Effect of High- vs Low-Dose Tranexamic Acid Infusion on Need for Red Blood Cell Transfusion and Adverse Events in Patients Undergoing Cardiac Surgery: The OPTIMAL Randomized Clinical Trial

Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention

Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.

Anticoagulation and Antiplatelet Regimen in Cardiac Transplant. Clinical Characteristics, Outcomes, and Blood Product Transfusion

BACKGROUND

We aimed to evaluate the characteristics, clinical outcomes, and blood product transfusion (BPT) rates of patients undergoing cardiac transplant (CT) while receiving uninterrupted anticoagulation and antiplatelet therapy.

METHODS

A retrospective, single-center, and observational study of adult patients who underwent CT was performed. Patients were classified into four groups: (1) patients without anticoagulation or antiplatelet therapy (control), (2) patients on antiplatelet therapy (AP), (3) patients on vitamin K antagonists (AVKs), and (4) patients on dabigatran (dabigatran). The primary endpoints were reoperation due to bleeding and perioperative BPT rates (packed red blood cells (PRBC), fresh frozen plasma, platelets). Secondary outcomes assessed included morbidity and mortality-related events.

RESULTS

Of the 55 patients included, 6 (11%) received no therapy (control), 8 (15%) received antiplatelet therapy, 15 (27%) were on AVKs, and 26 (47%) were on dabigatran. There were no significant differences in the need for reoperation or other secondary morbidity-associated events. During surgery patients on dabigatran showed lower transfusion rates of PRBC (control 100%, AP 100%, AVKs 73%, dabigatran 50%, p = 0.011) and platelets (control 100%, AP 100%, AVKs 100%, dabigatran 69%, p = 0.019). The total intraoperative number of BPT was also the lowest in the dabigatran group (control 5.5 units, AP 5 units, AVKs 6 units, dabigatran 3 units; p = 0.038); receiving significantly less PRBC (control 2.5 units, AP 3 units, AVKs 2 units, dabigatran 0.5 units; p = 0.011). A Poisson multivariate analysis showed that only treatment on dabigatran reduces PRBC requirements during surgery, with an expected reduction of 64.5% (95% CI: 32.4%-81.4%).

CONCLUSIONS

In patients listed for CT requiring anticoagulation due to nonvalvular atrial fibrillation, the use of dabigatran and its reversal with idarucizumab significantly reduces intraoperative BPT demand.

Development and validation of a machine learning predictive model for perioperative myocardial injury in cardiac surgery with cardiopulmonary bypass

BACKGROUND

Perioperative myocardial injury (PMI) with different cut-off values has showed to be associated with different prognostic effect after cardiac surgery. Machine learning (ML) method has been widely used in perioperative risk predictions during cardiac surgery. However, the utilization of ML in PMI has not been studied yet. Therefore, we sought to develop and validate the performances of ML for PMI with different cut-off values in cardiac surgery with cardiopulmonary bypass (CPB).

METHODS

This was a second analysis of a multicenter clinical trial (OPTIMAL) and requirement for written informed consent was waived due to the retrospective design. Patients aged 18-70 undergoing elective cardiac surgery with CPB from December 2018 to April 2021 were enrolled in China. The models were developed using the data from Fuwai Hospital and externally validated by the other three cardiac centres. Traditional logistic regression (LR) and eleven ML models were constructed. The primary outcome was PMI, defined as the postoperative maximum cardiac Troponin I beyond different times of upper reference limit (40x, 70x, 100x, 130x) We measured the model performance by examining the area under the receiver operating characteristic curve (AUROC), precision-recall curve (AUPRC), and calibration brier score.

RESULTS

A total of 2983 eligible patients eventually participated in both the model development (n = 2420) and external validation (n = 563). The CatboostClassifier and RandomForestClassifier emerged as potential alternatives to the LR model for predicting PMI. The AUROC demonstrated an increase with each of the four cutoffs, peaking at 100x URL in the testing dataset and at 70x URL in the external validation dataset. However, it's worth noting that the AUPRC decreased with each cutoff increment. Additionally, the Brier loss score decreased as the cutoffs increased, reaching its lowest point at 0.16 with a 130x URL cutoff. Moreover, extended CPB time, aortic duration, elevated preoperative N-terminal brain sodium peptide, reduced preoperative neutrophil count, higher body mass index, and increased high-sensitivity C-reactive protein levels were identified as risk factors for PMI across all four cutoff values.

CONCLUSIONS

The CatboostClassifier and RandomForestClassifer algorithms could be an alternative for LR in prediction of PMI. Furthermore, preoperative higher N-terminal brain sodium peptide and lower high-sensitivity C-reactive protein were strong risk factor for PMI, the underlying mechanism require further investigation.

Hemostatic effects of tranexamic acid in cardiac surgical patients with antiplatelet therapy: a systematic review and meta-analysis

BACKGROUND

The purpose of the current study was to assess the efficacy of tranexamic acid (TXA) on reducing bleeding in cardiac surgical patients with preoperative antiplatelet therapy (APT).

