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Coupland LA, Pai KG, Pye SJ, Butorac MT, Miller JJ, Crispin PJ, Rabbolini DJ, Stewart AHL, Aneman A. Protracted fibrinolysis resistance following cardiac surgery with cardiopulmonary bypass: A prospective observational study of clinical associations and patient outcomes. Acta Anaesthesiol Scand 2024; 68:772-780. [PMID: 38497568 DOI: 10.1111/aas.14409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/19/2024] [Accepted: 03/04/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Surgery on cardiopulmonary bypass (CPB) elicits a pleiomorphic systemic host response which, when severe, requires prolonged intensive care support. Given the substantial cross-talk between inflammation, coagulation, and fibrinolysis, the aim of this hypothesis-generating observational study was to document the kinetics of fibrinolysis recovery post-CPB using ClotPro® point-of-care viscoelastometry. Tissue plasminogen activator-induced clot lysis time (TPA LT, s) was correlated with surgical risk, disease severity, organ dysfunction and intensive care length of stay (ICU LOS). RESULTS In 52 patients following CPB, TPA LT measured on the first post-operative day (D1) correlated with surgical risk (EuroScore II, Spearman's rho .39, p < .01), time on CPB (rho = .35, p = .04), disease severity (APACHE II, rho = .52, p < .001) and organ dysfunction (SOFA, rho = .51, p < .001) scores, duration of invasive ventilation (rho = .46, p < .01), and renal function (eGFR, rho = -.65, p < .001). In a generalized linear regression model containing TPA LT, CPB run time and markers of organ function, only TPA LT was independently associated with the ICU LOS (odds ratio 1.03 [95% CI 1.01-1.05], p = .01). In a latent variables analysis, the association between TPA LT and the ICU LOS was not mediated by renal function and thus, by inference, variation in the clearance of intraoperative tranexamic acid. CONCLUSIONS This observational hypothesis-generating study in patients undergoing cardiac surgery with cardiopulmonary bypass demonstrated an association between the severity of fibrinolysis resistance, measured on the first post-operative day, and the need for extended postoperative ICU level support. Further examination of the role of persistent fibrinolysis resistance on the clinical outcomes in this patient cohort is warranted through large-scale, well-designed clinical studies.
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Affiliation(s)
- Lucy A Coupland
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
- Ingham Institute for Applied Medical Research, New South Wales, Australia
| | - Kieran G Pai
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
| | - Sidney J Pye
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Mark T Butorac
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
| | - Jennene J Miller
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Philip J Crispin
- Haematology Department, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- The Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - David J Rabbolini
- Kolling Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antony H L Stewart
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Anders Aneman
- Liverpool Hospital, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales Medicine, New South Wales, Australia
- Ingham Institute for Applied Medical Research, New South Wales, Australia
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Yang J, Xie X, Li J, Li Y, Li B, Wang C, Jiang P. Which strategy is better for lung transplantation: Cardiopulmonary bypass or extracorporeal membrane oxygenation? Perfusion 2024:2676591241242018. [PMID: 38557237 DOI: 10.1177/02676591241242018] [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: 04/04/2024]
Abstract
Background: In lung transplantation surgery, extracorporeal life support (ECLS) is essential for safety. Various support methods, including cardiopulmonary bypass (CPB) and off-pump techniques, are used, with extracorporeal membrane oxygenation (ECMO) gaining prominence. However, consensus on the best support strategy is lacking.Purpose: This article reviews risks, benefits, and outcomes of different support strategies in lung transplantation. By consolidating knowledge, it aims to clarify selecting the most appropriate ECLS modality.Research Design: A comprehensive literature review examined CPB, off-pump techniques, and ECMO outcomes in lung transplantation, including surgical results and complications.Study Sample: Studies, including clinical trials and observational research, focused on ECLS in lung transplantation, both retrospective and prospective, providing a broad evidence base.Data Collection and/or Analysis: Selected studies were analyzed for surgical outcomes, complications, and survival rates associated with CPB, off-pump techniques, and ECMO to assess safety and effectiveness.Results: Off-pump techniques are preferred, with ECMO increasingly vital as a bridge to transplant, overshadowing CPB. However, ECMO entails hidden risks and higher costs. While safer than CPB, optimizing ECMO postoperative use and monitoring is crucial for success.Conclusions: Off-pump techniques are standard, but ECMO's role is expanding. Despite advantages, careful ECMO management is crucial due to hidden risks and costs. Future research should focus on refining ECMO use and monitoring to improve outcomes, emphasizing individualized approaches for LT recipients.
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Affiliation(s)
- Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Xinling Xie
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Li
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Bin Li
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Cheng Wang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Peng Jiang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
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Laskey D, Housman B, Dawodu G, Scheinin S. Intraoperative Extracorporeal Support during Lung Transplantation: Not Just for the High-Risk Patient. J Clin Med 2023; 13:192. [PMID: 38202198 PMCID: PMC10779858 DOI: 10.3390/jcm13010192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
The use of intraoperative mechanical support during lung transplantation has traditionally been a controversial topic. Trends for intraoperative mechanical support strategies swing like a pendulum. Historically, cardiopulmonary bypass (CPB) was the modality of choice during transplantation. It provides full hemodynamic support including oxygenation and decarboxylation. Surgical exposure is improved by permitting the drainage of the heart and provides more permissive retraction. CPBs contain drainage reservoirs with hand-held pump suction catheters promoting blood conservation through collection and re-circulation. But CPB has its disadvantages. It is known to cause systemic inflammation and coagulopathy. CPB requires high doses of heparinization, which increases bleeding risks. As transplantation progressed, off-pump transplantation began to trend as a preferable option. ECMO, however, has many of the benefits of CPB with less of the risk. Outcomes were improved with ECMO compared to CPB. CPB has a higher blood transfusion requirement, a higher need for post-operative ECMO support, a higher re-intubation rate, high rates of kidney injury and need for hemodialysis, longer ICU stays, higher incidences of PGD grade 3, as well as overall in-hospital mortality when compared with ECMO use. The focus now shifts to using intraoperative mechanical support to protect the graft, helping to reduce ischemia-reperfusion injury and allowing for lung protective ventilator settings. Studies show that the routine use of ECMO during transplantation decreases the rate of primary graft dysfunction and many adverse outcomes including ventilator time, need for tracheostomy, renal failure, post-operative ECMO requirements, and others. As intraoperative planned ECMO is considered a safe and effective approach, with improved survival and better overall outcomes compared to both unplanned ECMO implementation and off-pump transplantation, its routine use should be taken into consideration as standard protocol.
