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Zhang Q, Zhao W, Gao S, Yan S, Diao X, Wang Y, Xu X, Tian Y, Ji B. Quality Management of a Comprehensive Blood Conservation Program During Cardiopulmonary Bypass. Ann Thorac Surg 2021; 114:142-150. [PMID: 34437859 DOI: 10.1016/j.athoracsur.2021.07.069] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 06/17/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Red blood cell transfusion is common and associated with adverse outcomes for cardiac surgery, while present blood conservation guidelines have not been fully implemented until now. This study aims to evaluate our comprehensive blood conservation program after quality management, exploring its impact on blood transfusion and outcomes in patients undergoing cardiopulmonary bypass (CPB). METHODS We retrospectively compared blood transfusions and outcomes of patients from two different time periods, before and after the quality management of the comprehensive blood conservation program. The comprehensive program included restrictive transfusion protocols, conventional ultrafiltration, cell salvage, residual pump blood ultrafiltration and a modified mini-extracorporeal circulation system. A 1:1 propensity score matching and subgroup analysis were conducted. RESULTS 3977 pairs were created, a significant decrease of red cell transfusion was observed during CPB (28.4% vs 18.6%, p<.001), in the operation (40.7% vs 34.3%, p<.001 ) and after the operation (6.2% vs 4.3%, p<.001). 30-day mortality and some major complications also reduced. Subgroup analysis showed that the comprehensive blood conservation program was more beneficial for the following patients: above 60, male and the medium-risk European System for Cardiac Operative Risk Evaluation (EuroSCORE) of score 3-5. CONCLUSIONS The comprehensive blood conservation program during CPB is safe and effective in adult cardiac surgery, reducing blood utilization with no adverse outcomes. For the patients who are older, male and EuroSCORE 3-5, blood transfusion should be more cautious.
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Affiliation(s)
- Qiaoni Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Wei Zhao
- Department of Information Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Xiaolin Diao
- Department of Information Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Yuefu Wang
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Xinyi Xu
- Department of Information Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Yu Tian
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China.
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Tantry US, Hartmann J, Neal MD, Schöechl H, Bliden KP, Agarwal S, Mason D, Dias JD, Mahla E, Gurbel PA. The role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. Platelets 2021; 33:520-530. [PMID: 34369848 DOI: 10.1080/09537104.2021.1961709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We carried out a literature search in MEDLINE (PubMed) and EMBASE literature databases to provide a concise review of the role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. The search identified 130 articles that were relevant for the review, covering the basic science of VHA and VHA in clinical settings including cardiac surgery, cardiology, neurology, trauma, non-cardiac surgery, obstetrics, liver disease, and COVID-19. Evidence from these articles is used to describe the important role of VHAs and platelet function testing in various peri-interventional setups. VHAs can help us to comprehensively assess the contribution of platelets and coagulation dynamics to clotting at the site-of-care much faster than standard laboratory measures. In addition to standard coagulation tests, VHAs are beneficial in reducing allogeneic transfusion requirements and bleeding, in predicting ischemic events, and improving outcomes in several peri-interventional care settings. Further focused studies are needed to confirm their utility in the peri-interventional case.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Hartmann
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Matthew D Neal
- Department of General Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert Schöechl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Seema Agarwal
- Department of Anaesthesia, Manchester University Foundation Trust, Manchester, UK
| | - Dan Mason
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Joao D Dias
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
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103
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STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:97-124. [PMID: 34194077 DOI: 10.1182/ject-2100053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022]
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104
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Tran L, Greiff G, Wahba A, Pleym H, Videm V. Relative impact of red blood cell transfusion and anaemia on 5-year mortality in cardiac surgery. Interact Cardiovasc Thorac Surg 2021; 32:386-394. [PMID: 33346352 DOI: 10.1093/icvts/ivaa266] [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: 06/15/2020] [Revised: 09/04/2020] [Accepted: 10/06/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim was to compare the relative effects of red blood cell (RBC) transfusion and preoperative anaemia on 5-year mortality following open-heart cardiac surgery using structural equation modelling. We hypothesized that patient risk factors associated with RBC transfusion are of larger importance than transfusion itself. METHODS This prospective cohort study, part of the Cardiac Surgery Outcome Study at St. Olavs University Hospital, Trondheim, Norway, included open-heart on-pump cardiac surgery patients operated on from 2000 through 2017 (n = 9315). Structural equation modelling, which allows for intervariable correlations, was used to analyse pathway diagrams between known risk factors and observed mortality between 30 days and 5 years postoperatively. Observation times between 30 days and 1 year, and 1-5 years postoperatively were also compared with the main analysis. RESULTS In a simplified model, preoperative anaemia had a larger effect on 5-year mortality than RBC transfusion (standardized coefficients: 0.17 vs 0.09). The complete model including multiple risk factors showed that patient risk factors such as age (0.15), anaemia (0.10), pulmonary disease (0.11) and higher creatinine level (0.12) had larger effects than transfusion (0.03). Results from several sensitivity analyses supported the main findings. The models showed good fit. CONCLUSIONS Preoperative anaemia had a larger impact on 5-year mortality than RBC transfusion. Differences in 5-year mortality were mainly associated with patient risk factors.
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Affiliation(s)
- Long Tran
- Department of Clinical and Molecular Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Department of Cardiothoracic Anaesthesia and Intensive Care, St. Olavs University Hospital, Trondheim, Norway
| | - Guri Greiff
- Department of Cardiothoracic Anaesthesia and Intensive Care, St. Olavs University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
| | - Alexander Wahba
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Clinic of Cardiothoracic Surgery, St. Olav's University Hospital, Trondheim, Norway
| | - Hilde Pleym
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Clinic of Anaesthesia and Intensive Care, St. Olav's University Hospital, Trondheim, Norway
| | - Vibeke Videm
- Department of Clinical and Molecular Medicine, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.,Department of Immunology and Transfusion Medicine, St. Olavs University Hospital, Trondheim, Norway
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105
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Baker L, Park L, Gilbert R, Ahn H, Martel A, Lenet T, Davis A, McIsaac DI, Tinmouth A, Fergusson DA, Martel G. Intraoperative Red Blood Cell Transfusion Decision-making: A Systematic Review of Guidelines. Ann Surg 2021; 274:86-96. [PMID: 33630462 DOI: 10.1097/sla.0000000000004710] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The objective of this work was to carry out a systematic review of clinical practice guidelines (CPGs) pertaining to intraoperative red blood cell (RBC) transfusions, in terms of indications, decision-making, and supporting evidence base. SUMMARY OF BACKGROUND DATA RBC transfusions are common during surgery and there is evidence of wide variability in practice. METHODS Major electronic databases (MEDLINE, EMBASE, and CINAHL), guideline clearinghouses and Google Scholar were systematically searched from inception to January 2019 for CPGs pertaining to indications for intraoperative RBC transfusion. Eligible guidelines were retrieved and their quality assessed using AGREE II. Relevant recommendations were abstracted and synthesized to allow for a comparison between guidelines. RESULTS Ten guidelines published between 1992 and 2018 provided indications for intraoperative transfusions. No guideline addressed intraoperative transfusion decision-making as its primary focus. Six guidelines provided criteria for transfusion based on hemoglobin (range 6.0-10.0 g/dL) or hematocrit (<30%) triggers. In the absence of objective transfusion rules, CPGs recommended considering other parameters such as blood loss (n = 7), signs of end organ ischemia (n = 5), and hemodynamics (n = 4). Evidence supporting intraoperative recommendations was extrapolated primarily from the nonoperative setting. There was wide variability in the quality of included guidelines based on AGREE II scores. CONCLUSION This review has identified several clinical practice guidelines providing recommendations for intraoperative transfusion. The existing guidelines were noted to be highly variable in their recommendations and to lack a sufficient evidence base from the intraoperative setting. This represents a major knowledge gap in the literature.
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Affiliation(s)
- Laura Baker
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lily Park
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Richard Gilbert
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Hilalion Ahn
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Andre Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Departments of Anesthesiology & Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Dean A Fergusson
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Canadian Blood Services, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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106
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981-1004. [PMID: 34217505 DOI: 10.1016/j.athoracsur.2021.03.033] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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107
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Cardiothorac Vasc Anesth 2021; 35:2569-2591. [PMID: 34217578 DOI: 10.1053/j.jvca.2021.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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108
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Bezerra ASDM, Santos VB, Lopes CT, de Barros ALBL. Effect of nurse-initiated forced-air warming blanket on the reduction of hypothermia complications following coronary artery bypass grafting: a randomized clinical trial. Eur J Cardiovasc Nurs 2021; 20:445-453. [PMID: 33620461 DOI: 10.1093/eurjcn/zvaa023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 11/08/2020] [Indexed: 11/14/2022]
Abstract
AIMS To evaluate the effect of postoperative forced-air warming (FAW) on the incidence of excessive bleeding (ExB), arrhythmia, acute myocardial infarction (AMI), and blood product transfusion in hypothermic patients following on-pump CABG and compare temperatures associated with the use of FAW and warming with a sheet and wool blanket. METHODS AND RESULTS A randomized clinical trial conducted with 200 patients undergoing isolated on-pump CABG from January to November 2018. Patients were randomly assigned into an Intervention Group (IG, FAW, n = 100) and Control Group (CG, sheet and blanket, n = 100). The tympanic temperature of all patients was measured over a 24-h period. ExB was the primary outcome, while arrhythmia, AMI, and blood product transfusion were secondary outcomes. The effect of the interventions on the outcomes was investigated through using bivariate logistic regression, with a level of significance of 5%. The IG was 79% less likely to experience bleeding than the CG [odds ratio (OR) = 0.21, confidence interval (CI) 95% 0.12-0.39, P < 0.001]; the occurrence of AMI in the IG was 94% lower than that experienced by the CG (OR = 0.06, CI 95% 0.01-0.48, P < 0.001); and the IG was also 77% less likely to experience arrhythmia than the CG (OR = 0.23, CI 95% 0.12-0.47, P < 0.001); no difference was found between groups in terms of blood product transfusion (P < 0.279). CONCLUSIONS These findings show that FAW can be used following CABG until patients reach normothermia to avoid undesirable clinical outcomes. TRIAL REGISTRATION REBeC RBR-5t582g.
