2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines

2024 EACTS/EACTAIC/EBCP Guidelines on cardiopulmonary bypass in adult cardiac surgery

Clinical practice guidelines consolidate and evaluate all pertinent evidence on a specific topic available at the time of their formulation. The goal is to assist physicians in determining the most effective management strategies for patients with a particular condition. These guidelines assess the impact on patient outcomes and weigh the risk-benefit ratio of various diagnostic or therapeutic approaches. While not a replacement for textbooks, they provide supplementary information on topics relevant to current clinical practice and become an essential tool to support the decisions made by specialists in daily practice. Nonetheless, it is crucial to understand that these recommendations are intended to guide, not dictate, clinical practice, and should be adapted to each patient's unique needs. Clinical situations vary, presenting a diverse array of variables and circumstances. Thus, the guidelines are meant to inform, not replace, the clinical judgement of healthcare professionals, grounded in their professional knowledge, experience and comprehension of each patient's specific context. Moreover, these guidelines are not considered legally binding; the legal duties of healthcare professionals are defined by prevailing laws and regulations, and adherence to these guidelines does not modify such responsibilities. The European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC) and the European Board of Cardiovascular Perfusion (EBCP) constituted a task force of professionals specializing in cardiopulmonary bypass (CPB) management. To ensure transparency and integrity, all task force members involved in the development and review of these guidelines submitted conflict of interest declarations, which were compiled into a single document available on the EACTS website (https://www.eacts.org/resources/clinical-guidelines). Any alterations to these declarations during the development process were promptly reported to the EACTS, EACTAIC and EBCP. Funding for this task force was provided exclusively by the EACTS, EACTAIC and EBCP, without involvement from the healthcare industry or other entities. Following this collaborative endeavour, the governing bodies of EACTS, EACTAIC and EBCP oversaw the formulation, refinement, and endorsement of these extensively revised guidelines. An external panel of experts thoroughly reviewed the initial draft, and their input guided subsequent amendments. After this detailed revision process, the final document was ratified by all task force experts and the leadership of the EACTS, EACTAIC and EBCP, enabling its publication in the European Journal of Cardio-Thoracic Surgery, the British Journal of Anaesthesia and Interdisciplinary CardioVascular and Thoracic Surgery. Endorsed by the EACTS, EACTAIC and EBCP, these guidelines represent the official standpoint on this subject. They demonstrate a dedication to continual enhancement, with routine updates planned to ensure that the guidelines remain current and valuable in the ever-progressing arena of clinical practice.

Direct Reinfusion of Unwashed Shed Autologous Blood During Thoracoabdominal Aortic Aneurysm Repair: A Retrospective Analysis

BACKGROUND

This study's purpose was to assess whether larger volumes of reinfused unwashed shed autologous blood (SAB) were associated with adverse events within 30 days for patients undergoing open thoracoabdominal aortic aneurysm (TAAA) repair. During TAAA repair, our institution uses a system wherein SAB is filtered, but not washed or centrifuged, and then returned to the patient via a rapid-infusion device. By reinfusing SAB, the system preserves the patient's autologous whole blood and may reduce the number of allogenic transfusions required during TAAA repair, but the end-organ effects of reinfusing unwashed SAB have not been extensively evaluated.

METHODS

Using a prospectively maintained database, we retrospectively analyzed data from 972 consecutive patients who underwent open TAAA repair at our institution from 2007 to 2021 and who received SAB. Multivariable logistic regressions were performed to assess whether SAB reinfusion volume was associated with a composite outcome of adverse events, as well as operative mortality, a composite of cardiac complications, a composite of pulmonary complications, or persistent paraplegia, stroke, or postoperative renal failure.

RESULTS

Among the cohort of 972 patients, the median volume of reinfused SAB was 4159 mL (quartile1-quartile3 [Q1-Q3]: 2524-6790 mL). Greater reinfusion volumes of unwashed SAB were not associated with greater odds of composite adverse events (odds ratio [OR], 1.02 per 1000 mL increase, 97.5% confidence interval [CI], 0.94-1.09, P = .624), nor with any individual outcome-operative mortality (OR, 1.02 per 1000 mL increase, 97.5% CI, 0.93-1.12, P = .617), a composite of cardiac complications (OR, 0.98 per 1000 mL increase, 97.5% CI, 0.93-1.04, P = .447), a composite of pulmonary complications (OR, 1.00 per 1000 mL increase, 97.5% CI, 0.94-1.06, P = .963), renal failure necessitating hemodialysis (OR, 1.01 per 1000 mL increase, 97.5% CI, 0.92-1.11, P = .821), persistent paraplegia (OR, 0.97 per 1000 mL increase, 97.5% CI, 0.84-1.13, P = .676), persistent stroke (OR, 0.85 per 1000 mL increase, 97.5% CI, 0.70-1.04, P = .070), or reoperation to control bleeding (OR, 0.99, 97.5% CI, 0.87-1.13, P = .900)-when adjusted for confounders.

CONCLUSIONS

For patients undergoing open TAAA repair, larger reinfusion volumes of unwashed SAB were not associated with greater odds of major early postoperative complications.

Intraoperative Factors Associated With Mechanical Ventilation Duration Following Aortic Surgery

OBJECTIVES

Prolonged postoperative mechanical ventilation is a common complication after major aortic surgery. The relationship between prolonged ventilation and intraoperative variables influenced by anesthesiologists, such as ventilation practices, fluid administration, and blood pressure control during major aortic surgery is unknown. We sought to identify perioperative factors, including intraoperative physiologic and anesthesia-related variables, which are associated with ventilation duration following aortic surgery.

DESIGN

Single-center retrospective observational study.

SETTING

A tertiary, high-volume cardiac surgery referral center.

PARTICIPANTS

Adult patients undergoing major aortic surgery requiring cardiopulmonary bypass (CPB).

INTERVENTIONS

None (retrospective observational study).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the duration of postoperative ventilation (hours). Mixed-effects regression was performed to identify factors associated with the primary outcome. Among the 647 patients included in this study, the median of postoperative mechanical ventilation duration was 9.0 (IQR 6.0, 14.4) hours, with 73 (11.3%) of patients receiving mechanical ventilation for more than 24 hours. Variables significantly associated with the outcome were increases in pre- to post-CPB driving pressure (β = 4.23; 95% CI [0.08, 8.39]; p = 0.04), reduction in pre- to post-CPB end-tidal carbon dioxide partial pressure (β = -5.12; 95% CI [-8.85, -1.39]; p < 0.001), and normalized transfusion volumes (β = 11.14; 95% CI [4.36, 17.91]; p < 0.001). Mechanical power was not associated with postoperative ventilation duration (β = -2.29; 95% CI [-6.48, 1.90]; p = 0.52).

CONCLUSIONS

Patients undergoing major aortic surgery are at risk for prolonged mechanical ventilation. Transfusion volume and pre- to post-CPB changes in driving pressures and end-tidal carbon dioxide are significantly associated with postoperative ventilation duration. Intraoperative mechanical ventilator power is not a significant predictor of mechanical ventilation duration after major aortic surgery. These variables are potentially modifiable by anesthesiologists and may be future therapeutic targets.

TEG® 6s-Guided Algorithm for Optimizing Patient Blood Management in Cardiovascular Surgery: Systematic Literature Review and Expert Opinion

OBJECTIVES

To propose a comprehensive TEG 6s-based intraoperative and/or immediately postoperative treatment algorithm for bleeding patients undergoing cardiac surgery. To achieve this, TEG-based treatment algorithms in cardiac surgery were evaluated through a literature review and structured expert opinion.

DESIGN

Systematic literature review.

SETTING

Cardiac surgery.

PARTICIPANTS

Adult patients undergoing cardiac surgery with intraoperative and/or immediately postoperative bleeding.

INTERVENTIONS

TEG-guided transfusion algorithm.

MEASUREMENTS AND MAIN RESULTS

A literature search was conducted for original studies reporting TEG-based treatment algorithms in cardiac surgery settings. Of 304 identified manuscripts, fourteen met all inclusion criteria, with two further articles identified through authors' suggestions. There is limited evidence describing the use of TEG 6s assays in cardiac surgery with only one study reporting a dedicated algorithm using the TEG 6s device at a non-US center. Two additional studies assessed TEG 6s assays. The remaining manuscripts reported algorithms based on the TEG 5000 device. Following the author's review of the available data, and feedback from expert opinion, a simple transfusion algorithm was proposed as an initial framework for developing a TEG 6s-based protocol with consideration for the 2021 Society of Thoracic Surgery/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology/Society for the Advancement of Patient Blood Management Patient Blood Management Guidelines.

CONCLUSIONS

A new algorithm for cardiac surgery based on TEG 6s assays has been proposed based on the available evidence and expert opinion for research alignment and clinical validation.

