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Crawford TM, Andersen CC, Hodyl NA, Robertson SA, Stark MJ. Effect of washed versus unwashed red blood cells on transfusion-related immune responses in preterm newborns. Clin Transl Immunology 2022; 11:e1377. [PMID: 35284073 PMCID: PMC8907378 DOI: 10.1002/cti2.1377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/04/2022] [Accepted: 02/04/2022] [Indexed: 12/22/2022] Open
Abstract
Objectives Transfusion with washed packed red blood cells (PRBCs) may be associated with reduced transfusion‐related pro‐inflammatory cytokine production. This may be because of alterations in recipient immune responses. Methods This randomised trial evaluated the effect of transfusion with washed compared with unwashed PRBCs on pro‐inflammatory cytokines and endothelial activation in 154 preterm newborns born before 29 weeks’ gestation. Changes in plasma cytokines and measures of endothelial activation in recipient blood were analysed after each of the first three transfusions. Results By the third transfusion, infants receiving unwashed blood had an increase in IL‐17A (P = 0.04) and TNF (P = 0.007), whereas infants receiving washed blood had reductions in IL‐17A (P = 0.013), TNF (P = 0.048), IL‐6 (P = 0.001), IL‐8 (P = 0.037), IL‐12 (P = 0.001) and IFN‐γ (P = 0.001). The magnitude of the post‐transfusion increase in cytokines did not change between the first and third transfusions in the unwashed group but decreased in the washed group for IL‐12 (P = 0.001), IL‐17A (P = 0.01) and TNF (P = 0.03), with the difference between the groups reaching significance by the third transfusion (P < 0.001 for each cytokine). Conclusion The pro‐inflammatory immune response to transfusion in preterm infants can be modified when PRBCs are washed prior to transfusion. Further studies are required to determine whether the use of washed PRBCs for neonatal transfusion translates into reduced morbidity and mortality.
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Affiliation(s)
- Tara M Crawford
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Chad C Andersen
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Nicolette A Hodyl
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Sarah A Robertson
- The Robinson Research Institute The University of Adelaide Adelaide SA Australia
| | - Michael J Stark
- The Women's and Children's Hospital Adelaide SA Australia.,The Robinson Research Institute The University of Adelaide Adelaide SA Australia
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102
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Guinn NR, Fuller M, Murray S, Aronson S. Treatment through a preoperative anemia clinic is associated with a reduction in perioperative red blood cell transfusion in patients undergoing orthopedic and gynecologic surgery. Transfusion 2022; 62:809-816. [PMID: 35275418 DOI: 10.1111/trf.16847] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/08/2022] [Accepted: 02/15/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND Preoperative anemia is associated with increased morbidity, mortality, and risk of transfusion. Treatment through a preoperative anemia clinic (PAC) may improve outcomes. STUDY DESIGN AND METHODS Adult patients undergoing elective orthopedic and gynecologic surgery with preoperative anemia were identified and referred for hemoglobin optimization with iron and/or erythropoietin from a single-site academic health center. Treated patients were propensity matched to untreated controls and compared on outcomes of erythrocyte transfusion, length of stay (LOS), and readmission. Changes in hemoglobin relative to treatment time before surgery were also measured in the treated cohort. RESULTS One thousand three hundred thirty-two patients were evaluated between July 2015 and March 2021, of which 161 underwent optimization through the PAC. After propensity matching, 127 (98 orthopedic and 29 gynecology) PAC-treated patients were compared to 127 (98 orthopedic and 29 gynecology) control patients who did not undergo treatment. The primary outcome of perioperative transfusion was significantly lower in treated patients compared with matched controls (12.60% vs. 26.77%, p = .005). A lower LOS was demonstrated in the gynecologic PAC subgroup (2.2 [1.5, 2.4] vs. 3.1 [2.2, 3.4], p = .002). Each day of treatment time before surgery was associated with an increase of 0.040 g/dL hemoglobin (p < .001) until 65 days, after which further time did not increase hemoglobin. CONCLUSION Treatment through a preoperative anemia clinic is associated with a reduction in perioperative transfusion and possible reduction in LOS and readmission compared with matched controls. Additionally, treatment time before surgery is correlated with a greater increase in hemoglobin up until 2 months prior to surgery.
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Affiliation(s)
- Nicole R Guinn
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matt Fuller
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sutton Murray
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Solomon Aronson
- Department Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA.,Department of Population Health Science, Duke University School of Medicine, Durham, North Carolina, USA
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Mladinov D, Padilla LA, Leahy B, Norman JB, Enslin J, Camp RS, Eudailey KW, Tanaka K, Davies JE. Hemodilution in high-risk cardiac surgery: Laboratory values, physiological parameters, and outcomes. Transfusion 2022; 62:826-837. [PMID: 35244229 DOI: 10.1111/trf.16844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 01/20/2022] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability, and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. STUDY DESIGN AND METHODS This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N = 66) and non-ANH controls (N = 103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass. RESULTS Intraoperatively, the ANH group received more albumin (p = .04) and vasopressor medications (p = .01), while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO2 ) values were similar before and after hemodilution. During bypass, rSO2 were discretely lower in the ANH versus control group (right rSO2 p = .03, left rSO2 p = .05). No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, intensive care unit length of stay, kidney injury, stroke, or infection were demonstrated. DISCUSSION This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better understanding and wider acceptance of ANH protocols in high-risk cardiac surgeries.
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Affiliation(s)
- Domagoj Mladinov
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Leahy
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph B Norman
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacob Enslin
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Riley S Camp
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - James E Davies
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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104
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Zou ZY, He LX, Yao YT. Tranexamic acid reduces postoperative blood loss in Chinese pediatric patients undergoing cardiac surgery: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e28966. [PMID: 35244062 PMCID: PMC8896488 DOI: 10.1097/md.0000000000028966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/07/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Tranexamic acid has been increasingly used for blood conservation in cardiac surgery. However, the evidence supporting the routine use of tranexamic acid in Chinese pediatric patients undergoing cardiac surgery remains weak. This meta-analysis aimed to systematically review the efficacy of tranexamic acid when applying to Chinese pediatric patients undergoing cardiac surgery. PARTICIPANTS Chinese pediatric patients undergoing cardiac surgery. INTERVENTIONS Tranexamic acid or control drugs (saline/blank). METHODS PUBMED, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Wanfang Data, and VIP Data till May 4, 2021, database search was updated on August 1. Primary outcomes of interest included postoperative bleeding, allogeneic transfusion, and reoperation for bleeding. Secondary outcomes of interest included postoperative recovery. For continuous/dichotomous variables, treatment effects were calculated as weighted mean difference (WMD)/odds ratio and 95% confidence interval. RESULTS A database search yielded 15 randomized controlled trials including 1641 patients, where 8 studies were allocated into non-cyanotic congenital group, 5 were allocated into cyanotic congenital group, and the other 2 were allocated into combined cyanotic/non-cyanotic group. This meta-analysis demonstrate that tranexamic acid administration can reduce the postoperative 24 hours blood loss in non-cyanotic, cyanotic, and combined cyanotic/non-cyanotic patients, the red blood cell transfusion in non-cyanotic and cyanotic patients, and the fresh frozen plasma transfusion in non-cyanotic and combined cyanotic/non-cyanotic patients. CONCLUSION This meta-analysis demonstrates that tranexamic acid is highly effective in reducing the blood loss in Chinese pediatric cardiac surgery, but it behaves poorly when it comes to the transfusion requirement. To further confirm this, more well-designed and adequately-powered randomized trials are needed.
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Affiliation(s)
- Zhi-yao Zou
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Yunnan Province, Kunming, China
| | - Li-xian He
- Department of Anesthesiology, Fuwai Yunnan Cardiovascular Hospital, Yunnan Province, Kunming, China
| | - Yun-tai Yao
- Anesthesia Center, Fuwai Hospital, NCCD, PUMC&CAMS, Beijing, China
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105
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Irving AH, Harris A, Petrie D, Higgins A, Smith JA, Tran L, Reid CM, McQuilten ZK. Economic Evaluation of National Patient Blood Management Clinical Guidelines in Cardiac Surgery. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:419-426. [PMID: 35227454 DOI: 10.1016/j.jval.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/02/2021] [Accepted: 07/22/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia's sole public blood provider, the National Blood Authority (NBA). METHODS We performed a cost analysis from the government perspective, comparing the NBA's cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals. RESULTS The estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant. CONCLUSIONS Insofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA's resources.
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Affiliation(s)
- Adam H Irving
- Centre for Health Economics, Monash University, Melbourne, Australia.
| | - Anthony Harris
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Alisa Higgins
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Lavinia Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Haematology, Monash Health, Monash University, Melbourne, Australia
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Preoperative patient factors associated with blood product use in cardiac surgery, a retrospective cohort study. J Cardiothorac Surg 2022; 17:23. [PMID: 35197104 PMCID: PMC8867771 DOI: 10.1186/s13019-022-01770-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cardiac surgery is associated with a high rate of blood use. The aim of this study is to identify preoperative patient factors associated with allogeneic Red Blood Cell (RBC) or non-Red Blood Cell (NRBC) use in cardiac surgery. METHODS All adult cardiac surgical procedures conducted at a single Western Australian institution were retrospectively analysed. Data was collected from the Australia and New Zealand Cardiac Surgery Database from 2015 to 2018. A number of preoperative factors were identified, relating to past medical history or preoperative cardiac status. Outcome 1 was defined as the use of one or more RBC products intra or post-operatively. Outcome 2 was defined as the use of one or more NRBC products intra or post-operatively. Multivariate logistical regression analysis was done to assess for the association between preoperative factors and allogeneic blood product use. RESULTS A total of 1595 patients were included in this study, of which 1488 underwent a Coronary Artery Bypass Graft, Valve or a combined procedure. Patients on dialysis preoperatively and those who had preoperative cardiogenic shock demonstrated the greatest risk of requiring RBC transfusion with an odds ratio of 5.643 (95% CI 1.305-24.40) and 3.257 (95% 1.801-5.882) respectively. Patients who had preoperative cardiogenic shock demonstrated the greatest risk of requiring NRBC transfusion with an odds ratio of 3.473 (95% CI 1.970-6.135). Patients who have had a previous cardiothoracic intervention are at increased risk of both RBC and NRBC transfusion, with adjusted odds ratios of 1.774 (95% CI 1.353-2.325) and 2.370 (95% CI 1.748-3.215) respectively. CONCLUSION A number of factors relating to past medical history or preoperative cardiac status are implicated with increased allogeneic blood product use in cardiac surgery. Identifying high-risk patients in a preoperative setting can enable us enrol them in a blood conservation program, therefore minimizing the risk of exposure to blood transfusion.
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107
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Ahmed TAN, Ki YJ, Choi YJ, El-Naggar HM, Kang J, Han JK, Yang HM, Park KW, Kang HJ, Koo BK, Kim HS. Impact of Systemic Inflammatory Response Syndrome on Clinical, Echocardiographic, and Computed Tomographic Outcomes Among Patients Undergoing Transcatheter Aortic Valve Implantation. Front Cardiovasc Med 2022; 8:746774. [PMID: 35224023 PMCID: PMC8863936 DOI: 10.3389/fcvm.2021.746774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundSystemic inflammatory response syndrome (SIRS) is a systemic insult that has been described with many interventional cardiac procedures. The outcomes of patients undergoing transcatheter aortic valve implantation (TAVI) are thought to be influenced by this syndrome not only on short-term, but also on long-term.ObjectiveWe assessed the association of SIRS to different clinical, echocardiographic, and computed tomographic (CT) outcomes after TAVI.MethodsTwo hundred and twenty-four consecutive patients undergoing TAVI were enrolled in this study. They were assessed for the occurrence of SIRS within the first 48 h after TAVI. Patients were followed-up for short- and long-term clinical outcomes. Serial echocardiographic follow-ups were conducted at 1-week, 6-months, and 1-year. CT follow-up at 1 year was recorded.ResultsEighty patients (36%) developed SIRS. Among different parameters, only pre-TAVI total leucocytic count (TLC), pre-TAVI heart rate, and post-TAVI systolic blood pressure independently predicted the occurrence of SIRS. The incidence of HALT was not significantly different between both groups, albeit higher among SIRS patients (p = 0.1) at 1-year CT follow-up. Both groups had similar patterns of LV recovery on serial echocardiography. Long-term follow-up showed that all-cause death, cardiac death, and re-admission for heart failure (HF) or acute coronary syndrome (ACS) were significantly more frequent among SIRS patients. Early safety and clinical efficacy outcomes were more frequently encountered in the SIRS group, while device-related events and time-related valve safety were comparable.ConclusionAlthough SIRS implies an early acute inflammatory status post-TAVI, yet its clinical sequelae seem to extend to long-term clinical outcomes.