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Affiliation(s)
- Amanda Silva de Macêdo Bezerra
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil.,Instituto Dante Pazzanese de Cardiologia (IDPC), Divisão de Enfermagem. 500 Dr Dante Pazzanese Av, Ibirapuera, São Paulo-SP, 04012-909, Brazil
| | - Vinícius Batista Santos
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil
| | - Camila Takáo Lopes
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil
| | - Alba Lúcia Bottura Leite de Barros
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil
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109
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Li CN, Ge YP, Liu H, Zhang CH, Zhong YL, Chen SW, Liu YM, Zheng J, Zhu JM, Sun LZ. Blood Transfusion and Acute Kidney Injury After Total Aortic Arch Replacement for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2021; 31:136-143. [PMID: 34120843 DOI: 10.1016/j.hlc.2021.05.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/28/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
AIM To evaluate the effect of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC) transfusions on acute kidney injury (AKI) in patients with acute Stanford type A aortic dissection (ATAAD) with total arch replacement (TAR). METHOD From December 2015 to October 2017, 421 consecutive patients with ATAAD undergoing TAR were included in the study. The clinical data of the patients and the amount of pRBCs, FFP, and PC were collected. Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Logistic regression was used to identify whether pRBCs, FFP, and platelet transfusions were risk factors for KDIGO AKI, stage 3 AKI, and AKI requiring renal replacement therapy (RRT). RESULTS The mean ± standard deviation age of the patients was 47.67±10.82 years; 77.7% were men; and the median time from aortic dissection onset to operation was 1 day (range, 0-2 days). The median transfusion amount was 8 units (range, 4-14 units) for pRBCs, 400 mL (range, 0-800 mL) for FFP, and no units (range, 0-2 units) for PC. Forty-one (41; 9.7%) patients did not receive any blood products. The rates of pRBC, PC, and FFP transfusions were 86.9%, 49.2%, and 72.9%, respectively. The incidence of AKI was 54.2%. Considering AKI as the endpoint, multivariate logistic regression showed that pRBCs (odds ratio [OR], 1.11; p<0.001) and PC transfusions (OR, 1.28; p=0.007) were independent risk factors. Considering KDIGO stage 3 AKI as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.15; p<0.001), PC transfusion (OR, 1.28; p<0.001), a duration of cardiopulmonary bypass (CPB) ≥293 minutes (OR, 2.95; p=0.04), and a creatinine clearance rate of ≤85 mL/minute (OR, 2.12; p=0.01) were independent risk factors. Considering RRT as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.12; p<0.001), PC transfusion (OR, 1.33; p=0.001), a duration of CPB ≥293 minutes (OR, 3.79; p=0.02), and a creatinine clearance rate of ≤85 mL/minute (OR, 3.34; p<0.001) were independent risk factors. CONCLUSIONS Kidney Disease: Improving Global Outcomes-defined stage AKI was common after TAR for ATAAD. Transfusions of pRBCs and PC increased the incidence of AKI, stage 3 AKI, and RRT. Fresh frozen plasma transfusion was not a risk factor for AKI.
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Affiliation(s)
- Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yi-Peng Ge
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Hao Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Chen-Han Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yong-Liang Zhong
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Su-Wei Chen
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Yong-Min Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jun Zheng
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jun-Ming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Li-Zhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Aortic Disease Center, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.
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110
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Elassal AA, Al-Ebrahim KE, Debis RS, Ragab ES, Faden MS, Fatani MA, Allam AR, Abdulla AH, Bukhary AM, Noaman NA, Eldib OS. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg 2021; 16:166. [PMID: 34099003 PMCID: PMC8183590 DOI: 10.1186/s13019-021-01545-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
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Affiliation(s)
- Ahmed Abdelrahman Elassal
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | | | - Ragab Shehata Debis
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ehab Sobhy Ragab
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | | | | | - Amr Ragab Allam
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Department of Cardiac Surgery, Naser Institute of Research and Treatment, Cairo, Egypt
| | - Ahmed Hasan Abdulla
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Alahrar Hospital, Zagazig, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Saber Eldib
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
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Mo A, Stanworth SJ, Shortt J, Wood EM, McQuilten ZK. Red cell transfusions: Is less always best?: How confident are we that restrictive transfusion strategies should be the standard of care default transfusion practice? Transfusion 2021; 61:2195-2203. [PMID: 34075594 DOI: 10.1111/trf.16429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/19/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Allison Mo
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia.,Austin Pathology and Department of Haematology, Austin Health, Melbourne, Australia
| | - Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant (NHSBT), Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Jake Shortt
- Department of Haematology, Monash Health, Melbourne, Australia.,School of Clinical Sciences, Faculty of Medicine, Nursing & Health Sciences, Monash University, Melbourne, Australia
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
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112
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Effect of blood transfusions on cognitive development in very low birth weight infants. J Perinatol 2021; 41:1412-1418. [PMID: 33911186 PMCID: PMC8238787 DOI: 10.1038/s41372-021-00997-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 12/16/2020] [Accepted: 02/04/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Preterm infants frequently receive red cell transfusions; however, the effect of transfusions on cognition is unclear. We evaluated the relationship between transfusions and cognitive outcomes in preterm infants enrolled in a randomized trial of erythropoiesis stimulating agents (ESAs). STUDY DESIGN Preterm infants were randomized to ESAs or placebo during initial hospitalization, and transfusions recorded. Children were evaluated using standard developmental tests of cognition at 18-22 months (56 ESA, 24 placebo) and 3.5-4 years (39 ESA, 14 placebo). RESULTS Cognitive scores at 18-22 months were inversely correlated with transfusion volume (p = 0.02). Among those receiving ≥1 transfusion, cognitive scores were significantly higher in the ESA-treated group (p = 0.003). At 3.5-4 years, transfusions were not correlated with cognitive scores. CONCLUSIONS In the placebo group, transfused children had lower cognitive scores than did non-transfused children at 18-22 months. In the ESA group, cognitive scores did not differ by transfusion status, suggesting ESAs might provide neuroprotection.
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113
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Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [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: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
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Abstract
To characterize current evidence and current foci of perioperative clinical trials, we systematically reviewed Medline and identified perioperative trials involving 100 or more adult patients undergoing surgery and reporting renal end points that were published in high-impact journals since 2004. We categorized the 101 trials identified based on the nature of the intervention and summarized major trial findings from the five categories most applicable to perioperative management of patients. Trials that targeted ischemia suggested that increasing perioperative renal oxygen delivery with inotropes or blood transfusion does not reliably mitigate acute kidney injury (AKI), although goal-directed therapy with hemodynamic monitors appeared beneficial in some trials. Trials that have targeted inflammation or oxidative stress, including studies of nonsteroidal anti-inflammatory drugs, steroids, N-acetylcysteine, and sodium bicarbonate, have not shown renal benefits, and high-dose perioperative statin treatment increased AKI in some patient groups in two large trials. Balanced crystalloid intravenous fluids appear safer than saline, and crystalloids appear safer than colloids. Liberal compared with restrictive fluid administration reduced AKI in a recent large trial in open abdominal surgery. Remote ischemic preconditioning, although effective in several smaller trials, failed to reduce AKI in two larger trials. The translation of promising preclinical therapies to patients undergoing surgery remains poor, and most interventions that reduced perioperative AKI compared novel surgical management techniques or existing processes of care rather than novel pharmacologic interventions.