METHODS

Five electronic databases were searched systematically for randomized-controlled trials (RCTs) assessing the impact of intravenous TXA on post-operative bleeding on cardiac surgical patients with preoperative APT until May 2024. Primary outcome of interest was post-operative blood loss. Secondary outcomes of interest included the incidence of reoperation due to post-operative bleeding, post-operative transfusion requirements of red blood cells (RBC), fresh-frozen plasma (FFP), and platelet concentrates. Mean difference (MD) with 95% confidence interval (CI) or odds ratios (OR) with 95% CI was employed to analyze the data. Subgroup and meta-regression analyses were performed to assess the possible influence of TXA administration on reducing bleeding and transfusion requirements.

RESULTS

A total of 12 RCTs with 3018 adult cardiac surgical patients (TXA group, 1510 patients; Control group, 1508 patients) were included. The current study demonstrated that TXA significantly reduced post-operative blood loss (MD =  - 0.38 L, 95% CI: - 0.73 to - 0.03, P = 0.03; MD =  - 0.26 L, 95% CI: - 0.28 to - 0.24, P < 0.00001; MD =  - 0.37 L, 95% CI: - 0.63 to - 0.10, P = 0.007) in patients receiving dual antiplatelet therapy (DAPT), aspirin, or clopidogrel, respectively. Patients in TXA group had significantly lower incidence of reoperation for bleeding as compared to those in Control group. The post-operative transfusion of RBC and FFP requirements was significantly lower in TXA group than Control group. Subgroup analyses showed that studies with DAPT discontinued on the day of surgery significantly increased the risk of post-operative blood loss [(MD: - 1.23 L; 95% CI: - 1.42 to - 1.04) vs. (MD: - 0.16 L; 95% CI: - 0.27 to - 0.05); P < 0.00001 for subgroup difference] and RBC transfusion [(MD: - 3.90 units; 95% CI: - 4.75 to - 3.05) vs. (MD: - 1.03 units; 95% CI: - 1.96 to - 0.10); P < 0.00001 for subgroup difference] than those with DAPT discontinued less than 5-7 days preoperatively.

CONCLUSIONS

This meta-analysis demonstrated that TXA significantly reduced post-operative blood loss and transfusion requirements for cardiac surgical patients with preoperative APT. These potential clinical benefits may be greater in patients with aspirin and clopidogrel continued closer to the day of surgery.

TRIAL REGISTRATION NUMBER

CRD42022309427.

A systematic review and meta-analysis of systematic and topical tranexamic acid administration in aesthetic plastic surgery

INTRODUCTION

Tranexamic acid has been widely used in plastic surgery. However, its efficacy has yet to be fully established. This meta-analysis aimed to determine its effectiveness in aesthetic plastic surgery.

METHODS

Following PRISMA guidelines, we conducted a meta-analysis of prospective randomised clinical trials that compared the effects of topical or systematic administration of tranexamic acid versus the control group in aesthetic plastic surgeries. The study was registered on the International Register of Systematic Reviews (PROSPERO) and is available online ( www.crd.york.uk/prospero , CRD42023492585).

RESULTS

Eleven studies encompassing 960 patients were included for the synthesis after critical evaluation. Systematic (MD - 18.05, 95% Cl, - 22.01, - 14.09, p < 0.00001) and topical (MD - 74.93, 95% Cl, - 88.79, - 61.07, p < 0.00001) administration of tranexamic acid reduced total blood loss. Topical tranexamic acid reduced drainage output (p < 0.0006).

CONCLUSION

Tranexamic acid reduced blood loss in aesthetic plastic surgery. More strictly defined RCTs, using high-quality methodology, are needed to evaluate the advantages and disadvantages of tranexamic acid in aesthetic plastic surgery.

Efficacy and safety of intravenous tranexamic acid in microscopic modified radical mastoidectomy: a study protocol for a prospective, randomised, double-blind controlled trial

INTRODUCTION

Radical mastoidectomy is a common procedure for chronic suppurative otitis media, typically performed under a microscope. The smooth operation is closely related to the clarity of the operative field. Our trial is designed to investigate whether the intravenous administration of tranexamic acid (TXA) can improve the clarity of the operative field, reduce the operative time, and increase surgeon satisfaction.

METHODS AND ANALYSIS

This study is a prospective, randomised, double-blinded, controlled trial that aims to investigate the effects of TXA on patients with otitis media. The trial will include patients between the ages of 18 and 65 who will be randomly assigned to either the TXA group or the control group. In the TXA group, patients will receive 1 g of TXA diluted to 20 mL of normal saline before anaesthesia induction while the control group will receive 20 mL of normal saline. The primary outcome measure will be the Modena Bleeding Score, which will assess the clarity of the surgical field. Secondary outcomes will include the surgeon's satisfaction with surgical conditions, operation time, laboratory measurements (prothrombin time, activated partial thromboplastin time, fibrin degradation products, D-dimer) and levels of inflammatory factors (such as IL-6) at 24 hours postoperatively. In addition, the incidence of general adverse reactions such as postoperative nausea, vomiting and dizziness; serious adverse events such as arterial and venous thromboembolism, myocardial infarction and epilepsy within 90 days will be compared between the two groups.

ETHICS AND DISSEMINATION

The protocol was approved by the Ethics Committee of Peking University People's Hospital (2021PHB173-001), on 19 July 2021. The trial results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ChiCTR2100049183.