Acute normovolemic haemodilution to reduce allogeneic red blood cell transfusion in patients undergoing coronary artery bypass grafting. An observational study

BACKGROUND AND OBJECTIVE

Patients undergoing cardiac surgery consume more than 50% of blood transfusions, and such transfusions have been associated with increased morbidity and mortality. Evidence in blood-saving techniques has increased the use of acute normovolemic haemodilution (ANH) in high-risk settings. The aim was to determine the incidence of allogeneic red blood cell transfusion perioperatively in acute normovolemic haemodilution (ANH) patients undergoing coronary artery bypass grafting (CABG).

MATERIALS AND METHODS

This prospective observational cohort study was conducted in the Cardiac OR and ICU over 6 months, involving elective CABG patients aged 35-70 with ASA status III and IV. Haemoglobin and haematocrit levels were assessed preoperatively, intraoperatively and 24 h postoperatively.

RESULTS

In a cohort of 50 ANH patients, 44% (22/50) required allogeneic blood transfusion perioperatively, with 24% (12/50) intraoperatively, 14% (7/50) in the ICU and 6% (3/50) both intraoperatively and postoperatively. Lower intraoperative haemoglobin levels during CPB were significantly associated with increased transfusion odds in both univariable (OR, 0.25; 95% CI, 0.10-0.49, p = 0.001) and multivariable analyses (Adj. OR, 0.24; 95% CI, 0.09-0.62, p = 0.003), and prolonged surgical duration was a significant predictor in multivariable analysis (Adj. OR, 2.18; 95% CI, 1.01-4.73, p = 0.044). Additionally, prolonged wound healing was significantly more frequent in the patients requiring allogeneic blood transfusions (p = 0.044) highlighting potential postoperative complications.

CONCLUSION

Our study highlights the varying RBC transfusion rates in CABG patients, with lower intraoperative haemoglobin levels and prolonged surgical duration significantly increasing transfusion needs. These findings emphasise the importance of optimising intraoperative management to minimise transfusions and improve patient outcomes.

Society of American Gastrointestinal and Endoscopic Surgeons guidelines development: Clinical Practice Guideline Update Standard Operating Procedure

INTRODUCTION

The SAGES Guidelines Committee creates evidence-based clinical practice guidelines (CPGs). Updates which incorporate new evidence into the guidelines are necessary to maintain relevance for clinical use. A description of our standard operating procedure for this process is described here, which contributes to SAGES' commitment to producing high-quality clinical recommendations.

METHODS

This paper outlines the SAGES Clinical Practice Guideline Update Standard Operating Procedure in order to incorporate regular updates to our guideline development process.

RESULTS

SAGES has developed an evidence-based, standardized approach in updating current clinical practice guidelines to ensure that physicians and patients have access to the most appropriate recommendations.

CONCLUSION

Societies that promote guidelines within their organization must make an intentional effort to regularly evaluate the relevance of their recommendations. The SAGES Guidelines Update Standard Operating Procedure aims to provide a framework to reliably and systematically review existing guidelines and update them as needed.

Comparison of Perioperative Outcomes for Transfusion of Hemoconcentrated Bypass Versus Cell Saver Blood in Cardiac Surgical Patients

OBJECTIVE

Hemoconcentration and cell saver use are blood conservation techniques that are often used in cardiac surgery to salvage the patient's own blood to reduce autologous transfusion. The purpose of this study was to examine the perioperative outcomes including transfusion rates in cardiac surgical patients receiving hemoconcentrated blood versus cell saver blood via retrospective chart review. We hypothesized that hemoconcentration would have better patient outcomes, including reduced transfusion rates, compared to only cell salvage technique.

DESIGN

Single-center, retrospective chart review case-control study SETTING: Cardiac operating room of a tertiary care center PARTICIPANTS: Patients over 18 years old who underwent elective open-heart surgery with cardiopulmonary bypass between January 2015 to January 2018. Patients for emergencies, off-pump cases, transplants, and reoperations and with a need for second bypass were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The specific outcomes assessed include perioperative transfusion of packed red blood cells and blood products, intensive care unit (ICU) length of stay, hospital length of stay, and surgical site infections. Patient characteristics such as ejection fraction and comorbidities, pulmonary hypertension, atrial fibrillation history, and coagulation dysfunction were also analyzed. Propensity score matching was done to balance the covariates between the groups. The differences for each outcome outlined above were calculated. Of the 744 observations, 735 were used for analysis after propensity matching. Postoperative ICU red blood cell transfusions recorded a mean difference of -0.37 (95% CI: -0.78, 0.04). Postoperative ICU platelets and fresh frozen plasma recorded mean differences of -0.01 (95% CI: -0.11, 0.09) and -0.08 (95% CI: -0.19, 0.03), respectively. There were no significant differences in outcomes in bivariate- and covariate-adjusted models.

CONCLUSIONS

There is no significant difference in postoperative blood transfusion rates in hemoconcentrated versus cell saver blood usage in cardiac surgery patients. Further studies are needed to analyze specific quantities and ratios of hemoconcentrated and cell saver blood used in these patients for a more clinically relevant analysis. This would allow incorporation of hemoconcentration and cell saver techniques into better blood conservation processes and guide overall transfusion strategies to reduce transfusion rates of blood and blood products in cardiac surgical patients.

Quality of registration and adherence to guidelines for blood management in CABG surgeries: a case study

In many hospitals, patients undergoing cardiac surgery receive a higher amount of blood products transfusions compared to other disciplines. Blood transfusion comes with risks and drawbacks, such as increased morbidity and mortality across different patient groups, and specifically patients undergoing cardiac surgery, and high costs. Patient Blood Management (PBM) practices focus on the application of evidence based medical and surgical concepts in order to preserve the patient's own blood. Unfortunately, studies suggest that only a small fraction of published guidelines are implemented and followed into daily clinical practicedue to clear guidance, concerns about risks, and lack of knowledge, interdisciplinary commitment or resources. The widespread adoption of electronic health record (EHR) offers the opportunity to improve clinical outcomes through use of decision support system to guide the healthcare providers through best practices and guidelines. Decision support systems can be active, data-based, patient-specific and act timely, and can be more useful that adding new clinical practice guidelines. This case study quantifies the quality of the data registration and provides the results for adherence to perioperative PBM guidelines for coronary artery bypass grafting (CABG) procedures during a three-year period (2018 to 2020), in the St. Antonius hospital, a single heart center that performs over 10% of the total number of heart operations in the Netherlands. With this case study we identify some of the possible improvement factors for PBM in our center. We also quantify the impact of the quality of the registration in the EHR on the analysis results and on possible implementation of decision support systems.

Efficacy and Safety of Blood Transfusion Protocols in the Treatment of Myocardial Infarction: A Review of Restrictive and Liberal Approaches

Acute myocardial infarction (AMI) is a leading cause of death worldwide, and anemia in patients following AMI is quite common. Blood transfusions are one means of treating anemia, but once again, it is surrounded by debate over the best approach for transfusion: whether it is restrictive or liberal. This review assesses the efficacy and safety of a restrictive versus liberal blood transfusion strategy in AMI patients. Literature searches of the existing database were made with a view to retrieving RCTs, meta-analyses, systematic reviews, and clinical practice guidelines pertaining to both restrictive and liberal transfusion strategies for comparison of outcomes. Evidence suggests that this restrictive approach brings no patient harm, except perhaps in high-risk subgroups such as larger cardiovascular comorbidities. Key trials have shown that a restrictive strategy is at least as effective as a liberal strategy for most patients, including TRICC, TRACS, FOCUS, MINT, TITRe2, and REALITY Trials. Specifically, particular populations, especially those with pre-existing heart disease, may benefit from higher hemoglobin thresholds to prevent adverse outcomes. The best transfusion strategy should be tailored for each patient based on his/her personal factors, above all in cardiovascular health. A more restrictive transfusion strategy was effective and safe for the general population, but the subgroup of patients with very poor cardiovascular disease may require a more liberal approach. Further studies with better management guidelines are warranted to guide transfusion practices for optimal care in AMI patients.

Systematic Review and Meta-Analysis of Risk Factors Associated with Postoperative Stress Hyperglycemia in Patients without Diabetes Following Cardiac Surgery

Background

To systematically evaluate risk factors for stress-induced hyperglycemia in patients without diabetes after cardiac surgery.

Methods

Databases including CNKI, WanFang data, VIP, SinoMed, PubMed, Web of Science, Embase, and the Cochrane Library were searched using computer retrieval. The data were subjected to an in-depth meta-analysis using RevMan 5.4 and Stata 15.0 software.

