A New Intraoperative Protocol for Reducing Perioperative Transfusions in Cardiac Surgery

Barriers to atrial fibrillation ablation during mitral valve surgery

BACKGROUND

Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.

METHODS

Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.

RESULTS

Among 66 respondents (66 of 135; 48.9%), the majority reported "very comfortable/frequently use" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.

CONCLUSIONS

Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.

Effect of an assessment of fibrin-based rotational thromboelastometry on blood transfusion and clinical outcomes in cardiovascular surgery: A cohort study

The clinical importance of viscoelastic testing in patient blood management when performing cardiovascular surgery is increasing. We aimed to examine the effect of a blood transfusion protocol including an assessment of fibrin-based rotational thromboelastometry on transfusion volume, mortality, and bleeding complications in patients undergoing cardiac or thoracic aortic surgery. We retrospectively studied a cohort of 376 consecutive patients who underwent cardiopulmonary bypass before (control group: 150 cardiac and 35 thoracic aortic surgeries) and after (assessment group: 154 cardiac and 37 thoracic aortic surgeries) introducing the fibrin polymerization assessment with thromboelastometry in the blood transfusion protocol. The transfusion volume and clinical outcomes were compared between the control and assessment groups, and the standardized (mean) difference (S[M]D) was calculated as an indicator of statistical effect size. Compared with the control group, the assessment group had a lower total blood transfusion volume (mL) in cardiac (2720 ± 1282 vs. 2034 ± 1330, p < 0.0001, [SMD] = 0.68) and thoracic aortic surgeries (5236 ± 2732 vs. 3714 ± 1768, p < 0.0001, SMD = 0.67). The 1-year mortality rates were 1.9 % and 2.7 % in cardiac and thoracic aortic surgeries, respectively. Significant differences were not observed in the 1-year mortality (3.2 % vs. 1.0 %, p = 0.16, relative risk [RR] = 0.32 with 95 % confidence intervals [CI] = 0.06-1.57, SD = 0.15), re-exploration for bleeding (4.8 % vs. 2.6 %, p = 0.28, RR = 0.53 with 95 % CI = 0.18-1.57, SD = 0.12), and major bleeding (17.3 % vs. 13.0 %, p = 0.31, RR = 0.75 with 95 % CI = 0.46-1.22, SD = 0.12) rates between the control and assessment groups. The assessment of fibrin polymerization with thromboelastometry using the blood transfusion protocol reduced the blood transfusion volume in cardiovascular surgery.

Effects of implementing rotational thromboelastometry in cardiac surgery: A retrospective cohort study

Since 2013, rotational thromboelastometry has been available in our hospital to assess coagulopathy. The aim of the study was to retrospectively evaluate the effect of thromboelastometry testing in cardiac surgery patients. Altogether 177 patients from 2012 and 177 patients from 2014 were included. In 2014, the thromboelastometry testing was performed on 56 patients. The mean blood drainage volume decreased and the number of patients receiving platelets decreased between 2012 and 2014. In addition, the use of fresh frozen plasma units decreased, and the use of prothrombin complex concentrate increased in 2014. When studied separately, the patients with a thromboelastometry testing received platelets, fresh frozen plasma, fibrinogen and prothrombin complex concentrate more often, but smaller amounts of red blood cells. In conclusion, after implementing the thromboelastometry testing to the practice, the blood products were given more cautiously overall. The use of thromboelastometry testing was associated with increased possibility to receive coagulation product transfusions. However, it appears that thromboelastometry testing was mostly used to assist in management of major bleeding.