Prevalence and Residual Risk of HIV in Volunteer Blood Donors of Zhejiang Province, China, from 2018 to 2022

Background

Blood safety levels have been significantly improved since the implementation of nucleic acid amplification technology (NAT) testing for blood donors. However, there remains a residual risk of transfusion transmission infections. This study aimed to evaluate the prevalence of HIV and its residual risk transmission among volunteer blood donors of Zhejiang Province, China, for five years after NAT implementation.

Materials and Methods

All specimens and information were collected from voluntary unpaid donors at all blood services in Zhejiang Province, China, from January 2018 to December 2022. The HIV antibody or antigen and HIV RNA were detected using enzyme-linked immunosorbent assay and NAT, respectively. The HIV residual risk transmission was calculated using the incidence or window period model.

Results

A total of 3,375,678 voluntary blood donors were detected, revealing an HIV prevalence of 9.92/100000. The HIV prevalence of blood donors in 12 blood services in Zhejiang Province was 6.11, 6.98, 7.45, 8.21, 8.36, 8.94, 9.04, 9.66, 9.73, 10.22, 11.80, and 12.47 per 100000 donors, without statistically significant difference observed among the services (p > 0.05). The HIV prevalence of males (15.49/100000) was significantly higher compared to females (1.95/100000; p < 0.05). There was an insignificant difference in HIV prevalence among blood donors of all different age groups (p > 0.05), but the HIV prevalence in the 26-35 age group and 18-25 age group was significantly higher compared to the 36-45 age group (p < 0.05). The difference in HIV prevalence between first-time blood donors (13.65/100,000) and repeat blood donors (6.78/100,000) was statistically significant (p < 0.05). From 2018 to 2022, the HIV residual risk in blood transfusion transmission was 0.266/100000.

Conclusion

The prevalence of HIV among blood donors in Zhejiang Province, China, is associated with age, gender, and times of blood donation. The HIV residual risk in blood transfusion transmission remains low in the province, and increasing the rate of repeat blood donors is beneficial to improve blood safety.

The Efficacy of Tranexamic Acid in Reducing Perioperative Drainage in Cardiac Surgery with Cardiopulmonary Bypass

INTRODUCTION

Although cardiopulmonary bypass procedures remain a critical treatment option for heart disease, they come with risks, including hemorrhage. Tranexamic acid is known to reduce morbidity and mortality in surgical hemorrhage.

OBJECTIVE

This study aimed to evaluate the efficacy of tranexamic acid, which is routinely used to treat hemorrhage, in decreasing the amount of intraoperative and postoperative drainage.

METHOD

A total of 80 patients who underwent cardiac surgery with cardiopulmonary bypass were included in this retrospective study. Forty patients who received tranexamic acid during the operation were assigned to Group 1, while 40 patients who did not receive tranexamic acid were assigned to Group 2. Patient data were collected from the hospital computer system and/or archive records after applying exclusion criteria, and the data were recorded. Statistical analyses were then performed to compare the data.

RESULTS

Age, sex, height, weight, body surface area, flow, and ejection fraction percentages, preoperative hematological parameters, and intraoperative variables (except tranexamic acid) were similar between the groups (P>0.05). However, there were statistically significant differences between the groups in terms of intraoperative (through the heart-lung machine) and postoperative red blood cell transfusion rates, intraoperative and postoperative bleeding drainage amounts, as well as postoperative hematocrit, hemoglobin, platelet, and red blood cell levels (P<0.05).

CONCLUSION

We concluded that intraoperative and postoperative use of tranexamic acid in patients who underwent coronary artery bypass grafting with cardiopulmonary bypass has positive effects on hematological parameters, reducing blood product use, and bleeding drainage amount.

Efficacy and safety of tranexamic acid in patients undergoing thoracic surgery: a systematic review and PRISMA-compliant meta-analysis

OBJECTIVES

Perioperative bleeding poses a significant issue during thoracic surgery. Tranexamic acid (TXA) is one of the most commonly used antifibrinolytic agents for surgical patients. The purpose of the current study was designed to investigate the efficacy and safety of TXA in patients undergoing thoracic surgery.

METHODS

An extensive search of PubMed, Web of Science (WOS), Cochrane Library (trials), Embase, OVID, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP electronic databases was performed to identify studies published between the inception of these databases and March 2023. The primary outcomes included perioperative blood loss and blood transfusions. Secondary outcomes of interest included the length of stay (LOS) in hospital and the incidence of thromboembolic events. Weighted mean differences (WMDs) or odds ratios (OR) with 95% confidence intervals (CI) were used to determine treatment effects for continuous and dichotomous variables, respectively.

RESULTS

Five qualified studies including 307 thoracic surgical patients were included in the current study. Among them, 65 patients were randomly allocated to the group receiving TXA administration (the TXA group); the other 142 patients were assigned to the group not receiving TXA administration (the control group). TXA significantly reduced the quantity of hemorrhage in the postoperative period (postoperative 12h: WMD = -81.90 ml; 95% CI: -139.55 to -24.26; P = 0.005; postoperative 24h: WMD = -97.44 ml; 95% CI: -121.44 to -73.44; P< 0.00001); The intraoperative blood transfusion volume (WMD = -0.54 units; 95% CI: -1.06 to -0.03; P = 0.04); LOS in hospital (WMD = -0.6 days; 95% CI: -1.04 to -0.16; P = 0.008); And there was no postoperative thromboembolic event reported in the included studies.