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Affiliation(s)
- Tarek A. N. Ahmed
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
- Department of Cardiovascular Medicine, Assiut University Heart Hospital, Assiut, Egypt
- *Correspondence: Tarek A. N. Ahmed
| | - You-Jeong Ki
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - You-Jung Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Heba M. El-Naggar
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
- Department of Cardiovascular Medicine, Assiut University Heart Hospital, Assiut, Egypt
| | - Jeehoon Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Jung-Kyu Han
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Han-Mo Yang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Hyun-Jae Kang
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
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Wang E, Yuan X, Wang Y, Chen W, Zhou X, Hu S, Yuan S. Tranexamic Acid Administered During Off-Pump Coronary Artery Bypass Graft Surgeries Achieves Good Safety Effects and Hemostasis. Front Cardiovasc Med 2022; 9:775760. [PMID: 35187119 PMCID: PMC8854353 DOI: 10.3389/fcvm.2022.775760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study. Methods This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed. Results Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47–0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management. Conclusions The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xingtong Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Shengshou Hu
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- Su Yuan
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Sharan S, Kapoor PM, Choudhury M, Prakash M, Chowdhury UK, Hote M, Ravi V. Platelet Function Test in Coronary Artery Bypass Grafting: Does It Predict Postoperative Bleeding? JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0042-1742402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background Patients undergoing on-pump coronary artery bypass grafting (CABG) are at increased risk of perioperative bleeding and morbidity associated with transfusion as a result of acquired and pharmacologically induced impaired platelet function.
Settings and Design In this a prospective observational study where 52 patients underwent on-pump CABG were analyzed with ROTEM platelet aggregometry.
Materials and Methods Patients were assigned to the “nonexcessive” and “excessive” postoperative bleeding groups according to the postoperative chest tube drainage over 24 hours. Platelet function was assessed by ROTEM platelet using three different activators (arachidonic acid, adenosine diphosphate, and thrombin receptor-activating peptide), at two perioperative time points (T1, before heparinization and T2, 5–10 minutes after protamine administration).
Results There were no differences regarding demographic, pre–cardiopulmonary bypass (CPB) platelet count and antiplatelet therapy. Platelet function was impaired over the time course in all parameters with three different activators. At T2 point, area under the curve (AUC) of all the three platelet indices, that is, TRAPTEM, ARATEM, and ADPTEM, showed significant difference between excessive and nonexcessive groups. At both T1 and T2 points, the amplitude after 6 minutes (A6) and maximum slope (MS) parameters of TRAPTEM, ARATEM, and ADPTEM tests were not significantly different in excessive and nonexcessive groups. At T1 point, AUC was also not significantly different in all three ROTEM platelet tests. Results after protamine administration showed correlation with postoperative chest tube drainage. Cut-off values, as determined by receiver operating characteristics (ROC) analyses, had a consistently weak positive predictive value for all tests at T2 time point, whereas negative predictive values were higher.
Conclusion Platelet function analysis using ROTEM platelet can help to exclude platelet dysfunction as the reason for bleeding after cardiac surgery. Point-of-care platelet function analysis, particularly in combination with viscoelastic testing can reduce perioperative bleeding and transfusion requirements, as well as improve patient outcomes in cardiac surgery.
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Affiliation(s)
- Sandeep Sharan
- Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Poonam Malhotra Kapoor
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Minati Choudhury
- Department of Cardiac Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Prakash
- Department of Cardiac Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal K. Chowdhury
- Department of Cardio Thoracic Vascular Surgery (CTVS), All India Institute of Medical Sciences, New Delhi, India
| | - Milind Hote
- Department of Cardio Thoracic Vascular Surgery (CTVS), All India Institute of Medical Sciences, New Delhi, India
| | - Vajala Ravi
- Department of Statistics, Delhi University, Lady Sriram College, New Delhi, India
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Abstract
PURPOSE OF REVIEW Major bleeding in cardiac surgery is commonly encountered, and, until recently, most frequently managed with fresh frozen plasma (FFP). However, a Cochrane review found this practice to be associated with a significant increase in red blood cell (RBC) transfusions and costs. These findings have led to off-label uses of prothrombin complex concentrates (PCCs) in cardiac surgery. The purpose of this review is to compare and contrast the use of FFP and PCC, review the components, limitations and risks of different types of PCCs, and discuss the latest evidence for the use of PCC versus FFP in cardiac surgery. RECENT FINDINGS A recent review and meta-analysis suggests that PCC administration in cardiac surgery is more effective than FFP in reducing RBC transfusions and costs. SUMMARY The current data supports the use of 4F-PCC instead of FFP as the primary hemostatic agent in cases of major bleeding in cardiac surgery. The use of PCCs is associated with reduced rates of RBC transfusions while maintaining a favorable safety profile. Clear advantages of PCC over FFP include its smaller volume, higher concentration of coagulation factors and shorter acquisition and administration times.
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Affiliation(s)
- Jeans M Santana
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
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111
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Gaudard P, Colson P. Central venous oxygen saturation to adjust transfusion trigger in cardiac surgery. Comment on Br J Anaesth 2021; 128: 37–44. Br J Anaesth 2022; 128:e291-e292. [DOI: 10.1016/j.bja.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 11/28/2022] Open
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Hassan K, Brüning T, Caspary M, Wohlmuth P, Pioch H, Schmoeckel M, Geidel S. Hemoadsorption of Rivaroxaban and Ticagrelor during Acute Type A Aortic Dissection Operations. Ann Thorac Cardiovasc Surg 2022; 28:186-192. [PMID: 35046210 PMCID: PMC9209888 DOI: 10.5761/atcs.oa.21-00154] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To analyze the results of hemoadsorption in patients with cardiac surgery to thoracic aortic surgery, who had been loaded beforehand with either Factor Xa inhibitor rivaroxaban or P2Y12 receptor antagonist ticagrelor. Methods: We investigated 21 of 171 consecutive patients (median age 71 [interquartile range 62, 76] years) who underwent emergency cardiac operations for acute type A aortic dissection between 2014 and 2020. These patients were pretreated with rivaroxaban (n = 9) or ticagrelor (n = 12). In ten of 21 cases (since 2017), we installed a hemoadsorber into the heart–lung machine and compared the results to eleven patients done without hemoadsorber before that time. Results: The operation time was significantly shorter in the adsorber group (286 ± 40 min vs. 348 ± 79 min; p = 0.045). The postoperative 24-hour drainage volume was significantly lower after adsorption (p <0.001; 482 ± 122 ml vs. 907 ± 427 ml) and no rethoracotomy had to be performed (compared to two rethoracotomies [18.9%] among patients without adsorber use). Also, patients without hemoadsorption required significantly more platelet transfusions (p = 0.049). Conclusions: In patients with acute type A aortic dissection who were pretreated with rivaroxaban and ticagrelor, the intraoperative use of CytoSorb hemoadsorption during cardiopulmonary bypass is reported for the first time. The method was found to be effective to prevent from bleeding and to improve the outcome in aortic dissection.
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Affiliation(s)
- Kambiz Hassan
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Tabea Brüning
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Michael Caspary
- Department of Anaesthesiology and Intensive Care Medicine, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Holger Pioch
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Michael Schmoeckel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
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Yu X, Feng Z. Analysis of Risk Factors for Perioperative Acute Kidney Injury and Management Strategies. Front Med (Lausanne) 2022; 8:751793. [PMID: 35004722 PMCID: PMC8738090 DOI: 10.3389/fmed.2021.751793] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/09/2021] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) is a serious clinical syndrome, and one of the common comorbidities in the perioperative period. AKI can lead to complications in surgical patients and is receiving increasing attention in clinical workup. In recent years, the analysis of perioperative risk factors has become more in-depth and detailed. In this review, the definition, diagnosis, and pathophysiological characteristics of perioperative AKI are reviewed, and the main risk factors for perioperative AKI are analyzed, including advanced age, gender, certain underlying diseases, impaired clinical status such as preoperative creatinine levels, and drugs that may impair renal function such as non-steroidal anti-inflammatory drugs (NASIDs), ACEI/ARB, and some antibiotics. Injectable contrast agents, some anesthetic drugs, specific surgical interventions, anemia, blood transfusions, hyperglycemia, and malnutrition are also highlighted. We also propose potential preventive and curative measures, including the inclusion of renal risk confirmation in the preoperative assessment, minimization of intraoperative renal toxin exposure, intraoperative management and hemodynamic optimization, remote ischemic preadaptation, glycemic control, and nutritional support. Among the management measures, we emphasize the need for careful perioperative clinical examination, timely detection and management of AKI complications, administration of dexmedetomidine for renal protection, and renal replacement therapy. We aim that this review can further increase clinicians' attention to perioperative AKI, early assessment and intervention to try to reduce the risk of AKI.