Results

This study involved 11,645 postoperative cardiac surgery patients, including 8 case-control studies and 3 cohort studies, over which 18 risk factors were identified. The results of the meta-analysis indicated that statistically significant risk factors included age >65 years [odds ratios (OR) (95% CI ) = 3.47 (2.61-4.32)], female gender [OR (95%) = 1.54 (1.34-1.76)], combined heart valve and coronary artery bypass surgery [OR (95%) = 1.82 (1.23-2.70)], ejection fraction <40% [OR (95%) = 1.38 (1.17-1.63)], history of heart surgery [OR (95%) = 1.30 (1.06-1.59)], myocardial infarction [OR (95%) = 1.17 (1.05-1.31)], hyperlipidemia [OR (95%) = 0.76 (0.67-0.86)], hypertension [OR (95%) = 1.12 (1.03-1.22)], anticoagulant medication [OR (95%) = 0.77 (0.65-0.90)], cardiopulmonary bypass time >2 hours [OR (95%) = 20.26 (17.03-23.48)] and history of cardiopulmonary bypass [OR (95%) = 1.24 (1.09-1.41)].

Conclusions

Current evidence suggests that there are key risk factors for postoperative stress hyperglycemia in patients without diabetes who have undergone cardiac surgery. These factors can help identify patients at a high risk of perioperative stress hyperglycemia during cardiac surgery. This evidence provides a basis for healthcare professionals to develop predictive management strategies for perioperative stress hyperglycemia in patients without diabetes. However, more high-quality studies are required to address the limitations of the current research.

The PROSPERO registration

CRD42024479215, https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=479215.

Fresh frozen plasma transfusion after cardiac surgery

INTRODUCTION

Fresh frozen plasma (FFP) transfusion in the intensive care unit (ICU) is commonly used to treat coagulopathy and bleeding in cardiac surgery, despite suggestion that it may increase the risk of morbidity and mortality through mechanisms such as fluid overload and infection.

METHODS

We retrospectively studied consecutive adults undergoing cardiac surgery from the Medical Information Mart for Intensive Care III and IV databases. We applied propensity score matching to investigate the independent association of within-ICU FFP transfusion with mortality and other key clinical outcomes.

RESULTS

Of our 12,043 adults who met inclusion criteria, 1585 (13.2%) received perioperative FFP with a median of 2.48 units per recipient (interquartile range [IQR]: 2.04, 4.33) at a median time of 1.83 h (IQR: 0.75, 3.75) after ICU admission. After propensity matching of 952 FFP recipients to 952 controls, we found no significant association between FFP use and hospital mortality (odds ratio (OR): 1.58; 99% confidence interval (CI): 0.57, 3.71), suspected infection (OR: 0.72; 99% CI: 0.49, 1.08), or acute kidney injury (OR: 1.23; 99% CI: 0.91, 1.67). However, FFP was associated with increased days in hospital (adjusted mean difference (AMD): 1.28; 99% CI: 0.27, 2.41; p = .0050), days in intensive care (AMD: 1.28; 99% CI: 0.27, 2.28; p = .0011), and chest tube output in millilitres up to 8 h after transfusion (AMD: 92.98; 99% CI: 52.22, 133.74; p < .0001).

CONCLUSIONS

After propensity matching, FFP transfusion was not associated with increased hospital mortality, but was associated with increased length of stay and no decrease in bleeding in the early post-transfusion period.

Supportive care strategies in myelodysplastic syndromes and acute myeloid leukemia in older adults: a national survey of Canadian hematologists

Myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) are severe myeloid disorders associated with significant morbidity and mortality. Because of patient and disease factors, many older adults are treated as outpatients with less-intensive therapy. Optimal supportive care strategies to minimize bleeding and infectious complications in this patient population have not been systematically evaluated. We conducted a survey of Canadian hematologists to explore current practice in the use of tranexamic acid (TXA) and prophylactic antimicrobials in patients with MDS/AML treated with less-intensive therapy, and to evaluate equipoise for future trials. Survey items were generated through a combination of literature review and discussion with content experts. The survey was disseminated to 304 potential respondents with a response rate of 52%. Prophylactic platelet transfusions were used by 95%, while prophylactic TXA was used by 57%; the most frequent reason for not using TXA was uncertainty about benefit or harm. Use of prophylactic antimicrobials varied by chemotherapy regimen. If antimicrobial prophylaxis was used, the most frequently prescribed antibacterials were fluroquinolones (90%) and trimethoprim/sulfamethoxazole (21%); the most commonly used antifungals were fluconazole (66%) and voriconazole (36%). The most common reason for not using prophylactic antimicrobials was insufficient evidence of benefit. Most respondents agreed that clinical trials are needed to define the use of TXA and prophylactic antimicrobials in this patient population. Among survey respondents, there was variation in the use of supportive care strategies to address bleeding and infection risk in older adults with MDS/AML. The results of this survey will help to inform clinical trials to assess the benefits and risks of these prophylactic strategies.

Methodological Considerations for Studies Evaluating Bleeding Prediction Using Hemostatic Point-of-Care Tests in Cardiac Surgery

A certain proportion of patients undergoing cardiac surgery may experience bleeding complications that worsen outcomes. Numerous studies have investigated bleeding in cardiac surgery and some evaluate the role of hemostatic point-of-care tests in cardiac surgery patients. The prevalence of excessive bleeding varies in the literature, and such variability stems from the lack of a standardized definition of excessive bleeding. Herein, we report numerous definitions of excessive bleeding and methodological considerations for studies evaluating bleeding using hemostatic point-of-care tests in cardiac surgery patients. We evaluated the role of hemostatic point-of-care devices in contemporary research on bleeding complications and hemostatic management in cardiac surgery. The type of studies (prospective vs. retrospective, interventional vs. observational), patient selection (less complex vs. complex cases), as well as data analysis with comprehensive statistical considerations have also been provided. This article provides a comprehensive insight into the research field of bleeding complications in cardiac surgery and may help readers to better understand methodological flaws and how they influence current evidence.

Postoperative bleeding outcome of fresh frozen plasma prime in pediatric cardiac surgery: A systematic review & meta-analysis

INTRODUCTION

Bleeding after cardiac surgeries holds risk of mortality and morbidity in pediatrics. This systematic review aimed to evaluate postoperative blood loss and blood transfusion requirements for pediatric patients undergoing cardiac surgery with fresh frozen plasma (FFP) priming.

METHODS

In 2024, the search reviewed four databases on randomized trials (RCTs) examining the impact of FFP prime intervention on 24-h postoperative blood loss and transfusion requirements in pediatric cardiac surgeries. The journals were appraised using Grading of Recommendation Assessment, Development, and Evaluation checklists, and random effects models estimated the effect size with a 95% confidence interval. Significance and study heterogeneity were indicated by p-values and I2.

RESULTS

Of the screened 2070 articles, one high-quality and four moderate-quality RCTs involving 354 children were identified. No significant reduction in 24-h mean postoperative blood loss was found following FFP priming (mean difference MD: -0.78, 95% CI [-3.3 to 1.75], p = .55) in general pediatric cardiac surgeries. However, subgroup analysis showed significant decrease in blood loss for younger children (<7 months) or those with lower body weight (<6 kg). There was no significant difference between groups in FFP (MD: -0.19, 95% CI [-0.42 to 0.05], p = .13) or red blood cell transfusion (MD: -0.25, 95% CI [-0.51 to 0.02], p = .07).

CONCLUSION

Administering FFP as prime fluid in cardiac surgery did not reduce postoperative bleeding in general pediatric patients, but younger children (<7 months) and those with lower weight (<6 kg) were the subjects who benefited from the FFP priming before surgery.

Evaluation of staged autologous blood transfusion during extracorporeal membrane oxygenation decannulation: A retrospective study

BACKGROUND

Clinical blood resources are scarce and autologous blood transfusion for extracorporeal membrane oxygenation (ECMO) withdrawal is less studied.

OBJECTIVES

To assess the use of staged autotransfusion during ECMO decannulation.

METHODS

The study included ECMO withdrawal patients. Patients in the autologous transfusion group underwent staged transfusion during ECMO withdrawal, while those in the control group received 2.0 units of allogeneic packed red blood cells (RBCs) to increase hemoglobin (Hb). Parameters such as Hb, hematocrit (Hct), adverse events, decannulation success rate, volume of allogeneic RBC transfusions, and transfusion costs were compared.

RESULTS

A total of 82 Chinese patients were enrolled, with a mean age of 46 years, 27 were female, and the top three primary diagnoses were cardiac arrest, acute myocarditis, and severe pneumonia. There were 41 individuals in the autologous blood transfusion group and 41 in the control group. No significant differences were observed in Hb, Hct, adverse events, and the success rate for decannulation between the two groups (all P > 0.05). Compared with the control group, the volume of allogeneic RBC transfusions [0 (0∼1.50) U vs. 3.5 (1.88∼40) U, P < 0.001] and the total cost [130 (130∼390) Chinese Yuan (CNY) vs. 910 (487.50, 1040) CNY, P = 0.002] were lower in the autologous transfusion group.