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Affiliation(s)
- Daniel Laskey
- Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, One Gustave L. Levy Place, Box 1023, New York, NY 10029, USA; (B.H.); (G.D.); (S.S.)
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Ripoll JG, Warner MA, Hanson AC, Marquez A, Dearani JA, Nuttall GA, Kor DJ, Mauermann WJ, Smith MM. Coagulation Tests and Bleeding Classification After Cardiopulmonary Bypass: A Prospective Study. J Cardiothorac Vasc Anesth 2023; 37:933-941. [PMID: 36863984 PMCID: PMC10149589 DOI: 10.1053/j.jvca.2023.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE No recent prospective studies have analyzed the accuracy of standard coagulation tests and thromboelastography (TEG) to identify patients with excessive microvascular bleeding following cardiopulmonary bypass (CPB). The aim of this study was to assess the value of coagulation profile tests, as well as TEG, for the classification of microvascular bleeding after CPB. DESIGN A prospective observational study. SETTING At a single-center academic hospital. PARTICIPANTS Patients ≥18 years of age undergoing elective cardiac surgery. INTERVENTIONS Qualitative assessment of microvascular bleeding post-CPB (surgeon and anesthesiologist consensus) and the association with coagulation profile tests and TEG values. MEASUREMENTS AND MAIN RESULTS A total of 816 patients were included in the study-358 (44%) bleeders and 458 (56%) nonbleeders. Accuracy, sensitivity, and specificity for the coagulation profile tests and TEG values ranged from 45% to 72%. The predictive utility was similar across tests, with prothrombin time (PT) (62% accuracy, 51% sensitivity, 70% specificity), international normalized ratio (INR) (62% accuracy, 48% sensitivity, 72% specificity), and platelet count (62% accuracy, 62% sensitivity, 61% specificity) displaying the highest performance. Secondary outcomes were worse in bleeders versus nonbleeders, including higher chest tube drainage, total blood loss, transfusion of red blood cells, reoperation rates (p < 0.001, respectively), readmission within 30 days (p = 0.007), and hospital mortality (p = 0.021). CONCLUSIONS Standard coagulation tests and individual components of TEG in isolation agree poorly with the visual classification of microvascular bleeding after CPB. The PT-INR and platelet count performed best but had low accuracy. Further work is warranted to identify better testing strategies to guide perioperative transfusion decisions in cardiac surgical patients.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Statistician, Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Sponholz C, Sommerfeld O, Moehl C, Lehmann T, Franz M, Bauer M, Doenst T, Faerber G, Diab M. Intraoperative Cell Savage, Infection and Organ Failure in Infective Endocarditis Patients-A Retrospective Single Center Evaluation. J Clin Med 2023; 12:jcm12010382. [PMID: 36615185 PMCID: PMC9821775 DOI: 10.3390/jcm12010382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Surgery is indicated in about 50% of infective endocarditis patients, and bleeding or the transfusion of blood a common finding. The intraoperative use of cell salvage may reduce the perioperative transfusion requirement, but its use is limited in the underlying disease. In this retrospective study, we therefore evaluated n = 335 patients fulfilling the modified Duke criteria for infective endocarditis characterized by the use of intraoperative cell salvage with autologous blood retransfusion. Inflammation markers and organ dysfunction, including catecholamine dependency, were evaluated by using linear regression analysis. Between 2015 and 2020, 335 patients underwent surgery for left-sided heart valve endocarditis. Intraoperative cell salvage was used in 40.3% of the cases, especially in complex scenarios and reoperation. Intraoperative cell salvage significantly altered the white blood cell count after surgery. On average, leucocytes were 3.0 Gpt/L higher in patients with intraoperative cell salvage compared to patients without after adjustment for confounders (95% CI: 0.39-5.54). Although the difference in WBC was statistically significant, i.e., higher in the ICS group compared to the no-ICS group, this difference may be clinically unimportant. Organ dysfunction, including hemodynamic instability and lactate values, were comparable between groups. In conclusion, intraoperative cell salvage enhanced the re-transfusion of autologous blood, with minor effects on the postoperative course of inflammatory markers, but was not associated with increased hemodynamic instability or organ dysfunction in general. The restriction of intraoperative cell salvage in surgery for infective endocarditis should be re-evaluated, and more prospective data in this topic are needed.
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Affiliation(s)
- Christoph Sponholz
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
- Correspondence: ; Tel.: +49-(36)-419322225
| | - Oliver Sommerfeld
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Caroline Moehl
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Marcus Franz
- Department of Internal Medicine I, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Michael Bauer
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Torsten Doenst
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Gloria Faerber
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Mahmoud Diab
- Clinic for Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University Jena, 07743 Jena, Germany
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Weingarten N, Schraufnagel D, Plitt G, Zaki A, Ayyat KS, Elgharably H. Comparison of mechanical cardiopulmonary support strategies during lung transplantation. Expert Rev Med Devices 2020; 17:1075-1093. [PMID: 33090042 DOI: 10.1080/17434440.2020.1841630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lung transplantation outcomes are influenced by the intraoperative mechanical cardiopulmonary support strategy used. This surgery was historically done either on cardiopulmonary bypass (CPB) or off pump. Recently, there has been increased interest in intraoperative support with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO). However, there is a lack of consensus on the relative risks, benefits and indications for each intraoperative support strategy. AREAS COVERED This review includes information from cohort studies, case-control studies, and case series that compare morbidity and/or mortality of two or more intraoperative cardiopulmonary support strategies during lung transplantation. EXPERT OPINION The optimal strategy for intraoperative cardiopulmonary support during lung transplantation remains an area of debate. Current data suggest that off pump is associated with better outcomes and could be considered whenever feasible. ECMO is generally associated with preferable outcomes to CPB, but the data supporting this association is not robust. Interestingly, whether CPB is unplanned or prolonged might influence outcomes more than the use of CPB itself. These observations can help guide surgical teams in their approach for intraoperative mechanical support strategy during lung transplantation and should serve as the basis for further investigations.