CONCLUSIONS

The present study demonstrated that TXA significantly decreased blood loss within 12 and 24 hours postoperatively. A qualitative review did not identify elevated risks of safety outcomes such as thromboembolic events. It also suggested that TXA administration was associated with shorter LOS in hospital as compared to control. To validate this further, additional well-planned and adequately powered randomized studies are necessary.

Development and validation of a machine learning prediction model for perioperative red blood cell transfusions in cardiac surgery

OBJECTIVE

Several machine learning (ML) models have been used in perioperative red blood cell (RBC) transfusion risk for cardiac surgery with limited generalizability and no external validation. Hence, we sought to develop and comprehensively externally validate a ML model in a large dataset to estimate RBC transfusion in cardiac surgery with cardiopulmonary bypass (CPB).

DESIGN

A retrospective analysis of a multicenter clinical trial (NCT03782350).

PATIENTS

The study patients who underwent cardiac surgery with CPB came from four cardiac centers in China and Medical Information Mart for Intensive Cared (MIMIC-IV) dataset.

MEASUREMENTS

Data from Fuwai Hospital were used to develop an individualized prediction model for RBC transfusion. The model was externally validated in the data from three other centers and MIMIC-IV dataset. Twelve models were constructed.

MAIN RESULTS

A total of 11,201 eligible patients were included in the model development (2420 in Fuwai Hospital) and external validation (563 in the other three centers and 8218 in the MIMIC-IV dataset). A significant difference was observed between the Logistic Regression and CatboostClassifier (0.72 Vs. 0.74, P = 0.031) or RandomForestClassifier (0.72 Vs. 0.75 p = 0.012) in the external validation and MIMIV-IV datasets (age ≤ 70:0.63 Vs. 0.71, p < 0.001; age > 70:0.63 Vs. 0.70, 0.63 Vs. 0.71, p < 0.001). The CatboostClassifier and RandomForestClassifier model was comparable in development (0.83 Vs. 0.82, p = 0.419), external (0.74 Vs. 0.75, p = 0.268), and MIMIC-IV datasets (age ≤ 70: 0.71 Vs. 0.71, p = 0.574; age > 70: 0.70 Vs. 0.71, p = 0.981). Of note, they outperformed other ML models with excellent discrimination and calibration. The CatboostClassifier and RandomForestClassifier models achieved higher area under precision-recall curve and lower brier loss score in validation and MIMIC-IV datasets. Additionally, we confirmed that low preoperative hemoglobin, low body mass index, old age, and female sex increased the risk of RBC transfusion.

CONCLUSIONS

In our study, enrolling a broad range of cardiovascular surgeries with CPB and utilizing a restrictive RBC transfusion strategy, robustly validates the generalizability of ML algorithms for predicting RBC transfusion risk. Notably, the CatboostClassifier and RandomForestClassifier exhibit strong external clinical applicability, underscoring their potential for widespread adoption. This study provides compelling evidence supporting the efficacy and practical value of ML-based approaches in enhancing transfusion risk prediction in clinical practice.

Intravenous tranexamic acid for intracerebral meningioma resections: A randomized, parallel-group, non-inferiority trial

STUDY OBJECTIVES

Tranexamic acid (TXA) is an antifibrinolytic that is widely used to reduce surgical bleeding. However, TXA occasionally causes seizures and the risk might be especially great after neurosurgery. We therefore tested the hypothesis that TXA does not meaningfully increase the risk of postoperative seizures within 7 days after intracranial tumor resections.

DESIGN

Randomized, double-blind, placebo-controlled, non-inferiority trial.

SETTING

Beijing Tiantan Hospital, Capital Medical University.

PATIENTS

600 patients undergoing supratentorial meningioma resection were included from October 2020 to August 2022.

INTERVENTIONS

Patients were randomly assigned to a single dose of 20 mg/kg of TXA after induction (n = 300) or to the same volume of normal saline (n = 300).

MEASUREMENT

The primary outcome was postoperative seizures occurring within 7 days after surgery, analyzed in both the intention-to-treat and per-protocol populations. Non-inferiority was defined by an upper limit of the 95% confidence interval for the absolute difference being <5.5%. Secondary outcomes included incidence of non-epileptic complication within 7 days, changes in hemoglobin concentration, estimated intraoperative blood loss. Post hoc analyses included the types and timing of seizures, oozing assessment, and a sensitivity analysis for the primary outcome in patients with pathologic diagnosis of meningioma.

MAIN RESULTS

All 600 enrolled patients adhered to the protocol and completed the follow-up for the primary outcome. Postoperative seizures occurred in 11 of 300 (3.7%) of patients randomized to normal saline and 13 of 300 (4.3%) patients assigned to tranexamic acid (mean risk difference, 0.7%; 1-sided 97.5% CI, -∞ to 4.3%; P = 0.001 for noninferiority). No significant differences were observed in any secondary outcome. Post hoc analysis indicated similar amounts of oozing, calculated blood loss, recurrent seizures, and timing of seizures.