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Affiliation(s)
- David R McIlroy
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Marcos G Lopez
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Frederic T Billings
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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115
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Ripoll JG, Smith MM, Hanson AC, Schulte PJ, Portner ER, Kor DJ, Warner MA. Sex-Specific Associations Between Preoperative Anemia and Postoperative Clinical Outcomes in Patients Undergoing Cardiac Surgery. Anesth Analg 2021; 132:1101-1111. [PMID: 33543869 DOI: 10.1213/ane.0000000000005392] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Preoperative anemia is common in cardiac surgery, yet there were limited data describing the role of sex in the associations between anemia and clinical outcomes. Understanding these relationships may guide preoperative optimization efforts. METHODS This is an observational cohort study of adults undergoing isolated coronary artery bypass grafting or single- or double-valve surgery from 2008 to 2018 at a large tertiary medical center. Multivariable regression assessed the associations between preoperative hemoglobin concentrations and a primary outcome of postoperative acute kidney injury (AKI) and secondary outcomes of perioperative red blood cell (RBC) transfusion, reoperation, vascular complications (ie, stroke, pulmonary embolism, and myocardial infarction), and hospital length of stay (LOS). Each outcome was a single regression model, using interaction terms to assess sex-specific associations between hemoglobin and outcome. RESULTS A total of 4117 patients were included (57% men). Linear splines with sex-specific knots (13 g/dL in women and 14 g/dL in men) provided the best overall fit for preoperative hemoglobin and outcome relationships. In women, each 1 g/dL decrease in hemoglobin <13 g/dL was associated with increased odds of AKI (odds ratio = 1.49; 95% confidence interval [CI], [1.23-1.81]; P < .001), and there was no significant association between hemoglobin per 1 g/dL >13 g/dL and AKI (0.90 [0.56-1.45]; P = .67). The association between hemoglobin and AKI in men did not meet statistical significance (1.10 [0.99-1.22]; P = .076, per 1 g/dL decrease <14 g/dL; 1.00 [0.79-1.26]; P = .98 for hemoglobin per 1 g/dL >14 g/dL). In women, lower preoperative hemoglobin (per 1 g/dL decrease <13 g/dL) was associated with increased odds of RBC transfusion (2.90 [2.33-3.60]; P < .001), reoperation (1.27 [1.11-1.45]; P < .001) and a longer hospital LOS (multiplicative increase in geometric mean 1.05 [1.03-1.07]; P < .001). In men, preoperative hemoglobin (per 1 g/dL decrease <14 g/dL) was associated with increased odds of perioperative RBCs (2.56 [2.27-2.88]; P < .001) and longer hospital LOS (multiplicative increase in geometric mean 1.02 [1.01-1.04] days; P < .001) but not reoperation (0.94 [0.85-1.04]; P = .256). Preoperative hemoglobin per 1 g/dL >13 g/dL in women and 14 g/dL in men were associated with lower odds of RBCs transfusion (0.57 [0.47-0.69]; P < .001 and 0.74 [0.60-0.91]; P = .005, respectively). CONCLUSIONS Preoperative anemia was associated with inferior clinical outcomes after cardiac surgery. The associations between hemoglobin and outcomes were distinct for women and men, with different spline knot points identified (13 and 14 g/dL, respectively). Clinicians should consider data-driven approaches to determine preoperative hemoglobin values associated with increasing risk for adverse perioperative outcomes across sexes.
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Affiliation(s)
- Juan G Ripoll
- From the Department of Anesthesiology and Perioperative Medicine
| | - Mark M Smith
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Perioperative Medicine
| | | | | | - Erica R Portner
- Anesthesia Clinical Research Unit, Department of Anesthesiology and Perioperative Medicine
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew A Warner
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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116
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Khoshbin E, Spencer S, Solomon L, Tang A, Clark S, Stokes E, Wordsworth S, Dabner L, Edwards J, Reeves B, Rogers C. Is there a renoprotective value to leukodepletion during heart valve surgery? A randomized controlled trial (ROLO). J Cardiothorac Surg 2021; 16:58. [PMID: 33771192 PMCID: PMC8004389 DOI: 10.1186/s13019-021-01402-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Background Acute Kidney Injury (AKI) adversely affects outcomes after cardiac surgery. A major mediator of AKI is the activation of leukocytes through exposure to the cardiopulmonary bypass circuit. We evaluate the use of leukodepletion filters throughout bypass to protect against post-operative AKI by removing activated leukocytes during cardiac surgery. Methods This is a single-centre, double-blind, randomized controlled trial comparing the use of leukodepletion versus a standard arterial filter throughout bypass. Elective adult patients undergoing heart valve surgery with or without concomitant procedures were investigated. The primary clinical outcome measured was the development of AKI according to the KDIGO criteria. Secondary measures included biomarkers of renal tubular damage (urinary Retinol Binding Protein and Kidney Injury Molecule-1), glomerular kidney injury (urinary Micro Albumin and serum Cystatin C) and urinary Neutrophil Gelatinase Associated Lipocalin, as well as the length of hospital stay and quality of life measures through EQ-5D-5L questionnaires. Results The ROLO trial randomized 64 participants with a rate of recruitment higher than anticipated (57% achieved, 40% anticipated). The incidence of AKI was greater in the leukodepletion filter group (44% versus 23%, risk difference 21, 95% CI − 2 to 44%). This clinical finding was supported by biomarker levels especially by a tendency toward glomerular insult at 48 h, demonstrated by a raised serum Cystatin C (mean difference 0.11, 95% CI 0.00 to 0.23, p = 0.068) in the leukodepleted group. There was however no clear association between the incidence or severity of AKI and length of hospital stay. On average, health related quality of life returned to pre-operative levels in both groups within 3 months of surgery. Conclusions Leukocyte depletion during cardiopulmonary bypass does not significantly reduce the incidence of AKI after valvular heart surgery. Other methods to ameliorate renal dysfunction after cardiac surgery need to be investigated. Trial registration The trial was registered by the International Standard Randomized Controlled Trial Number Registry ISRCTN42121335. Registered on the 18 February 2014. The trial was run by the Bristol Clinical Trials and Evaluation Unit. This trial was financially supported by the National Institute of Health Research (Research for Patient Benefit), award ID: PB-PG-0711-25,090. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01402-4.
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Affiliation(s)
- Espeed Khoshbin
- Department of Cardiothoracic Surgery, Freeman Hospital, High Heaton, Newcastle upon Tyne, NE7 7DN, UK.
| | - Sally Spencer
- School of Health and Medicine, Lancaster University, Bailing, Upper Market Street, Lancaster, Lancashire, LA1 4YW, UK
| | - Laurence Solomon
- Renal Unit, Lancashire Teaching Hospitals NHS Foundation Trust, Sharoe Green Lane, Fulwood, Preston, Lancashire, PR2 9HT, UK
| | - Augustine Tang
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, FY3 8NR, UK
| | - Stephen Clark
- Department of Cardiothoracic Surgery, Freeman Hospital, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
| | - Elizabeth Stokes
- Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Sarah Wordsworth
- Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Lucy Dabner
- Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, BS2 8HW, UK
| | - Julia Edwards
- Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, BS2 8HW, UK
| | - Barnaby Reeves
- Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, BS2 8HW, UK
| | - Chris Rogers
- Clinical Trials and Evaluation Unit, Bristol Medical School, University of Bristol, Bristol, BS2 8HW, UK
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117
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Abstract
Anemia is a very common comorbidity in patients with heart failure (HF), affecting ∼30% of stable ambulatory patients and 50% patients with acute decompensated HF. Absolute or functional iron deficiency (ID) is seen in ∼50% patients with HF. Both of these comorbidities often coexist and are independently associated with increased mortality and hospitalizations. These findings led several investigators to test the hypotheses that treatment of anemia and ID in HF would improve symptoms and long-term outcomes. Small studies showed that erythropoiesis-stimulating agents (ESAs) improve subjective measures of HF. However, a large pivotal outcome trial found that the ESA darbepoetin alfa did not improve long-term outcomes in patients with HF with reduced ejection fraction and instead was associated with adverse effects. Studies using IV iron have had somewhat greater success, showing improvements in subjective and some objective measures of HF. However, more research is needed to establish the best treatment options for these high-risk patients. We present 5 common scenarios of patients with HF and anemia and describe our personal approach on how we might treat them based on objective evidence where available. An algorithm that offers guidance in regard to personalized therapy for such patients is also presented.