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Affiliation(s)
- Noah Weingarten
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Dean Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Gilman Plitt
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Kamal S Ayyat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
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Application of a Modified Extracorporeal Circulation Perfusion Method During Surgery for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2020; 29:1203-1209. [PMID: 32059950 DOI: 10.1016/j.hlc.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/10/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
AIM The aim of this study was to investigate the effect of the modified extracorporeal circulation perfusion method during surgery for acute Stanford type A aortic dissection in patients who underwent stented elephant trunk implantation and arch replacement. METHOD A total of 69 patients with acute Stanford type A aortic dissection who underwent stented elephant trunk implantation and arch replacement were retrospectively analysed from 2017 to 2018. According to the perfusion method of extracorporeal circulation, patients were divided into a routine perfusion (RP) group and a modified perfusion (MP) group. Clinical data were collected, including the time of extracorporeal circulation and deep hypothermic circulatory arrest, incidence of acute kidney injury and neurological complications, and comparisons between the two groups were conducted by using independent sample t-tests for normally distributed qualitative data, the Mann-Whitney U-test for skewed qualitative data, and the chi square test or Fisher's exact test for categorical data. RESULTS There were 55 (80%) males and 14 (20%) females in the entire cohort, and the mean ± standard deviation age was 50.4±9.0 years. A total of 53 (77%) patients were included in the RP group, and 16 (23%) were included in the MP group. Patients in the MP group were older (55.5±7.8 vs 48.8±8.9 years), and the difference was significant (p=0.008). Compared with the RP group, the time of extracorporeal circulation (218.0 [44.7] vs 246.0 [58.0] min; p=0.005) and deep hypothermic circulatory arrest (4.0 [2.0] vs 25.0 [10.0] min; p<0.001) was shorter, and the incidence of postoperative acute kidney injury (n=6 [37.5%] vs n=36 [67.9%]; p=0.029) was lower in the MP group; the differences were significant. Six (6) patients died in the RP group; no patients died in the MP group. The total in-hospital mortality rate was 8.7%. CONCLUSIONS The modified extracorporeal circulation perfusion method is feasible, with satisfactory results.
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Wu D, Zhou Y, Fan Y, Zhang Q, Gu F, Mao W, Zhang M. LncRNA CAIF was downregulated in end-stage cardiomyopathy and is a promising diagnostic and prognostic marker for this disease. Biomarkers 2019; 24:735-738. [PMID: 31587591 DOI: 10.1080/1354750x.2019.1677778] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiac autophagy inhibitory factor (CAIF) is a novel lncRNA with protective effects on myocardial infarction. We explored the involvement of CAIF in end-stage cardiomyopathy. Patients with end-stage cardiomyopathy and healthy volunteers were included in this study. Myocardial tissues and serum were collected. CAIF was detected by RT-qPCR. ROC curve was used for diagnostic analysis. Prognostic value of CAIF expression for end-stage cardiomyopathy was evaluated by survival curve analysis. Correlations between CAIF expression and clinicopathological data of patients with end-stage cardiomyopathy were analysed by chi-square test. Downregulated CAIF was observed in end-stage cardiomyopathy patients than in healthy controls. CAIF expression distinguished end-stage cardiomyopathy patients from healthy controls and predict the survival of patients. LncRNA CAIF was downregulated in end-stage cardiomyopathy and may serve as a promising prognostic and diagnostic marker for this disease.
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Affiliation(s)
- Di Wu
- Department of Cardiovascular, China Meitan General Hospital, Beijing City, P.R. China
| | - Yanqiu Zhou
- Central Laboratory, China Meitan General Hospital, Beijing City, P.R. China
| | - Yudong Fan
- Department of Cardiovascular, China Meitan General Hospital, Beijing City, P.R. China
| | - Qingjun Zhang
- Department of Cardiovascular, China Meitan General Hospital, Beijing City, P.R. China
| | - Feifei Gu
- Department of Cardiovascular, China Meitan General Hospital, Beijing City, P.R. China
| | - Wen Mao
- Department of Cardiovascular, China Meitan General Hospital, Beijing City, P.R. China
| | - Miaomiao Zhang
- Department of Cardiovascular, China Meitan General Hospital, Beijing City, P.R. China
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Terada R, Ikeda T, Mori Y, Yamazaki S, Kashiwabara K, Yamauchi H, Ono M, Yamada Y, Okazaki H. Comparison of two point of care whole blood coagulation analysis devices and conventional coagulation tests as a predicting tool of perioperative bleeding in adult cardiac surgery-a pilot prospective observational study in Japan. Transfusion 2019; 59:3525-3535. [PMID: 31614002 DOI: 10.1111/trf.15523] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/10/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is widely accepted that Point-of Care Test (PoCT) devices are useful in the detection of coagulopathies in situations of massive bleeding such as major cardiac surgery. These devices contribute to the reduction of blood transfusion. However, their implementation remains limited in Japan because of their cost and lack of health insurance support. STUDY DESIGN AND METHODS Conventional coagulation tests and thromboelastography (TEG)/Sonoclot values were measured in 50 consecutive cardiac surgery cases. Clinical background information such as operative procedures was obtained from electronic medical records, and the theoretical perioperative total blood loss was calculated by measuring the hemoglobin content and total red blood cell transfusion volume. The correlation between perioperative total blood loss and the measured laboratory values or clinical parameters was evaluated by a multivariate linear regression analysis. The risk factors of the total amount of platelet transfusion and postoperative drain bleeding volume were similarly evaluated. RESULTS No significant association between the estimated perioperative total blood loss (eTBL) and the laboratory measurements including conventional coagulation tests, TEG and Sonoclot was observed. On the other hand, postoperative drain bleeding volume was significantly associated with postoperative Sonoclot CR (p = 0.039) as well as preoperative use of oral anticoagulants and cell saver treated blood volume. Platelet transfusion amount was significantly associated with post-CBP PF and time to peak value of Sonoclot (p = 0.014 and 0.001, respectively). CONCLUSION Sonoclot measurements may be useful to estimate the risks of postoperative bleeding and platelet transfusion in cardiac surgeries in Japan.
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Affiliation(s)
- Rui Terada
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Toshiyuki Ikeda
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshiteru Mori
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Sho Yamazaki
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Kosuke Kashiwabara
- Department of Biostatistics Division, Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Yoshitsugu Yamada
- Department of Anesthesiology and Pain Relief Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Hitoshi Okazaki
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
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Kara H, Erden T. Feasibility and acceptability of continuous postoperative pericardial flushing for blood loss reduction in patients undergoing coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 68:219-226. [PMID: 31325107 DOI: 10.1007/s11748-019-01174-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Postoperative bleeding requires blood transfusion and surgical re-exploration that can affect the short- and long-term postoperative outcomes. Interventions that can be used in the postoperative period to reduce blood loss should be developed. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. This study examined the feasibility and acceptability of CPPF for reducing bleeding after coronary artery bypass surgery. METHODS This pilot study adopted a prospective and group comparison design. Between January and April 2018, 42 patients who underwent isolated coronary artery bypass surgery received CPPF from sternal closure up to 8 h postoperative. The mean actual blood loss in the CPPF group was compared to the mean of retrospectively group (n = 58). In the CPPF group, an extra infusion catheter was inserted through one of the tube incision holes and an irrigation solution (0.9% NaCl at 38 °C) was delivered to the pericardial cavity by using a volumetric pump. Safety aspects, feasibility issues, and complications were documented. The primary outcome was blood loss, and it was assessed 18 h after the surgery. RESULTS CPPF was successfully completed in 40 patients (95.24%). Method-related complications were not observed. Feasibility was good in this experimental setting. Blood loss was lower in the CPPF group (257.24 mL) than non-CPPF group (p < 0.001). CONCLUSIONS CPPF after coronary artery bypass grafting surgery is safe, effective, feasible, and acceptable. However, standardized randomized clinical trials are necessary to draw definitive conclusions.
