley Taylor
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - John S McNeil
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Bruce A Bollen
- Department of Anesthesiology, Missoula Anesthesiology and International Heart Institute of Montana, Missoula, Montana
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma
| | - Jacob Raphael
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Laurent Glance
- Departments of Anesthesiology and Perioperative Medicine.,Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.,RAND Health, Boston, Massachusetts
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83
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Fabbro M, Patel PA, Henderson RA, Bolliger D, Tanaka KA, Mazzeffi MA. Coagulation and Transfusion Updates From 2021. J Cardiothorac Vasc Anesth 2022; 36:3447-3458. [PMID: 35750604 PMCID: PMC8986228 DOI: 10.1053/j.jvca.2022.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 12/02/2022]
Abstract
2021 and the COVID 19 pandemic have brought unprecedented blood shortages worldwide. These deficits have propelled national efforts to reduce blood usage, including limiting elective services and accelerating Patient Blood Management (PBM) initiatives. A host of research dedicated to blood usage and management within cardiac surgery has continued to emerge. The intent of this review is to highlight this past year's research pertaining to PBM and COVID-19-related coagulation changes.
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84
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Knight JB, Subramanian H, Sultan I, Kaczorowski DJ, Subramaniam K. Prehabilitation of Cardiac Surgical Patients, Part 1: Anemia, Diabetes Mellitus, Obesity, Sleep Apnea, and Cardiac Rehabilitation. Semin Cardiothorac Vasc Anesth 2022; 26:282-294. [PMID: 36006868 DOI: 10.1177/10892532221121118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The concept of "prehabilitation" consists of screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgery, but may have profound impacts on outcomes particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of prehabilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision making. In this two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized by our center for cardiac presurgical care. This first installment will focus on the management of anemia, obesity, sleep apnea, diabetes, and cardiac rehabilitation prior to surgery. The second will focus on frailty, malnutrition, respiratory disease, alcohol and smoking cessation, and depression.
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Affiliation(s)
- Joshua B Knight
- 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Ibrahim Sultan
- 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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85
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Norton EL, Kim KM, Fukuhara S, Monaghan KP, Naeem A, Wu X, Ailawadi G, Patel HJ, Deeb GM, Yang B. Autologous blood transfusion in acute type A aortic dissection decreased blood product consumption and improved postoperative outcomes. JTCVS OPEN 2022; 12:20-29. [PMID: 36590717 PMCID: PMC9801237 DOI: 10.1016/j.xjon.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 06/02/2022] [Accepted: 06/22/2022] [Indexed: 01/04/2023]
Abstract
Objective To evaluate the effect of autologous blood use on blood product consumption and outcomes after acute type A aortic dissection repair. Methods From 2010 to October 2020, 497 patients underwent open acute type A aortic dissection repair, including those with autologous blood harvesting before cardiopulmonary bypass and transfusion after cardiopulmonary bypass (autologous blood transfusion [ABT], n = 397) and without autologous blood harvesting and transfusion (No-ABT, n = 100). The median ABT volume was 900 mL. Using propensity score matching, 89 matched pairs were identified based on age, sex, body mass index, preoperative hemoglobin, acute preoperative stroke, previous cardiac surgery, and cardiogenic shock. Results After propensity score matching, both groups were similar in demographic characteristics and aortic procedures. The ABT group required significantly less intraoperative transfusion of blood products (6 vs 11 units; P < .0001), including packed red blood cells (2 vs 4), fresh frozen plasma (2 vs 4), platelets (2 vs 2), and cryoprecipitate (0 vs 1); and combined intraoperative and postoperative transfusion (9 vs 13; P < .001). ABT was protective against intra- and postoperative blood product transfusion (odds ratio, 0.28; P = .01). The ABT group had significantly less sepsis, acute renal failure requiring dialysis, reintubation, and shorter intubation times and postoperative lengths of stay. Operative mortality was 6.7% in the ABT group versus 13% in the No-ABT group (P = .14). The midterm survival was similar between the 2 groups (5 year: 76% vs 74%). ABT had a hazard ratio of 0.81 for midterm mortality (P = .41). Conclusions Autologous blood transfusion was associated with better short-term outcomes and could be used routinely for acute type A aortic dissection repair. External multicenter prospective validation would be warranted.