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118
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Abstract
BACKGROUND Recent guidelines on transfusion in cardiac surgery suggest that hemoglobin might not be the only criterion to trigger transfusion. Central venous oxygen saturation (Svo2), which is related to the balance between tissue oxygen delivery and consumption, may help the decision process of transfusion. We designed a randomized study to test whether central Svo2-guided transfusion could reduce transfusion incidence after cardiac surgery. METHODS This single center, single-blinded, randomized controlled trial was conducted on adult patients after cardiac surgery in the intensive care unit (ICU) of a tertiary university hospital. Patients were screened preoperatively and were assigned randomly to two study groups (control or Svo2) if they developed anemia (hemoglobin less than 9 g/dl), without active bleeding, during their ICU stay. Patients were transfused at each anemia episode during their ICU stay except the Svo2 patients who were transfused only if the pretransfusion central Svo2 was less than or equal to 65%. The primary outcome was the proportion of patients transfused in the ICU. The main secondary endpoints were (1) number of erythrocyte units transfused in the ICU and at study discharge, and (2) the proportion of patients transfused at study discharge. RESULTS Among 484 screened patients, 100 were randomized, with 50 in each group. All control patients were transfused in the ICU with a total of 94 transfused erythrocyte units. In the Svo2 group, 34 (68%) patients were transfused (odds ratio, 0.031 [95% CI, 0 to 0.153]; P < 0.001 vs. controls), with a total of 65 erythrocyte units. At study discharge, eight patients of the Svo2 group remained nontransfused and the cumulative count of erythrocyte units was 96 in the Svo2 group and 126 in the control group. CONCLUSIONS A restrictive transfusion strategy adjusted with central Svo2 may allow a significant reduction in the incidence of transfusion. EDITOR’S PERSPECTIVE
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119
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Laroche V, Blais‐Normandin I. Clinical Uses of Blood Components. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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120
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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121
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Lo BD, Cho BC, Hensley NB, Cruz NC, Gehrie EA, Frank SM. Impact of body weight on hemoglobin increments in adult red blood cell transfusion. Transfusion 2021; 61:1412-1423. [PMID: 33629773 DOI: 10.1111/trf.16338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/14/2021] [Accepted: 01/23/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Though weight is a major consideration when transfusing blood in pediatric patients, it is generally not considered when dosing transfusions in adults. We hypothesized that the change in hemoglobin (Hb) concentration is inversely proportional to body weight when transfusing red blood cells (RBC) in adults. METHODS A total of 13,620 adult surgical patients at our institution were assessed in this retrospective cohort study (2009-2016). Patients were stratified based on total body weight (kg): 40-59.9 (16.6%), 60-79.9 (40.4%), 80-99.9 (28.8%), 100-119.9 (11.3%), and 120-139.9 (2.9%). The primary outcome was the change in Hb per RBC unit transfused. Subgroup analyses were performed after stratification by sex (male/female) and the total number of RBC units received (1/2/≥3 units). Multivariable models were used to assess the association between weight and change in Hb. RESULTS As patients' body weight increased, there was a decrease in the mean change in Hb per RBC unit transfused (40-59.9 kg: 0.85 g/dL, 60-79.9 kg: 0.73 g/dL, 80-99.9 kg: 0.66 g/dL, 100-119.9 kg: 0.60 g/dL, 120-139.9 kg: 0.55 g/dL; p < .0001). This corresponded with a 35% difference in the change in Hb between the lowest and highest weight categories on univariate analysis. Similar trends were seen after subgroup stratification. On multivariable analysis, for every 20 kg increase in patient weight, there was a ~6.5% decrease in the change in Hb per RBC unit transfused (p < .0001). CONCLUSIONS Patient body weight differentially impacts the change in Hb after RBC transfusion. These findings justify incorporating body weight into the clinical decision-making process when transfusing blood in adult surgical patients.
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Affiliation(s)
- Brian D Lo
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Brian C Cho
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nadia B Hensley
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nicolas C Cruz
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Eric A Gehrie
- Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.,The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Lomivorotov VV, Moroz G, Abubakirov M, Osinsky R, Landoni G. Volatile and Intravenous Anesthetics for Brain Protection in Cardiac Surgery: Does the Choice of Anesthesia Matter? J Cardiothorac Vasc Anesth 2021; 36:567-576. [PMID: 33766470 DOI: 10.1053/j.jvca.2021.02.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 11/11/2022]
Abstract
Postoperative neurologic complications have a significant effect on morbidity, mortality, and long-term disability in patients undergoing cardiac surgery. The etiology of brain injury in patients undergoing cardiac surgery is multifactorial and remains unclear. There are several perioperative causative factors for neurologic complications, including microembolization, hypoperfusion, and systemic inflammatory response syndrome. Despite technologic advances and the development of new anesthetic drugs, there remains a high rate of postoperative neurologic complications. Moreover, despite the strong evidence that volatile anesthesia exerts cardioprotective effects in patients undergoing cardiac surgery, the neuroprotective effects of volatile agents remain unclear. Several studies have reported an association of using volatile anesthetics with improvement of biochemical markers of brain injury and postoperative neurocognitive function. However, there is a need for additional studies to define the optimal anesthetic drug for protecting the brain in patients undergoing cardiac surgery.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Department of Anesthesiology and Intensive Care, Novosibirsk State University, Novosibirsk, Russia.
| | - Gleb Moroz
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Marat Abubakirov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Roman Osinsky
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia
| | - Giovanni Landoni
- Anesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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123
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Qureshi SH, Ruel M. Commentary: A Long-Lasting Complication: Re-exploration for Bleeding and Its Negative Correlation With Long-Term Survival. Semin Thorac Cardiovasc Surg 2021; 33:776-777. [PMID: 33600978 DOI: 10.1053/j.semtcvs.2020.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Saqib H Qureshi
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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124
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Abstract
Acute kidney injury (AKI) occurs frequently after cardiac surgery and is associated with high morbidity and mortality. Although the number of cardiac surgical procedures is constantly growing worldwide, incidence of cardiac surgery-associated AKI is still around 40% and has a significant impact on global health care costs. Numerous trials attempted to identify strategies to prevent AKI and attenuate its detrimental consequences. Effective options remained elusive. Current evidence supports a multimodal risk-stratification approach with biomarker-guided management of high-risk patients, perioperative administration of dexmedetomidine, and implementation of a care bundle as recommended by the Kidney Disease: Improving Global Outcomes group.
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125
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Ducrocq G, Gonzalez-Juanatey JR, Puymirat E, Lemesle G, Cachanado M, Durand-Zaleski I, Arnaiz JA, Martínez-Sellés M, Silvain J, Ariza-Solé A, Ferrari E, Calvo G, Danchin N, Avendaño-Solá C, Frenkiel J, Rousseau A, Vicaut E, Simon T, Steg PG. Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial. JAMA 2021; 325:552-560. [PMID: 33560322 PMCID: PMC7873781 DOI: 10.1001/jama.2021.0135] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
IMPORTANCE The optimal transfusion strategy in patients with acute myocardial infarction and anemia is unclear. OBJECTIVE To determine whether a restrictive transfusion strategy would be clinically noninferior to a liberal strategy. DESIGN, SETTING, AND PARTICIPANTS Open-label, noninferiority, randomized trial conducted in 35 hospitals in France and Spain including 668 patients with myocardial infarction and hemoglobin level between 7 and 10 g/dL. Enrollment could be considered at any time during the index admission for myocardial infarction. The first participant was enrolled in March 2016 and the last was enrolled in September 2019. The final 30-day follow-up was accrued in November 2019. INTERVENTIONS Patients were randomly assigned to undergo a restrictive (transfusion triggered by hemoglobin ≤8; n = 342) or a liberal (transfusion triggered by hemoglobin ≤10 g/dL; n = 324) transfusion strategy. MAIN OUTCOMES AND MEASURES The primary clinical outcome was major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days. Noninferiority required that the upper bound of the 1-sided 97.5% CI for the relative risk of the primary outcome be less than 1.25. The secondary outcomes included the individual components of the primary outcome. RESULTS Among 668 patients who were randomized, 666 patients (median [interquartile range] age, 77 [69-84] years; 281 [42.2%] women) completed the 30-day follow-up, including 342 in the restrictive transfusion group (122 [35.7%] received transfusion; 342 total units of packed red blood cells transfused) and 324 in the liberal transfusion group (323 [99.7%] received transfusion; 758 total units transfused). At 30 days, MACE occurred in 36 patients (11.0% [95% CI, 7.5%-14.6%]) in the restrictive group and in 45 patients (14.0% [95% CI, 10.0%-17.9%]) in the liberal group (difference, -3.0% [95% CI, -8.4% to 2.4%]). The relative risk of the primary outcome was 0.79 (1-sided 97.5% CI, 0.00-1.19), meeting the prespecified noninferiority criterion. In the restrictive vs liberal group, all-cause death occurred in 5.6% vs 7.7% of patients, recurrent myocardial infarction occurred in 2.1% vs 3.1%, emergency revascularization prompted by ischemia occurred in 1.5% vs 1.9%, and nonfatal ischemic stroke occurred in 0.6% of patients in both groups. CONCLUSIONS AND RELEVANCE Among patients with acute myocardial infarction and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of MACE after 30 days. However, the CI included what may be a clinically important harm. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02648113.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Jose R. Gonzalez-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Etienne Puymirat
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, Lille, France
- French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine, Paris, France
| | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Manuel Martínez-Sellés
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), INSERM UMRS 1166, Paris, France
| | - Albert Ariza-Solé
- University Hospital Bellvitge, Heart Disease Institute, Barcelona, Spain
| | - Emile Ferrari
- Université Côte d’Azur, CHU de Nice, Hôpital Pasteur 1, Service de Cardiologie, Nice, France
| | - Gonzalo Calvo
- Àrea del Medicament, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Nicolas Danchin
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Cristina Avendaño-Solá
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Jerome Frenkiel
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine, Paris, France
| | - Eric Vicaut
- AP-HP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Clinical Research Platform of the East of Paris (URC-CRC-CRB), AP-HP, Hôpital St Antoine, Paris, France
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
- Royal Brompton Hospital, Imperial College, London, United Kingdom
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Restriktives vs. liberales Transfusionsregime in der Kardiochirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-020-00416-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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127
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Schoenes B, Schrezenmeier H, Welte M. Rationale Therapie mit Erythrozytenkonzentraten – Update 2020. TRANSFUSIONSMEDIZIN 2021. [DOI: 10.1055/a-1256-4487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
ZusammenfassungDer Einsatz von Erythrozytenkonzentraten muss dem Gebot einer rationalen Indikation folgen. Um dies weiter zu gewährleisten, wurden die 2009 publizierten und zuletzt 2014 in Teilen revidierten „Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten“ 1 der Bundesärztekammer 2020 einer systematischen Novellierung unterzogen. Der Artikel stellt sie vor.