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Affiliation(s)
- Xiang Yu
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center of Kidney Diseases, Chinese PLA Institute of Nephrology, Chinese PLA General Hospital, Beijing, China
| | - Zhe Feng
- State Key Laboratory of Kidney Diseases, Department of Nephrology, National Clinical Research Center of Kidney Diseases, Chinese PLA Institute of Nephrology, Chinese PLA General Hospital, Beijing, China
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114
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Wang E, Yuan X, Wang Y, Chen W, Zhou X, Hu S, Yuan S. Tranexamic Acid Administered During Off-Pump Coronary Artery Bypass Graft Surgeries Achieves Good Safety Effects and Hemostasis. Front Cardiovasc Med 2022. [PMID: 35187119 DOI: 0.3389/fcvm.2022.775760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Tranexamic acid (TXA) administered during off-pump coronary artery bypass (OPCAB) surgeries has achieved good blood control in small cohorts. We aimed to investigate the safety issues and hemostasis associated with TXA administration during OPCAB in a large retrospective cohort study. METHODS This study included 19,687 patients with OPCAB from 2009 to 2019. A total of 1,307 patients were excluded because they were younger than 18 years or certain values were missing. Among the remaining 18,380 patients, 10,969 were in the TXA group and 7,411 patients were in the no-TXA group. There were 4,889 patients whose TXA dose was ≥50 mg/kg, and the remaining 6,080 patients had a TXA dose of <50 mg/kg. Propensity score matching (PSM) was performed between the TXA and no-TXA groups and between the high-dose and low-dose groups, and statistical analysis was performed. RESULTS Tranexamic acid administration did not increase the risk of hospital death or thromboembolic events. Patients who administered TXA had less blood loss at 24 h (478.32 ± 276.41 vs. 641.28 ± 295.09, p < 0.001) and 48 h (730.59 ± 358.55 vs. 915.24 ± 390.13, p < 0.001) and total blood loss (989.00 ± 680.43 vs. 1,220.01 ± 720.68, p < 0.001) after OPCAB than the patients with non-TXA. Therefore, the risk of total blood exposure [odds ratio (OR) = 0.50, 95% CI 0.47-0.54, p < 0.001] or blood component exposure (p < 0.001) was decreased significantly in the patients who administered TXA. The TXA dosage did not impact the patient survival, thromboembolic events, or blood management. CONCLUSIONS The application of TXA was safe and provided blood control in patients with OPCAB, and the dosage did not affect these parameters.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Medical Research and Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xingtong Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6555495. [DOI: 10.1093/ejcts/ezac208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
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Muszynski JA, Banks R, Reeder RW, Hall MW, Berg RA, Zuppa A, Shanley TP, Cornell TT, Newth CJL, Pollack MM, Wessel D, Doctor A, Lin JC, Harrison RE, Meert KL, Dean JM, Holubkov R, Carcillo JA. Outcomes Associated With Early RBC Transfusion in Pediatric Severe Sepsis: A Propensity-Adjusted Multicenter Cohort Study. Shock 2022; 57:88-94. [PMID: 34628452 PMCID: PMC8678199 DOI: 10.1097/shk.0000000000001863] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about the epidemiology of and outcomes related to red blood cell (RBC) transfusion in septic children across multiple centers. We performed propensity-adjusted secondary analyses of the Biomarker Phenotyping of Pediatric Sepsis and Multiple Organ Failure (PHENOMS) study to test the hypothesis that early RBC transfusion is associated with fewer organ failure-free days in pediatric severe sepsis. METHODS Four hundred one children were enrolled in the parent study. Children were excluded from these analyses if they received extracorporeal membrane oxygenation (n = 22) or died (n = 1) before sepsis day 2. Propensity-adjusted analyses compared children who received RBC transfusion on or before sepsis day 2 (early RBC transfusion) with those who did not. Logistic regression was used to model the propensity to receive early RBC transfusion. A weighted cohort was constructed using stabilized inverse probability of treatment weights. Variables in the weighted cohort with absolute standardized differences >0.15 were added to final multivariable models. RESULTS Fifty percent of children received at least one RBC transfusion. The majority (68%) of first transfusions were on or before sepsis day 2. Early RBC transfusion was not independently associated with organ failure-free (-0.34 [95%CI: -2, 1.3] days) or PICU-free days (-0.63 [-2.3, 1.1]), but was associated with the secondary outcome of higher mortality (aOR 2.9 [1.1, 7.9]). CONCLUSIONS RBC transfusion is common in pediatric severe sepsis and may be associated with adverse outcomes. Future studies are needed to clarify these associations, to understand patient-specific transfusion risks, and to develop more precise transfusion strategies.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P Shanley
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Timothy T Cornell
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Allan Doctor
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - John C Lin
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - Rick E Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Nuttall GA, Smith MM, Smith BB, Christensen JM, Santrach PJ, Schaff HV. A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients. Ann Thorac Cardiovasc Surg 2021; 28:204-213. [PMID: 34937821 PMCID: PMC9209891 DOI: 10.5761/atcs.oa.21-00222] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy. Materials and Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements. Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups. Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paula J Santrach
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Wang E, Yuan X, Wang Y, Chen W, Zhou X, Hu S, Yuan S. Blood conservation outcomes and safety of tranexamic acid in coronary artery bypass graft surgery. Int J Cardiol 2021; 348:50-56. [PMID: 34920046 DOI: 10.1016/j.ijcard.2021.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The safety and blood management effects of Tranexamic acid (TXA) and its dose effects in coronary artery bypass graft (CABG) were still ambiguous. This study aimed to analyze these TXA effects. METHODS Overall, 42,010 patients undergoing CABG were enrolled in this retrospective cohort study. Patients were assigned to the TXA group (n = 29,536) and the no-TXA group (n = 12,474). Furthermore, the TXA group was divided into the high-dose (≥50 mg/kg) (16,488) and the low-dose (<50 mg/kg) (13,048) subgroup. Propensity score matching was performed in both groups respectively. The primary endpoint after CABG was composed of hospital death, perioperative myocardial infarction (PMI), stroke, acute kidney injury (AKI), and pulmonary embolism. The secondary endpoint included blood loss and blood transfusion after surgery. RESULTS TXA led to a 1.40-fold risk of PMI (p < 0.001). Patients in the TXA group had fewer re-operations for bleeding or tamponade [Odd ratio (OR) = 0.82, p = 0.044], less blood loss after surgery (p < 0.001), and a lower risk for blood transfusion exposure (OR = 0.45, p < 0.001) than those in the no-TXA group. The high-dose TXA reduced blood loss after cardiac surgery compared to the low-dose TXA (p < 0.001) with no associations with blood exposure or adverse events. CONCLUSIONS The use of TXA during CABG increased the risk of PMI despite better blood control after surgery. The high dose of TXA acquired better bleeding management. Meanwhile, it did not increase the risk of primary endpoint.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Xicheng District, Beijing 100037, China
| | - Weinan Chen
- Information Center, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Xingtong Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China.
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Xicheng District, Beijing 100037, China.
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119
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Pupovac SS, Hemli JM, Scheinerman SJ, Hartman AR, Brinster DR. Transfusion in Elective Proximal Aortic Reconstruction: Where Do We Currently Stand? Int J Angiol 2021; 30:292-297. [PMID: 34853577 DOI: 10.1055/s-0041-1729860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Aortic procedures are associated with higher risks of bleeding, yet data regarding perioperative transfusion in this patient population are lacking. We evaluated transfusion patterns in patients undergoing proximal aortic surgery to provide a benchmark against which future standards can be assessed. Between June 2014 and July 2017, 247 patients underwent elective aortic reconstruction for aneurysm. Patients with acute aortic syndrome, endocarditis, and/or prior cardiac surgery were excluded. Transfusion data were analyzed by type of operation: ascending aorta replacement ± aortic valve procedure (group 1, n = 122, 49.4%); aortic root replacement with a composite valve-graft conduit ± ascending aorta replacement (group 2, n = 93, 37.7%); valve-sparing aortic root replacement (VSARR) ± ascending aorta replacement (group 3, n = 32, 13.0%). Thirty-day mortality for the entire cohort was 2.02% (5 deaths). Overall, 75 patients (30.4%) did not require any transfusion of blood or other products. Patients in groups 1 and 3 were significantly more likely to avoid transfusion than those in group 2. Mean transfusion volume for any individual patient was modest; those who underwent VSARR (group 3) required less intraoperative red blood cells (RBC) than others. Intraoperative transfusion of RBC was independently associated with an increased risk of death at 30 days. Elective proximal aortic reconstruction can be performed without the need for excessive utilization of blood products. Composite root replacement is associated with a greater need for transfusion than either VSARR or isolated replacement of the ascending aorta.
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Affiliation(s)
- Stevan S Pupovac
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, New York
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York
| | - S Jacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York
| | - Alan R Hartman
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital/Northwell Health, Manhasset, New York
| | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York
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Kupryashov AA, Kuksina EV, Kchycheva GA, Haydarov GA. Impact of anemia on outcomes in on-pump coronary artery bypass surgery patients. KARDIOLOGIIA 2021; 61:42-48. [PMID: 34882077 DOI: 10.18087/cardio.2021.11.n1802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/03/2021] [Indexed: 06/13/2023]
Abstract
Aim To study the contribution of preoperative anemia to the prognosis of adverse clinical events (mortality, complications, transfusion) in patients with ischemic heart disease (IHD) after myocardial revascularization in the conditions of artificial circulation.Material and methods This retrospective cohort study included 1 133 patients with IHD who had undergone isolated myocardial revascularization in the conditions of artificial circulation in 2019. The primary endpoints were mortality and a composite endpoint that included, in addition to mortality, cases of acute coronary syndrome, heart, respiratory and renal failure, neurological deficit, and infectious complications. The secondary endpoints were duration of artificial ventilation of more than 12 h, duration of stay in the resuscitation and intensive care unit (RICU) of more than one day, and duration of postoperative inpatient treatment of more than 7 days. Results Preoperative anemia was found in 196 (17.3 %) patients. The anemia was not associated with mortality but increased the risk of the composite endpoint, prolonged artificial ventilation, stay in RICU for more than one day, and red blood cell transfusion. Despite the absence of a relationship between red blood cell transfusion and mortality, the use of transfusion was associated with increased risks of the composite endpoint and prolonged stay in the RICU and hospital.Conclusion Preoperative anemia is a risk factor for adverse outcomes of myocardial revascularization in the conditions of artificial circulation. Timely treatment of preoperative anemia may improve outcomes of the treatment.
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Affiliation(s)
- A A Kupryashov
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - E V Kuksina
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - G A Kchycheva
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
| | - G A Haydarov
- Bakoulev`s Center for Cardiovascular Surgery, Moscow, Russia
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Red blood cell transfusion induces abnormal HIF-1α response to cytokine storm after adult cardiac surgery. Sci Rep 2021; 11:22230. [PMID: 34782683 PMCID: PMC8592994 DOI: 10.1038/s41598-021-01695-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
Patients undergoing cardiac surgery develop a marked postoperative systemic inflammatory response. Blood transfusion may contribute to disruption of homeostasis in these patients. We sought to evaluate the impact of blood transfusion on serum interleukin-6 (IL-6), hypoxia induced factor-1 alpha (HIF-1α) levels as well as adverse outcomes in patients undergoing adult cardiac surgery. We prospectively enrolled 282 patients undergoing adult cardiac surgery. Serum IL-6 and HIF-1α levels were measured preoperatively and on the first postoperative day. Packed red blood cells were transfused in 26.3% of patients (mean 2.93 ± 3.05 units) by the time of postoperative sampling. Postoperative IL-6 levels increased over 30-fold and were similar in both groups (p = 0.115), whilst HIF-1α levels (0.377 pg/mL vs. 0.784 pg/mL, p = 0.002) decreased significantly in patients who received red blood cell transfusion. Moreover, greater decrease in HIF-1α levels predicted worse in-hospital and 3mo adverse outcome. Red blood cell transfusion was associated with higher risk of major adverse outcomes (stroke, pneumonia, all-cause mortality) during the index hospitalization. Red blood cell transfusion induces blunting of postoperative HIF-1 α response and is associated with higher risk of adverse thrombotic and pulmonary adverse events after cardiac surgery.
Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03444259.
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Hanson SJ, Karam O, Birch R, Goel R, Patel RM, Sola-Visner M, Sachais BS, Hauser RG, Luban NLC, Gottschall J, Josephson CD, Hendrickson JE, Karafin MS, Nellis ME. Transfusion Practices in Pediatric Cardiac Surgery Requiring Cardiopulmonary Bypass: A Secondary Analysis of a Clinical Database. Pediatr Crit Care Med 2021; 22:978-987. [PMID: 34261944 PMCID: PMC8570986 DOI: 10.1097/pcc.0000000000002805] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe blood component usage in transfused children with congenital heart disease undergoing cardiopulmonary bypass surgery across perioperative settings and diagnostic categories. DESIGN Datasets from U.S. hospitals participating in the National Heart, Lung, and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III were analyzed. SETTING Inpatient admissions from three U.S. hospitals from 2013 to 2016. PATIENTS Transfused children with congenital heart disease undergoing single ventricular, biventricular surgery, extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eight hundred eighty-two transfused patients were included. Most of the 185 children with single ventricular surgery received multiple blood products: 81% RBCs, 79% platelets, 86% plasma, and 56% cryoprecipitate. In the 678 patients undergoing biventricular surgery, 85% were transfused plasma, 75% platelets, 74% RBCs, and 48% cryoprecipitate. All 19 patients on extracorporeal membrane oxygenation were transfused RBCs, plasma, and cryoprecipitate, and 18 were transfused platelets. Intraoperatively, patients commonly received all three components, while postoperative transfusions were predominantly single blood components. Pretransfusion hemoglobin values were normal/low-normal for age for all phases of care for single ventricular surgery (median hemoglobin 13.2-13.5 g/dL). Pretransfusion hemoglobin values for biventricular surgeries were higher intraoperatively compared with other timing (12.2 g/dL vs 11.2 preoperative and postoperative; p < 0.0001). Plasma transfusions for all patients were associated with a near normal international normalized ratio: single ventricular surgeries median international normalized ratio was 1.3 postoperative versus 1.8 intraoperative and biventricular surgeries median international normalized ratio was 1.1 intraoperative versus 1.7 postoperative. Intraoperative platelet transfusions with biventricular surgeries had higher median platelet count compared with postoperative pretransfusion platelet count (244 × 109/L intraoperative vs 69 × 109/L postoperative). CONCLUSIONS Children with congenital heart disease undergoing cardiopulmonary bypass surgery are transfused many blood components both intraoperatively and postoperatively. Multiple blood components are transfused intraoperatively at seemingly normal/low-normal pretransfusion values. Pediatric evidence guiding blood component transfusion in this population at high risk of bleeding and with limited physiologic reserve is needed to advance safe and effective blood conservation practices.