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Affiliation(s)
- Elizabeth L. Norton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Karen M. Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | | | - Aroma Naeem
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - G. Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich,Address for reprints: Bo Yang, MD, PhD, Department of Cardiac Surgery, Michigan Medicine, 5155 Frankel Cardiovascular Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109.
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86
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Relationship between Preoperative Hemoglobin and Hospital Stays in Patients Receiving Prime Total Knee Arthroplasty. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2022; 2022:3627688. [PMID: 35875776 PMCID: PMC9307341 DOI: 10.1155/2022/3627688] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/05/2022] [Accepted: 06/30/2022] [Indexed: 11/17/2022]
Abstract
Previous evidence has shown that preoperative hemoglobin is related to poor prognosis after primary total knee arthroplasty. Reviewing cohort research was conducted at the third-level academic medical center in Singapore and involved 2,676 patients. Population statistics, complications, preoperative hemoglobin (Hb) levels, length of hospital stay (LOS), and readmission information of thirty days were obtained. Anemia was defined based on the World Health Organization (WHO). LOS extension was with the definition as no less than six days with >1/75 LOS corresponding to the data. According to the study requirements, we finally collected 2273 patients. We plotted the relationship between hemoglobin levels and length of stay. We analyzed 2273 patients, with 140 cases of Hb ≤ 11.0 g/dL, 831 cases of Hb 11.0–12.9 g/dL, and the other 1320 cases of Hb ≥ 13.0 g/dL. The mean age of patients with prolonged LOS (68.4 ± 8.2 years) was higher than that of patients with familiar LOS (65.9 ± 8.0 years). In addition, patients with extended LOS had higher ASA-PS values, a history of cerebrovascular accidents (CVA), diabetes mellitus (DM), and ischemic heart disease (IHD) (P < 0.001), repeated surgery within 30 days, HB, and operative time (min) (P < 0.01). Variables independently related to increased risk of extended LOS included general anesthesia (GA) (adjusted OR (aOR) 1.4, P=0.005, P=0.005), CVA (aOR 3.0, P < 0.001), DM (aOR 1.4, P=0.032), and HB < 11 g/dL. Variables increased LOS included HB ≥ 13 g/dL (aOR 0.4, P < 0.001) and Hb 11.0–12.9 g/dL (aOR 0.5, P=0.001). Hb was 14 g/dL, and LOS decreased by at least 0.24 days for each 1 g increase in preoperative Hb before the inflection point (95%CI 0.12 to 0.36, P=0.0001). Anemia is familiar in patients receiving elective total knee arthroplasty (TKA) in Singapore. Thus, this study describes that the preoperative hemoglobin was associated with length of stay. We found that on the left where HB was 14, length of stay decreased with increased hemoglobin values. We recommend preoperative correction of anemia to determine the diagnosis.
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87
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Immediate Higher-Dose Prothrombin Complex Concentrate Without Fresh Frozen Plasma or Fibrinogen Concentrate for Significant Coagulopathic Cardiac Surgical Field Bleeding. Heart Lung Circ 2022; 31:1300-1306. [PMID: 35843859 DOI: 10.1016/j.hlc.2022.05.048] [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: 12/21/2021] [Revised: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Treatment of significant coagulopathic cardiac surgical field bleeding with immediate higher-dose prothrombin complex concentrate (PCC) without fresh frozen plasma (FFP) or fibrinogen concentrate is unexplored. AIMS To study characteristics, chest drainage, and clinical outcomes of patients with significant coagulopathic surgical field bleeding treated with immediate higher-dose (defined at >15 IU/kg based on factor IX) PCC without FFP or fibrinogen concentrate. METHODS We screened sequential cardiac surgery patients. We reviewed electronic blood bank data, Australian Society of Cardiothoracic Surgery database information and anaesthetic, intensive care unit (ICU), ward and radiological charts and electronic data. We identified patients deemed by the operating surgeon to require treatment for significant coagulopathic surgical field bleeding who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. RESULTS Among 168 patients, we identified 30 who underwent immediate higher-dose PCC without FFP or fibrinogen concentrate. Median age was 68 years, 23 were male, 17 underwent coronary artery bypass surgery and three underwent complex surgery (David procedure, redo mitral valve surgery, and redo thoraco-abdominal aneurysm repair). Median dose of PCC was 2,500 IU. In addition, 27% underwent platelets and one underwent cryoprecipitate. Chest drainage at 24 hours was 505 ml. Survival to hospital discharge was 100%. There were no cases of pulmonary embolism, stroke, or other thrombotic events. Stage 1 AKI occurred in one patient. CONCLUSION In a pilot cohort of patients with significant coagulopathic surgical field bleeding, immediate higher-dose PCC without FFP or fibrinogen concentrate was feasible and had an acceptable efficacy and safety profile, which justifies future controlled studies.