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Restriktives oder patientenadaptiertes Transfusionsmanagement: Wann und für wen? ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-020-00417-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Chapalain X, Ozier Y, Le Niger C, McQuilten Z, Huet O, Aubron C. Is there an optimal trade-off between anaemia and red blood cell transfusion in surgical critically ill patients after oncologic surgery? Vox Sang 2021; 116:808-820. [PMID: 33493382 DOI: 10.1111/vox.13068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Equipoise remains on the optimal transfusion strategy in surgical oncologic patients. The primary objective of our study was to determine the impact of anaemia and red blood cells (RBCs) transfusion on severe postoperative complications in surgical oncologic critically ill patients. MATERIALS AND METHODS Retrospective single-centre study. Adults admitted to intensive care unit after major oncologic surgery were eligible. Analyses to determine the independent risk factors, including anaemia or RBC transfusion, for postoperative complications and/or hospital mortality were performed. RESULTS Of the 283 patients included, 246 patients (86.9%) had anaemia. Fifty-five patients (19·4%) were transfused. Patients exposed to moderate-to-severe anaemia or RBC transfusion had more often severe complications, especially acute kidney injury and infectious complications. Multivariate analysis found an independent association between moderate and severe anaemia and severe postoperative complications (moderate anaemia: OR 14·02 [2·52-264]; severe anaemia: OR 16·25 [2·62-318·5]; P < 0·05). Elderly, obese patients and patients operated from abdominal surgery appeared to be more vulnerable to anaemia than other patients. Transfusion was also an independent risk factor for postoperative complications (OR 4·19 [2·12-8·39]; P < 0·001). When considering moderate-to-severe anaemic patients, RBC transfusion was no longer associated with postoperative complications. CONCLUSIONS Anaemia was associated with severe postoperative complications, and this association was stronger in elderly, obese patients and after abdominal surgery. RBC transfusion also negatively impacts on patients' prognosis. However, this association was not found in case of moderate-to-severe anaemia exposure (haemoglobin < 10 g/dl).
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Affiliation(s)
- Xavier Chapalain
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
| | - Yves Ozier
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
| | - Catherine Le Niger
- Haemovigilance Unit, Centre Hospitalier et Universitaire de Brest, Brest, France
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Olivier Huet
- Department of Anaesthesiology and Surgical Intensive Care, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
| | - Cécile Aubron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Medical Intensive Care Unit, Centre Hospitalier et Universitaire de Brest - Université de Bretagne Occidentale, Brest, France
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Zhou L, Liu X, Yan M, Zhao W, Luo D, Liu J, Chen C, Ming Y, Zhang F, Li Q, Du L, Liu J. Postoperative Nadir Hemoglobin and Adverse Outcomes in Patients Undergoing On-Pump Cardiac Operation. Ann Thorac Surg 2021; 112:708-716. [PMID: 33484676 DOI: 10.1016/j.athoracsur.2021.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 12/23/2020] [Accepted: 01/12/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients undergoing cardiac operation are susceptible to anemia. Low hemoglobin concentration is a risk factor for composite adverse events and death after cardiac operation. Here we investigated the association of postoperative nadir hemoglobin with adverse outcomes in patients undergoing on-pump cardiac operation. METHODS Adult patients in 2 medical centers were retrospectively analyzed. The primary outcome was postoperative composite adverse events. The secondary outcome was all-cause death in the hospital. RESULTS Of the 8206 patients analyzed, 1628 (19.8%) experienced composite adverse events after operation and 109 (1.3%) died. Patients receiving on-pump cardiac operation with nadir hemoglobin of 9.0 to 9.9 g/L showed a low incidence of composite adverse events (175 of 1423 [12.3%]) and death (5 of 1423 [0.4%]). Compared with nadir hemoglobin at 9.0 to 9.9 g/dL, the relative risk (RR) of composite adverse events increased stepwise as nadir hemoglobin fell below 9.0 g/dL: adjusted RR was 1.44 (95% confidence interval [CI], 1.14-1.83) for 8.5 to 8.9 g/dL, 1.56 (95% CI, 1.23-1.99) for 8.0 to 8.4 g/dL, 1.66 (95% CI, 1.31-2.11) for 7.5 to 7.9 g/dL, 2.22 (95% CI, 1.75-2.83) for 7.0 to 7.4 g/dL, and 4.00 (95% CI, 3.18-5.04) for less than 7 .0 g/dL. Furthermore, the risk of death was significantly higher when nadir hemoglobin was below 7.0 g/dL than when it was 9.0 to 9.9 g/dL (RR, 5.36; 95% CI, 2.20-16.12). CONCLUSIONS Compared with the risks when nadir hemoglobin is 9.0 to 9.9 g/dL, the risk of composite adverse events increases when postoperative nadir hemoglobin is below 9.0 g/dL, whereas risk of death increases when nadir hemoglobin is below 7.0 g/dL.
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Affiliation(s)
- Li Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xinhao Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Wei Zhao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dan Luo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jing Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Changwei Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Zaouter C, Damphousse R, Moore A, Stevens LM, Gauthier A, Carrier FM. Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:746-765. [PMID: 33589344 DOI: 10.1053/j.jvca.2021.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 12/12/2022]
Abstract
Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.
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Affiliation(s)
- Cédrick Zaouter
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Remy Damphousse
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alex Moore
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Louis-Mathieu Stevens
- Department of Surgery, Division of Cardiac surgery, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Alain Gauthier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - François Martin Carrier
- Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
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Ma HP, Zhang L, Chen CL, Li J, Ma ZT, Jiang QQ, Liang YY, Li SS, Long F, Zheng H. Evaluation of a novel Cardiac Peri-Operative Transfusion Trigger Scoring system in patients with coronary artery disease. BMC Cardiovasc Disord 2021; 21:40. [PMID: 33468068 PMCID: PMC7814977 DOI: 10.1186/s12872-021-01854-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/05/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND A simple and accurate scoring system to guide perioperative blood transfusion in patients with coronary artery disease (CAD) undergoing cardiac surgery is lacking. The trigger point for blood transfusions for these patients may be different from existing transfusion guidelines. This study aimed to evaluate the safety and efficacy of a new scoring strategy for use in guiding transfusion decisions in patients with CAD. METHODS A multicenter randomized controlled trial was conducted at three third-level grade-A hospitals from January 2015 to May 2018. Data of 254 patients in a Cardiac Peri-Operative Transfusion Trigger Score (cPOTTS) group and 246 patients in a group receiving conventional evaluation of the need for transfusion (conventional group) were analysed. The requirements for transfusion and the per capita consumption of red blood cells (RBCs) were compared between groups. RESULTS Baseline characteristics of the two groups were comparable. Logistic regression analyses revealed no significant differences between the two groups in primary outcomes (1-year mortality and perioperative ischemic cardiac events), secondary outcomes (shock, infections, and renal impairment), ICU admission, and ICU stay duration. However, patients in the cPOTTS group had significantly shorter hospital stays, lower hospital costs, lower utilization rate and lower per capita consumption of transfused RBCs than controls. Stratified analyses revealed no significant differences between groups in associations between baseline characteristics and perioperative ischemic cardiac events, except for hemofiltration or dialysis and NYHA class in I. CONCLUSIONS This novel scoring system offered a practical and straightforward guideline of perioperative blood transfusion in patients with CAD. Trial registration chiCTR1800016561(2017/7/19).
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Affiliation(s)
- Hai-Ping Ma
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Lei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Chun-Ling Chen
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Jin Li
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Zhi Tong Ma
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Qiao Qiao Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Yuan Yuan Liang
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Shan Shan Li
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Fei Long
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China
| | - Hong Zheng
- Department of Anesthesiology, The First Affiliated Hospital of Xinjiang Medical University, 37 Liyushan South Road, Xinshi District, Urumqi, 830054, Xinjiang, China.
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Ducrocq G, Calvo G, González-Juanatey JR, Durand-Zaleski I, Avendano-Sola C, Puymirat E, Lemesle G, Arnaiz JA, Martínez-Sellés M, Rousseau A, Cachanado M, Vicaut E, Silvain J, Karam C, Danchin N, Simon T, Steg PG. Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial. Clin Cardiol 2021; 44:143-150. [PMID: 33405291 PMCID: PMC7852166 DOI: 10.1002/clc.23453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 01/28/2023] Open
Abstract
Background Anemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear. Hypothesis We hypothesized that a “restrictive” transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a “liberal” transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly. Methods REALITY is an international, randomized, multicenter, open‐label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost‐effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all‐cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year. Results The trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost‐effectiveness of the restrictive strategy at a threshold of €50 000 per quality‐adjusted life year. Conclusions REALITY will provide important guidance on the management of patients with AMI and anemia.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Gonzalo Calvo
- Àrea del Medicament Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - José Ramón González-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Cristina Avendano-Sola
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Etienne Puymirat
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV; Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Alexandra Rousseau
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Marine Cachanado
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Eric Vicaut
- AP-HP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, AP-HP, INSERM UMRS 1166, Paris, France
| | - Carma Karam
- Cardiology Department, Ambroise Paré Hospital, AP-HP, Boulogne, University of Versailles-Saint Quentin en Yvelines, Boulogne-Billancourt, France
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.,Royal Brompton Hospital, Imperial College, London, UK
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Surti J, Jain I, Mishra A, Gajjar T, Solanki A, Patel J, Shah J, Shah S. Venoarterial extra corporeal membrane oxygenation and blood component usage in pediatric patients undergoing cardiac surgery: Single centre experience. Ann Card Anaesth 2021; 24:203-208. [PMID: 33884977 PMCID: PMC8253037 DOI: 10.4103/aca.aca_112_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery. Materials and Methods Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients. Objective of the Study The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients. Results Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days). Conclusion The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers.