CONCLUSION

Among patients having supratentorial meningioma resection, a single intraoperative dose of TXA did not significantly reduce bleeding and was non-inferior with respect to postoperative seizures after surgery.

REGISTRY INFORMATION

This trial was registered at clinicaltrials.gov (NCT04595786) on October 22, 2020, by Dr.Yuming Peng.

Effects of albumin and crystalloid priming strategies on red blood cell transfusions in on-pump cardiac surgery: a network meta-analysis

BACKGROUND

In on-pump cardiac surgery, the albumin priming strategy could maintain colloid osmotic pressure better than crystalloid solutions and reduce excessive perioperative fluid balance. However, a high-quality meta-analysis is required to compare the safety of these approaches in perioperative red blood cell (RBC) transfusions. Owing to limited direct evidence, we conducted a network meta-analysis (NMA) to increase the pool of studies and provide indirect evidence.

METHODS

The pre-defined primary outcomes were intraoperative and the first 24 h postoperative RBC transfusion volume in units. The pre-defined secondary outcome was postoperative blood loss (the first 24 h). We reviewed all randomized controlled trials comparing albumin, crystalloid, and artificial colloid priming strategies. Studies that only displayed pre-defined outcomes could be included. A pairwise meta-analysis was performed on studies that directly compared the pre-defined outcomes between albumin and crystalloids. Additionally, a random-effects network meta-analysis (NMA) model was employed to generate indirect evidence for the pre-defined outcomes between albumin and crystalloids.

RESULTS

The literature search identified 830 studies,10 of which were included in the final analysis. Direct meta-analysis indicated that crystalloid priming significantly decreased total perioperative RBC transfusions (MD: -0.68U; 95%CI: -1.26, -0.09U; P = 0.02) and intraoperative RBC transfusions (MD: -0.20U; 95%CI: -0.39, -0.01U; P = 0.03) compared to albumin. Postoperative RBC transfusions showed a decreasing trend in the crystalloid group; however, the difference was not statistically significant. (MD: -0.16U; 95%CI: -0.45, 0.14U; P = 0.30). After including indirect evidence, the NMA results continued to demonstrate a higher RBC receiving with the albumin priming strategy compared to crystalloids, although the differences did not reach statistical significance. For postoperative blood loss, direct evidence showed no significant differences between albumin and crystalloid priming strategies. However, NMA evidence displayed that albumin exist higher probability of reducing postoperative blood loss than crystalloid.

CONCLUSION

Both direct and NMA evidence indicated that the albumin priming strategy resulted in more perioperative RBC transfusions than crystalloids. Considering the additional blood management burden, the application of an albumin-priming strategy in on-pump cardiac surgery still needs more consideration.

Optimizing Safety and Success: The Advantages of Bloodless Cardiac Surgery. A Systematic Review and Meta-Analysis of Outcomes in Jehovah's Witnesses

Transfusions are extremely frequent after cardiac surgery, and they have a considerable economic burden and impact on outcomes. Optimal patient blood management could play a fundamental role in reducing the rate of transfusion and Jehovah's Witnesses (JW) represent the ideal surrogate study population. This meta-analysis compares outcomes of JWs and non-JWs' patients undergoing cardiac surgery, assessing the safety of a bloodless cardiac surgery. A scoping review was conducted using a search strategy for studies assessing outcomes of JW undergoing cardiac surgery. The primary outcome was perioperative mortality, and a random-effects meta-analysis was performed. Ten studies were included in our meta-analysis, involving 780 JW patients refusing any type of transfusion ("JW") and 1182 patients accepting transfusion if needed ("non-JW"). 86% of non-JW patients received at least 1 transfusion. There was no significant difference in terms of perioperative mortality (OR 0.91; 95% CI 0.55-1.52; p = 0.72). The volume blood loss was significantly less in the JW (p = 0.001), while the rate of reoperation for bleeding was also lower, but not statistically significative, in the JW (p = 0.16). Both preoperative and postoperative hemoglobin and hematocrit were significantly higher in the JW. Therefore, we concluded that bloodless cardiac surgery is safe and early outcomes are similar between JW and non-JW patients: optimal patient blood management is fundamental in guarantying these results. Further studies are needed to assess if a limitation of transfusion could have a positive long-term impact on outcomes.

The Efficacy and Safety of a Low-Dose Tranexamic Acid Bolus-Only Protocol Compared with the Moderate-Dose Protocol in Valvular Heart Surgery

In 873 propensity score-matched pairs of patients undergoing valvular heart surgery, we compared a "moderate dose" of tranexamic acid (TXA) protocol (group 1; median TXA dose: 24 mg/kg body weight) with a 1.5-g "bolus-only" protocol (group 2; median TXA dose: 19 mg/kg body weight). The number of transfused patients was higher in group 2 than in group 1 (74.5 vs 66.0%, p < 0.001), as was the number of transfused red blood cell concentrates (p = 0.001). The risks of re-exploration and convulsive seizures were similar between groups (p > 0.50). Data indicate an impaired efficacy following the "bolus-only" protocol, without a significant safety improvement.