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Affiliation(s)
- Hakan Kara
- Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey.
| | - Tuncay Erden
- Department of Cardiovascular Surgery, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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Guan Z, Zhang YJ, Liu L, Shen X, Gao YF, Li XG, Zhou RS, Liu JJ. The association of preoperative atrial fibrillation with post-cardiopulmonary bypass hyperfibrinolysis in rheumatic valvular heart disease patients. Heart Lung 2019; 48:515-518. [PMID: 31146967 DOI: 10.1016/j.hrtlng.2019.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/22/2019] [Accepted: 05/18/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the fibrinolytic status after cardiopulmonary bypass in rheumatic valvular heart disease patients, and detect the associated factors of post-cardiopulmonary bypass hyperfibrinolysis. METHODS According to the fibrinolytic status after cardiopulmonary bypass, 203 rheumatic valvular heart disease patients were divided into two groups: hyperfibrinolysis group (H group, n = 78) and non-hyperfibrinolysis group (NH group, n = 125). The demographic characteristics, operative variables, and postoperative follow-ups were compared between these two groups. RESULTS The incidence of hyperfibrinolysis was 38.4% after cardiopulmonary bypass. Patients in the H group had a significant higher incidence of preoperative atrial fibrillation than patients in the NH group (92.3% vs. 55.2%, P < 0.01). Furthermore, postoperative daily drainage (655.3 ± 131.5 ml vs. 535.4 ± 161.4 ml, P < 0.01), transfusion volume of fresh frozen plasma (621.8 ± 220.2 ml vs. 455.2 ± 208.5 ml, P < 0.01), and red blood cells (5.9 ± 2.2 u vs. 4.7 ± 2.8 u, P < 0.01) was greater in the H group than in the NH group. Moreover, the logistic regression analysis revealed that preoperative atrial fibrillation was associated with post-cardiopulmonary bypass hyperfibrinolysis (OR = 19.691, 95% CI = 6.849-56.612; P < 0.05). CONCLUSION Preoperative artial fibrillation is associated with post-cardiopulmonary bypass hyperfibrinolysis in rheumatic valvular heart disease patients.
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Affiliation(s)
- Zheng Guan
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Yong-Jian Zhang
- Department of Cardiac Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Lin Liu
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Xin Shen
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Yan-Feng Gao
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Xiao-Gang Li
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Rong-Sheng Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China
| | - Jing-Jie Liu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, PR China.
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12
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Deep Hypothermic Circulatory Arrest Does Not Show Better Protection for Vital Organs Compared with Moderate Hypothermic Circulatory Arrest in Pig Model. BIOMED RESEARCH INTERNATIONAL 2019; 2019:1420216. [PMID: 31119151 PMCID: PMC6500684 DOI: 10.1155/2019/1420216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 03/19/2019] [Indexed: 11/17/2022]
Abstract
Background Continued debates exist regarding the optimal temperature during hypothermic circulatory arrest in aortic arch repair for patients with type A aortic dissection. This study seeks to examine whether the use of moderate hypothermic circulatory arrest in a pig model provides comparable vital organ protection outcomes to the use of deep hypothermic circulatory arrest. Methods Thirteen pigs were randomly assigned to 30 minutes of hypothermic circulatory arrest without cerebral perfusion at 15°C (n = 5), 25°C (n = 5), and a control group (n = 3). The changes in standard laboratory tests and capacity for protection against apoptosis in different vital organs were monitored with different temperatures of hypothermic circulatory arrest management in pig model to determine which temperature was optimal for hypothermic circulatory arrest. Results There were no significant differences in the capacity for protection against apoptosis in vital organs between 2 groups (p > 0.05, respectively). Compared with the moderate hypothermic circulatory arrest group, the deep hypothermic circulatory arrest group had no significant advantages in terms of the biologic parameters of any other organs (p > 0.05). Conclusions Compared with deep hypothermic circulatory arrest, moderate hypothermic circulatory arrest is a moderate technique that has similar advantages with regard to the levels of biomarkers of injury and capacity for protection against apoptosis in vital organs.
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Saes JL, Schols SEM, van Heerde WL, Nijziel MR. Hemorrhagic disorders of fibrinolysis: a clinical review. J Thromb Haemost 2018; 16:S1538-7836(22)02207-3. [PMID: 29847021 DOI: 10.1111/jth.14160] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Indexed: 12/28/2022]
Abstract
Hyperfibrinolytic bleeding can be caused by a deficiency of one of the inhibitors of fibrinolysis (plasminogen activator inhibitor type 1 [PAI-1] or α2-antiplasmin [α2-AP]), or an excess of one of the activators of fibrinolysis: tissue-type plasminogen activator or urokinase-type plasminogen activator. This review focuses on the clinical implications of these disorders. The bleeding phenotype of fibrinolytic disorders is characterized by delayed bleeding after trauma, surgery and dental procedures. Bleeding in areas of high fibrinolytic activity is also common, such as menorrhagia and epistaxis. Patients with α2-AP deficiency present with the most severe bleeding episodes. Recently, it was discovered that hyperfibrinolytic disorders are associated with a high rate of obstetric complications such as miscarriage and preterm birth, especially in PAI-1 deficient patients. Hyperfibrinolytic disorders are probably underdiagnosed because of lack of knowledge and lack of accurate diagnostic tests. A substantial part of the large group of patients diagnosed as 'bleeding of unknown origin' could actually have a hyperfibrinolytic disorder. In the case of a high index of suspicion (i.e. because of a positive family history, recurrent bleeding or uncommon type of bleeding such as an intramedullary hematoma), further testing should not be withheld because of normal results of standard hemostatic screening assays. Timely diagnosis is important because these disorders can generally be treated well with antifibrinolytic agents.