CONCLUSION

In comparison with allogeneic RBC transfusion, staged autotransfusion during ECMO decannulation not only effectively maintained Hb levels but also reduced the requirement for allogeneic RBC transfusions. In addition, this approach decreased the associated costs and did not increase the risk of clinical adverse events.

Thromboelastography with Platelet Mapping to Optimize Surgical Timing in Coronary Artery Bypass Grafting Patients on P2Y12 Receptor Blockers Therapy

INTRODUCTION

An increasing number of patients attending coronary artery bypass grafting (CABG) receive preoperative antiplatelet drugs (acetylsalicylic acid, clopidogrel, prasugrel, ticagrelor). The optimal assessment of preoperative platelet function is the aim of this study for a shorter surgical timing in patients undergoing elective coronary artery bypass grafting.

METHODS

This study was performed on patients presenting for first-time isolated CABG on therapy with an P2Y12 receptor blockers loading dose (clopidogrel [300 mg] or prasugrel [60 mg] or ticagrelor [180 mg]) or P2Y12 receptor blockers maintenance therapy at least for five days (clopidogrel [75 mg once daily], prasugrel [10 mg once daily], ticagrelor [90 mg twice daily]). All patients received simultaneously acetylsalicylate acid (100 mg daily). Exclusion criterion was emergency CABG regardless of preoperative antiplatelet and anticoagulant therapy. All patients' data were recorded in an Excel® file and analyzed using RStudio® software.

RESULTS

Forty-eight consecutive adult patients presenting for CABG were enrolled. Preoperative thromboelastography-platelet mapping showed platelet resistance to P2Y12 blockers receptor - 25% for clopidogrel (6/24), 33% for ticagrelor (6/18), 33% for prasugrel (2/6), and this data was useful to obtain a shorter CABG waiting time in comparison with current guidelines (2.7 vs. five days for clopidogrel, 2.5 vs. five days for ticagrelor, 3.3 vs. seven days for prasugrel).

CONCLUSION

Preoperative thromboelastography-platelet mapping is helpful to detect harmful P2Y12 receptor blockers resistance and to minimize CABG waiting time avoiding unnecessary and life-threatening delays.

Intraoperative Allogeneic Blood Transfusion Has No Impact on Postoperative Short-Term Outcomes After Pancreatoduodenectomy for Periampullary Malignancies: A Propensity Score Matching Analysis and Mediation Analysis

Background/Objectives: The aim of this study was to investigate the association between intraoperative blood transfusion (BT) and the short-term outcomes of pancreatoduodenectomy (PD) for patients with periampullary malignancies. Methods: In a retrospective two-center cohort analysis, we utilized a logistic and mixed-effects ordinal regression, nonparametric partial correlation, and mediation analysis, complemented by propensity score matching (PSM) and weighting. Results: A total of 491 patients were included. Of these, 18 (3.7%) received an intraoperative BT. An intraoperative BT was associated with blood loss (odds ratio (OR) per 100 mL = 1.42; 95% CI 1.27 to 1.62; p < 0.001) and relatively high ASA classes (OR = 3.75; 95% CI 1.05 to 17.74; p = 0.041). Intraoperative blood loss (r = 0.27; p < 0.001) but not intraoperative BT (r = 0.015; p = 0.698) was associated with postoperative complications. Intraoperative BT was associated with postoperative complications according to the unadjusted regression (OR = 1.95; 95% CI 1.38-2.42, p < 0.001) but not the multivariable ordinal regression. In the mediation analysis for relative risk (RR), intraoperative BT was beneficial (RR = 0.51; 95% CI: 0.01-0.78), and blood loss (RR = 2.49; 95% CI: 1.75-177.34) contributed to the occurrence of major postoperative complications. After PSM, analyses revealed that an intraoperative BT did not have a significant impact on the rates of postoperative major complications (OR = 1.048; p = 0.919), clinically relevant postoperative pancreatic fistula (OR = 0.573; p = 0.439) or postoperative 90-day mortality (OR = 0.714; p = 0.439). Conclusions: When adjusting for intraoperative blood loss, intraoperative BT is not associated with postoperative complications.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients. To address this challenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung Transplantation Standards and Guidelines Committee. International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods. Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria. These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

Desmopressin use in major cardiac surgery is associated with renal impairment: a retrospective single-center analysis

BACKGROUND

Desmopressin acetate (1-deamino-8-d-arginine vasopressin-DDAVP) is a analogue of the antidiuretic hormone vasopressin. DDAVP is suggested to reduce bleeding after cardiac surgery using cardiopulmonary bypass. The aim of this study was to determine if DDAVP has any negative impact on renal function leading to acute kidney injury (AKI) and therefore increases the need for renal replacement therapy (RRT).

METHODS

We performed a retrospective single institutional cohort analysis of 2,179 patients undergoing elective and urgent cardiac surgery with CPB from 2017 to 2021. Logistic regression analysis was used to investigate any association between DDAVP, the incidence of AKI KDIGO class 3 and the need for RRT, respectively. The model was adjusted for relevant covariates, including preexisting renal impairment, pharmacological hemodynamic support with vasopressors, complexity of the surgery and postoperative lactate. Secondary outcomes included, in hospital mortality and the need for allogenic blood transfusion.

RESULTS

A total of 992 (45.5%) patients received DDAVP intraoperatively during surgery or shortly thereafter. The use of DDAVP was associated with a significant increase in in AKI KDIGO class 3 (OR 2.27; 95% CI 1.46-3.55; p < 0,001) and the need for RRT (OR 2.19; 95%CI 1.48-3.24; p < 0,001). Both findings persisted after covariate adjusting. No increased in-hospital mortality was associated with DDAVP.

CONCLUSION

In cardiac surgery, the use of DDAVP was associated with an increased rate of server AKI and the requirement for RRT. Given the severity of the potential harm associated with DDAVP, an evidence-based reevaluation is needed to enable an accurate risk and benefit assessment.

Comparison of Low Dose Recombinant Factor VIIa and 4-Factor Prothrombin Complex Concentrate for Treatment of Bleeding Related to Cardiac Surgery

Background: Recombinant factor VIIa (rFVIIa) and prothrombin concentrate complex (PCC) are used for uncontrolled bleeding in cardiac surgery (CS), however, there are limited direct comparisons of these agents. Objective: To evaluate the efficacy and safety of rFVIIa and PCC in CS related bleeding. Methods: This retrospective study included adult CS patients who received either low dose rFVIIa (<30 mcg/kg) or 4-factor PCC. The primary outcome was transfusion requirements of packed red blood cells (pRBC) within 6 hours of factor administration. Secondary efficacy outcomes included transfusion requirements 0-18 hours, doses of additional factor product, thrombotic events, and acute kidney injury (AKI). Results: A total of 179 patients were included (n = 78 rFVIIa; n = 101 PCC). Of patients who received blood products, there was no difference in the requirement of pRBCs within 6 hours (73.8 vs 68.9%, P = .5359) or in the median amount of pRBC transfused (500 mL vs 640 mL, P = .0723) in the rFVIIa and PCC groups respectively. Patients in the PCC group were more likely to require additional factor products (24.4% vs 47.5%, P = .0015), develop AKI (12.8% vs 25.7%, P = .0325), have longer ICU lengths of stay [2 (IQR 1-5) vs 4 (IQR 2-6), P = .0487] and greater in-hospital mortality (2.6% vs 10.9%, P = .033). There was no difference in thrombotic events. Conclusion: Although, there was no difference in pRBC transfusion requirements between PCC and rFVIIa, more patients in the PCC group required additional factor products and had increased adverse effects. Further comparisons of PCC and rFVIIa are warranted.

Prediction of Acute Kidney Injury After Coronary Artery Bypass Graft From Preoperative Serum Uric Acid

OBJECTIVE

To examine the association of an elevated level of uric acid (UA) in the bloodstream with an increased likelihood of acute kidney injury (AKI) following coronary artery bypass grafting (CABG) surgery.

DESIGN

Retrospective cohort study using a multivariate logistic regression model.

SETTING

Single institution.

PARTICIPANTS

Recipients of CABG surgery.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

A total of 761 individuals who underwent CABG were included in the study. The participants were categorized into 4 groups based on their UA level: Q1 group (UA <292.5 μmol/L), Q2 group (292.5 ≤ UA <353 μmol/L), Q3 group (353 ≤ UA < 423 μmol/L), and Q4 group (UA ≥423 μmol/L). A total of 167 patients, accounting for 21.9% of the sample, experienced postoperative AKI. The study found a significantly higher risk of AKI in the Q4 group compared to the Q1 group (40.4% v 8.9%; p < 0.001). After adjustment for confounding variables, an independent association between serum UA concentration and an elevated risk of AKI post-CABG was identified (odds ratio, 6.41; 95% confidence interval, 3.49-12.32; p < 0.001; p for trend < 0.001).