A Perioperative Blood Management Algorithm Aimed at Conservation of Platelets in Clinical Practice: The Role of the Anesthesiologist in Decision-Making

Platelet dysfunction and thrombocytopenia are associated with postoperative morbidity not only from modifiable preoperative factors but also from a lack of local patient blood management algorithms. In this regard, platelet transfusions have risen after the COVID-19 pandemic. Simultaneously, there has been a shortage of donors. It is logical, therefore, that each hospital should develop a triage tool, posting their algorithm on walls. Anesthesiologists should assist in planning a strategy to minimize blood transfusions while improving tissue oxygenation. A flowchart posted in each operating theatre may be customized per patient and hospital. Clinicians need reminders to draw a prothrombin time, fibrinogen, complete blood count every hour, and the appropriate threshold to transfuse. In summary, anesthesiologists are often unable to have a discussion with a patient until the preoperative day; thus, the onus falls on our surgical colleagues to reduce risk factors for coagulopathy or to delay surgery until after proper consultants have optimized a patient. The most important problems that an individual patient has ideally should be listed in a column where an anesthesiologist can write a timeline of key steps across a row, corresponding to each problem. If a handoff in the middle of the case is required, this handoff tool is superior to simply checking a box on an electronic medical record. In summary, in the operating suite, an anesthesiologist should emphasize the importance of a multidisciplinary approach. Continuing education, regular stakeholder meetings, and posters can assist in reinforcing algorithms in clinical practice.

Tranexamic acid in endoscopic sinus and skull base surgery: A systematic review and meta-analysis

OBJECTIVE

Endoscopic sinus surgery (ESS) and endoscopic skull base surgery (ESBS) approaches have revolutionized the management of sinonasal and intracranial pathology. Maintaining surgical hemostasis is essential as bleeding can obscure the visibility of the surgical field, thus increasing surgical duration, risk of complications, and procedural failure. Tranexamic acid (TXA) acts to reduce bleeding by inhibiting fibrin degradation. This review aims to assess whether TXA improves surgical field quality and reduces intraoperative blood loss compared with control.

METHODS

We searched PubMed, MEDLINE, Embase, Web of Science, and Cochrane Library from inception until September 1, 2022. Two reviewers independently screened citations, extracted data, and assessed methodological quality using the Cochrane risk-of-bias tool for randomized trials. Data were pooled using a random-effect model, with continuous data presented as mean differences and dichotomous data presented as odds ratios.

RESULTS

Seventeen ESS randomized controlled trials (n = 1377) and one ESBS randomized controlled trial (n = 50) were reviewed. Significant improvement in surgical field quality was achieved with both systemic TXA (six studies, p < 0.00001) and topical TXA (six studies, p = 0.01) compared with the control. Systemic TXA (eight studies) and topical TXA (three studies) both achieved a significant reduction in intraoperative blood loss compared with the control (p < 0.00001). There were significant differences in operative times (p < 0.001) but no significant difference in perioperative outcomes (p = 0.30).

CONCLUSION

This meta-analysis demonstrated that the administration of TXA in ESS can improve surgical field quality and reduce intraoperative blood loss. TXA use did not result in increased perioperative complications including thrombotic events.

Perioperative hemostatic management of patients with type A aortic dissection

Coagulopathy is common in patients undergoing thoracic aortic repair for Stanford type A aortic dissection. Non-critical administration of blood products may adversely affect the outcome. It is therefore important to be familiar with the pathologic conditions that lead to coagulopathy in complex cardiac surgery. Adequate care of these patients includes the collection of the medical history regarding the use of antithrombotic and anticoagulant drugs, and a sophisticated diagnosis of the coagulopathy with viscoelastic testing and subsequently adapted coagulation therapy with labile and stable blood products. In addition to the above-mentioned measures, intraoperative blood conservation measures as well as good interdisciplinary coordination and communication contribute to a successful hemostatic management strategy.

Perioperative Management of Heart Transplantation: A Clinical Review

In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.

A modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement

Background

One of the crucial aspects of ascending aorta replacement is to achieve hemostasis of the proximal anastomosis. This study aimed to describe a modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement and compare its operative outcomes with the conventional prosthesis eversion technique.

Methods

We conducted a retrospective analysis of all consecutive patients who had ascending aortic aneurysm and underwent ascending aorta replacement with the modified or conventional prosthesis eversion technique between January 2019 and December 2022 in our center.

Results

A total of 108 patients were included: 55 in the modified group and 53 in the conventional group. The durations of cardiopulmonary bypass, aortic cross-clamping and total operation in the conventional group were longer than those in the modified group. Furthermore, perioperative blood loss and the incidence of re-exploration for bleeding were significantly lower in the modified group. Accordingly, patients in the conventional group accepted more blood transfusion. The modified group had a shorter duration in intensive care unit (ICU) and hospital, and lower total hospitalization costs than those in the conventional group.

Conclusions

The modified prosthesis eversion technique is an effective alternative for proximal anastomosis in ascending aorta replacement, with less blood loss, shorter operation time, and lower rate of postoperative complications compared with the conventional technique.

Tranexamic acid for haemostasis and beyond: does dose matter?