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Affiliation(s)
- J L Saes
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - S E M Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - W L van Heerde
- Haemophilia Treatment Center, Nijmegen-Eindhoven-Maastricht, the Netherlands
| | - M R Nijziel
- Department of Hematology, Catharina Hospital, Eindhoven, the Netherlands
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14
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McConnell M, Baisden J, Duncan AE. Pro: Third-Generation Hydroxyethyl Starch Solution Is Safe and Effective for Plasma Volume Expansion During Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:570-575. [DOI: 10.1053/j.jvca.2017.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Indexed: 11/11/2022]
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15
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He S, Blombäck M, Wallén H, Jeppsson A, Grass S. Global impairments in the haemostasis systems after cardiopulmonary bypass. Thromb Res 2017; 151:63-66. [DOI: 10.1016/j.thromres.2017.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 01/12/2017] [Accepted: 01/23/2017] [Indexed: 10/20/2022]
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16
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A Comparison of a New Ultrasound-Based Whole Blood Viscoelastic Test (SEER Sonorheometry) Versus Thromboelastography in Cardiac Surgery. Anesth Analg 2016; 123:1400-1407. [DOI: 10.1213/ane.0000000000001362] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Reddy S, McGuinness S, Parke R, Young P. Choice of Fluid Therapy and Bleeding Risk After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:1094-103. [DOI: 10.1053/j.jvca.2015.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Indexed: 02/07/2023]
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18
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Aminocaproic acid for the management of bleeding in patients on extracorporeal membrane oxygenation: Four adult case reports and a review of the literature. Heart Lung 2016; 45:232-6. [DOI: 10.1016/j.hrtlng.2016.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/26/2016] [Accepted: 01/28/2016] [Indexed: 11/22/2022]
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19
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Kuiper GJAJM, Kleinegris MCF, van Oerle R, Spronk HMH, Lancé MD, Ten Cate H, Henskens YMC. Validation of a modified thromboelastometry approach to detect changes in fibrinolytic activity. Thromb J 2016; 14:1. [PMID: 26770073 PMCID: PMC4712545 DOI: 10.1186/s12959-016-0076-2] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/10/2016] [Indexed: 11/24/2022] Open
Abstract
Background Thus far, validated whole blood assays used in in vitro fibrinolysis experiments using thromboelastometry (ROTEM) are lacking or have yet to be tested in humans. The objective was first, to establish a standardized modified ROTEM approach to detect both hypo- and hyperfibrinolysis. And second, to perform a technical and clinical validation of the assay. Methods Blood was used of healthy volunteers, patients with sepsis, patients after cardiothoracic surgery, pregnant women, and cirrhotic liver disease patients. A whole blood tissue factor (TF) activated ROTEM assay with and without the addition of recombinant tissue plasminogen activator (rTPA) was developed. Plasma fibrinolysis determinants were measured in all volunteers and patients. Results Thirty five pM TF and additions of 125 and 175 ng/ml rTPA resulted in full lysis within 60 min in healthy volunteers. Coefficients of variation were below 10 % without and below 20 % with rTPA addition. In sepsis the hypofibrinolytic ROTEM profiles with 175 ng/ml rTPA were in line with the plasma determinants (high PAI-1, high fibrinogen, low tPA activity, and high d-dimers). After cardiothoracic surgery, reduced fibrinogen and platelet levels accounted for the reduced maximum clot firmness. The hypofibrinolytic profile is attributed to tranexamic acid use and elevated PAI-1 levels. The lowest rTPA concentration in cirrhosis resulted in hyperfibrinolysis in only few of the patients. In pregnancy normal profiles were found. Discussion Our high rTPA concentration demonstrates hypofibrinolytic profiles adequately in sepsis and after cardiothoracic surgery. Our low rTPA concentration of 125 ng/ml seems too high for demonstrating hyperfibrinolysis in cirrhotic liver disease. Conclusions We were able to present a validated whole blood ROTEM approach to fibrinolysis testing using added rTPA, which can be of added value next to classical plasma based fibrinolysis assays.
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Affiliation(s)
- Gerhardus J A J M Kuiper
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands ; Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marie-Claire F Kleinegris
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - René van Oerle
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands ; Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Henri M H Spronk
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Marcus D Lancé
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Center (MUMC+), P. Debyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Laboratory for Clinical Thrombosis and Haemostasis, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Cluster for Hemostasis and transfusion, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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Ozolina A, Strike E, Nikitina-Zake L, Jaunalksne I, Krumina A, Lacis R, Bjertnaes LJ, Vanags I. Polymorphisms on PAI-1 and ACE genes in association with fibrinolytic bleeding after on-pump cardiac surgery. BMC Anesthesiol 2015; 15:122. [PMID: 26340801 PMCID: PMC4560913 DOI: 10.1186/s12871-015-0101-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 08/26/2015] [Indexed: 12/11/2022] Open
Abstract
Background Carriers of plasminogen activator inhibitor -1 (PAI-1) -675 genotype 5G/5G may be associated with lower preoperative PAI-1 plasma levels and higher blood loss after heart surgery using cardiopulmonary bypass (CPB). We speculate if polymorphisms of PAI-1 -844 A/G and angiotensin converting enzyme (ACE) intron 16 I/D also might promote fibrinolysis and increase postoperative bleeding. Methods We assessed PAI-1 -844 A/G, and ACE intron 16 I/D polymorphisms by polymerase chain reaction technique and direct sequencing of genomic DNA from 83 open heart surgery patients that we have presented earlier. As primary outcome, accumulated chest tube drainage (CTD) at 4 and 24 h were analyzed for association with genetic polymorphisms. As secondary outcome, differences in plasma levels of PAI-1, t-PA/PAI-1 complex and D-dimer were determined for each polymorphism. SPSS® was used for statistical evaluation. Results The lowest preoperative PAI-1 plasma levels were associated with PAI-1 -844 genotype G/G, and higher CTD, as compared with genotype A/A at 4 and 24 h after surgery. Correspondingly, 4 h after the surgery CTD was higher in carriers of ACE intron 16 genotype I/I, as compared with genotype D/D. PAI-1 plasma levels and t-PA/PAI-1 complex reached nadir in carriers of ACE intron 16 genotype I/I, in whom we also noticed the highest D-dimer levels immediately after surgery. Notably, carriers of PAI-1 -844 genotype G/G displayed higher D-dimer levels at 24 h after surgery as compared with those of genotype A/G. Conclusions Increased postoperative blood loss secondary to enhanced fibrinolysis was associated with carriers of PAI-1 -844 G/G and ACE Intron 16 I/I, suggesting that these genotypes might predict increased postoperative blood loss after cardiac surgery using CPB. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0101-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Agnese Ozolina
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Eva Strike
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Liene Nikitina-Zake
- Latvian Biomedical Research and Study Center, Ratsupites Street 1, Riga, Latvia.
| | - Inta Jaunalksne
- Clinical Immunology Centre, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia.
| | - Angelika Krumina
- Department of Infectology and Dermatology, Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Romans Lacis
- Department of Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu Street 13, Riga, Latvia. .,Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
| | - Lars J Bjertnaes
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, 9037, Tromsø, Norway.
| | - Indulis Vanags
- Riga Stradins University, Dzirciema Street 16, Riga, Latvia.