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Affiliation(s)
| | - Oliver Karam
- Children’s Hospital of Richmond. Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Ruchika Goel
- Johns Hopkins University School of Medicine, Baltimore, MD
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Schreurs RHP, Joore MA, Ten Cate H, Ten Cate-Hoek AJ. Using the Functional Resonance Analysis Method to explore how elastic compression therapy is organised and could be improved from a multistakeholder perspective. BMJ Open 2021; 11:e048331. [PMID: 34642192 PMCID: PMC8513256 DOI: 10.1136/bmjopen-2020-048331] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Elastic compression stocking (ECS) therapy is an important treatment for patients with deep venous thrombosis (DVT) and chronic venous insufficiency (CVI). This study aimed to provide insight into the structure and variability of the ECS therapy process, its effects on outcomes, and to elicit improvement themes from a multiple stakeholder perspective. DESIGN Thirty semi-structured interviews with professionals and patients were performed. The essential functions for the process of ECS therapy were extracted to create two work-as-done models using the Functional Resonance Analysis Method (FRAM). These findings were used to guide discussion between stakeholders to identify improvement themes. SETTING Two regions in the Netherlands, region Limburg and region North-Holland, including an academic hospital and a general hospital and their catchment region. PARTICIPANTS The interviewees were purposely recruited and included 25 healthcare professionals (ie, general practitioners, internists, dermatologists, nurses, doctor's assistants, occupational therapists, home care nurses and medical stocking suppliers) and 5 patients with DVT or CVI. RESULTS Two FRAM models were created (one for each region). The variability of the functions and their effect on outcomes, as well as interdependencies between functions, were identified. These were presented in stakeholder meetings to identify the structure of the process and designated variable and uniform parts of the process and its outcomes. Ultimately, six improvement themes were identified: dissemination of knowledge of the entire process; optimising and standardising initial compression therapy; optimising timing to contact the medical stocking supplier (when oedema has disappeared); improving the implementation of assistive devices; harmonising follow-up duration for patients with CVI; personalising follow-up and treatment duration in patients with DVT. CONCLUSIONS This study provided a detailed understanding of how ECS therapy is delivered in daily practice by describing major functions and variability in performances and elicited six improvement themes from a multistakeholder perspective.
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Affiliation(s)
- Rachel Hellen Petra Schreurs
- Department of Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Heart and Vascular Center and Thrombosis Expertise Center, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Arina J Ten Cate-Hoek
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Heart and Vascular Center and Thrombosis Expertise Center, Maastricht University Medical Centre+, Maastricht, The Netherlands
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Liu M, Tan W, Yuan W, Wang T, Lu X, Liu N. Development and Validation of a Diagnostic Model to Predict the Risk of Ischemic Liver Injury After Stanford A Aortic Dissection Surgery. Front Cardiovasc Med 2021; 8:701537. [PMID: 34631813 PMCID: PMC8494972 DOI: 10.3389/fcvm.2021.701537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To define the risk factors of ischemic liver injury (ILI) following Stanford A aortic dissection surgery and to propose a diagnostic model for individual risk prediction. Methods: We reviewed the clinical parameters of ILI patients who underwent cardiac surgery from Beijing Anzhen Hospital, Capital Medical University between January 1, 2015 and October 30, 2020. The data was analyzed by the use of univariable and multivariable logistic regression analysis. A risk prediction model was established and validated, which showed a favorable discriminating ability and might contribute to clinical decision-making for ILI after Stanford A aortic dissection (AAD) surgery. The discriminative ability and calibration of the diagnostic model to predict ILI were tested using C statistics, calibration plots, and clinical usefulness. Results: In total, 1,343 patients who underwent AAD surgery were included in the study. After univariable and multivariable logistic regression analysis, the following variables were incorporated in the prediction of ILI: pre-operative serum creatinine, pre-operative RBC count <3.31 T/L, aortic cross-clamp time >140 min, intraoperative lactic acid level, the transfusion of WRBC, atrial fibrillation within post-operative 24 h. The risk model was validated by internal sets. The model showed a robust discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.718. The calibration plots for the probability of perioperative ischemic liver injury showed coherence between the predictive probability and the actual probability (Hosmer-Lemeshow test, P = 0.637). In the validation cohort, the nomogram still revealed good discrimination (C statistic = 0.727) and good calibration (Hosmer-Lemeshow test, P = 0.872). The 10-fold cross-validation of the nomogram showed that the average misdiagnosis rate was 9.95% and the lowest misdiagnosis rate was 9.81%. Conclusion: Our risk model can be used to predict the probability of ILI after AAD surgery and have the potential to assist clinicians in making treatment recommendations.
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Affiliation(s)
- Maomao Liu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen Tan
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen Yuan
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tengke Wang
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xuran Lu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Liu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Li Y, Cheang I, Zhang Z, Zuo X, Cao Q, Li J. Prognostic Association Between Perioperative Red Blood Cell Transfusion and Postoperative Cardiac Surgery Outcomes. Front Cardiovasc Med 2021; 8:730492. [PMID: 34631829 PMCID: PMC8497961 DOI: 10.3389/fcvm.2021.730492] [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: 06/25/2021] [Accepted: 08/24/2021] [Indexed: 12/28/2022] Open
Abstract
Objective: To investigate the correlation between red blood cell transfusion and clinical outcome in patients after cardiac surgery. Methods: Demographic, clinical characteristics, treatment with/without transfusion, and outcomes of patients after cardiac surgery from the Medical Information Mart for Intensive Care—III database were collected. Patients were divided into two groups according to perioperative transfusion. A multivariable logistic regression analysis was utilized to adjust for the effect of red blood cell transfusion on outcomes for baseline and covariates and to determine its association with outcomes. Results: In total, 6,752 patients who underwent cardiac surgery were enrolled for the analysis. Among them, 2,760 (40.9%) patients received a perioperative transfusion. Compared with patients without red blood cell transfusion, transfused patients demonstrated worse outcomes in inhospital mortality, 1-year mortality, and all-cause mortality. Adjusting odds ratios (ORs) for the significant characteristic, patients with perioperative transfusion remained significantly associated with an increased risk of inhospital mortality [OR = 2.8, 95% confidence interval (CI) 1.5–5.1, P = 0.001], 1-year mortality (OR = 2.0, 95% CI 1.4–2.7, P < 0.001), and long-term mortality (OR = 2.2, 95% CI 1.8–2.8, P < 0.001). Conclusion: Perioperative red blood cell transfusion is associated with a worse prognosis of cardiac surgery patients. Optimal perioperative management and restricted transfusion strategy might be considered in selected patients.
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Affiliation(s)
- Yanxiu Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Iokfai Cheang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhongwen Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangrong Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Quan Cao
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinghang Li
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Hang D, Koss K, Rokkas CK, Pagel PS. Recombinant activated factor VII for hemostasis in patients undergoing complex ascending aortic surgery: A single-center, single-surgeon retrospective analysis. J Card Surg 2021; 36:4558-4563. [PMID: 34608671 DOI: 10.1111/jocs.16048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/23/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Use of recombinant activated factor VII (rFVIIa) to achieve hemostasis during cardiac surgery continues to be debated, as support for its efficacy and safety has not been consistent. We examined our experience with rFVIIa for achieving hemostasis in high-risk patients undergoing complex ascending aortic surgery. METHODS We reviewed patients who underwent complex ascending aortic surgery performed by a single surgeon (C. K. R.) from August 2014 to February 2019. Outcomes of patients who received rFVIIa were compared with those who did not. RESULTS Of 59 consecutive patients, 20 patients (33.9%) received rFVIIa, whereas 39 (66.1%) did not. Median dose was 45.4 mcg/kg. rFVIIa was administered intraoperatively to 95% of patients who received it. Most patients underwent combined aortic valve, ascending aorta, and aortic arch surgery (80.0% vs. 64.1%, p = .52). Patients receiving rFVIIa had longer mean cross clamp times (212 vs. 173 min, p = .03) and received a greater median number of intraoperative blood products (18.5 vs. 12.0, p < .001). The number of patients who needed postoperative products (75.0% vs. 60.5%, p = .39), the median number of blood products transfused postoperatively (2 vs. 2, p = .40), and chest tube output (1138 vs. 805 ml, p = .17) were similar between groups. In-hospital mortality was similar between groups (10.0% vs. 10.3%, p = 1.00). Incidences of postoperative stroke (10.0% vs. 13.5%, p = 1.00) and thromboembolic events (10.0% vs. 13.5%, p = 1.00) were similar. CONCLUSIONS Administration of rFVIIa intraoperatively for refractory bleeding during complex ascending aortic surgery provided hemostasis without greater in-hospital mortality or a higher risk of stroke and thromboembolic events.
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Affiliation(s)
- Dustin Hang
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kevin Koss
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Chris K Rokkas
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul S Pagel
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
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Hong Y, Dufendach K, Wang Y, Thoma F, Kilic A. Impact of early massive transfusion and blood component ratios in patients undergoing left ventricular assist device implantation. J Card Surg 2021; 36:4519-4526. [PMID: 34558110 DOI: 10.1111/jocs.16010] [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: 06/17/2021] [Accepted: 08/29/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND This study evaluates the impact of early massive transfusion and blood component ratios on outcomes following left ventricular assist device (LVAD) implantation. METHODS Adults undergoing LVAD implantation between 2009 and 2018 at a single institution were included. Transfusions were analyzed during the intraoperative and the initial 24-h postoperative period. Patients were stratified into massive and nonmassive transfusion groups. The primary outcome was survival, and secondary outcomes included postoperative complications. Sub-analyses were performed to evaluate the impact of balanced transfusion. RESULTS A total of 278 patients were included. A total of 45.3% (n = 126) required massive transfusions. The massive transfusion group experienced significantly higher rates of postimplant adverse events, including reoperation, renal failure, and hepatic dysfunction (all, p ≤ .05). Furthermore, the massive transfusion group had significantly lower 30-day, 90-day, 1-year, 2-year, and overall survival rates following LVAD implantation (all, p < .05). In multivariable analysis, massive transfusion significantly impacted overall risk-adjusted mortality rate (hazard ratio: 2.402, 95% confidence Interval: 1.677-3.442, p < .001). In the sub-analyses evaluating the impact of balanced massive transfusion, balanced fresh frozen plasma to packed red blood cell (pRBC) transfusion did not provide any survival benefit (all, p > .05). However, balanced platelet to pRBC massive transfusion did improve 2-year and overall mortality rates in the massive transfusion cohort (both, p ≤ .05). CONCLUSIONS This study demonstrates a significant association between early massive transfusion and adverse outcomes following LVAD implantation. Balancing platelet to pRBC transfusion in the early postoperative period may help mitigate some of these detrimental effects of massive transfusion on subsequent survival.