Tranexamic acid (TXA) is a widely used antifibrinolytic agent that has been used since the 1960's to reduce blood loss in various conditions. TXA is a lysine analogue that competes for the lysine binding sites in plasminogen and tissue-type plasminogen activator impairing its interaction with the exposed lysine residues on the fibrin surface. The presence of TXA therefore, impairs the plasminogen and tPA engagement and subsequent plasmin generation on the fibrin surface, protecting fibrin clot from proteolytic degradation. However, critical lysine binding sites for plasmin(ogen) also exist on other proteins and on various cell-surface receptors allowing plasmin to exert potent effects on other targets that are unrelated to classical fibrinolysis, notably in relation to immunity and inflammation. Indeed, TXA was reported to significantly reduce post-surgical infection rates in patients after cardiac surgery unrelated to its haemostatic effects. This has provided an impetus to consider TXA in other indications beyond inhibition of fibrinolysis. While there is extensive literature on the optimal dosage of TXA to reduce bleeding rates and transfusion needs, it remains to be determined if these dosages also apply to blocking the non-canonical effects of plasmin.

Plasma Transfusion and Procoagulant Product Administration in Extracorporeal Membrane Oxygenation: A Secondary Analysis of an International Observational Study on Current Practices

OBJECTIVES

To achieve optimal hemostatic balance in patients on extracorporeal membrane oxygenation (ECMO), a liberal transfusion practice is currently applied despite clear evidence. We aimed to give an overview of the current use of plasma, fibrinogen concentrate, tranexamic acid (TXA), and prothrombin complex concentrate (PCC) in patients on ECMO.

DESIGN

A prespecified subanalysis of a multicenter retrospective study. Venovenous (VV)-ECMO and venoarterial (VA)-ECMO are analyzed as separate populations, comparing patients with and without bleeding and with and without thrombotic complications.

SETTING

Sixteen international ICUs.

PATIENTS

Adult patients on VA-ECMO or VV-ECMO.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 420 VA-ECMO patients, 59% (n = 247) received plasma, 20% (n = 82) received fibrinogen concentrate, 17% (n = 70) received TXA, and 7% of patients (n = 28) received PCC. Fifty percent of patients (n = 208) suffered bleeding complications and 27% (n = 112) suffered thrombotic complications. More patients with bleeding complications than patients without bleeding complications received plasma (77% vs. 41%, p < 0.001), fibrinogen concentrate (28% vs 11%, p < 0.001), and TXA (23% vs 10%, p < 0.001). More patients with than without thrombotic complications received TXA (24% vs 14%, p = 0.02, odds ratio 1.75) in VA-ECMO, where no difference was seen in VV-ECMO. Of 205 VV-ECMO patients, 40% (n = 81) received plasma, 6% (n = 12) fibrinogen concentrate, 7% (n = 14) TXA, and 5% (n = 10) PCC. Thirty-nine percent (n = 80) of VV-ECMO patients suffered bleeding complications and 23% (n = 48) of patients suffered thrombotic complications. More patients with than without bleeding complications received plasma (58% vs 28%, p < 0.001), fibrinogen concentrate (13% vs 2%, p < 0.01), and TXA (11% vs 2%, p < 0.01).

CONCLUSIONS

The majority of patients on ECMO receive transfusions of plasma, procoagulant products, or antifibrinolytics. In a significant part of the plasma transfused patients, this was in the absence of bleeding or prolonged international normalized ratio. This poses the question if these plasma transfusions were administered for another indication or could have been avoided.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Current advances in 2022: A critical review of selected topics by the Association for the Advancement of Blood and Biotherapies (AABB) Clinical Transfusion Medicine Committee

BACKGROUND

The Association for the Advancement of Blood and Biotherapies Clinical Transfusion Medicine Committee (CTMC) composes a summary of new and important advances in transfusion medicine (TM) on an annual basis. Since 2018, this has been assembled into a manuscript and published in Transfusion.

STUDY DESIGN AND METHODS

CTMC members selected original manuscripts relevant to TM that were published electronically and/or in print during calendar year 2022. Papers were selected based on perceived importance and/or originality. References for selected papers were made available to CTMC members to provide feedback. Members were also encouraged to identify papers that may have been omitted initially. They then worked in groups of two to three to write a summary for each new publication within their broader topic. Each topic summary was then reviewed and edited by two separate committee members. The final manuscript was assembled by the first and senior authors. While this review is extensive, it is not a systematic review and some publications considered important by readers may have been excluded.

RESULTS

For calendar year 2022, summaries of key publications were assembled for the following broader topics within TM: blood component therapy; infectious diseases, blood donor testing, and collections; patient blood management; immunohematology and genomics; hemostasis; hemoglobinopathies; apheresis and cell therapy; pediatrics; and health care disparities, diversity, equity, and inclusion.

DISCUSSION

This Committee Report reviews and summarizes important publications and advances in TM published during calendar year 2022, and maybe a useful educational tool.

Anesthesia management for pericardiectomy- a case series study

BACKGROUND

Constrictive pericarditis (CP) is an uncommon disease that limits both cardiac relaxation and contraction. Patients often present with right-sided heart failure as the pericardium thickens and impedes cardiac filling. Pericardiectomy is the treatment of choice for improving hemodynamics in CP patients; however, the procedure carries a high morbidity and mortality, and the anesthetic management can be challenging. Acute heart failure, bleeding and arrhythmias are all concerns postoperatively.