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88
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Radadiya D, Devani K, Rockey DC. The impact of red blood cell transfusion practices on inpatient mortality in variceal and non-variceal gastrointestinal bleeding patients: a 20-year US nationwide retrospective analysis. Aliment Pharmacol Ther 2022; 56:41-55. [PMID: 35591774 PMCID: PMC10829766 DOI: 10.1111/apt.16965] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/12/2021] [Accepted: 04/27/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Previous studies in upper gastrointestinal (GI) bleeding have reported inconsistent outcomes about packed red blood cell (PRBC) transfusion practices. AIM To assess whether PRBC transfusion is more likely to be dangerous in variceal bleeding than in non-variceal bleeding due to concern of over-transfusion leading to elevated portal pressure. METHODS We used the Nationwide Inpatient Sample (1999-2018). We identified patients with upper GI bleeding using an algorithmic approach, categorising bleeding from non-variceal or variceal sources. Our primary outcome was all-cause inpatient mortality. To control for the severity of bleeding, we performed propensity matching of baseline features, including age, gender, the presence of shock, the need for ICU care and co-morbidities. We also examined PRBC transfusion, inpatient mortality and hospitalisation rates for both populations. RESULTS We included 10,228,524 upper GI bleeding discharges; 755,135 patients had variceal bleeding. After propensity matching, PRBC transfusion in variceal bleeders was associated with a 22% increase in inpatient mortality, whereas non-variceal bleeders had a 9% increase in inpatient mortality. Compared to non-variceal bleeders receiving blood transfusion, variceal bleeders had nearly four-fold higher odds of inpatient mortality (propensity-matched OR: 3.8; 95% CI: 3.7-3.8; p < 0.001). Notably, PRBC transfusion rates in both groups have declined since 2011, although it has remained higher in variceal bleeders. Mortality for upper GI bleeding has been declining since 1999. CONCLUSIONS Although decreased over the last decade, PRBC transfusion rates remain high for variceal bleeders. In addition, PRBC transfusion appears to be more detrimental in variceal bleeders than in non-variceal bleeders.