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Affiliation(s)
- Yeahwa Hong
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Keith Dufendach
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Nie Z, Ma W, Hu J. Models to predict the probability for intraoperative RBC transfusion during lumbar spinal stenosis and femoral fracture surgeries in aged patients. Transfus Apher Sci 2021; 60:103277. [PMID: 34563458 DOI: 10.1016/j.transci.2021.103277] [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: 07/08/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 01/28/2023]
Abstract
OBJECTIVE The goal of this study was to predict the probability of transfusion of red blood cells and the volume of blood consumption based on the clinical characteristics of patients before surgery. METHODS The medical records of 565 patients over 65 years old who underwent posterior lumbar surgery and 586 patients over 65 years old receiving femoral fracture surgery were reviewed. The clinical characteristics of the patients were subjected to multivariate regression analysis. The scores of these factors' influences on intraoperative red blood cells infusion were based on the odds ratio of each multivariate risk factor. Non-linear regression was performed to predict the probability of intraoperative blood transfusion and the volume of blood used for patients with different scores. RESULTS The factors that significantly influenced blood use during lumbar spinal stenosis and femoral fracture surgery in aged patients(P < 0.05) included age, body mass index, abnormal coagulation function, preoperative hemoglobin, administration of antithrombotic drugs, multisegmental lesions of the lumbar spine, femoral shaft fracture, secondary lumbar surgery and the time from fracture to surgery exceeding 48 h. According to our risk scoring system, patients of posterior lumbar surgery scored 0-10 and patients of femoral fracture had a score of 0-12. More than 50 % of patients receiving an intraoperative red blood cells transfusion during surgery scored>1. CONCLUSION The scoring system can be used as a predictive model for the probability of red blood cells transfusion and the blood volume in aged patients undergoing lumbar spinal stenosis and femoral fracture surgeries.
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Affiliation(s)
- Zhiyang Nie
- Transfusion Department, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, China.
| | - Wanru Ma
- Transfusion Department, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, China.
| | - Junhua Hu
- Transfusion Department, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, China.
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Kondo T, Morimoto R, Mutsuga M, Fujimoto K, Okumura T, Shibata N, Kazama S, Kimira Y, Oishi H, Kuwayama T, Hiraiwa H, Usui A, Murohara T. Comparison of Impella 5.0 and extracorporeal left ventricular assist device in patients with cardiogenic shock. Int J Artif Organs 2021; 44:846-853. [PMID: 34488481 DOI: 10.1177/03913988211040530] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Choice of mechanical circulatory support to stabilize hemodynamics until cardiac recovery or next treatment is a strategic cornerstone for improving outcomes in patients with severe cardiogenic shock. We aimed to clarify the difference in treatment course and outcomes with the use of Impella 5.0 and an extracorporeal left ventricular assist device (eLVAD) in patients with cardiogenic shock refractory to medical therapy or other mechanical circulatory support. METHODS We performed a retrospective medical record review of consecutive patients who were implanted with Impella 5.0 or eLVAD as a bridge to decision at our medical center. RESULTS A total of 26 patients (median age 40 years, 16 males) were analyzed. Of seven patients managed with Impella 5.0, the Impella 5.0 was removed successfully in two patients and five patients underwent surgery for durable LVAD implantation. Of 19 patients managed with eLVAD, the eLVAD was successfully removed in 3 patients, 9 patients required durable LVAD, and 7 patients died during eLVAD management. The period between Impella 5.0 or eLVAD implantation to durable LVAD surgery was significantly shorter with Impella 5.0 (58 vs 235 days, p = 0.001). Cardiopulmonary bypass time was significantly shorter and a significantly smaller amount of red blood cell transfusion was required with Impella 5.0 (149 vs 192 min, p = 0.042; 7.0 vs 15.0 units, p = 0.019). There were four massive stroke events with eLVAD, but no massive stroke event with Impella 5.0. CONCLUSION Impella 5.0 facilitates smoother management as a bridge to decision and reduces surgical invasiveness during durable LVAD implantation.
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Affiliation(s)
- Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuro Fujimoto
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naoki Shibata
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuki Kimira
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Huang X, Wang Y, Chen B, Huang Y, Wang X, Chen L, Gui R, Ma X. Ability of a Machine Learning Algorithm to Predict the Need for Perioperative Red Blood Cells Transfusion in Pelvic Fracture Patients: A Multicenter Cohort Study in China. Front Med (Lausanne) 2021; 8:694733. [PMID: 34485333 PMCID: PMC8415266 DOI: 10.3389/fmed.2021.694733] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/20/2021] [Indexed: 01/20/2023] Open
Abstract
Background: Predicting the perioperative requirement for red blood cells (RBCs) transfusion in patients with the pelvic fracture may be challenging. In this study, we constructed a perioperative RBCs transfusion predictive model (ternary classifications) based on a machine learning algorithm. Materials and Methods: This study included perioperative adult patients with pelvic trauma hospitalized across six Chinese centers between September 2012 and June 2019. An extreme gradient boosting (XGBoost) algorithm was used to predict the need for perioperative RBCs transfusion, with data being split into training test (80%), which was subjected to 5-fold cross-validation, and test set (20%). The ability of the predictive transfusion model was compared with blood preparation based on surgeons' experience and other predictive models, including random forest, gradient boosting decision tree, K-nearest neighbor, logistic regression, and Gaussian naïve Bayes classifier models. Data of 33 patients from one of the hospitals were prospectively collected for model validation. Results: Among 510 patients, 192 (37.65%) have not received any perioperative RBCs transfusion, 127 (24.90%) received less-transfusion (RBCs < 4U), and 191 (37.45%) received more-transfusion (RBCs ≥ 4U). Machine learning-based transfusion predictive model produced the best performance with the accuracy of 83.34%, and Kappa coefficient of 0.7967 compared with other methods (blood preparation based on surgeons' experience with the accuracy of 65.94%, and Kappa coefficient of 0.5704; the random forest method with an accuracy of 82.35%, and Kappa coefficient of 0.7858; the gradient boosting decision tree with an accuracy of 79.41%, and Kappa coefficient of 0.7742; the K-nearest neighbor with an accuracy of 53.92%, and Kappa coefficient of 0.3341). In the prospective dataset, it also had a food performance with accuracy 81.82%. Conclusion: This multicenter retrospective cohort study described the construction of an accurate model that could predict perioperative RBCs transfusion in patients with pelvic fractures.
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Affiliation(s)
- Xueyuan Huang
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yongjun Wang
- Department of Blood Transfusion, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Bingyu Chen
- Department of Transfusion, Zhejiang Provincial People's Hospital, Hangzhou, China
| | - Yuanshuai Huang
- Department of Transfusion, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Xinhua Wang
- Department of Transfusion, Beijing Aerospace Center Hospital, Beijing, China
| | - Linfeng Chen
- Department of Transfusion, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Rong Gui
- Department of Blood Transfusion, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xianjun Ma
- Department of Blood Transfusion, Qilu Hospital of Shandong University, Jinan, China
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Rahe-Meyer N, Levy JH, Ueda Y, Schmidt DS, Gill R. Viscoelastic testing to assess the effects of rapid fibrinogen concentrate administration after cardiopulmonary bypass: insights from the REPLACE study. Blood Coagul Fibrinolysis 2021; 32:359-365. [PMID: 33973891 DOI: 10.1097/mbc.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Haemorrhage during and following surgery results in increased morbidity and mortality. Low plasma fibrinogen levels have been associated with increased blood loss and transfusion requirements. Fibrinogen supplementation has been shown to reduce bleeding in coagulopathic patients. This post hoc study evaluated fibrinogen repletion and pharmacokinetic data from the REPLACE study. One hundred and fifty-two adult patients undergoing elective aortic surgery requiring cardiopulmonary bypass (CPB) with defined bleeding of 60-250 g at first 5 min bleeding mass were included in the phase III trial. Patients were randomized to receive either fibrinogen concentrate (FCH) or placebo following CPB removal. Plasma fibrinogen levels and viscoelastic testing parameters (ROTEM-based FIBTEM and EXTEM assays) were measured before, during, and after study treatment administration. A mean dose of 6.3 g FCH was administered in the FCH group, with a median infusion duration of 2 min. Immediately following completion of FCH administration, a rapid increase in plasma fibrinogen levels to near baseline (median change from baseline -0.10 g/l) was seen in the FCH group but not in the placebo group (median change from baseline -1.29 g/l). FCH administration also caused an immediate increase in FIBTEM maximum clot firmness (MCF) to 23 mm and improvements in EXTEM coagulation time and clot formation time by the end of infusion. There was a strong correlation between the plasma fibrinogen level and FIBTEM MCF. Treatment with high doses of FCH with a rapid infusion time resulted in immediate recovery to baseline levels of plasma fibrinogen and viscoelastic testing parameters.
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Affiliation(s)
| | - Jerrold H Levy
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuichi Ueda
- Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Ravi Gill
- University Hospital of Southampton, Southampton, UK
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Bianco V, Kilic A, Aranda-Michel E, Dunn-Lewis C, Serna-Gallegos D, Chen S, Navid F, Sultan I. Mild hypothermia versus normothermia in patients undergoing cardiac surgery. JTCVS OPEN 2021; 7:230-242. [PMID: 36003710 PMCID: PMC9390284 DOI: 10.1016/j.xjon.2021.05.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
Objective Temperature during cardiopulmonary bypass (CPB) for cardiac surgery has been controversial. The aim of the current study is to compare the outcomes for patients with mild hypothermia versus normothermic CPB temperatures. Methods All patients who underwent cardiac surgery with CPB and temperatures ≥32°C from 2011 to 2018 were included, which consisted of mild hypothermia (32°C-35°C) and normothermia (>35°C) cohorts. Propensity matching (1:1) was performed for risk adjustment. Primary outcomes included operative and long-term survival. Secondary outcomes included postoperative complications. Results A total of 6525 patients comprised 2 cohorts: mild hypothermia (32°C-35°C; n = 3148) versus normothermia (>35°C; n = 3377). Following adjustment for surgeon preference, there were 1601 propensity-matched patients who had similar baseline characteristics (standard mean difference, ≤0.10), including CPB time, crossclamp time, and intra-aortic balloon pump placement. Kaplan-Meier analysis showed no difference in long-term survival (82.6% vs 81.6%; P = .81). Over a median follow-up of 4.4 years, there were no differences in overall mortality (18.1% vs 18.1%; P = 1.1) or readmission (50.3% vs 48.3%; P = .2). Acute renal failure (3.7% vs 2.4%; P = .03) and intensive care unit hours (46.5 vs 45.1; P = .04) were significantly higher with hypothermia. There was no difference between cohorts for postoperative stroke (2.0% vs 2.0%; P = 1.0), reoperation (5.9% vs 6.0%; P = .9), or operative intra-aortic balloon pump placement (1.7% vs 1.8%; P = .9). Conclusions Patients with mild hypothermia during CPB had increased postoperative renal failure and length of intensive care unit stay. Although there was no difference in long-term survival, mild hypothermia does not appear to offer patients appreciable benefits, compared with normothermia.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Shangzhen Chen
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
- Address for reprints: Ibrahim Sultan, MD, Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, 5200 Centre Ave, Suite 715, Pittsburgh, PA 15232.