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Affiliation(s)
- Jigar Surti
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Imelda Jain
- Department of Cardiac Anesthesia, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Amit Mishra
- Department of Pediatric Cardiac Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Trushar Gajjar
- Department of Pediatric Cardiac Surgery, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Atul Solanki
- Department of Perfusion, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jigar Patel
- Department of Perfusion, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Jatin Shah
- Department of Pediatrics, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
| | - Sapna Shah
- Department of Cardiology, U.N. Mehta Institute of Cardiology and Research Center, Ahmedabad, Gujarat, India
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Kander T, Nilsson CU, Larsson D, Bentzer P. Effects of red blood cell transfusions given to non-septic critically ill patients: a propensity score matched study. Anaesthesiol Intensive Ther 2021; 53:390-397. [PMID: 35100796 PMCID: PMC10172944 DOI: 10.5114/ait.2021.111739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2023] Open
Abstract
INTRODUCTION Previous studies have demonstrated that low-grade red blood cell transfusions (RBC) given to septic patients are harmful. The objectives of the present study were to compare mortality and morbidity in non-septic critically ill patients who were given low-grade RBC transfusions at haemoglobin level > 70 γ L-1 with patients without RBC-transfusions any of the first 5 days in intensive care. MATERIAL AND METHODS Adult patients admitted to a general intensive care unit between 2007 and 2018 at a university hospital were eligible for inclusion. Patients who received > 2 units RBC transfusion per day during the first 5 days after admisasion, with pre-transfusion haemoglobin level < 70 γ L-1 or with severe sepsis or septic shock, were excluded. RESULTS In total, 9491 admissions were recorded during the study period. Propensity score matching resulted in 2 well matched groups with 674 unique patients in each. Median pre-transfusion haemoglobin was 98 γ L-1 (interquartile range 91-107 γ L-1). Mortality was higher in the RBC group with an absolute risk increase for death at 180 days of 5.9% (95% CI: 3.6-8.3; P < 0.001). Low-grade RBC-transfusion was also associated with renal, circulatory, and respiratory failure as well as a higher SOFA-max score. Sensitivity analyses suggested that disease trajectories during the exposure time did not significantly differ between the groups. CONCLUSIONS Low-grade RBC-transfusions given to non-septic critically ill patients without significant anaemia were associated with increased mortality, increased kidney, circulatory, and respiratory failure, as well as higher SOFA-max score.
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Affiliation(s)
- Thomas Kander
- Department of Clinical Sciences, Medical Faculty, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Caroline U. Nilsson
- Department of Clinical Sciences, Medical Faculty, Lund University, Lund, Sweden
- Department of Intensive and Perioperative Care, Skåne University Hospital, Lund, Sweden
| | - Daniel Larsson
- Department of Clinical Sciences, Medical Faculty, Lund University, Lund, Sweden
| | - Peter Bentzer
- Department of Clinical Sciences, Medical Faculty, Lund University, Lund, Sweden
- Department of Anaesthesia and Intensive Care, Helsingborg lasarett, Sweden
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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137
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Bayliss CD, Maier R, Kasim A, Hancock H, Akowuah E. Does Blood Transfusion Have an Effect on Outcomes After Aortic Valve Replacement Surgery? Heart Lung Circ 2020; 30:909-916. [PMID: 33262022 DOI: 10.1016/j.hlc.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/28/2020] [Accepted: 10/08/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Long-term outcomes following surgical aortic valve replacement (AVR) are excellent. However, there is a significant early morbidity burden. Red cell transfusion is common in the perioperative period and deleterious effects of receiving a transfusion on early postoperative morbidity are well described in observational studies. This study aimed to assess the effect of transfusion on ischaemic or infective outcomes after aortic valve replacement. METHODS Data from 270 patients enrolled in the Manubrium-limited ministernotomy versus conventional sternotomy for aortic valve replacement (MAVRIC) randomised controlled trial was used to create two cohorts, patients that received red cell transfusions following AVR and those that did not. Propensity score matching was performed to limit the effect of confounding variables. Strict transfusion thresholds were maintained, with patients receiving a transfusion if haemoglobin concentration fell below 80 g/L, or if significant bleeding or haemodynamic instability occurred. The primary outcome was a composite of ischaemic event (myocardial infarction, permanent stroke, gut ischaemia or acute kidney injury) or serious infection (sepsis, endocarditis, respiratory tract or wound infection). Patients were followed for 12 weeks following surgery. RESULTS Sixty-three (63) of 270 patients received a red cell transfusion (23.3%). Transfused patients had significantly lower body mass index (BMI), a higher proportion of females, a lower preoperative haemoglobin and haematocrit, a higher EuroSCORE II score, worse renal function and were more likely to have undergone urgent surgery compared to the unadjusted control cohort. Once matched, there was no difference in the primary outcome between cohorts. There was a significantly increased length of hospital stay in the transfused group (median 7 days transfused, median 5 days not-transfused, p=0.001). CONCLUSIONS Red cell transfusion, using a transfusion threshold of 80 g/L, does not appear to be associated with adverse ischaemic or infective outcomes after aortic valve replacement.
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Affiliation(s)
- Christopher D Bayliss
- Department of Cardiothoracic Surgery, The James Cook University Hospital, Middlesbrough, UK
| | - Rebecca Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Adetayo Kasim
- Department of Anthropology, Durham University, Durham, UK
| | - Helen Hancock
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Enoch Akowuah
- Department of Cardiothoracic Surgery, The James Cook University Hospital, Middlesbrough, UK.
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138
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Wise R, Bishop D, Gibbs M, Govender K, James MFM, Kabambi F, Louw V, Mdladla N, Moipalai L, Motchabi-Chakane P, Nolte D, Rodseth R, Schneider F, Turton E. South African Society of Anaesthesiologists Perioperative Patient Blood Management Guidelines 2020. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Anaesthesiologists regularly request and administer blood components to their patients, a potentially life-saving intervention. All anaesthesiologists must be familiar with the indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematologists and their local haematology blood sciences laboratory is encouraged. In the last decade, there have been considerable changes in approaches to optimal use of blood components, together with the use of alternative products, with a need to update previous guidelines and adapt them for anaesthesiologists working throughout the hospital system.
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Affiliation(s)
- R Wise
- University of KwaZulu-Natal
| | | | | | | | | | | | | | - N Mdladla
- Sefako Makgatho Health Sciences University
| | | | | | - D Nolte
- University of the Witwatersrand
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139
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Shah A, Oczkowski S, Aubron C, Vlaar AP, Dionne JC. Transfusion in critical care: Past, present and future. Transfus Med 2020; 30:418-432. [PMID: 33207388 DOI: 10.1111/tme.12738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/27/2020] [Indexed: 01/28/2023]
Abstract
Anaemia and coagulopathy are common in critically ill patients and are associated with poor outcomes, including increased risk of mortality, myocardial infarction, failure to be liberated from mechanical ventilation and poor physical recovery. Transfusion of blood and blood products remains the corner stone of anaemia and coagulopathy treatment in critical care. However, determining when the benefits of transfusion outweigh the risks of anaemia may be challenging in some critically ill patients. Therefore, the European Society of Intensive Care Medicine prioritised the development of a clinical practice guideline to address anaemia and coagulopathy in non-bleeding critically ill patients. The aims of this article are to: (1) review the evolution of transfusion practice in critical care and the direction for future developments in this important area of transfusion medicine and (2) to provide a brief synopsis of the guideline development process and recommendations in a format designed for busy clinicians and blood bank staff. These clinical practice guidelines provide recommendations to clinicians on how best to manage non-bleeding critically ill patients at the bedside. More research is needed on alternative transfusion targets, use of transfusions in special populations (e.g., acute neurological injury, acute coronary syndromes), use of anaemia prevention strategies and point-of-care interventions to guide transfusion strategies.