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Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg 2015; 2:43. [PMID: 26389122 PMCID: PMC4558465 DOI: 10.3389/fsurg.2015.00043] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/17/2015] [Indexed: 12/18/2022] Open
Abstract
Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University , Townsville, QLD , Australia
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Manshanden JS, Gielen CL, de Borgie CA, Klautz RJ, de Mol BA, Koolbergen DR. Continuous Postoperative Pericardial Flushing: A Pilot Study on Safety, Feasibility, and Effect on Blood Loss. EBioMedicine 2015; 2:1217-23. [PMID: 26501121 PMCID: PMC4587997 DOI: 10.1016/j.ebiom.2015.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Prolonged or excessive blood loss is a common complication after cardiac surgery. Blood remnants and clots, remaining in the pericardial space in spite of chest tube drainage, induce high fibrinolytic activity that may contribute to bleeding complications. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. In this pilot study, the safety and feasibility of CPPF were evaluated and the effect on blood loss and other related complications was investigated. METHODS Between November 2011 and April 2012 twenty-one adult patients undergoing surgery for congenital heart disease (CHD) received CPPF from sternal closure up to 12 h postoperative. With an inflow Redivac drain that was inserted through one of the chest tube incision holes, an irrigation solution (NaCl 0.9% at 38 °C) was delivered to the pericardial cavity using a volume controlled flushing system. Safety aspects, feasibility issues and complications were registered. The mean actual blood loss in the CPPF group was compared to the mean of a retrospective group (n = 126). RESULTS CPPF was successfully completed in 20 (95.2%) patients, and no method related complications were observed. Feasibility was good in this experimental setting. Patients receiving CPPF showed a 30% (P = 0.038) decrease in mean actual blood loss 12 h postoperatively. CONCLUSIONS CPPF after cardiac surgery was found to be safe and feasible in this experimental setting. The clinically relevant effect on blood loss needs to be confirmed in a randomized clinical trial.
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Affiliation(s)
- Johan S.J. Manshanden
- Department of Cardiothoracic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Chantal L.I. Gielen
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Robert J.M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Bas A.J.M. de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - David R. Koolbergen
- Department of Cardiothoracic Surgery, Academic Medical Center (AMC), Amsterdam, The Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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GREIFF G, PLEYM H, STENSETH R, WAHBA A, VIDEM V. Genetic variation influences the risk of bleeding after cardiac surgery: novel associations and validation of previous findings. Acta Anaesthesiol Scand 2015; 59:796-806. [PMID: 25762219 DOI: 10.1111/aas.12504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/02/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Severe post-operative bleeding in cardiac surgery is associated with increased morbidity and mortality. We hypothesized that variation in genetic susceptibility contributes to post-operative bleeding in addition to clinical factors. METHODS We included 1036 adults undergoing cardiac surgery with cardiopulmonary bypass. Two different endpoints for excessive post-operative bleeding were used, either defined as blood loss exceeding 2 ml/kg/h the first 4 h post-operatively or a composite including bleeding, transfusions, and reoperations. Twenty-two single nucleotide polymorphisms (SNPs) central in the coagulation and fibrinolysis systems or in platelet membrane receptors were genotyped, focusing on replication of earlier non-replicated findings and exploration of potential novel associations. Using logistic regression, significant SNPs were added to a model with only clinical variables to evaluate whether the genetic variables provided additional information. RESULTS Univariate tests identified rs1799809 (located in the promoter region of the PROC gene), rs27646 and rs1062535 (in the ITGA2 gene), rs630014 (in the ABO gene), and rs6048 (in the F9 gene) as significantly associated with excessive post-operative bleeding (P < 0.05, P-values confirmed by permutation). The SNPs were significant also after adjustment with clinical variables, showing almost unchanged odds ratios except for rs1799809 (P = 0.06). Addition of the genetic covariates to a logistic regression model with clinical variables significantly improved the model (P < 0.01). CONCLUSION We identified five SNPs associated with post-operative bleeding after cardiac surgery, of which two validated previously published associations. Addition of genetic information to models with only clinical variables improved the models. Our results indicate that common genetic variations significantly influence post-operative bleeding after cardiac surgery.
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Affiliation(s)
- G. GREIFF
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Department of Cardiothoracic Anaesthesia and Intensive Care; St. Olavs University Hospital; Trondheim Norway
| | - H. PLEYM
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Clinic of Anaesthesia and Intensive Care; St. Olavs University Hospital; Trondheim Norway
| | - R. STENSETH
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Department of Cardiothoracic Anaesthesia and Intensive Care; St. Olavs University Hospital; Trondheim Norway
| | - A. WAHBA
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Clinic of Cardiothoracic Surgery; St. Olavs University Hospital; Trondheim Norway
| | - V. VIDEM
- Department of Laboratory Medicine; Children's and Women's Health; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Department of Immunology and Transfusion Medicine; St. Olavs University Hospital; Trondheim Norway
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Comparison of three point-of-care testing devices to detect hemostatic changes in adult elective cardiac surgery: a prospective observational study. BMC Anesthesiol 2014; 14:80. [PMID: 25276093 PMCID: PMC4179787 DOI: 10.1186/1471-2253-14-80] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022] Open
Abstract
Background Bleeding complications in cardiac surgery may lead to increased morbidity and mortality. Traditional blood coagulation tests are not always suitable to detect rapid changes in the patient's coagulation status. Point-of-care instruments such as the TEG (thromboelastograph) and RoTEM (thromboelastometer) have been shown to be useful as a guide for the clinician in the choice of blood products and they may lead to a reduction in the need for blood transfusion, contributing to better patient blood management. Methods The purpose of this study was to evaluate the ability of the TEG, RoTEM and Sonoclot instruments to detect changes in hemostasis in elective cardiac surgery with cardiopulmonary bypass and to investigate possible correlations between variables from these three instruments and routine hematological coagulation tests. Blood samples from thirty-five adult patients were drawn before and after surgery and analyzed in TEG, RoTEM, Sonoclot and routine coagulation tests. Data were compared using repeated measures analysis of variance and Pearson's test for linear correlation. Results We found significant changes for all TEG variables after surgery, for three of the RoTEM variables, and for one variable from the Sonoclot. There were significant correlations postoperatively between plasma fibrinogen levels and variables from the three instruments. Conclusions TEG and RoTEM may be used to detect changes in hemostasis following cardiac surgery with CPB. Sonoclot seems to be less suitable to detect such changes. Variables from the three instruments correlated with plasma fibrinogen and could be used to monitor treatment with fibrinogen concentrate.