CONCLUSIONS

There is a relationship between preoperative blood UA level and the occurrence of AKI following CABG surgery.

Effect of Preoperative Recombinant Human Erythropoietin on the Need for Blood Transfusion and Surgical Outcomes in Adult Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

This study aimed to examine the value of preoperative recombinant human erythropoietin (rhEPO) administration to adults undergoing elective cardiac surgery. Databases were searched for randomized controlled trials (RCTs) comparing rhEPO plus standard treatment versus standard treatment only. Primary outcomes were the need for and volume of homologous blood transfusion (HBT). Secondary outcomes were the lengths of intensive care unit (ICU) and hospital stay and the incidence of major adverse events. There was very low certainty that rhEPO is associated with a reduction in the need for HBT, with a number needed to treat of 5.6 (95% confidence interval [CI], 3.9-12.5), and low certainty that it is associated with a moderate reduction in HBT volume (Hedges g = -0.55; 95% CI, -0.79 to -0.32). Meta-regression revealed that studies with a higher proportion of females or older patients demonstrated less benefit of rhEPO in terms of reduced consumption of HBT. Trial sequential analysis showed that rhEPO was superior to standard treatment only for reducing the need for and volume of HBT. Regarding secondary outcomes, there was moderate certainty that rhEPO is associated with a limited reduction in the length of ICU (Hedges g = -0.10; 95% CI, -0.19 to -0.01) and hospital stay (Hedges g = -0.13; 95% CI = -0.25 to -0.02), and low certainty for increased risk of myocardial infarction, with a number needed to harm of 36.1 (95% CI, 17.9-127.4). More well-designed, adequately powered RCTs are needed to draw conclusions regarding the value of rhEPO.

Acquired antithrombin deficiency in adult patients with postcardiotomy extracorporeal membrane oxygenation

INTRODUCTION

This study aimed to investigate the relationship between acquired antithrombin deficiency in patients undergoing postcardiotomy extracorporeal membrane oxygenation (PC-ECMO) and thromboembolic or haemorrhagic events such as bleeding, peripheral arterial thromboembolism, and ischemic cerebrovascular events.

METHODS

The study was designed as a single-center, prospective study and conducted at our hospital between November 2019 and June 2021. 50 patients who underwent ECMO due to postcardiotomy cardiogenic shock were included in the study. Antithrombin (AT) activity testing was performed immediately after ECMO placement and continued for 5 days. The total of haemorrhagic or thromboembolic events was defined as morbidity. The entire patient population was assessed daily for AT measurements according to morbidity status, and ROC analysis was applied to determine the cut-off point. The correlation between clinical outcomes and morbidities with antithrombin levels was analysed.

RESULTS

In our study, we identified a cut-off for AT levels on the first postoperative day. The risk of both bleeding (p = .006) and thromboembolism (p = .012) was significantly higher in patients below the 48.9% cut-off value. AT levels were compared with data on separation from PC-ECMO. The rate of separation from ECMO was 7.969 times higher in cases with AT levels above 51.8 on the third postoperative day and 5.6 times higher in cases with AT levels above 47.5 on the fourth postoperative day.

CONCLUSION

Acquired antithrombin deficiency may develop in adults undergoing PC-ECMO. In our study, we demonstrated that in patients with low antithrombin levels, the risk of bleeding and thromboembolism increased. Additionally, since AT levels were higher in survivors, this can be considered an indicator of severity. This study is the first prospective study related to determining target antithrombin levels in adult patients undergoing PC-ECMO.

Protocol for a phase 3, randomised, active-control study of four-factor prothrombin complex concentrate versus frozen plasma in bleeding adult cardiac surgery patients requiring coagulation factor replacement: the LEX-211 (FARES-II) trial

INTRODUCTION

Reduced thrombin generation is an important component of post cardiopulmonary bypass (CPB) coagulopathy. To replenish coagulation factors and enhance thrombin generation in bleeding surgical patients, frozen plasma (FP) and four-factor prothrombin complex concentrate (4F-PCC) are used. However, the efficacy-safety balance of 4F-PCC relative to FP in cardiac surgery is unconfirmed.

METHODS AND ANALYSIS

LEX-211 (FARES-II) is an active-control, randomised, phase 3 study comparing two coagulation factor replacement therapies in bleeding adult cardiac surgical patients at 12 hospitals in Canada and the USA. The primary objective is to determine whether 4F-PCC (Octaplex/Balfaxar, Octapharma) is clinically non-inferior to FP for haemostatic effectiveness. Inclusion criteria are any index (elective or non-elective) cardiac surgery employing CPB and coagulation factor replacement with 4F-PCC or FP ordered in the operating room for bleeding management. Patients will be randomised to receive 1500 or 2000 international units of 4F-PCC or 3 or 4 units of FP, depending on body weight. The primary endpoint of haemostatic treatment response is 'effective' if no additional haemostatic intervention is required from 60 min to 24 hours after the first initiation of 4F-PCC or FP; or 'ineffective' if any other haemostatic intervention (including a second dose of study drug) is required. An estimated 410 evaluable patients will be required to demonstrate non-inferiority (one-sided α of 0.025, power ≥90%, non-inferiority margin 0.10). Secondary outcomes include transfusions, bleeding-related clinical endpoints, coagulation parameters and safety.

ETHICS AND DISSEMINATION

The trial has been approved by the institutional review boards of all participating centres. Trial completion is anticipated at the end of 2024, and results will be disseminated via publications in peer-reviewed journals and conference presentations in 2025. The results will advance our understanding of coagulation management in bleeding surgical patients, potentially reducing the need for allogeneic blood products and improving outcomes in surgical patients.

TRIAL REGISTRATION NUMBER

NCT05523297.

Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial

BACKGROUND

Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain.

METHODS

This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions.

RESULTS

The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications.

CONCLUSION

The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB.

STUDY REGISTRATION

This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

Tranexamic acid - a promising hemostatic agent with limitations: a narrative review

Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been used for several decades to reduce blood loss during surgery and after trauma. TXA was traditionally used to reduce bleeding in various clinical settings such as menorrhagia, hemophilia, or other bleeding disorder. Numerous studies have demonstrated the efficacy of TXA in reducing blood loss and the need for transfusions. Interest in the potential applications of TXA beyond its traditional use has been growing recently, with studies investigating the use of TXA in postpartum hemorrhage, cardiac surgery, trauma, neurosurgery, and orthopedic surgery. Despite its widespread use and expanding indications, data regarding the safe and appropriate use of TXA is lacking. Recent clinical trials have found various potential risks and limitations in the long-term benefits of TXA. This narrative review summarizes the clinical applications and limitations of TXA.

Topical Tranexamic Acid (TXA) Decreases Time to Drain Removal, Wound Healing Complications, and Postoperative Blood Loss in Autologous Breast Reconstruction: A Retrospective Study

Introduction: Drain placement is commonplace after many plastic surgery procedures to evacuate excess blood and fluid. Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease bleeding and fluid production at surgical sites and can be administered orally, intravenously, and topically. The purpose of this study is to evaluate the effect of topical TXA on drain removal in abdominally based autologous breast reconstruction (ABABR). Methods: A retrospective chart review was performed on patients who underwent ABABR from August 2018 to November 2019. In 1 cohort, a 2.5% TXA solution was topically applied to the abdominal wall prior to closure. Drains were removed when output was less than 30 mL/day for 2 consecutive days. The primary outcome was days to drain removal. Secondary outcomes include daily inpatient drain output, postoperative hemoglobin levels, blood transfusions, and complications within 30 days postoperatively. Results: Eighty-three patients were included, with 47 in the control group and 36 in the TXA group. Drains were removed significantly earlier in patients who received TXA (16 days vs 23 days, P = .02). Additionally, significantly fewer patients required postoperative blood transfusions in the TXA group (2 vs 14, P = .005). Abdominal complications were fewer in the TXA group with significantly less wound healing complications (22% vs 49%, P = .01). There was no difference in flap loss or systemic thromboembolic events. Conclusion: Topical TXA use in ABABR results in earlier abdominal drain removal, less blood transfusions, and lower abdominal wound complications without an increased risk of flap loss or adverse patient outcomes.

Evaluation of the Factors Influencing Blood Transfusion during Minimally Invasive Direct Coronary Artery Bypass Surgery

INTRODUCTION

The objective of this study was to analyze the blood transfusion factors of minimally invasive direct coronary artery bypass (MIDCAB) surgery using artificial intelligence.