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada.,Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Cecile Aubron
- Department of Intensive Care Medicine, Centre Hospitalier Regional et Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada.,Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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140
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Apostolidou E, Kolte D, Kennedy KF, Beale CE, Abbott JD, Ehsan A, Gurm HS, Carson JL, Mamdani S, Aronow HD. Institutional Red Blood Cell Transfusion Rates Are Correlated Following Endovascular and Surgical Cardiovascular Procedures: Evidence That Local Culture Influences Transfusion Decisions. J Am Heart Assoc 2020; 9:e016232. [PMID: 33140685 PMCID: PMC7763716 DOI: 10.1161/jaha.119.016232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The relationship between local hospital culture and transfusion rates following endovascular and surgical cardiovascular procedures has not been well studied. Methods and Results Patients undergoing coronary revascularization, aortic valve replacement, lower extremity peripheral vascular intervention, or carotid artery revascularization from up to 852 US hospitals in the Nationwide Readmissions Database were identified. Crude and risk‐standardized red blood cell transfusion rates were determined for each procedure. Pearson correlation coefficients were calculated between respective procedural transfusion rates. Median odds ratios were estimated to reflect between‐hospital variability in red blood cell transfusion rates following the same procedure for a given patient. There was wide variation in red blood cell transfusion rates across different procedures, from 2% following carotid endarterectomy to 29% following surgical aortic valve replacement. For surgical and endovascular modalities, transfusion rates at the same hospital were highly correlated for aortic valve replacement (r=0.67; P<0.001), moderately correlated for coronary revascularization (r=0.56; P<0.001) and peripheral vascular intervention (r=0.51; P<0.001), and weakly correlated for carotid artery revascularization (r=0.19, P<0.001). Median odds ratios were all >2, highest for coronary artery bypass graft surgery and surgical aortic valve replacement, indicating substantial site variation in transfusion rates. Conclusions After adjustment for patient‐related factors, wide variation in red blood cell transfusion rates remained across surgical and endovascular procedures employed for the same cardiovascular condition. Transfusion rates following these procedures are highly correlated at individual hospitals and vary widely across hospitals. In aggregate, these findings suggest that local institutional culture significantly influences the decision to transfuse following invasive cardiovascular procedures and highlight the need for randomized data to inform such decisions.
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Affiliation(s)
- Eirini Apostolidou
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Dhaval Kolte
- Division of Cardiology Massachusetts General Hospital and Harvard Medical School Boston MA
| | - Kevin F Kennedy
- Statistical Consultant to the Cardiovascular Institute Kansas City MO
| | | | - J Dawn Abbott
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Afshin Ehsan
- Division of Cardiothoracic Surgery Alpert Medical School of Brown University Providence RI
| | | | - Jeffrey L Carson
- Division of Internal Medicine Robert Wood Johnson University Hospital New Brunswick NJ
| | - Shafiq Mamdani
- Division of Cardiology Alpert Medical School of Brown University Providence RI
| | - Herbert D Aronow
- Division of Cardiology Alpert Medical School of Brown University Providence RI
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141
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Tenure R, Kiefer JJ, Augoustides JG. Blood Transfusion in Extracorporeal Membrane Oxygenation-Defining Thresholds and Unresolved Questions. J Cardiothorac Vasc Anesth 2020; 35:1203-1204. [PMID: 33293218 DOI: 10.1053/j.jvca.2020.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Richard Tenure
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse J Kiefer
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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142
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Bolliger D, Erb JM, Buser A. Controversies in the Clinical Practice of Patient Blood Management. J Cardiothorac Vasc Anesth 2020; 35:1933-1941. [PMID: 33277164 DOI: 10.1053/j.jvca.2020.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
Patient blood management (PBM) has been proposed as a standard of care in modern perioperative medicine. PBM-related interventions usually are implemented as bundles, but randomized controlled trials on the implementation of PBM as a bundle are missing. This special article focuses on the current evidence and controversies in the clinical practice of PBM and on emerging data related to specific PBM-related interventions in patients undergoing cardiac surgery. Strong evidence for many PBM-related interventions is limited because of missing studies or the poor quality of published findings and study endpoints. Restrictive blood transfusion and timely interventions to maintain hemoglobin concentration and to reduce blood loss potentially might result in improved patient outcome, although the latter has yet to be proven.
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Affiliation(s)
- Daniel Bolliger
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
| | - Joachim M Erb
- Department for Anesthesia, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, Switzerland; Department of Hematology, University Hospital Basel, Basel, Switzerland
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143
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Xiao K, Zhao F, Liu Q, Jiang J, Chen Z, Gong W, Zheng Z, Le A. Effect of Red Blood Cell Storage Duration on Outcomes of Isolated Traumatic Brain Injury. Med Sci Monit 2020; 26:e923448. [PMID: 33159032 PMCID: PMC7657062 DOI: 10.12659/msm.923448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background The aim of this study was to investigate the effects of red blood cell (RBC) storage duration on the outcomes of adult isolated traumatic brain injury (iTBI) patients after transfusion. Material/Methods A total of 1252 adult iTBI patients who received the fresh RBCs (stored for ≤14 days) or old RBCs (stored for >14 days) were finally enrolled in this study. The primary outcome was 90-day mortality. The secondary outcomes were in-hospital mortality, nosocomial infection, and complications. Results By 90 days after RBC transfusion, 89 patients (17.0%) had died in the fresh RBC group, and 107 had died (14.7%) in the old RBC group, with no significant difference in 90-day mortality between the 2 groups (OR=1.192, 95% CI: 0.877–1.620, P=0.261). According to ISS score, no differences were discovered in mild injury (OR=1.079, 95% CI: 0.682–1.707, P=0.746), severe injury (OR=1.055, 95% CI: 0.634–1.755, P=0.838), and more severe injury (OR=1.940, 95% CI: 0.955–3.943, P=0.064). For GCS score, there were no differences in mild injury (OR=1.546, 95% CI: 0.893–2.676, P=0.118), moderate injury (OR=0.965, 95% CI: 0.616–1.513, P=0.877), and severe injury (OR=1.332, 95% CI: 0.677–2.620, P=0.406). We also observed no significant differences in secondary outcomes. Conclusions Use of old RBCs did not increase the 90-day mortality in adult iTBI patients.
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Affiliation(s)
- Kun Xiao
- Department of Blood Transfusion, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Fei Zhao
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Qiang Liu
- Department of Information, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Jinliang Jiang
- Department of Science and Technology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Zhiyong Chen
- Department of Personnel, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Wei Gong
- President's Office, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Zengwang Zheng
- Department of Medical Administration, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
| | - Aiping Le
- Department of Blood Transfusion, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China (mainland)
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144
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Shore S, Hanff TC, Mazurek JA, Seigerman M, Zhang R, Grandin EW, Vorovich E, Mather P, Olt C, Howard J, Wald J, Acker MA, Goldberg LR, Atluri P, Margulies KB, Rame JE, Birati EY. The effect of transfusion of blood products on ventricular assist device support outcomes. ESC Heart Fail 2020; 7:3573-3581. [PMID: 33263224 PMCID: PMC7754735 DOI: 10.1002/ehf2.12780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/17/2020] [Accepted: 05/07/2020] [Indexed: 11/05/2022] Open
Abstract
AIMS Perioperative blood transfusions are common among patients undergoing left ventricular assist device (LVAD) implantation. The association between blood product transfusion at the time of LVAD implantation and mortality has not been described. METHODS AND RESULTS This was a retrospective cohort study of all patients who underwent continuous flow LVAD implantation at a single, large, tertiary care, academic centre, from 2008 to 2014. We assessed used of packed red blood cells (pRBCs), platelets, and fresh frozen plasma (FFP). Outcomes of interest included all-cause mortality and acute right ventricular (RV) failure. Standard regression techniques were used to examine the association between blood product exposure and outcomes of interest. A total of 170 patients were included in this study (mean age: 56.5 ± 15.5 years, 79.4% men). Over a median follow-up period of 11.2 months, for every unit of pRBC transfused, the hazard for mortality increased by 4% [hazard ratio (HR) 1.04; 95% CI 1.02-1.07] and odds for acute RV failure increased by 10% (odds ratio 1.10; 95% CI 1.05-1.16). This association persisted for other blood products including platelets (HR for mortality per unit 1.20; 95% CI 1.08-1.32) and FFP (HR for mortality per unit 1.08; 95% CI 1.04-1.12). The most significant predictor of perioperative blood product exposure was a lower pre-implant haemoglobin. CONCLUSIONS Perioperative blood transfusions among patients undergoing LVAD implantation were associated with a higher risk for all-cause mortality and acute RV failure. Of all blood products, FFP use was associated with worst outcomes. Future studies are needed to evaluate whether pre-implant interventions, such as intravenous iron supplementation, will improve the outcomes of LVAD candidates by decreasing need for transfusions.