Retrospective Analysis of Thromboelastography-Directed Transfusion in Isolated CABG: Impact on Blood Product Use, Cost, and Outcomes

Cardiac surgeries account for approximately 20% of blood use in the United States. Allogeneic transfusion has been associated with increased risk of morbidity and mortality, further justifying the need to reduce blood use. This study aimed at determining whether a point-of-care coagulation test, thromboelastography (TEG), impacted blood product administration and outcomes. Patients undergoing isolated coronary artery bypass grafting (CABG) were retrospectively reviewed before the use of TEG (2008-2009) (n = 640) and after implementation (2011-2012) (n = 458). Blood product use was compared between time frames. Logistic regression and generalized linear models were created to estimate the impact on outcomes including the reoperation rate, mortality, and cost. The mean use of each blood product was significantly reduced in the perioperative period. Overall blood product use was decreased by over 40%. Mediastinal re-exploration of bleeding was significantly reduced with TEG (4.8 vs. 1.5%). Six-month mortality was not impacted in this cohort nor was the readmission rate or hospital length of stay. However, blood cost and patient charges were significantly lower after TEG was introduced. The use of TEG to guide the administration of blood products during isolated CABG significantly affected the amounts and types of products given intra- and perioperatively. This resulted in less chest tube drainage, fewer returns to the operating room, and more accurate diagnosis of coagulopathic status. Cost savings to the patient and institution were appreciated as a consequence of these improved clinical outcomes.

Goal-directed resuscitation following cardiac surgery reduces acute kidney injury: A quality initiative pre-post analysis

OBJECTIVE

Acute kidney injury (AKI) occurs in 20% of patients following cardiac surgery. To reduce AKI in our institution, we instituted a quality improvement (QI) initiative using a goal-directed volume resuscitation protocol. Our protocol was designed to achieve quantifiable physiologic goals (eg, cardiac index > 2.5 L/min/m², mean arterial pressure > 65 mm Hg) using fluid and vasoactive agents. The objective of this study was to evaluate AKI in the pre- and post-QI eras, hypothesizing that AKI incidence would decrease in the post-QI era.

METHODS

In this observational retrospective cohort study, we identified patients who underwent cardiac operations from July 2011 to July 2015 with a risk score available. Kidney injury was determined using the lowest postoperative GFR within 7 days of surgery and standard Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease (RIFLE) classification criteria. The primary outcome was the rate of AKI, as defined by glomerular filtration rate-based RIFLE classification criteria injury, in the post- versus pre-QI eras.

RESULTS

A total of 1979 patients were included, of whom 725 were in the pre-QI cohort, and 1254 in the post-QI cohort. Overall, rates of RIFLE classification criteria risk, injury and failure were 27.5%, 5.9%, and 3.6%, respectively. RIFLE classification criteria injury saw the largest decrease in the post-QI cohort (8.1% vs 4.6%; P = .001). Multivariable analysis demonstrated a 37% reduction in the odds of AKI in the post-QI cohort (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.90).

CONCLUSIONS

A goal-directed volume resuscitation protocol centered on patient fluid responsiveness is associated with significantly reduced risk for AKI after cardiac surgery. Protocol-driven approaches should be employed in intensive care units to improve outcomes.

The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management

Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.

Noteworthy Literature published in 2017 for Cardiothoracic Anesthesiologists

The year 2017 was a year dominated by large-scale clinical studies reporting the outcome of various interventions in cardiac surgery and heart failure (HF) patients, relevant to all cardiothoracic anesthesiologists. Among them were studies investigating the addition of levosimendan, an alternative inotropic agent, to standard management of patients with HF undergoing cardiac surgery. Also, corticosteroids have been used for various purposes in cardiac patients. Here, a new study reports the effect of high-dose methylprednisolone on recovery and delirium. Furthermore, with increasing evidence that transfusions increase morbidity and mortality, a publication reports the use of rotational thromboelastometry to reduce transfusion requirements. In addition, several randomized controlled multicenter studies report the outcomes of patients undergoing cardiac procedures: surgical versus transcatheter aortic valve replacement in intermediate-risk patients and the use of centrifugal-flow versus axial-flow left-ventricular devices in patients with HF. These studies demonstrate the dynamic and ever-evolving state of perioperative cardiovascular medicine and show us the direction of future developments.