METHODS

A retrospective analysis was performed for patients undergoing MIDCAB operations and no heart-lung machine was used from January 2017 to September 2022 in our hospital. The influencing factors of blood transfusion were used to build the artificial intelligence model. Eighty percent of the database was used as the training set, and twenty percent database was used as the testing set. To predict whether to use red blood cells during operation, we compared 104 artificial intelligence models. We aimed to assess whether which factors influence allogeneic transfusion in MIDCAB operations.

RESULTS

Of the 104 machine learning algorithms, the XGBoost model delivered the best performance, with an AUC of 0.726 in the testing set and an accuracy of 0.854 in the testing set. The artificial intelligence model showed preoperative hemoglobin less than 120 g/L, prothrombin time greater than 13.75, body mass index less than 22.7 kg/m2, coronary heart disease with additional comorbidities, a history of percutaneous coronary intervention, weight lower than 67 kg were the six major risk factors of allogeneic transfusion.

CONCLUSION

The XGBoost model can predict transfusion or not transfusion in MIDCBA surgery with high accuracy.

INTRODUCTION

The objective of this study was to analyze the blood transfusion factors of minimally invasive direct coronary artery bypass (MIDCAB) surgery using artificial intelligence.

METHODS

A retrospective analysis was performed for patients undergoing MIDCAB operations and no heart-lung machine was used from January 2017 to September 2022 in our hospital. The influencing factors of blood transfusion were used to build the artificial intelligence model. Eighty percent of the database was used as the training set, and twenty percent database was used as the testing set. To predict whether to use red blood cells during operation, we compared 104 artificial intelligence models. We aimed to assess whether which factors influence allogeneic transfusion in MIDCAB operations.

RESULTS

Of the 104 machine learning algorithms, the XGBoost model delivered the best performance, with an AUC of 0.726 in the testing set and an accuracy of 0.854 in the testing set. The artificial intelligence model showed preoperative hemoglobin less than 120 g/L, prothrombin time greater than 13.75, body mass index less than 22.7 kg/m2, coronary heart disease with additional comorbidities, a history of percutaneous coronary intervention, weight lower than 67 kg were the six major risk factors of allogeneic transfusion.

CONCLUSION

The XGBoost model can predict transfusion or not transfusion in MIDCBA surgery with high accuracy.

Aprotinin in high-risk isolated coronary artery bypass graft patients: a 3-year propensity matched study

BACKGROUND

Aprotinin, a serine protease inhibitor, has been used variably in cardiac surgery amidst ongoing debates about its safety following several previous studies. This study assesses the outcomes of aprotinin in high-risk isolated Coronary Artery Bypass Graft (iCABG) patients.

METHODS

The study retrospectively analysed a cohort of 1026 iCABG patients, including 51 patients who underwent aprotinin treatment. Logistic regression powered score matching was employed to compare aprotinin patients with a control group, in a propensity-matched cohort of 96 patients. The primary outcome measured was in-hospital death, with secondary outcomes including renal dysfunction, stroke, myocardial infarction, re-exploration for bleeding or tamponade, and postoperative stay durations.

RESULTS

The aprotinin cohort had high-risk preoperative patients with significantly higher EUROSCORE II values, 7.5 (± 4.2), compared to 3.9 (± 2.5) in control group. However, aprotinin group showed no statistically significant increase (p-value: 0.44) in hospital mortality with OR 2.5 [95% CI 0.51, 12.3]. Major secondary outcome rates of renal replacement therapy and postoperative stroke compared to the control group were also statistically insignificant between the two groups.

CONCLUSION

This study suggests that aprotinin may be safely used in a select group of high-risk iCABG patients. The reintroduction of aprotinin under specific conditions reflects its potential benefits in managing bleeding in high-risk surgeries, but also underscores the complexity of its risk-benefit profile in such critical care settings. Nonetheless, it highlights the importance of carefully selecting patients and conducting additional research, including larger and more controlled studies to fully comprehend the potential risks and benefits of aprotinin.

Improvement of Transfusion Practice in Cardiothoracic Surgery Through Implementing a Patient Blood Management Program

Background

In this study, we examined the impact of a patient blood management (PBM) program on red blood cell (RBC) transfusion practices in cardiothoracic surgery.

Methods

The PBM program had 3 components: monitoring transfusions through an order communication system checklist, educating the medical team about PBM, and providing feedback to ordering physicians on the appropriateness of transfusion. The retrospective analysis examined changes in the hemoglobin levels triggering transfusion and the proportions of appropriate RBC transfusions before, during, and after PBM implementation. Further analysis was focused on patients undergoing cardiac surgery, with outcomes including 30-day mortality, durations of intensive care unit and hospital stays, and rates of pneumonia, sepsis, and wound complications.

Results

The study included 2,802 patients admitted for cardiothoracic surgery. After the implementation of PBM, a significant decrease was observed in the hemoglobin threshold for RBC transfusion. This threshold dropped from 8.7 g/dL before PBM to 8.3 g/dL during the PBM education phase and 8.0 g/dL during the PBM feedback period. Additionally, the proportion of appropriate RBC transfusions increased markedly, from 23.9% before PBM to 34.9% and 58.2% during the education and feedback phases, respectively. Among the 381 patients who underwent cardiac surgery, a significant reduction was noted in the length of hospitalization over time (p<0.001). However, other clinical outcomes displayed no significant differences.

Conclusion

PBM implementation effectively reduced the hemoglobin threshold for RBC transfusion and increased the rate of appropriate transfusion in cardiothoracic surgery. Although transfusion practices improved, clinical outcomes were comparable to those observed before PBM implementation.

Antifibrinolytic and Adjunct Hemostatic Agents: The Pediatric Extracorporeal Membrane Oxygenation Anticoagulation CollaborativE Consensus Conference

OBJECTIVES

To derive systematic-review informed, modified Delphi consensus regarding antifibrinolytic and adjunct hemostatic agents in neonates and children supported with extracorporeal membrane oxygenation (ECMO) for the Pediatric ECMO Anticoagulation CollaborativE consensus conference.

DATA SOURCES

A structured literature search was performed using PubMed, EMBASE, and Cochrane Library (CENTRAL) databases from January 1988 to May 2021.

STUDY SELECTION

Use of antifibrinolytics (epsilon-aminocaproic acid [EACA] or tranexamic acid), recombinant factor VII activated (rFVIIa), or topical hemostatic agents (THAs).

DATA EXTRACTION

Two authors reviewed all citations independently, with a third independent reviewer resolving conflicts. Eleven references were used for data extraction and informed recommendations. Evidence tables were constructed using a standardized data extraction form.

MEASUREMENTS AND MAIN RESULTS

Risk of bias was assessed using the Quality in Prognosis Studies tool. The evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation system. Forty-eight experts met over 2 years to develop evidence-based recommendations and, when evidence was lacking, expert-based consensus statements for the management of bleeding and thrombotic complications in pediatric ECMO patients. A web-based modified Delphi process was used to build consensus via the Research And Development/University of California Appropriateness Method. Consensus was defined as greater than 80% agreement. One weak recommendation and three consensus statements are presented.

CONCLUSIONS

Evidence supporting recommendations for administration of antifibrinolytics (EACA or tranexamic acid), rFVIIa, and THAs were sparse and inconclusive. Much work remains to determine effective and safe usage strategies.

Association of perioperative transfusion of fresh frozen plasma and outcomes after cardiac surgery

BACKGROUND

Fresh frozen plasma (FFP) transfusion is used to manage coagulopathy and bleeding in cardiac surgery patients despite uncertainty about its safety and effectiveness.

METHODS

We performed a propensity score matched analysis of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database including patients from 39 centres from 2005 to 2018. We investigated the association of perioperative FFP transfusion with mortality and other clinical outcomes.

RESULTS

Of 119,138 eligible patients, we successfully matched 13,131 FFP recipients with 13,131 controls. FFP transfusion was associated with 30-day mortality (odds ratio (OR), 1.41; 99% CI, 1.17-1.71; p < .0001), but not with long-term mortality (hazard ratio (HR), 0.92; 99% CI, 0.85-1.00; p = .007, Holm-Bonferroni α = 0.0004). FFP was also associated with return to theatre for bleeding (OR, 1.97; 99% CI, 1.66-2.34; p < .0001), prolonged intubation (OR, 1.15; 99% CI, 1.05-1.26; p < .0001) and increased chest tube drainage (Mean difference (MD) in mL, 131; 99% CI, 120-141; p < .0001). It was also associated with reduced postoperative creatinine levels (MD in g/L, -6.33; 99% CI, -10.28 to -2.38; p < .0001).

CONCLUSION

In a multicentre, propensity score matched analysis, perioperative FFP transfusion was associated with increased 30-day mortality and had variable associations with secondary clinical outcomes.

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.