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Mladinov D, Eudailey KW, Padilla LA, Norman JB, Leahy B, Enslin J, Parker K, Cornelius KF, Davies JE. Effects of acute normovolemic hemodilution on post-cardiopulmonary bypass coagulation tests and allogeneic blood transfusion in thoracic aortic repair surgery: An observational cohort study. J Card Surg 2021; 36:4075-4082. [PMID: 34431128 DOI: 10.1111/jocs.15943] [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: 05/24/2021] [Revised: 07/22/2021] [Accepted: 08/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. METHODS Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair with cardiopulmonary bypass (CPB) from 2019 to 2021. RESULTS A total of 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p < 0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH versus control group: FFP 1.1 ± 1.6 versus 1.9 ± 2.3 (p = 0.003), platelets 0.6 ± 0.8 versus 1.2 ± 1.3 (p = 0.0008), and cryoprecipitate 0.3 ± 0.7 versus 0.7 ± 1.1 (p = 0.008). Reduction in red blood cell transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p = 0.42). There was no significant difference in major adverse outcomes. CONCLUSIONS ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests ANH can improve some coagulation values after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph B Norman
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Leahy
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacob Enslin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keli Parker
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katherine F Cornelius
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James E Davies
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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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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Sharan S, Kapoor PM, Choudhury M, Devagourou V, Choudhury UK, Ravi V. Role of Platelet Function Test in Predicting Postoperative Bleeding Risk after Coronary Artery Bypass Grafting: A Prospective Observational Study. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1728978] [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] Open
Abstract
AbstractPatients undergoing cardiac surgery are at risk of excessive bleeding and its associated complications. Excessive bleeding during and after cardiac surgery has an incidence of ~20%. Massive bleeding and subsequent requirement for blood product administration and mediastinal reexploration are associated with significant morbidity and mortality. Postoperative, nonsurgical bleeding in cardiac surgical patients is often multifactorial. Platelet dysfunction, excessive fibrinolysis, hypothermia, preoperative anemia, and deficiency of coagulation factors or their dilution are all suggested etiologies of postoperative bleeding. In the Arachidonic Acid Thromboelastometry (ARATEM) test, platelets are activated with arachidonic acid; in Adenosine diphosphate Thromboelastometry (ADPTEM) test, platelets are activated with adenosine diphosphate; and in TRAPTEM test, platelets are activated with thrombin receptor-activating peptide 6. Measurement time is 6 minutes, and results are expressed in three different parameters: A6 (amplitude at 6 minutes, in Ohm); MS (maximum slope of the aggregation curve in Ohm/min), and AUC (area under the curve in Ohm.min). Algorithm-based point-of-care platelet function testing helped us to preemptively give the right blood component therapy, avoiding fibrinolytic bleeding in the postoperative period.
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Affiliation(s)
- Sandeep Sharan
- Department of Cardiac Anaesthesia, CTC, AIIMS, New Delhi, India
| | | | | | - V Devagourou
- Department of CTVS, CTC, AIIMS, New Delhi, India
| | | | - Vajala Ravi
- Department of Statistics, Lady Shri Ram College, University of Delhi New Delhi, India
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Al-Adhami A, Avtaar Singh SS, De SD, Singh R, Panjrath G, Shah A, Dalzell JR, Schroder J, Al-Attar N. Primary Graft Dysfunction after Heart Transplantation - Unravelling the Enigma. Curr Probl Cardiol 2021; 47:100941. [PMID: 34404551 DOI: 10.1016/j.cpcardiol.2021.100941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/09/2021] [Indexed: 11/03/2022]
Abstract
Primary graft dysfunction (PGD) remains the main cause of early mortality following heart transplantation despite several advances in donor preservation techniques and therapeutic strategies for PGD. With that aim of establishing the aetiopathogenesis of PGD and the preferred management strategies, the new consensus definition has paved the way for multiple contemporaneous studies to be undertaken and accurately compared. This review aims to provide a broad-based understanding of the pathophysiology, clinical presentation and management of PGD.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow.
| | - Sudeep Das De
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, Virginia
| | - Gurusher Panjrath
- Heart Failure and Mechanical Circulatory Support Program, George Washington University Hospital, Washington, DC
| | - Amit Shah
- Advanced Heart Failure and Cardiac Transplant Unit, Fiona Stanley Hospital, Perth, Australia
| | - Jonathan R Dalzell
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Jacob Schroder
- Heart Transplantation Program, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Nawwar Al-Attar
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow UK; Institute of Cardiovascular and Medical Sciences (ICAMS), University of Glasgow
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Ciardetti N, Ciatti F, Nardi G, Di Muro FM, Demola P, Sottili E, Stolcova M, Ristalli F, Mattesini A, Meucci F, Di Mario C. Advancements in Transcatheter Aortic Valve Implantation: A Focused Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:711. [PMID: 34356992 PMCID: PMC8306774 DOI: 10.3390/medicina57070711] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 01/07/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) has become the leading technique for aortic valve replacement in symptomatic patients with severe aortic stenosis with conventional surgical aortic valve replacement (SAVR) now limited to patients younger than 65-75 years due to a combination of unsuitable anatomies (calcified raphae in bicuspid valves, coexistent aneurysm of the ascending aorta) and concerns on the absence of long-term data on TAVI durability. This incredible rise is linked to technological evolutions combined with increased operator experience, which led to procedural refinements and, accordingly, to better outcomes. The article describes the main and newest technical improvements, allowing an extension of the indications (valve-in-valve procedures, intravascular lithotripsy for severely calcified iliac vessels), and a reduction of complications (stroke, pacemaker implantation, aortic regurgitation).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Carlo Di Mario
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Clinica Medica, Room 124, Careggi University Hospital, Largo Brambilla 3, 50139 Florence, Italy; (N.C.); (F.C.); (G.N.); (F.M.D.M.); (P.D.); (E.S.); (M.S.); (F.R.); (A.M.); (F.M.)
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Platelet and Red Blood Cell Transfusions and Risk of Acute Graft-versus-Host Disease after Myeloablative Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2021; 27:866.e1-866.e9. [PMID: 34252580 DOI: 10.1016/j.jtct.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/28/2021] [Accepted: 07/04/2021] [Indexed: 12/22/2022]
Abstract
Transfusion therapy is a critical part of supportive care early after allogeneic hematopoietic cell transplantation (allo-HCT). Platelet and RBC transfusions elicit immunomodulatory effects in the recipient, but if this impacts the risk of acute graft-versus-host disease (aGVHD) has only been scarcely investigated. We investigated if platelet and RBC transfusions were associated with the development of aGVHD following myeloablative allo-HCT in a cohort of 664 patients who underwent transplantation between 2000 and 2019. Data were further analyzed for the impact of blood donor age and sex and blood product storage time. Exploratory analyses were conducted to assess correlations between transfusion burden and plasma biomarkers of inflammation and endothelial activation and damage. Between day 0 and day +13, each patient received a median of 7 (IQR, 5 to 10) platelet transfusions and 3 (IQR, 2 to 6) RBC transfusions (Spearman's ρ = 0.49). The cumulative sums of platelet and RBC transfusions, respectively, received from day 0 to day +13 were associated with subsequent grade II-IV aGVHD in multivariable landmark Cox models (platelets: adjusted hazard ratio [HR], 1.27; 95% confidence interval [CI], 1.06 to 1.51; RBCs: adjusted HR, 1.41; 95% CI, 1.09 to 1.82; both per 5 units; 184 events). For both platelet and RBC transfusions, we did not find support for a difference in the risk of aGVHD according to age or sex of the blood donor. Transfusion of RBCs with a storage time longer than the median of 8 days was inversely associated with aGVHD (HR per 5 units, 0.54; 95% CI, 0.30 to 0.96); however, when using an RBC storage time of ≥14 days as a cutoff, there was no longer evidence for an association with aGVHD (HR, 1.03 per 5 units; 95% CI, 0.53 to 2.00). For platelets, there was no clear association between storage time and the risk of aGVHD. The transfusion burdens of platelets and RBCs were positively correlated with plasma levels of TNF-α, IL-6, and soluble thrombomodulin at day +14. In conclusion, platelet and RBC transfusions in the first 2 weeks after myeloablative allo-HCT were associated with subsequent development of grade II-IV aGVHD. We did not find evidence of an impact of blood donor age or sex or blood product storage time on the risk of aGVHD. Our findings support restrictive transfusion strategies in allo-HCT recipients.
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Sera VA, Stevens AE, Song HK, Rodriguez VM, Tibayan FA, Treggiari MM. Factor VIII inhibitor bypass activity (FEIBA) for the reduction of transfusion in cardiac surgery: a randomized, double-blind, placebo-controlled, pilot trial. Pilot Feasibility Stud 2021; 7:137. [PMID: 34215339 PMCID: PMC8252226 DOI: 10.1186/s40814-021-00873-5] [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: 03/30/2021] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Uncontrolled bleeding after cardiac surgery can be life-threatening. Factor eight inhibitor bypassing activity (FEIBA) is a prothrombin complex concentrate empirically used as rescue therapy for correction of refractory bleeding diathesis post-cardiopulmonary bypass (CPB). FEIBA used as rescue therapy for bleeding diathesis after CPB has been associated with a low incidence of complications and a reduction in transfusion requirement and re-exploration. The feasibility and efficacy of early administration of FEIBA after the termination of CPB have not been studied in a prospective randomized trial. METHODS We designed a small randomized, double-blinded, placebo-controlled pilot trial to determine the feasibility of a larger trial testing the hypothesis that FEIBA decreases transfusion requirements after CPB. The study was designed to evaluate the feasibility of a larger pivotal trial to determine the effectiveness of FEIBA in reducing the total volume of blood products transfused perioperatively, and its safety profile. Study participants were adult patients undergoing elective major aortic cardiovascular surgery at a tertiary referral hospital, who were equally randomized to receive a single dose of either FEIBA or matched placebo intraoperatively at the end of CPB. RESULTS Twenty patients were screened and 12 were randomized and included in the analysis. Protocol adherence was high, and all patients received the study drug per intention-to-treat except one patient. There were no protocol deviations or events of unblinding, and adverse events were not different between groups. Patients in the FEIBA group were older and more likely to be female and had higher BMI, lower hematocrit, and longer hypothermic circulatory arrest. There were no differences in post-randomization blood product transfusions (difference FEIBA vs. placebo -899 mL; 95% CI -5206 to 3409) or in the administration of open-label FEIBA. CONCLUSIONS This pilot trial confirmed the adequacy of the trial design that involved the early, blinded administration of FEIBA, by demonstrating excellent protocol adherence. We conclude that a larger trial establishing the effectiveness of early prothrombin complex concentrate administration to reduce the use of blood products in the setting of high-risk cardiac surgery is feasible. TRIAL REGISTRATION ClinicalTrials.gov, NCT02577614 . Registered 16 October 2015.
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Affiliation(s)
- Valerie A Sera
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Ann E Stevens
- Department of Anesthesiology, Kaiser Permanente, Portland, OR, USA
| | - Howard K Song
- Department of Cardiothoracic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Victor M Rodriguez
- Department of Surgery, Division of Cardiothoracic Surgery, UC Davis Vascular Center, Davis, CA, USA
| | - Frederick A Tibayan
- Department of Cardiothoracic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Miriam M Treggiari
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA. .,Department of Anesthesiology, Yale University, 333 Cedar Street, TMP-3, New Haven, CT, USA.