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Taneja R, Liaw PL, Al Ghazaly S, Priestap F, Murkin JM, Martin CM. Effect of cardiopulmonary bypass on thrombin generation and protein C pathway. J Cardiothorac Vasc Anesth 2013; 27:35-40. [PMID: 23312776 DOI: 10.1053/j.jvca.2012.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the mechanisms of cardiopulmonary bypass (CPB)-induced dysregulation between thrombin and its regulatory anticoagulant activated protein C (APC). DESIGN A prospective observational cohort study. SETTING A tertiary care university hospital and associated research laboratory. PATIENTS Twenty patients undergoing elective coronary artery bypass surgery with (n = 10) or without CPB (n = 10). INTERVENTIONS Blood samples were collected at 7 time points: preinduction; after heparin; 1 hour after the institution of CPB (or the completion of distal anastomoses in off-CPB group); after protamine; and at 0, 4, and 18 hours in the Intensive care unit (ICU). Samples were analyzed for prothrombin fragments (F1+2), thrombin-antithrombin complexes, protein C (PC), APC, soluble thrombomodulin (sTM), and soluble endothelial protein C receptor (sEPCR). MEASUREMENTS AND MAIN RESULTS F1+2 levels increased significantly 1 hour after the initiation of CPB in comparison with baseline (2.7 ± 0.5 v 0.5 ± 0.2 nmol/L, p < 0.001) (mean ± standard deviation) and remained elevated until 4 hours after ICU admission (p < 0.001). In contrast, APC levels did not show any significant changes over time in either group. sEPCR, sTM, and PC levels did not change during CPB although sEPCR decreased significantly after the termination of CPB compared with baseline in the CPB group. CONCLUSIONS Exposure to CPB is associated with a distinct thrombin surge that continues postoperatively for 4 hours. The impaired ability to generate APC reflects a complex process that is not associated with increased levels of sEPCR and thrombomodulin during CPB. Further studies are required to evaluate the regulation of the host APC response in cardiac surgery.
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Affiliation(s)
- Ravi Taneja
- Centre for Critical Illness Research, Lawson Health Research Institute, London Health Sciences Centre, London, Ontario, Canada.
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Dobson GP, Faggian G, Onorati F, Vinten-Johansen J. Hyperkalemic cardioplegia for adult and pediatric surgery: end of an era? Front Physiol 2013; 4:228. [PMID: 24009586 PMCID: PMC3755226 DOI: 10.3389/fphys.2013.00228] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/05/2013] [Indexed: 12/16/2022] Open
Abstract
Despite surgical proficiency and innovation driving low mortality rates in cardiac surgery, the disease severity, comorbidity rate, and operative procedural difficulty have increased. Today's cardiac surgery patient is older, has a "sicker" heart and often presents with multiple comorbidities; a scenario that was relatively rare 20 years ago. The global challenge has been to find new ways to make surgery safer for the patient and more predictable for the surgeon. A confounding factor that may influence clinical outcome is high K(+) cardioplegia. For over 40 years, potassium depolarization has been linked to transmembrane ionic imbalances, arrhythmias and conduction disturbances, vasoconstriction, coronary spasm, contractile stunning, and low output syndrome. Other than inducing rapid electrochemical arrest, high K(+) cardioplegia offers little or no inherent protection to adult or pediatric patients. This review provides a brief history of high K(+) cardioplegia, five areas of increasing concern with prolonged membrane K(+) depolarization, and the basic science and clinical data underpinning a new normokalemic, "polarizing" cardioplegia comprising adenosine and lidocaine (AL) with magnesium (Mg(2+)) (ALM™). We argue that improved cardioprotection, better outcomes, faster recoveries and lower healthcare costs are achievable and, despite the early predictions from the stent industry and cardiology, the "cath lab" may not be the place where the new wave of high-risk morbid patients are best served.
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Affiliation(s)
- Geoffrey P. Dobson
- Department of Physiology and Pharmacology, Heart and Trauma Research Laboratory, James Cook UniversityTownsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Jakob Vinten-Johansen
- Cardiothoracic Research Laboratory of Emory University Hospital Midtown, Carlyle Fraser Heart CenterAtlanta, GA, USA
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Krishnan A, Vogler EA, Sullenger BA, Becker RC. The effect of surface contact activation and temperature on plasma coagulation with an RNA aptamer directed against factor IXa. J Thromb Thrombolysis 2013; 35:48-56. [PMID: 23054460 DOI: 10.1007/s11239-012-0778-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The anticoagulant properties of a novel RNA aptamer that binds FIXa depend collectively on the intensity of surface contact activation of human blood plasma, aptamer concentration, and its binding affinity for FIXa. Accordingly, anticoagulation efficiency of plasma containing any particular aptamer concentration is low when coagulation is strongly activated by hydrophilic surfaces compared to the anticoagulation efficiency in plasma that is weakly activated by hydrophobic surfaces. Anticoagulation efficiency is lower at hypothermic temperatures possibly because aptamer-FIXa binding decreases with decreasing temperatures. Experimental results demonstrating these trends are qualitatively interpreted in the context of a previously established model of anticoagulation efficiency of thrombin-binding DNA aptamers that exhibit anticoagulation properties similar to the FIXa aptamer. In principle, FIXa aptamer anticoagulants should be more efficient and therefore more clinically useful than thrombin-binding aptamers because aptamer binding to FIXa competes only with FX that is at much lower blood concentration than fibrinogen (FI) that competes with thrombin-binding aptamers. Our findings may have translatable relevance in the application of aptamer anticoagulants for clinical conditions in which blood is in direct contact with non-biological surfaces such as those encountered in cardiopulmonary bypass circuits.
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Affiliation(s)
- Anandi Krishnan
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Box 3850, Durham, NC 27705, USA.