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Affiliation(s)
- Dhruvil Radadiya
- Division of Gastroenterology, Hepatology, and Motility, Department of Internal Medicine, University of Kansas – School of Medicine, Kansas City, Kansas, USA
| | - Kalpit Devani
- Prisma Health, Gastroenterology & Liver Center, Greenville, South Carolina, USA
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of South Carolina School of Medicine Greenville Campus, Greenville, South Carolina, USA
| | - Don C. Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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O'Shaughnessy S, Tangel V, Dzotsi S, Jiang S, White R, Hoyler M. Non-White Race/Ethnicity and Female Sex Are Associated with Increased Allogeneic Red Blood Cell Transfusion in Cardiac Surgery Patients: 2007-2018. J Cardiothorac Vasc Anesth 2022; 36:1908-1918. [PMID: 34969561 DOI: 10.1053/j.jvca.2021.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate racial and/or ethnic and sex disparities in allogeneic and autologous red blood cell (RBC) transfusions in cardiac surgery. DESIGN A retrospective observational study. SETTING 2007 to 2018 data from FL, MD, KY, WA, NY, and CA from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. PARTICIPANTS A total of 710,296 inpatients who underwent elective or emergency coronary artery bypass grafting (CABG), cardiac valve surgery,or combination CABG and/or valve surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were cohorted by race and/or ethnicity and sex, as defined by SID-HCUP. Demographic characteristics and comorbidities were compared. Rates and risk-adjusted odds ratios (aOR) were calculated for allogeneic and autologous RBC transfusion (primary outcomes). Additional secondary analyses were conducted for in-hospital mortality, 30-day readmission, 90-day readmission, hospital length of stay, and total charges to examine the effect of RBC transfusion status. Effect modification between race and sex was assessed. When controlling for patient demographics, comorbidities, and hospital characteristics, non-White patients were more likely to receive an allogeneic RBC transfusion during cardiac surgery than White patients (Black: aOR 1.17, 99% CI 1.13-1.20, p < 0.001, Hispanic: aOR 1.22, 99% CI 1.19-1.22, p < 0.001). Women were more likely to receive allogeneic RBC than men (aOR 1.69, 99% CI 1.66-1.72, p < 0.001). In interaction models, non-White women had the highest odds of allogeneic blood transfusion as compared to White men (reference category; Black women: aOR 2.04, 99% CI 1.91-2.17, p < 0.001, Hispanic women: aOR 2.03, 99% CI 1.90-2.16, p < 0.001). CONCLUSION These findings highlighted the differences in the rates of allogeneic RBC transfusion for non-White and female patients undergoing cardiac surgery, which is a well-established marker of poorer outcomes.
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Affiliation(s)
- Sinead O'Shaughnessy
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY.
| | - Virginia Tangel
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Safiya Dzotsi
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Silis Jiang
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Robert White
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Marguerite Hoyler
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
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90
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O'Hanlan KA, Bassett P. Exploring Adverse Events and Utilization of Topical Hemostatic Agents in Surgery. JSLS 2022; 26:JSLS.2022.00033. [PMID: 36071989 PMCID: PMC9439288 DOI: 10.4293/jsls.2022.00033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background and Objectives: This retrospective study provides preliminary qualitative assessment of the adverse events (AEs), focusing on pelvic and abdominal AEs and patient outcomes reported for three hemostatic agents used in gynecologic surgery. Methods: Utilization rates for oxidized regenerated cellulose powder (ORC), polysaccharide powder (PSP), and fibrin sealant solution (FSS) were obtained from hospitals via the Premier Healthcare databases for all surgical procedures from January 1, 2018 to September 30, 2020. All reported cases were extracted from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for ORC and PSP and from the FDA Adverse Event Reporting System (FAERS) database for FSS. Distributions of AEs by anatomical site (MAUDE/FAERS) and surgical procedures by specialty (Premier) were evaluated for each product. Number of cases and number and types of AEs were compared to the total utilization for each product. Results: PSP was the most used product during the period analyzed (n = 126,509 uses), followed by FSS (n = 80,628 uses), and ORC (n = 41,583 uses). Distribution of surgical procedures by anatomical site varied significantly between hemostatic agents (p < 0.001). ORC was associated with more patient cases with AEs and numbers of reported AEs compared with PSP and FSS (p < 0.001). ORC was associated with higher number of infections than PSP (p < 0.001) and FSS (p < 0.001). Conclusion: These findings suggest that ORC use in abdominal and pelvic surgery may result in more postoperative complications compared with non-ORC hemostatic agents. Further prospective randomized studies are needed to compare efficacy and safety of these products.