Temperance With Tranexamic Acid: Increased Risk of Venous Thromboembolism in Abdominoplasty

Tranexamic acid (TXA) is used widely in surgery to mitigate blood loss by inhibiting the fibrinolytic degradation of clots. The occurrence of venous thromboembolism (VTE) with TXA has not been reported in the plastic surgery literature. In the realm of plastic surgery, abdominoplasty has the highest rate of VTE. The purpose of this study is to report 5 cases of VTE with TXA. A single surgeon reviewed the records of 5 patients who incurred VTE with TXA. TXA was added to the tumescent fluid, 20 mg/kg total. Four of the 5 patients underwent abdominoplasty combined with liposuction and breast surgery, and the fifth, fat transfer to the breast. The abdominoplasty patients had received chemoprophylaxis. Upon presentation of symptoms, the patients were sent to the hospital for anticoagulation and hematology consultation. The 5 patients survived their VTE events; 2 only required oral anticoagulation, 2 required IV heparin then oral, and 1 required tissue plasminogen activator (tPA) then oral. VTE with abdominoplasty occurred in 0 of 399 cases prior to the use of TXA and in 4 of 98 cases after the use of TXA in the tumescent. Although the occurrence of VTE with abdominoplasty increased with the use of TXA for the senior author, this retrospective case study does not prove a causal relationship between TXA and VTE.

Level of Evidence 4

Perfusion Measures and Outcomes (PERForm) registry: First annual report

BACKGROUND

The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology.

METHODS

This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported.

RESULTS

A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%).

CONCLUSION

Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.

Cardiac Surgery-Associated Acute Kidney Injury

AKI is a common and serious complication of cardiac surgery that has a significant impact on patient morbidity and mortality. The Kidney Disease Improving Global Outcomes definition of AKI is widely used to classify and identify AKI associated with cardiac surgery (cardiac surgery-associated AKI [CSA-AKI]) on the basis of changes in serum creatinine and/or urine output. There are various preoperative, intraoperative, and postoperative risk factors for the development of CSA-AKI which should be recognized and addressed as early as possible to expedite its diagnosis, reduce its occurrence, and prevent or ameliorate its devastating complications. Crucial issues are the inaccuracy of serum creatinine as a surrogate parameter of kidney function in the perioperative setting of cardiothoracic surgery and the necessity to discover more representative markers of the pathophysiology of AKI. However, except for the tissue inhibitor of metalloproteinase-2 and insulin-like growth factor binding protein 7 ratio, other diagnostic biomarkers with an acceptable sensitivity and specificity are still lacking. This article provides a comprehensive review of various aspects of CSA-AKI, including pathogenesis, risk factors, diagnosis, biomarkers, classification, prevention, and treatment management.

Use of Intravenous Tranexamic Acid in Patients Undergoing Plastic Surgery: Implications and Recommendations per a Systematic Review and Meta-Analysis

With increasing interest in aesthetic plastic procedures, the event of blood loss has compromised patients' safety and satisfaction. Tranexamic acid (TXA) is a drug used for the reduction of blood loss during surgical procedures. This systematic review aims to evaluate the clinical efficacy and safety of TXA in aesthetic plastic surgery for the reduction of bleeding and related complications. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Electronic databases PubMed, EMBASE, Cochrane Library, and Google Scholar were searched. The medical subject headings (MeSH) keywords used for data extraction were ("TXA," OR "tranexamic acid,") AND ("plastic surgery," OR "aesthetic surgery," OR "rhinoplasty," OR "blepharoplasty,") AND ("blood loss" OR "bleeding" OR "TBL") AND ("Edema" OR "ecchymosis"). A combination of these MeSH terms was used in the literature search. The timeline of research was set from 2015 to January 2024. A total of 7380 research articles were identified from the above-mentioned databases, and only 13 research articles met the inclusion criteria. There was a significant difference in total blood loss (TBL) among patients who had undergone plastic surgery procedures while on TXA as compared to a placebo (mean difference = -6.02; Cl: -1.07 to -0.16; p > 0.00001), and heterogeneity was found (degrees of freedom (df) = 9; I2 = 97%). Only two studies reported the average ecchymosis scores after TXA among interventions in comparison to the placebo group. This review provides evidence that TXA lowers TBL, ecchymosis, edema, and anemia during cosmetic surgery without significantly increasing thromboembolic consequences.

The Adherence to an Intraoperative Blood Product Transfusion Algorithm Is Associated With Reduced Blood Product Transfusions in Cardiac Surgical Patients Undergoing Coronary Artery Bypass Grafts and Aortic and/or Valve Replacement Surgery: A Single-Center, Observational Study

OBJECTIVE

To demonstrate the value of a viscoelastic-based intraoperative transfusion algorithm to reduce non-RBC product administration in adult cardiac surgical patients.

DESIGN

A prospective observational study.

SETTING

At a quaternary academic teaching hospital.

PARTICIPANTS

Cardiac surgical patients.

INTERVENTIONS

Viscoelastic-based intraoperative transfusion algorithm.

MEASUREMENTS AND MAIN RESULTS

The study authors compared intraoperative blood product transfusion rates in 184 cardiac surgical patients to 236 historic controls after implementing a viscoelastic-based algorithm. The authors found a non-significant reduction in transfusion of 23.8% for fresh frozen plasma (FFP) units (0.84 ± 1.4 v 0.64 ± 1.38; p = ns), 33.4% for platelet units (0.90 ± 1.39 v 0.60 ± 131; p = ns), and 15.8% for cryoprecipitate units (0.19 ± 0.54 v 0.16 ± 0.50; p = ns). They found a 43.9% reduction in red blood cell (RBC) units transfused (1.98 ± 2.24 v 0.55 ± 1.36; p = 0.008). There were no statistically significant differences in time to extubation (8.0 hours (4.0-21.0) v 8.0 (4.0-22.3), reoperation for bleeding (15 [12.3%] v 10 [10.6%]), intensive care unit length of stay (ICU LOS) (51.0 hours [28.0-100.5] v 53.5 [33.3-99.0]) or hospital LOS (9.0 days [6.0-15.0] v 10.0 [7.0-17.0]). Deviation from algorithm adherence was 32.7% (48/147). Packed RBC, FFP, platelets, cryoprecipitate, and cell saver were significantly reduced in the Algorithm Compliant Cohort compared with historic controls, whereas times to extubation, ICU LOS, and hospital LOS did not reach significance.

CONCLUSIONS

After the implementation of a viscoelastic-based algorithm, patients received fewer packed RBC, FFP, platelets, cryoprecipitate, and cell saver. Algorithm-compliant patients received fewer transfusions; however, reductions in times to extubation, ICU LOS, and hospital LOS were not statistically significant compared with historic controls.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Antifibrinolytics

The use of strategies to reduce blood loss and transfusions is essential in the treatment of surgical patients, including in complex cardiac surgeries and those that use cardiopulmonary bypass. Antifibrinolytics, such as epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA), are widely used in these procedures, as well as in other types of surgeries. These medicines are included in the World Health Organization (WHO) list of 'essential medicines'. Scientific evidence demonstrates the effectiveness of EACA in reducing bleeding and the need for transfusions in heart surgery. EACA is highly recommended for use in heart surgery by the American Society of Anesthesiology Task Force on Perioperative Blood Management. Regarding the safety of EACA, there is no robust evidence of any significant thrombotic potential. TXA has also been shown to be effective in reducing the use of blood transfusions in cardiac and non-cardiac surgeries and is considered safer than other antifibrinolytic agents. There is no evidence of any increased risk of thromboembolic events with TXA, but doses greater than 2 g per day have been associated with an increased risk of seizures. It is also important to adjust the dose in patients with renal impairment. In conclusion, antifibrinolytics, such as EACA and TXA, are effective in reducing blood loss and transfusion use in cardiac and non-cardiac surgeries, without causing serious adverse effects.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Acute normovolemic hemodilution and intraoperative autotransfusion

Autologous blood transfusion can be achieved through different techniques, including by the patient donating blood before surgery (pre-deposit), collecting blood from the patient immediately before the operation and replacing the volume with colloids or plasma expanders (acute normovolemic hemodilution) or through the salvage of lost blood, during or immediately after surgery, and its retransfusion after washing (intraoperative or postoperative recovery). We will focus on the two methods used intraoperatively that are of fundamental importance in the management and conservation of the patient's own blood.

Examining Bleeding Risk, Transfusion-related Complications, and Strategies to Reduce Transfusions in Lung Transplantation

Blood product transfusions for bleeding management in lung transplantation affect recipient outcomes. Interventions are needed to reduce perioperative bleeding risk and optimize outcomes.