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140
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Kikura M, Suzuki Y, Sato T, Uraoka M, Kawashima S. Effect of an assessment of fibrin-based rotational thromboelastometry on blood transfusion and clinical outcomes in cardiovascular surgery: A cohort study. Transfus Apher Sci 2021; 60:103202. [PMID: 34238708 DOI: 10.1016/j.transci.2021.103202] [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: 01/05/2021] [Revised: 06/11/2021] [Accepted: 06/30/2021] [Indexed: 11/30/2022]
Abstract
The clinical importance of viscoelastic testing in patient blood management when performing cardiovascular surgery is increasing. We aimed to examine the effect of a blood transfusion protocol including an assessment of fibrin-based rotational thromboelastometry on transfusion volume, mortality, and bleeding complications in patients undergoing cardiac or thoracic aortic surgery. We retrospectively studied a cohort of 376 consecutive patients who underwent cardiopulmonary bypass before (control group: 150 cardiac and 35 thoracic aortic surgeries) and after (assessment group: 154 cardiac and 37 thoracic aortic surgeries) introducing the fibrin polymerization assessment with thromboelastometry in the blood transfusion protocol. The transfusion volume and clinical outcomes were compared between the control and assessment groups, and the standardized (mean) difference (S[M]D) was calculated as an indicator of statistical effect size. Compared with the control group, the assessment group had a lower total blood transfusion volume (mL) in cardiac (2720 ± 1282 vs. 2034 ± 1330, p < 0.0001, [SMD] = 0.68) and thoracic aortic surgeries (5236 ± 2732 vs. 3714 ± 1768, p < 0.0001, SMD = 0.67). The 1-year mortality rates were 1.9 % and 2.7 % in cardiac and thoracic aortic surgeries, respectively. Significant differences were not observed in the 1-year mortality (3.2 % vs. 1.0 %, p = 0.16, relative risk [RR] = 0.32 with 95 % confidence intervals [CI] = 0.06-1.57, SD = 0.15), re-exploration for bleeding (4.8 % vs. 2.6 %, p = 0.28, RR = 0.53 with 95 % CI = 0.18-1.57, SD = 0.12), and major bleeding (17.3 % vs. 13.0 %, p = 0.31, RR = 0.75 with 95 % CI = 0.46-1.22, SD = 0.12) rates between the control and assessment groups. The assessment of fibrin polymerization with thromboelastometry using the blood transfusion protocol reduced the blood transfusion volume in cardiovascular surgery.
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Affiliation(s)
- Mutsuhito Kikura
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan.
| | - Yuji Suzuki
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tsunehisa Sato
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Masahiro Uraoka
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Hamamatsu, Japan
| | - Shingo Kawashima
- Department of Anesthesiology and Intensive Care Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Bjelic M, Ayers B, Paic F, Bernstein W, Barrus B, Chase K, Gu Y, Alexis JD, Vidula H, Cheyne C, Prasad S, Gosev I. Study results suggest less invasive HeartMate 3 implantation is a safe and effective approach for obese patients. J Heart Lung Transplant 2021; 40:990-997. [PMID: 34229916 DOI: 10.1016/j.healun.2021.06.001] [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: 02/15/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Historically, obesity was considered a relative contraindication to left ventricular assist device (LVAD) implantation with less invasive surgery (LIS). The present study aimed to compare the outcomes of obese patients who underwent LVAD implantation through LIS with those who received full sternotomy (FS) implantation. METHODS We retrospectively reviewed all patients implanted with HeartMate 3 LVAD in our institution between September 2015 and June 2020. Obese patients (BMI ≥ 30 kg/m2) were included and dichotomized based on surgical approach into the FS or LIS cohort. RESULTS Of 231 implanted patients, 107 (46%) were obese and included in the study. FS was performed in 26 (24%) patients and LIS approach in 81 (76%) patients. Preoperative patient characteristics were similar between the cohorts. Postoperatively, patients in LIS cohort had less bleeding (p = 0.029), fewer transfusions (p = 0.042), shorter duration of inotropic support (p = 0.049), and decreased incidence of severe RV failure (11.1% vs 30.8%, p = 0.028). Survival to discharge for the obese population was 87.5% overall and did not differ based on an approach (91.4% LIS vs 76.9% FS, p = 0.079). More LIS patients were discharged home (60.0% vs 82.4%, p = 0.041) rather than to rehabilitation center. CONCLUSION Our results showed that the LIS approach in obese patients is associated with fewer postoperative complications and a trend towards better short-term survival. These results suggest that less invasive LVAD implantation is a safe and effective approach for obese patients. Future prospective randomized trials are required to substantiate these results.
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Affiliation(s)
- Milica Bjelic
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Brian Ayers
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Frane Paic
- Department of Medical Biology and Genetics, University of Zagreb Medical School, Zagreb, Croatia
| | - Wendy Bernstein
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
| | - Bryan Barrus
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Karin Chase
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey D Alexis
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Himabindu Vidula
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Christina Cheyne
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Sunil Prasad
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
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Barimani B, Moisan P, Santaguida C, Weber M. Therapeutic Application of Fibrinogen in Spine Surgery: A Review Article. Int J Spine Surg 2021; 15:549-561. [PMID: 33963032 PMCID: PMC8176831 DOI: 10.14444/8075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The aim of this review is to investigate current uses of fibrinogen as a tool to reduce operative and postoperative blood loss in different surgical fields especially orthopedic spine surgery. This is a systematic review. METHODS MEDLINE (via Ovid 1946 to June 1, 2020) and Embase (via Ovid 1947 to June 1, 2020) were searched using the keywords "fibrinogen", "surgery", and "spine" for relevant studies. The search strategy used text words and relevant indexing to identify articles discussing the use of fibrinogen to control surgical blood loss. RESULTS The original literature search yielded 407 articles from which 68 duplications were removed. Three hundred thirty-nine abstracts and titles were screened. Results were separated by surgical specialties. CONCLUSIONS Multiple studies have looked at the role of fibrinogen for acute bleeding in the operative setting. The current evidence regarding the use of fibrinogen concentrate in spine surgery is promising but limited, even though this is a field with the potential for severe hemorrhage. Further trials are required to understand the utility of fibrinogen concentrate as a first-line therapy in spine surgery and to understand the importance of target fibrinogen levels and subsequent dosing and administration to allow recommendations to be made in this field.
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Affiliation(s)
- Bardia Barimani
- Division of Orthopedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Philippe Moisan
- Division of Orthopedic Surgery, McGill University, Montreal, Quebec, Canada
| | - Carlos Santaguida
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Michael Weber
- Department of Surgery, McGill University, Montreal, Quebec, Canada
- Montreal General Hospital, Montreal, Quebec, Canada
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Bianchi P, Constantine A, Costola G, Mele S, Shore D, Dimopoulos K, Aw T. Ultra-Fast-Track Extubation in Adult Congenital Heart Surgery. J Am Heart Assoc 2021; 10:e020201. [PMID: 33998289 PMCID: PMC8483528 DOI: 10.1161/jaha.120.020201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/07/2021] [Indexed: 11/16/2022]
Abstract
Background In pediatric cardiac surgery, perioperative management has evolved from slow weaning of mechanical ventilation in the intensive care unit to "ultra-fast-track" anesthesia with early extubation (EE) in theater to promote a faster recovery. The strategy of EE has not been assessed in adults with congenital heart disease, a growing population of patients who often require surgery. Methods And Results Data were collected retrospectively on all patients >16 years of age who underwent adult congenital heart surgery in our tertiary center between December 2012 and January 2020. Coarsened exact matching was performed for relevant baseline variables. Overall, 711 procedures were performed: 133 (18.7%) patients underwent EE and 578 (81.3%) patients received conventional extubation. After matching, patients who received EE required less inotropic or vasopressor support in the early postoperative period (median Vasoactive-inotropic score 0.5 [0.0-2.0] versus 2.0 [0.0-3.5]; P<0.0001) and had a lower total net fluid balance than patients after conventional extubation (1168±723 versus 847±733 mL; P=0.0002). The overall reintubation rate was low at 0.3%. EE was associated with a significantly shorter postoperative length of stay in higher dependency care units before a "step-down" to ward-based care (48 [45-50] versus 50 [47-69] hours; P=0.004). Lower combined intensive care unit and high dependency unit costs were incurred by patients who received EE compared with patients who received conventional extubation (£3949 [3430-4222] versus £4166 [3893-5603]; P<0.0001). Conclusions In adult patients undergoing surgery for congenital heart disease, EE is associated with a reduced need for postoperative hemodynamic support, a shorter intensive care unit stay, and lower health-care-related costs.
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Affiliation(s)
- Paolo Bianchi
- Department of Anaesthesia and Intensive CareRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- Division of Anaesthetics, Pain Medicine and Intensive CareDepartment of Surgery and CancerImperial College LondonLondonUnited Kingdom
| | - Andrew Constantine
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Giulia Costola
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Sara Mele
- Department of Anaesthesia and Intensive CareRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
| | - Darryl Shore
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary HypertensionRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
- National Heart and Lung InstituteImperial College LondonLondonUnited Kingdom
| | - Tuan‐Chen Aw
- Department of Anaesthesia and Intensive CareRoyal Brompton HospitalGuy’s and St Thomas’ NHS Foundation TrustLondonUnited Kingdom
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144
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Cibulskis CC, Maheshwari A, Rao R, Mathur AM. Anemia of prematurity: how low is too low? J Perinatol 2021; 41:1244-1257. [PMID: 33664467 DOI: 10.1038/s41372-021-00992-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/20/2021] [Accepted: 02/04/2021] [Indexed: 12/11/2022]
Abstract
Anemia of prematurity (AOP) is a common condition with a well-described chronology, nadir hemoglobin levels, and timeline of recovery. However, the underlying pathophysiology and impact of prolonged exposure of the developing infant to low levels of hemoglobin remains unclear. Phlebotomy losses exacerbate the gradual decline of hemoglobin levels which is insidious in presentation, often without any clinical signs. Progressive anemia in preterm infants is associated with poor weight gain, inability to take oral feeds, tachycardia and exacerbation of apneic, and bradycardic events. There remains a lack of consensus on treatment thresholds for RBC transfusion which vary considerably. This review elaborates on the current state of the problem, its implication for the premature infant including association with subphysiologic cerebral tissue oxygenation, necrotizing enterocolitis, and retinopathy of prematurity. It outlines the impact of prophylaxis and treatment of anemia of prematurity and offers suggestions on improving monitoring and management of the condition.
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Affiliation(s)
- Catherine C Cibulskis
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Akhil Maheshwari
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rakesh Rao
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA.
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Issitt R, Booth J, Crook R, Robertson A, Molyneux V, Richardson R, Cross N, Shaw M, Tsang V, Muthurangu V, Sebire NJ, Burch M, Fenton M. Intraoperative anti-A/B immunoadsorption is associated with significantly reduced blood product utilization with similar outcomes in pediatric ABO-incompatible heart transplantation. J Heart Lung Transplant 2021; 40:1433-1442. [PMID: 34187714 PMCID: PMC8579753 DOI: 10.1016/j.healun.2021.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative anti-A/B immunoadsorption (ABO-IA) was recently introduced for ABO-incompatible heart transplantation. Here we report the first case series of patients transplanted with ABO-IA, and compare outcomes with those undergoing plasma exchange facilitated ABO-incompatible heart transplantation (ABO-PE). Methods Data were retrospectively analysed on all ABO-incompatible heart transplants undertaken at a single centre between January 1, 2000 and June 1, 2020. Data included all routine laboratory tests, demographics and pre-operative characteristics, intraoperative details and post-operative outcomes. Primary outcome measures were volume of blood product transfusions, maximum post-transplant isohaemagglutinin titres, occurrence of rejection and graft survival. Secondary outcome measures were length of intensive care and hospital stay. Demographic and survival data were also obtained for ABO-compatible transplants during the same time period for comparison. Results Thirty-seven patients underwent ABO-incompatible heart transplantation, with 27 (73%) using ABO-PE and 10 (27%) using ABO-IA. ABO-IA patients were significantly older than ABO-PE patients (p < 0.001) and the total volume of blood products transfused during the hospital admission was significantly lower (164 [126-212] ml/kg vs 323 [268-379] ml/kg, p < 0.001). No significant differences were noted between methods in either pre or post-transplant maximum isohaemagglutinin titres, incidence of rejection, length of intensive care or total hospital stay. Survival comparison showed no significant difference between antibody reduction methods, or indeed ABO-compatible transplants (p = 0.6). Conclusions This novel technique appears to allow a significantly older population than typical to undergo ABO-incompatible heart transplantation, as well as significantly reducing blood product utilization. Furthermore, intraoperative anti-A/B immunoadsorption does not demonstrate increased early post-transplant isohaemagglutinin accumulation or rates of rejection compared to ABO-PE. Early survival is equivalent between ABO-IA, ABO-PE and ABO-compatible heart transplantation.