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91
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Left Ventricular Assist Device Implantation via Lateral Thoracotomy: A Systematic Review and Meta-Analysis. J Heart Lung Transplant 2022; 41:1440-1458. [DOI: 10.1016/j.healun.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/25/2022] [Accepted: 07/06/2022] [Indexed: 12/29/2022] Open
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92
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VENTURINI E, IANNUZZO G, DI LORENZO A, CUOMO G, D'ANGELO A, MERONE P, CUDEMO G, PACILEO M, D'ANDREA A, VIGORITO C, GIALLAURIA F. Short-term treatment of iron deficiency anemia after cardiac surgery. IJC HEART & VASCULATURE 2022; 40:101038. [PMID: 35514874 PMCID: PMC9066354 DOI: 10.1016/j.ijcha.2022.101038] [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: 02/08/2022] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
Iron deficiency anemia (IDA) is frequent after cardiac surgery and is associated with increased morbidity and mortality. In a retrospective study, we analyzed 106 patients with IDA (hemoglobin [Hb] ≤ 12 g/dl in women and ≤ 13 g/dl in men, transferrin saturation [TSAT] ≤ 20%) on admission to a Cardiac Rehabilitation Unit after cardiac surgery. The patients were divided into two groups, one was treated with oral sucrosomial iron (SI) and the other with intravenous ferric carboxymaltose (FCM). Patients received a single 1000 mg dose of FCM from the day after admission to rehabilitation (T1), or a 120 mg/day dose of SI from T1 until discharge (T2); after discharge, SI was reduced to 30 mg/day until the end of follow-up (T3). Hb was evaluated at T1, T2 and T3; the other hematological parameters at T1 and T3; natriuretic peptides at T1, T2 and T3; 6-minute walk test (6MWT) at T1 and T2. Folate, vitamin B12 and reticulocytes were sampled on admission. Folate deficiency was documented in 60.4% of patients. Hb increased in both groups with no significant differences between the two treatments (p = 0.397). The other iron metabolism parameters (sideremia, transferrin, TSAT) displayed similar behavior, showing a significant increase at T3 (p < 0.001) with both therapies, although the increase was faster with FCM. Ferritin – high on admission – decreased at T3 in the SI group and rose significantly in the FCM group (SI 219.5 vs. FCM 689 ng/ml p < 0.0001). The 6MWT increased significantly at T2, with an overlap between SI and FCM. In conclusion, the results of this study show that SI and FCM exhibit the same effectiveness on IDA; the response time to therapy of both treatments is also equally fast. SI and FCM induce a similar increase in functional capacity. The study shows that SI can be a viable alternative to FCM after cardiac surgery in terms of effectiveness and tolerability.
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Affiliation(s)
- Elio VENTURINI
- Cardiac Rehabilitation Unit and Department of Cardiology, Azienda USL Toscana Nord-Ovest, “Cecina Civil Hospital”, 57023 - Cecina (LI), Italy
| | - Gabriella IANNUZZO
- Department of Clinical Medicine and Surgery, “Federico II” University, 80131 – Naples, Italy
| | - Anna DI LORENZO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Gianluigi CUOMO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Andrea D'ANGELO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Pasquale MERONE
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Giuseppe CUDEMO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Mario PACILEO
- Department of Cardiology and Intensive Coronary Care, “Umberto I Hospital”, 84014 - Nocera Inferiore (SA), Italy
| | - Antonello D'ANDREA
- Department of Cardiology and Intensive Coronary Care, “Umberto I Hospital”, 84014 - Nocera Inferiore (SA), Italy
| | - Carlo VIGORITO
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
| | - Francesco GIALLAURIA
- Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, 80131 – Naples, Italy
- Corresponding author at: Department of Translational Medical Sciences, Division of Internal Medicine and Cardiac Rehabilitation, “Federico II” University of Naples, Naples, Italy.