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Ozolina A, Strike E, Jaunalksne I, Krumina A, Bjertnaes LJ, Vanags I. PAI-1 and t-PA/PAI-1 complex potential markers of fibrinolytic bleeding after cardiac surgery employing cardiopulmonary bypass. BMC Anesthesiol 2012; 12:27. [PMID: 23110524 PMCID: PMC3524048 DOI: 10.1186/1471-2253-12-27] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 10/23/2012] [Indexed: 11/12/2022] Open
Abstract
Background Enhanced bleeding remains a serious problem after cardiac surgery, and fibrinolysis is often involved. We speculate that lower plasma concentrations of plasminogen activator inhibitor – 1 (PAI-1) preoperatively and tissue plasminogen activator/PAI-1 (t-PA/PAI-1) complex postoperatively might predispose for enhanced fibrinolysis and increased postoperative bleeding. Methods Totally 88 adult patients (mean age 66 ± 10 years) scheduled for cardiac surgery, were enrolled into a prospective study. Blood samples were collected pre-operatively, on admission to the recovery and at 6 and 24 hours postoperatively. Patients with a surgical bleeding that was diagnosed during reoperation were discarded from the study. The patients were allocated to two groups depending on the 24-hour postoperative chest tube drainage (CTD): Group I > 500ml, Group II ≤ 500ml. Associations between CTD, PAI-1, t-PA/PAI-1 complex and D-dimer were analyzed with SPSS. Results Nine patients were excluded because of surgical bleeding. Of the 79 remaining patients, 38 were allocated to Group I and 41 to Group II. The CTD volumes correlated with the preoperative plasma levels of PAI-1 (r = − 0.3, P = 0.009). Plasma concentrations of preoperative PAI-1 and postoperative t-PA/PAI-1 complex differed significantly between the groups (P < 0.001 and P = 0.012, respectively). Group I displayed significantly lower plasma concentrations of fibrinogen and higher levels of D-dimer from immediately after the operation and throughout the first 24 hours postoperatively. Conclusions Lower plasma concentrations of PAI-1 preoperatively and t-PA/PAI-1 complex postoperatively leads to higher plasma levels of D-dimer in association with more postoperative bleeding after cardiac surgery.
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Affiliation(s)
- Agnese Ozolina
- Department of Anaesthesiology and Cardiac surgery, Pauls Stradins Clinical University Hospital, Pilsonu street 13, Riga, Latvia.
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Emeklibas N, Kammerer I, Bach J, Sack FU, Hellstern P. Preoperative hemostasis and its association with bleeding and blood component transfusion requirements in cardiopulmonary bypass surgery. Transfusion 2012; 53:1226-34. [DOI: 10.1111/j.1537-2995.2012.03885.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Sniecinski RM, Chandler WL. Activation of the Hemostatic System During Cardiopulmonary Bypass. Anesth Analg 2011; 113:1319-33. [DOI: 10.1213/ane.0b013e3182354b7e] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Lu Q, Malinauskas RA. Comparison of two platelet activation markers using flow cytometry after in vitro shear stress exposure of whole human blood. Artif Organs 2010; 35:137-44. [PMID: 20946295 DOI: 10.1111/j.1525-1594.2010.01051.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Platelet activation is the initiating step to thromboembolic complications in blood-contacting medical devices. Currently, there are no widely accepted testing protocols or relevant metrics to assess platelet activation during the in vitro evaluation of new medical devices. In this article, two commonly used platelet activation marker antibodies, CD62P (platelet surface P-selectin) and PAC1 (activated GP IIb/IIIa), were evaluated using flow cytometry. Anticoagulant citrate dextrose solution A (ACDA) and heparin anticoagulated human blood from healthy donors were separately exposed to shear stresses of 0, 10, 15, and 20 Pa for 120 s using a cone-plate rheometer model, and immediately mixed with the platelet marker antibodies for analysis. To monitor for changes in platelet reactivity between donors and over time, blood samples were also evaluated after exposure to 0, 2, and 20 µM of adenosine diphosphate (ADP). Following ADP stimulation, the percentage of both CD62P and PAC1 positive platelets increased in a dose dependent fashion, even 8 h after the blood was collected. After shear stress stimulation, both CD62P and PAC1 positive platelets increased significantly at shear stress levels of 15 and 20 Pa when ACDA was used as the anticoagulant. However, for heparinized blood, the PAC1 positive platelets decreased with increasing shear stress, while the CD62P positive platelets increased. Besides the anticoagulant effect, the platelet staining buffer also impacted PAC1 response, but had little effect on CD62P positive platelets. These data suggest that CD62P is a more reliable marker compared with PAC1 for measuring shear-dependent platelet activation and it has the potential for use during in vitro medical device testing.
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Affiliation(s)
- Qijin Lu
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD 20993, USA.
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Fedorow CA, Moon MC, Mutch WA, Grocott HP. Lumbar Cerebrospinal Fluid Drainage for Thoracoabdominal Aortic Surgery. Anesth Analg 2010; 111:46-58. [DOI: 10.1213/ane.0b013e3181ddddd6] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Karlsson M, Ternström L, Hyllner M, Baghaei F, Skrtic S, Jeppsson A. Prophylactic Fibrinogen Infusion in Cardiac Surgery Patients: Effects on Biomarkers of Coagulation, Fibrinolysis, and Platelet Function. Clin Appl Thromb Hemost 2010; 17:396-404. [DOI: 10.1177/1076029610366437] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: We have recently reported that prophylactic fibrinogen infusion reduces bleeding after coronary artery bypass grafting (CABG) surgery. Because fibrinogen for the first time was administered to patients without hereditary fibrinogen deficiency or ongoing bleeding, a detailed analysis of the effects of fibrinogen concentrate on biomarkers of coagulation, fibrinolysis, and platelet function was performed. Methods: Twenty CABG patients with preoperative plasma fibrinogen levels <3.8 g/L were included in a prospective study. Patients were randomized to preoperative infusion of 2 g fibrinogen concentrate (fibrinogen group) or no infusion (control group). Activated partial thromboplastin time (aPTT), prothrombin time, activated clotting time, and plasma concentrations of fibrinogen, antithrombin, thrombin-antithrombin complex, prothrombin fragment 1.2, and D-dimer, thromboelastometry, platelet count, and platelet aggregometry were analyzed before and 15 minutes after infusion, and 2 and 24 hours after surgery. Results: Fifteen minutes after infusion of fibrinogen concentrate, fibrinogen plasma levels increased by 0.6 ± 0.2 g/L (P < .001 between groups), and induced minimal changes in aPTT and plasma levels of antithrombin, while remaining variables remained unchanged. After surgery, fibrinogen levels no longer differed between groups. D-dimer was significantly higher after surgery in the fibrinogen group (P = .03), while none of the other markers were statistically different between groups. Conclusions: Infusion of 2 g fibrinogen to cardiac surgery patients, without hereditary or acquired fibrinogen deficiency or ongoing bleeding, results in no or minimal changes in biomarkers reflecting coagulation and platelet function. An increased release of fibrin degradation products was detected after surgery in fibrinogen-treated patients.
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Affiliation(s)
- Martin Karlsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,
| | - Lisa Ternström
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Monica Hyllner
- Department of Cardiothoracic Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fariba Baghaei
- Department of Medicine/Haematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stanko Skrtic
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden, Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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