Contributing factors to heparin resistance during cardiopulmonary bypass

Since the risk factors for heparin resistance (HR) before cardiopulmonary bypass (CPB) have not been fully clarified, this study investigated the contributing factors for HR after the initial unfractionated heparin (UFH) dose of 500 IU/kg. We retrospectively analyzed the data of 371 patients who underwent CPB surgery, with the initial UFH dose of 500 IU/kg, between May 2017 and December 2021. We defined HR as the failure to achieve activated clotting time (ACT) of > 480 s after the initial UFH dose of 500 IU/kg. HR was observed in 36 patients (9.7%) (HR group), while HR was not observed in 335 patients (control group). The HR group included significantly more patients with preoperative use of UFH, with significantly higher white blood cell counts, fibrinogen, fibrinogen degradation products, D-dimer, and C-reactive protein, and lower hemoglobin and albumin. The multivariable logistic regression analysis identified albumin (OR: 3.09, 95% CI 1.3504-7.0845, p = 0.0075) and fibrinogen (OR: 0.99, 95% CI 0.9869-0.9963, p = 0.0003) as independent predictors for HR. Using the Youden index, the cutoffs of albumin and fibrinogen were calculated as 3.8 g/dL and 303 mg/dL, respectively. The receiver operating characteristic curves showed the predictive performance of albumin (area under the curve (AUC): 0.78, sensitivity: 65%, specificity: 81%) and fibrinogen (AUC: 0.77, sensitivity: 56%, specificity: 88%). The incidence of HR after the initial UFH dose of 500 IU/kg was 9.7%. The preoperative albumin < 3.8 g/dL and fibrinogen > 303 mg/dL were independent predictors for HR.

Nomogram for predicting major bleeding after off-pump coronary artery bypass grafting

OBJECTIVE

The purpose of this investigation is to develop a novel nomogram for predicting major bleeding following off-pump coronary artery bypass grafting (CABG).

METHODS

Between January 2012 and December 2022, 541 patients who underwent off-pump isolated primary CABG were included in a retrospective analysis. The primary outcome measure after off-pump CABG was major bleeding. Based on the outcomes of a multivariate analysis, nomograms were constructed. Using receiver operating characteristic analysis and calibration, the predictive accuracy of the nomograms was assessed. Using decision curve analysis (DCA), the clinical benefit of the nomograms was determined.

RESULTS

We categorized 399 and 142 patients in the "no major bleeding group" and "major bleeding group", respectively. Age (odds ratio (OR) 1.038; 95% confidence interval (CI) 1.009-1.068; p = 0.009), body mass index (OR 0.913; 95% CI 0.849-0.982; p = 0.014), hemoglobin (OR 0.958; 95% CI 0.945-0.971; p < 0.001), sodium (OR 0.873; 95% CI 0.807-0.945; p = 0.001), blood urea nitrogen (OR 1.198; 95% CI 1.073-1.338; p = 0.001), and operation time (OR 1.012; 95% CI 1.008-1.017; p < 0.001) were independent predictors for major bleeding after off-pump CABG. The model based on independent predictors exhibited excellent discrimination and calibration, with good agreement between actual and nomogram-estimated probabilities of generalization. DCA demonstrated that nomogram-assisted decisions have a greater positive benefit than treating all patients or none.

CONCLUSIONS

The plotted nomogram accurately predicted major bleeding outcomes following off-pump CABG and may therefore contribute to clinical decision-making, patient treatment, and consultation services.

Survey of the Impact of Decision Support in Preoperative Management of Anemia (i-Anemia): Survey Study

BACKGROUND

Major surgery on patients with anemia has demonstrated an increased risk of perioperative blood transfusions and postoperative morbidity and mortality. Recent studies have shown that integrating preoperative anemia treatment as a component of perioperative blood management may reduce blood product utilization and improve outcomes in both cardiac and noncardiac surgery. However, outpatient management of anemia falls outside of daily practice for most anesthesiologists and is probably weakly understood.

OBJECTIVE

We conducted a simulated case survey with anesthesiologists to accomplish the following aims: (1) evaluate the baseline knowledge of the preoperative optimization of anemia and (2) determine the impact of real-time clinical decision support on anemia management.

METHODS

We sent a digital survey (i-Anemia) to members of the French Society of Anaesthesia and Critical Care. The i-Anemia survey contained 7 simulated case vignettes, each describing a patient's brief clinical history and containing up to 3 multiple-choice questions related to preoperative anemia management (12 questions in total). The cases concerned potential situations of preoperative anemia and were created and validated with a committee of patient blood management experts. Correct answers were determined by the current guidelines or by expert consensus. Eligible participants were randomly assigned to control or decision support groups. In the decision support group, the primary outcome measured was the correct response rate.

RESULTS

Overall, 1123 participants were enrolled and randomly divided into control (n=568) and decision support (n=555) groups. Among them, 763 participants fully responded to the survey. We obtained a complete response rate of 65.6% (n=364) in the group receiving cognitive aid and 70.2% (n=399) in the group without assistance. The mean duration of response was 10.2 (SD 6.8) minutes versus 7.8 (SD 5) minutes for the decision support and control groups, respectively (P<.001). The score significantly improved with cognitive aid (mean 10.3 out of 12, SD 2.1) in comparison to standard care (mean 6.2 out of 12, SD 2.1; P<.001).

CONCLUSIONS

Management strategies to optimize preoperative anemia are not fully known and applied by anesthesiologists in daily practice despite their clinical importance. However, adding a decision support tool can significantly improve patient care by reminding practitioners of current recommendations.

Red Blood Cell Transfusion: 2023 AABB International Guidelines

Importance

Red blood cell transfusion is a common medical intervention with benefits and harms.

Objective

To provide recommendations for use of red blood cell transfusion in adults and children.

Evidence Review

Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed.

Findings

For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence).

Conclusions and Relevance

It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.

Neurologic complications after cardiopulmonary bypass - A narrative review

Neurologic complications, associated with cardiac surgery and cardiopulmonary bypass (CPB) in adults, are common and can be devastating in some cases. This comprehensive review will not only consider the broad categories of stroke and neurocognitive dysfunction, but it also summarises other neurological complications associated with CPB, and it provides an update about risks, prevention and treatment. Where appropriate, we consider the impact of off-pump techniques upon our understanding of the contribution of CPB to adverse outcomes.

The effect of perioperative antithrombin supplementation on blood conservation and postoperative complications after cardiopulmonary bypass surgery: A systematic review, meta-analysis and trial sequential analysis

Study objective

Antithrombin (AT) activity is reduced during cardiopulmonary bypass (CPB) surgery. Guidelines has demonstrated that perioperative AT supplementation contributed to blood conservation and prevent perioperative thrombotic complications and target organ injury owing to its role in reducing thrombin generation. But these recommends is lack of support of meta-analysis in the guidelines. This meta-analysis aims to include all the relevant randomized controlled trails (RCT) on patients who experienced cardiac surgeries with CPB and investigate the effect of perioperative AT on blood conservation and complications after cardiac surgery.

Methods

Standard published RCTs were searched from bibliographic databases to identify all evidence reporting perioperative AT supplementation for patients undergoing cardiovascular surgeries. The primary outcome was postoperative blood loss, the secondary outcomes were blood component transfusion (red blood cell (RBC), fresh frozen plasma (FFP), platelet and autologous blood), postoperative morbidity and in hospital mortality. The relative risk (RR) for dichotomous outcomes and the standardized mean difference (SMD) for continuous outcomes were estimated using a random-effects model. Trial sequential analysis (TSA) was performed using TSA software 0.9.5.10.

Results

13 RCTs with 996 participants undergoing different cardiovascular surgeries were included. Meta-analysis showed AT did not decrease postoperative blood loss (SMD -0.01, 95%CI -0.2 to 0.19). Subgroup analysis showed the effect of AT on postoperative blood loss was not associated with age, RCT type, surgery type, injection time of AT and AT deficiency. TSA further suggested that no additional studies were required for the stable result. Perioperative AT also did not reduce RBC ((SMD 0.10, 95%CI -0.66 to 0.85), (RR 0.99, 95%CI 0.83 to 1.19)), FFP ((SMD 0.11, 95%CI -0.19 to 0.41), (RR 1.30, 95%CI 0.90 to 1.87)), platelet (RR 1.10, 95%CI 0.83 to 1.46) and autologous blood (SMD 0.46, 95%CI -0.12 to 1.8504) transfusions. Perioperative AT significantly increased in hospital mortality (RR 2.53, 95%CI 1.02 to 6.28) and acute kidney injury (AKI) (RR 3.72, 95%CI 1.73 to 8.04) incidence. There was no significant difference in postoperative reexploration, thromboembolism, ECMO/IABP support, and stroke incidence between AT and non-AT group.

Conclusions

With the improvement of AT level and heparin sensitivity, perioperative AT has no significant effect on blood conservation. And it is noteworthy that the treatment increased in hospital mortality and the incidence of AKI after cardiac surgery.