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93
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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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94
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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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95
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Wang E, Wang Y, Hu S, Yuan S. Impact of gender differences on hemostasis in patients after coronary artery bypass grafts surgeries in the context of tranexamic acid administration. J Cardiothorac Surg 2022; 17:123. [PMID: 35598028 PMCID: PMC9123662 DOI: 10.1186/s13019-022-01874-y] [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] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sex differences present in the blood management of patients after coronary artery bypass grafts (CABG) surgeries. Tranexamic acid (TXA) performed well in maintaining hemostasis during and after surgeries. However, the impact of sex differences on blood control after CABG in patients who received TXA was not investigated. METHODS Overall, 29,536 patients undergoing CABG with TXA administration from 2009 to 2019 in our hospital were included. Propensity score matching was performed. Finally, 6808 males and 6808 females were matched based on 23 covariates. RESULTS Female patients had a 0.36-fold lower incidence of reoperations due to major hemorrhage or cardiac tamponade compared to males (1.3% vs. 2.0%, p = 0.001, OR = 0.64, 95%CI = 0.49-0.84). Females had a median of 100 ml less blood loss in 24 h (median 360 vs. 460 ml, p < 0.0001), 150 ml less in 48 h (median 580 vs. 730 ml, p < 0.0001), and 180 ml less in total (median 760 vs. 940 ml, p < 0.0001) than male patients. The red blood cell (RBC) transfusion rate in female was 1.53-fold higher than that in male (33.0% vs. 21.6%, OR = 1.53, 95% CI = 1.43-1.63, p < 0.0001). Females also had higher morbidities than males after CABGs. CONCLUSIONS Females had less blood loss than males after CABG with the TXA treatment. Females still had a higher RBC transfusion rate after surgery. Morbidities in women were also higher than that in men.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing, 100037, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Xicheng District, Beijing, 100037, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing, 100037, China.
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing, 100037, China.
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96
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Hemli JM, Ducca EL, Chaplin WF, Arader LL, Scheinerman SJ, Lesser ML, Ahn S, Mihelis EA, Jahn LA, Patel NC, Brinster DR. Transfusion in Root Replacement for Aortic Dissection: STS Adult Cardiac Surgery Database Analysis. Ann Thorac Surg 2022; 114:2149-2156. [PMID: 35452664 DOI: 10.1016/j.athoracsur.2022.03.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Transfusion in acute aortic syndromes has been studied in a limited fashion. We sought to describe contemporary transfusion practice for root replacement in acute (Stanford) type A aortic dissection (ATAAD). METHODS The STS Adult Cardiac Surgery Database was interrogated to identify patients who underwent primary aortic root replacement for ATAAD (July 2014 - June 2017). Patients (n = 1558) were stratified by type of root replacement. Multivariate regression was used to determine those variables associated with transfusion and postoperative morbidity. RESULTS Transfusion was required in 90.5% of cases (n = 1410). Operative mortality for all patients was 17.3% (261 deaths). Intraoperative red blood cell (RBC) transfusion portended reduced short-term survival (odds ratio {OR} 2.00, p = 0.025). Massive postoperative transfusion was associated with prolonged ventilation (OR 13.47, p < 0.001), sepsis (OR 4.13, p < 0.001), and new dialysis-dependent renal-failure (OR 2.43, p < 0.001). Females were more likely to require transfusion (OR 3.03, p < 0.001), as were patients who had coronary bypass (OR 1.57, p = 0.009), and those in shock (OR 2.27, p < 0.001). Valve-sparing aortic root replacement (VSARR) was associated with reduced transfusion requirements vs. composite roots. Institutional case volume was not appreciably correlated with transfusion. CONCLUSIONS Most patients undergoing root replacement for aortic dissection require blood products. Composite root replacement is associated with a greater likelihood of transfusion than a valve-sparing operation. Transfusion independently foreshadows greater operative mortality.
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Affiliation(s)
- Jonathan M Hemli
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA.