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Affiliation(s)
- Supriya Shore
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Thomas C Hanff
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew Seigerman
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Zhang
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edward W Grandin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Esther Vorovich
- Division of Cardiovascular Medicine, Northwestern University, Chicago, IL, USA
| | - Paul Mather
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline Olt
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Howard
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joyce Wald
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael A Acker
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Lee R Goldberg
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kenneth B Margulies
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Edo Y Birati
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, PA, USA
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145
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Trentino KM, Farmer SL, Isbister JP, Sanfilippo FM, Leahy MF, Hofmann A, Shander A, Murray K. Restrictive Versus Liberal Transfusion Trials: Are They Asking the Right Question? Anesth Analg 2020; 131:1950-1955. [PMID: 33044262 DOI: 10.1213/ane.0000000000005227] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Kevin M Trentino
- From the School of Population and Global Health, The University of Western Australia, Perth, Australia.,Data and Digital Innovation, East Metropolitan Health Service, Perth, Australia
| | - Shannon L Farmer
- Medical School and Division of Surgery, The University of Western Australia, Perth, Australia.,Department of Haematology, Royal Perth Hospital, Perth, Australia
| | | | - Frank M Sanfilippo
- From the School of Population and Global Health, The University of Western Australia, Perth, Australia
| | - Michael F Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Australia.,School of Medicine and Laboratory Science, The University of Western Australia, Perth, Australia
| | - Axel Hofmann
- Medical School and Division of Surgery, The University of Western Australia, Perth, Australia.,Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Aryeh Shander
- Department of Anesthesiology, Englewood Hospital and Medical Center, TeamHealth Research Institute, Englewood, New Jersey
| | - Kevin Murray
- From the School of Population and Global Health, The University of Western Australia, Perth, Australia
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146
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Turan A, Cohen B, Rivas E, Liu L, Pu X, Maheshwari K, Farag E, Onal O, Wang J, Ruetzler K, Devereaux PJ, Sessler DI. Association between postoperative haemoglobin and myocardial injury after noncardiac surgery: a retrospective cohort analysis. Br J Anaesth 2020; 126:94-101. [PMID: 33039122 DOI: 10.1016/j.bja.2020.08.056] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Myocardial injury after noncardiac surgery (MINS) is common, mostly silent, and a strong predictor of postoperative mortality. MINS appears to result from myocardial supply-demand mismatch. Recent data support restrictive perioperative transfusion strategies that can result in low postoperative haemoglobin concentrations. Whether low postoperative haemoglobin is associated with myocardial injury remains unknown. We therefore tested the hypothesis that anaemia is associated with an increased risk of myocardial injury in adults having noncardiac surgery. METHODS We conducted a retrospective analysis of adults ≥45 yr old who had routine postoperative troponin T (TnT) monitoring after noncardiac surgery at the Cleverland Clinic (including those enrolled in the PeriOperative ISchemic Evaluation-2 Trial [POISE-2], the Safety of Addition of Nitrous Oxide to General Anaesthesia in At-risk Patients Having Major Non-cardiac Surgery [ENIGMA-II], Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study [VISION], and Anaesthetic Depth and Complications After Major Surgery [BALANCED] trial). Patients with baseline increase in TnT and non-ischaemic aetiologies for TnT increase were excluded. The association between postoperative haemoglobin concentration during the 3 initial postoperative days and the incidence of MINS (fourth-generation TnT ≥0.03 ng ml-1 judged as attributable to ischaemia) was assessed using a time-varying covariate Cox proportional hazards survival analysis. RESULTS Among 6141 patients, 4480 were analysed. The incidence of MINS was 155/4480 (3.5%), ranging from 0/345 (0%) among patients whose lowest postoperative haemoglobin exceeded 13 g dl-1 to 52/611 (8.5%) in patients whose minimum postoperative haemoglobin was <8 g dl-1. The confounder-adjusted hazard ratio [95% confidence interval] for having MINS was 1.29 [1.16-1.42] for every 1 g dl-1 decrease in postoperative haemoglobin in a time-varying covariate analysis. Similar associations were identified in sensitivity analyses. CONCLUSION Lower postoperative haemoglobin values are associated with MINS. Whether this association is modifiable by prevention or treatment of anaemia remains to be determined.
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Affiliation(s)
- Alparslan Turan
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA.
| | - Barak Cohen
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Division of Anesthesia, Critical Care, and Pain Management, Tel Aviv Medical Center, Tel Aviv University, Tel-Aviv, Israel
| | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Liu Liu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Kamal Maheshwari
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Ehab Farag
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Ozkan Onal
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Jiayi Wang
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesia, Cleveland Clinic, Cleveland, OH, USA
| | - Philip J Devereaux
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada; Department Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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147
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Hemli JM, Scheinerman SJ, Lesser ML, Ahn S, Mihelis EA, Jahn LA, Patel NC, Brinster DR. Transfusion in Elective Aortic Root Replacement: Analysis of the STS Adult Cardiac Surgery Database. Ann Thorac Surg 2020; 110:1225-1233. [DOI: 10.1016/j.athoracsur.2020.01.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 01/07/2020] [Accepted: 01/13/2020] [Indexed: 10/24/2022]
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148
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Frank SM, Cushing MM. Bleeding, anaemia, and transfusion: an ounce of prevention is worth a pound of cure. Br J Anaesth 2020; 126:5-9. [PMID: 32981674 DOI: 10.1016/j.bja.2020.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 11/19/2022] Open
Affiliation(s)
- Steven M Frank
- Department of Anesthesiology, Critical Care Medicine, Johns Hopkins Health System Patient Blood Management Program, The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA.
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine and Cellular Therapy and Clinical Laboratories, Department of Pathology, NewYork-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
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149
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Abbasciano RG, Yusuff H, Vlaar APJ, Lai F, Murphy GJ. Blood Transfusion Threshold in Patients Receiving Extracorporeal Membrane Oxygenation Support for Cardiac and Respiratory Failure-A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2020; 35:1192-1202. [PMID: 33046363 DOI: 10.1053/j.jvca.2020.08.068] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/08/2020] [Accepted: 08/31/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To review studies that have evaluated the effects of liberal or restrictive red cell transfusion thresholds on clinical outcomes in patients requiring extracorporeal membrane oxygenation (ECMO) support for cardiac or respiratory failure. DESIGN A systematic review and meta-analysis. SETTING AND PARTICIPANTS The study comprised 1,070 patients from observational studies and randomized controlled trials analyzing transfusion policies in venoarterial (VA) and venovenous (VV) ECMO adult populations. MEASUREMENTS AND MAIN RESULTS Eligible studies were identified by searching the Cochrane Central Register of Controlled Trials, Medline, and EMBASE until March 4, 2020, using a combination of subject headings and text words. Risk of bias assessment was performed to assess study quality according to the ROBINS-I tool and the case series studies appraisal checklist. There was high risk of bias in the studies analyzed, and none had methodologic adequacy. Three studies analyzed VA ECMO and VV ECMO patients separately. Five datasets were related exclusively or mostly to VA ECMO. Four were retrospective analyses, and one was conducted as a prospective observational study; the median transfusion threshold reported was 8 g/dL, with a mean mortality of 52%. Eight datasets were related either exclusively or mostly to VV ECMO. Six were retrospective and two were prospective observational studies; the median transfusion threshold was 8 g/dL, and the mean mortality rate was 33%. CONCLUSIONS The present study did not resolve uncertainty as to transfusion management in ECMO, although several studies (most of them in VV ECMO) demonstrated that a restrictive threshold has acceptable outcomes in single-center cohorts.
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Affiliation(s)
- Riccardo Giuseppe Abbasciano
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, United Kingdom.
| | - Hakeem Yusuff
- Department of Anaesthesia and Intensive Care Medicine, Glenfield Hospital, Leicester, United Kingdom
| | | | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, United Kingdom
| | - Gavin James Murphy
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, United Kingdom
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150
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Frank SM, Lo BD, Yesantharao LV, Merkel KR, Qin CX, Cho BC, Lee KHK, Wintermeyer TL, Hebbar S, Burkhart RA, Goel R, Gehrie EA. Blood utilization and clinical outcomes in pancreatic surgery before and after implementation of patient blood management. Transfusion 2020; 60:2581-2590. [PMID: 32897635 DOI: 10.1111/trf.16063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/23/2020] [Accepted: 07/23/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Over the past decade, patient blood management (PBM) programs have been developed to reduce allogeneic blood utilization. This is particularly important in pancreatic surgery, which has historically been associated with high transfusion requirements and morbid event rates. This study investigated blood utilization and clinical outcomes in pancreatic surgery before, during, and after the implementation of PBM. STUDY DESIGN AND METHODS A total of 3482 pancreatic surgery patients were assessed in a 10-year retrospective cohort study (2009-2019) at a single academic center. Baseline patient characteristics, transfusion practices, postoperative morbidity (infectious, thrombotic, ischemic, respiratory, and renal complications), mortality, and length of stay were compared between patients in the pre-PBM (2009-2013), early-PBM (2014-2016), and mature-PBM (2017-2019) time periods. Multivariable analysis assessed the odds for composite morbidity/mortality. RESULTS Comparing the mature-PBM to pre-PBM cohorts, transfused units per 100 discharged patients decreased by 53% for erythrocytes (155 to 73; P < .0001), 81% for plasma (79 to 15; P < .038), and 75% for platelets (10 to 2.5; P < .005). Clinical outcomes improved as well, with composite morbid event rates decreasing by more than 50%, from 236 in 1438 patients (16.4%) to 85 in 1145 patients (7.4%) (P < .0001). Mortality and length of stay remained unchanged. Compared to the pre-PBM time period, early-PBM was associated with a risk-adjusted decrease in composite morbidity/mortality (OR 0.73; 95% CI 0.57-0.93; P = .010), while mature-PBM demonstrated a further incremental decrease (OR 0.44; 95% CI 0.33-0.57; P < .0001). CONCLUSIONS The implementation of PBM was associated with substantially decreased blood utilization in pancreatic surgery, without negatively impacting clinical outcomes.
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Affiliation(s)
- Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, Faculty, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Brian D Lo
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lekha V Yesantharao
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Kevin R Merkel
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Caroline X Qin
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Brian C Cho
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - K H Ken Lee
- Clinical and Value Analytics, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Tyler L Wintermeyer
- Clinical and Value Analytics, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Sachidanand Hebbar
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Richard A Burkhart
- Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Ruchika Goel
- Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Eric A Gehrie
- Department of Pathology (Transfusion Medicine), The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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