METHODS

After IRB approval, we performed the retrospective analysis of 66 consecutive patients with CP who underwent pericardiectomy from July 2018 to May 2022.

RESULTS

Most patients had significant preoperative comorbidities, including congestive hepatopathy (75.76%), New York Heart Association Type III/IV heart failure (59.09%) and atrial fibrillation (51.52%). Despite this, 75.76% of patients were extubated within the first 24 h and all but 2 of the patients survived to discharge (96.97%).

CONCLUSIONS

Anesthetic management, including a thorough understanding of the pathophysiology of CP, the use of advanced monitoring and transesophageal echocardiography (TEE) guidance, all played an important role in patient outcomes.

Year in Review 2022: Noteworthy Literature in Cardiac Anesthesiology

Last year researchers made substantial progress in work relevant to the practice of cardiac anesthesiology. We reviewed 389 articles published in 2022 focused on topics related to clinical practice to identify 16 that will impact the current and future practice of cardiac anesthesiology. We identified 4 broad themes including risk prediction, postoperative outcomes, clinical practice, and technological advances. These articles are representative of the best work in our field in 2022.

The efficacy and safety of intravenous administration of tranexamic acid in patients undergoing cardiac surgery: Evidence from a single cardiovascular center

BACKGROUND

The current study was performed to systemically review the efficacy and safety of tranexamic acid (TXA) in patients undergoing cardiac surgery at a single large-volume cardiovascular center.

METHODS

A computerized search of electronic databases was performed to identify all relevant studies using search terms till December 31st, 2021. The primary outcomes were postoperative blood loss and the composite incidence of mortality and morbidities during hospitalization. Secondary outcomes included postoperative massive bleeding and transfusion, postoperative recovery profiles, coagulation functions, inflammatory variables, and biomarkers of vital organ injury.

RESULTS

Database search yielded 23 qualified studies including 27,729 patients in total. Among them, 14,136 were allocated into TXA group and 13,593 into Control group. The current study indicated that intravenous TXA significantly reduced total volume of postoperative bleeding in both adult and pediatric patients, and that medium- and high-dose TXA were more effective than low-dose TXA in adult patients (P < .05). The current study also demonstrated that intravenous TXA, as compared to Control, remarkably reduced postoperative transfusion incidences and volume of red blood cell and fresh frozen plasma, and reduced postoperative transfusion incidence of platelet concentrates (PC) (P < .05) without obvious dose-effects (P > .05), but TXA did not reduce PC transfusion volume postoperatively in adult patients (P > .05). For pediatrics, TXA did not significantly reduce postoperative transfusion incidence and volume of allogenic red blood cell, fresh frozen plasma and PC (P > .05). Additionally, the current study demonstrated that intravenous TXA did not influence the composite incidence of postoperative mortality and morbidities in either adults or pediatrics during hospitalization (P > .05), and that there was no obvious dose-effect of TXA in adult patients (P > .05).

CONCLUSIONS

This current study suggested that intravenous TXA significantly reduced total volume of postoperative bleeding in both adult and pediatric patients undergoing cardiac surgery at the single cardiovascular center without increasing the composite incidence of mortality and morbidities.

Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis

BACKGROUND

Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population.

METHODS

We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty).

CONCLUSION

When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level IV.

The Effect of Cell Salvage on Bleeding and Transfusion Needs in Cardiac Surgery

Introduction. Cell salvaging is well established in the blood management of cardiac patients, but there remain some concerns about its effects on perioperative bleeding and transfusion variables. This randomized controlled study investigated the potential effects of the centrifuged end-product on bleeding, transfusion rates, and other transfusion-related variables in adult cardiac surgery patients submitted to extracorporeal circulation. Materials and Methods. Patients were randomly chosen to receive (cell-salvage group, 99 patients) or not to receive (control group, 110 patients) the centrifuged product of a cell salvage apparatus. Bleeding and transfusion rates according to the universal definition of perioperative bleeding (UDPB) classification, postoperative hemoglobin, coagulation, and oxygenation indices were recorded and compared between the groups. Results. Both groups had almost identical bleeding and transfusion rates (median value: 2 units of red blood cells (RBC) and no units of fresh frozen plasma (FFP) and platelets (PLT) for both groups, $p>0.05$ ). Patients in the cell-salvage group presented slightly higher hemoglobin concentrations (10.6 ± 1.1 vs. 10.1 ± 1.7 g/dL, $p<0.05$ , respectively) and a tendency towards better oxygenation indices (PaO2/FiO2: 241 ± 94 vs. 207 ± 84, $p=0.013$ ) in the postoperative period albeit with a tendency for prolongation of prothrombin time (INR: 1.31 ± 0.18 vs. 1.26 ± 0.12, $p=0.008$ ). Conclusion. Within the study’s constraints, the perioperative use of the cell salvage concentrate does not seem to affect bleeding or transfusion variables, although it could probably ameliorate postoperative oxygenation in adult cardiac surgery patients. A tendency to promote coagulation disturbances was detected.