| | - Emma L Ducca
- Department of Psychology, St John's University, Queens, NY, USA
| | | | | | - S Jacob Scheinerman
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Martin L Lesser
- Biostatistics Unit, Feinstein Institutes for Medical Research / Northwell Health, Great Neck, NY, USA
| | - Seungjun Ahn
- Biostatistics Unit, Feinstein Institutes for Medical Research / Northwell Health, Great Neck, NY, USA
| | - Efstathia A Mihelis
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Lynda A Jahn
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Nirav C Patel
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Derek R Brinster
- Department of Cardiovascular & Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
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97
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Byeon GJ, Yoon JU, Kim HJ, Choi EJ, Kim EJ, Park S, Park SJ, Heo W, Kim HY. The influence of circulating fibrinogen level on postoperative blood loss and blood transfusion in pediatric cardiac surgery: a retrospective observational study. Transl Pediatr 2022; 11:514-525. [PMID: 35558986 PMCID: PMC9085943 DOI: 10.21037/tp-21-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatric patients are at high risk of massive bleeding after cardiac surgery under cardiopulmonary bypass (CPB). Fibrinogen is essential for coagulation; however, pediatric patients with congenital heart disease (CHD) present abnormal fibrinogen function. The pre- and post-operative fibrinogen level may affect the bleeding and transfusion amount in patients undergoing cardiac surgery. However, the relationship between plasma fibrinogen levels and the bleeding and transfusion amount in pediatric cardiac surgery remains unclear. This study aimed to assess the association of pre-CPB fibrinogen levels (PreFib) and post-CPB fibrinogen levels (PostFib) with postoperative bleeding and transfusion volume in pediatric cardiac surgery. METHODS We reviewed the medical records of 375 newborns and infants who underwent cardiac surgery under CPB for CHD. The primary endpoint was the correlation of the PreFib and PostFib values, as well as their difference (FibGap), with the bleeding and transfusion amount within 24 postoperative hours. RESULTS There was no correlation of the PreFib, PostFib, and FibGap values with the bleeding and transfusion amounts at postoperative 24 hours. However, patients with PreFib and PostFib values of <150 and <100 mg/dL, respectively, showed a significantly higher frequency of postoperative platelet (PLT) transfusion. In patients with complex CHD, PreFib showed a weak negative correlation with the bleeding amount at postoperative 24 hours and the number of PLT-transfused patients. CONCLUSIONS Our findings suggest that in pediatric patients with CHD who cannot undergo point-of-care (POC) tests, those presenting PreFib and PostFib values of <150 and <100 mg/dL, respectively, have a significantly higher frequency of postoperative PLT transfusion.
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Affiliation(s)
- Gyeong-Jo Byeon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Ji-Uk Yoon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea.,Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Korea
| | - Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ji Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wonjae Heo
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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98
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Maimaitiming M, Zhang C, Xie J, Zheng Z, Luo H, Ooi OC. Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review. Vox Sang 2022; 117:887-899. [PMID: 35332942 DOI: 10.1111/vox.13274] [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: 09/22/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES There is an ongoing controversy regarding the risks of restrictive and liberal red blood cell (RBC) transfusion strategies. This meta-analysis assessed whether transfusion at a lower threshold was superior to transfusion at a higher threshold, with regard to thrombosis-related events, that is, whether these outcomes can benefit from a restrictive transfusion strategy is debated. MATERIALS AND METHODS We searched PubMed, Cochrane Central Register of Controlled Trials and Scopus from inception up to 31 July 2021. We included randomized controlled trials (RCTs) in any clinical setting that evaluated the effects of restrictive versus liberal RBC transfusion in adults. We used random-effects models to calculate the risk ratios (RRs) and 95% confidence intervals (CIs) based on pooled data. RESULTS Thirty RCTs involving 17,334 participants were included. The pooled RR for thromboembolic events was 0.65 (95% CI 0.44-0.94; p = 0.020; I2 = 0.0%, very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR = 0.83; 95% CI 0.64-1.09; p = 0.180; I2 = 0.0%, very low-quality evidence) or myocardial infarction (RR = 1.05; 95% CI 0.87-1.26; p = 0.620; I2 = 0.0%, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced (1) thromboembolic events in RCTs conducted in North America and (2) myocardial infarctions in the subgroup of RCTs where the restrictive transfusion threshold was 7 g/dl but not in the 8 g/dl subgroup (with a liberal transfusion threshold of 10 g/dl in both subgroups). CONCLUSIONS A restrictive (relative to liberal) transfusion strategy may be effective in reducing venous thrombosis but not arterial thrombosis.