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Affiliation(s)
- Richard Issitt
- Perfusion Department, Great Ormond Street Hospital, London, UK; Institute of Cardiovascular Science, University College London, London, UK; Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK.
| | - John Booth
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Richard Crook
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Alex Robertson
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | | | | | - Nigel Cross
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Michael Shaw
- Perfusion Department, Great Ormond Street Hospital, London, UK
| | - Victor Tsang
- Institute of Cardiovascular Science, University College London, London, UK; Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Vivek Muthurangu
- Institute of Cardiovascular Science, University College London, London, UK
| | - Neil J Sebire
- Digital Research Informatics and Virtual Environment Unit, NIHR Great Ormond Street Hospital BRC, London, UK
| | - Michael Burch
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
| | - Matthew Fenton
- Department of Cardiothoracic Transplantation, Great Ormond Street Hospital, London, UK; Department of Paediatric Cardiology, Institute of Child Health, University College London, London, UK
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Micovic S, Everts P, Calija B, Strugarevic E, Grubor N, Boricic M, Lesanovic J, Box H, Abazovic D. Novel autologous, high concentrated fibrin as advanced hemostatic agent for coronary surgery. Transfus Apher Sci 2021; 60:103171. [PMID: 34099403 DOI: 10.1016/j.transci.2021.103171] [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: 02/16/2021] [Revised: 05/09/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Variability in transfusion outcomes and excessive postoperative bleeding represents a significant problem in cardiac surgery. The effort to reduce bleeding complications and transfusion outcomes is desirable. Our study investigated the feasibility of reducing bleeding complications and transfusion requirements by applying perioperatively prepared autologous bio-regenerative fibrin sealant. METHODS A prospective, case-control study enrolled 74 patients undergoing coronary artery bypass grafting by a single surgeon. Patients in the control group (N = 43), received traditional methods of hemostasis, while patients in the experimental group (N = 31) were treated additionally with autologous bio-regenerative fibrin. RESULTS Patients were well-matched with regard to basic demographic, laboratory and procedural data. Allogeneic blood transfusion requirement in control group was 39.5 % (17 of 43 patients), compared to 6.5 % (2 of 31 patients) in treated group (p < 0,001). The lower infection rate in the experimental group was also noted. No safety issues were identified during the preparation and application process. CONCLUSION Autologous bio-regenerative fibrin can be safely prepared, with no time consuming, and was demonstrated to be a useful tool to decrease allogeneic blood transfusion requirements following elective coronary artery bypass grafting surgery. A prospective randomized trial is needed to confirm these findings.
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Affiliation(s)
- Slobodan Micovic
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | - Peter Everts
- Gulf Coasts Biologics Inc, 4331 Veronica S Shoemaker Blvd, Fort Myers, FL, 33916, United States.
| | - Branko Calija
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | | | - Nikola Grubor
- Clinical Centre of Serbia, Pasterova2, 11000, Belgrade, Serbia.
| | - Mladen Boricic
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | - Jelena Lesanovic
- Cardiovascular Institute Dedinje, Milana Tepića 1, 11000, Belgrade, Serbia.
| | - Henk Box
- St Catherine's Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, the Netherlands.
| | - Dzihan Abazovic
- Emergency Medical Centre of Montenegro, Vaka Đurovića bb, 81110, Podgorica, Montenegro.
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Abstract
Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.
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148
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Hastings S, Myles PS, Medcalf RL. Plasmin, Immunity, and Surgical Site Infection. J Clin Med 2021; 10:2070. [PMID: 34065949 PMCID: PMC8150767 DOI: 10.3390/jcm10102070] [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: 03/15/2021] [Revised: 05/05/2021] [Accepted: 05/10/2021] [Indexed: 12/20/2022] Open
Abstract
SSI are a universal economic burden and increase individual patient morbidity and mortality. While antibiotic prophylaxis is the primary preventative intervention, these agents are not themselves benign and may be less effective in the context of emerging antibiotic resistant organisms. Exploration of novel therapies as an adjunct to antimicrobials is warranted. Plasmin and the plasminogen activating system has a complex role in immune function. The immunothrombotic role of plasmin is densely interwoven with the coagulation system and has a multitude of effects on the immune system constituents, which may not always be beneficial. Tranexamic acid is an antifibrinolytic agent which inhibits the conversion of plasminogen to plasmin. Clinical trials have demonstrated a reduction in surgical site infection in TXA exposed patients, however the mechanism and magnitude of this benefit is incompletely understood. This effect may be through the reduction of local wound haematoma, decreased allogenic blood transfusion or a direct immunomodulatory effect. Large scale randomised clinical trial are currently being undertaken to better explain this association. Importantly, TXA is a safe and widely available pharmacological agent which may have a role in the reduction of SSI.
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Affiliation(s)
- Stuart Hastings
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC 3004, Australia;
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Robert L. Medcalf
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC 3004, Australia;
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Klein A, Agarwal S, Cholley B, Fassl J, Griffin M, Kaakinen T, Mzallassi Z, Paulus P, Rex S, Siegemund M, van Saet A. A survey of patient blood management for patients undergoing cardiac surgery in nine European countries. J Clin Anesth 2021; 72:110311. [PMID: 33905900 DOI: 10.1016/j.jclinane.2021.110311] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/30/2021] [Accepted: 04/01/2021] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVE To describe and compare patient blood management (PBM) practices in cardiac surgery in nine European countries and identify the main risk factors for bleeding or transfusion according to the surveyed centres. DESIGN We set up an online survey to evaluate PBM practices in two clinical scenarios, risk factors for bleeding or transfusion, and previous experience with antifibrinolytics. SETTING This survey was completed by European anesthesiologists in 2019. PATIENTS No patients were included in the survey. INTERVENTION None. MEASUREMENTS We evaluated the degree of implementation of PBM practices in patients undergoing cardiac surgery. MAIN RESULTS Ninety-eight of 177 responses (38%) were complete with variable response rates by country. In a non-emergent situation, no respondents would transfuse red cells preoperatively in an anaemic patient, while cell salvage (89%) and antifibrinolytics (82%) would almost always be used. Optimization of Hemoglobin level (36%) and use of off-pump techniques (34%), minimally invasive surgery (25%) and relatively recently-developed CPB technologies such as mini-bypass (32%) and autologous priming (38%), varied greatly across countries. In an emergent clinical situation, topical haemostatic agents would frequently be used (61%). Tranexamic acid (72%) and aprotinin (20%) were the main antifibrinolytics used, with method of administration and dose varying markedly across countries. Five factors were considered to increase risk of bleeding or transfusion by at least 90% of respondents: pre-operative anaemia, prior cardiac surgery, clopidogrel 5 days or less before surgery, use of other P2Y12 inhibitors at any point, and thrombocytopenia <100.109 platelets/mm3. CONCLUSION PBM guidelines are not universally implemented in European cardiac surgery centres or countries, resulting in discrepancies in techniques and products used for a given clinical situation.
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Affiliation(s)
- Andrew Klein
- Consultant, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, UK.
| | - Seema Agarwal
- Consultant in Cardiac Anaesthesia and ICU Honorary Senior Lecturer Manchester University Hospitals, Manchester, UK
| | - Bernard Cholley
- AP-HP Hôpital Européen Georges Pompidou, 20 rue Leblanc, F-75015 Paris, France; Université de PARIS, INSERM UMR-S 1140, Innovations Thérapeutiques en Hémostase, Faculté de Pharmacie, 4 avenue de l'observatoire, 75006 Paris, France
| | - Jens Fassl
- Herzzentrum Dresden GmbH Universitätsklinik an der Technischen Universität Dresden, Fetscherstraße 76, 01307 Dresden, Germany
| | - Michael Griffin
- Mater University Hospital and Mater Private Hospital, Dublin, Associate Professor of Anaesthesiology & Perioperative Medicine, UCD Medical School, Irish Medical Council, Dublin, Ireland
| | - Timo Kaakinen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine, Medical Research Center of Oulu University, Oulu University Hospital, Oulu, Finland
| | - Zineb Mzallassi
- Department of Anesthesiology; Erasmus Medical Center, Rotterdam, the Netherlands
| | - Patrick Paulus
- Kepler University Hospital GmbH, Med Campus III, Department of Anesthesiology and Intensive Care Medicine, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium; and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Martin Siegemund
- Intensive Care Unit Department of Clinical Research, University Basel, Switzerland
| | - Annewil van Saet
- Department of Anesthesiology; Erasmus Medical Center, Rotterdam, the Netherlands
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Généreux P, Piazza N, Alu MC, Nazif T, Hahn RT, Pibarot P, Bax JJ, Leipsic JA, Blanke P, Blackstone EH, Finn MT, Kapadia S, Linke A, Mack MJ, Makkar R, Mehran R, Popma JJ, Reardon M, Rodes-Cabau J, Van Mieghem NM, Webb JG, Cohen DJ, Leon MB. Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research. Eur Heart J 2021; 42:1825-1857. [DOI: 10.1093/eurheartj/ehaa799] [Citation(s) in RCA: 126] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/22/2020] [Accepted: 09/24/2020] [Indexed: 12/17/2022] Open
Abstract
Abstract
Aims
The Valve Academic Research Consortium (VARC), founded in 2010, was intended to (i) identify appropriate clinical endpoints and (ii) standardize definitions of these endpoints for transcatheter and surgical aortic valve clinical trials. Rapid evolution of the field, including the emergence of new complications, expanding clinical indications, and novel therapy strategies have mandated further refinement and expansion of these definitions to ensure clinical relevance. This document provides an update of the most appropriate clinical endpoint definitions to be used in the conduct of transcatheter and surgical aortic valve clinical research.
Methods and results
Several years after the publication of the VARC-2 manuscript, an in-person meeting was held involving over 50 independent clinical experts representing several professional societies, academic research organizations, the US Food and Drug Administration (FDA), and industry representatives to (i) evaluate utilization of VARC endpoint definitions in clinical research, (ii) discuss the scope of this focused update, and (iii) review and revise specific clinical endpoint definitions. A writing committee of independent experts was convened and subsequently met to further address outstanding issues. There were ongoing discussions with FDA and many experts to develop a new classification schema for bioprosthetic valve dysfunction and failure. Overall, this multi-disciplinary process has resulted in important recommendations for data reporting, clinical research methods, and updated endpoint definitions. New definitions or modifications of existing definitions are being proposed for repeat hospitalizations, access site-related complications, bleeding events, conduction disturbances, cardiac structural complications, and bioprosthetic valve dysfunction and failure (including valve leaflet thickening and thrombosis). A more granular 5-class grading scheme for paravalvular regurgitation (PVR) is being proposed to help refine the assessment of PVR. Finally, more specific recommendations on quality-of-life assessments have been included, which have been targeted to specific clinical study designs.
Conclusions
Acknowledging the dynamic and evolving nature of less-invasive aortic valve therapies, further refinements of clinical research processes are required. The adoption of these updated and newly proposed VARC-3 endpoints and definitions will ensure homogenous event reporting, accurate adjudication, and appropriate comparisons of clinical research studies involving devices and new therapeutic strategies.
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Affiliation(s)
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, NJ, USA
| | - Nicolo Piazza
- McGill University Health Centre, Montreal, QC, Canada
| | - Maria C Alu
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Tamim Nazif
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Rebecca T Hahn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Philippe Pibarot
- Quebec Heart & Lung Institute, Laval University, Quebec, QC, Canada
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Philipp Blanke
- Department of Radiology, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic and Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T Finn
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | | | - Michael J Mack
- Baylor Scott & White Heart Hospital Plano, Plano, TX, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | - John G Webb
- Department of Cardiology, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - David J Cohen
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Martin B Leon
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and Cardiovascular Research Foundation, New York, NY, USA
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