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Affiliation(s)
- Mairehaba Maimaitiming
- School of Management, University of Science and Technology of China, Hefei, Anhui, China
| | - Chenxiao Zhang
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Jingui Xie
- School of Management, Technical University of Munich, Heilbronn, Germany.,Munich Data Science Institute, Technical University of Munich, Munich, Germany
| | - Zhichao Zheng
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - Oon Cheong Ooi
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
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99
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Crawford TM, Andersen CC, Hodyl NA, Robertson SA, Stark MJ. Effect of washed versus unwashed red blood cells on transfusion-related immune responses in preterm newborns. Clin Transl Immunology 2022; 11:e1377. [PMID: 35284073 PMCID: PMC8907378 DOI: 10.1002/cti2.1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/04/2022] [Accepted: 02/04/2022] [Indexed: 12/22/2022] Open
Abstract
Objectives Transfusion with washed packed red blood cells (PRBCs) may be associated with reduced transfusion‐related pro‐inflammatory cytokine production. This may be because of alterations in recipient immune responses. Methods This randomised trial evaluated the effect of transfusion with washed compared with unwashed PRBCs on pro‐inflammatory cytokines and endothelial activation in 154 preterm newborns born before 29 weeks’ gestation. Changes in plasma cytokines and measures of endothelial activation in recipient blood were analysed after each of the first three transfusions. Results By the third transfusion, infants receiving unwashed blood had an increase in IL‐17A (P = 0.04) and TNF (P = 0.007), whereas infants receiving washed blood had reductions in IL‐17A (P = 0.013), TNF (P = 0.048), IL‐6 (P = 0.001), IL‐8 (P = 0.037), IL‐12 (P = 0.001) and IFN‐γ (P = 0.001). The magnitude of the post‐transfusion increase in cytokines did not change between the first and third transfusions in the unwashed group but decreased in the washed group for IL‐12 (P = 0.001), IL‐17A (P = 0.01) and TNF (P = 0.03), with the difference between the groups reaching significance by the third transfusion (P < 0.001 for each cytokine). Conclusion The pro‐inflammatory immune response to transfusion in preterm infants can be modified when PRBCs are washed prior to transfusion. Further studies are required to determine whether the use of washed PRBCs for neonatal transfusion translates into reduced morbidity and mortality.
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Affiliation(s)
- Tara M Crawford
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Chad C Andersen
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Nicolette A Hodyl
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Sarah A Robertson
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Michael J Stark
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
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100
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Guinn NR, Fuller M, Murray S, Aronson S. Treatment through a preoperative anemia clinic is associated with a reduction in perioperative red blood cell transfusion in patients undergoing orthopedic and gynecologic surgery. Transfusion 2022; 62:809-816. [PMID: 35275418 DOI: 10.1111/trf.16847] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preoperative anemia is associated with increased morbidity, mortality, and risk of transfusion. Treatment through a preoperative anemia clinic (PAC) may improve outcomes. STUDY DESIGN AND METHODS Adult patients undergoing elective orthopedic and gynecologic surgery with preoperative anemia were identified and referred for hemoglobin optimization with iron and/or erythropoietin from a single-site academic health center. Treated patients were propensity matched to untreated controls and compared on outcomes of erythrocyte transfusion, length of stay (LOS), and readmission. Changes in hemoglobin relative to treatment time before surgery were also measured in the treated cohort. RESULTS One thousand three hundred thirty-two patients were evaluated between July 2015 and March 2021, of which 161 underwent optimization through the PAC. After propensity matching, 127 (98 orthopedic and 29 gynecology) PAC-treated patients were compared to 127 (98 orthopedic and 29 gynecology) control patients who did not undergo treatment. The primary outcome of perioperative transfusion was significantly lower in treated patients compared with matched controls (12.60% vs. 26.77%, p = .005). A lower LOS was demonstrated in the gynecologic PAC subgroup (2.2 [1.5, 2.4] vs. 3.1 [2.2, 3.4], p = .002). Each day of treatment time before surgery was associated with an increase of 0.040 g/dL hemoglobin (p < .001) until 65 days, after which further time did not increase hemoglobin. CONCLUSION Treatment through a preoperative anemia clinic is associated with a reduction in perioperative transfusion and possible reduction in LOS and readmission compared with matched controls. Additionally, treatment time before surgery is correlated with a greater increase in hemoglobin up until 2 months prior to surgery.
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Affiliation(s)
- Nicole R Guinn
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matt Fuller
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sutton Murray
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Solomon Aronson
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA
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