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Ha M, Stewart KE, Butt AL, Vandyck KB, Tran S, Jain A, Edil B, Tanaka KA. Trends and predictions of perioperative transfusion and venous thromboembolism in hepatectomy using a North American Registry. Transfusion 2023; 63:2061-2071. [PMID: 37656947 DOI: 10.1111/trf.17528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023]
Abstract
BACKGROUND Studies indicate a link between allogeneic blood transfusion and venous thromboembolism (VTE) post-major surgery. Analyzing trends and predictors of these outcomes after hepatectomy can inform risk management. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used for a retrospective analysis. Primary outcomes were perioperative red blood cell (RBC) transfusion and VTE events within 30 days of hepatectomy. Seven-year trends and predictors were evaluated. RESULTS Among 29,131 hepatectomy patients, transfusion rates showed no statistically significant decreasing trends (p = .122) from 2014 to 2020 (18.13%-16.71%), while VTE rates showed a downward trend over the 7 years (p = .021); 17.2% received RBC transfusion, with higher rates in surgeries lasting ≥282 min (median: 220 min). Calculated RBC mass [hematocrit (%) × body weight (kg) × 10-5 × 70/ √ (body mass index/22)] at or below 1.5 L substantially increased transfusion odds. VTE was reported postoperatively in 2.6% of cases more frequently in longer cases involving transfusions. The adjusted odds ratio (aOR) of VTE escalated from the shortest operative time to the longest (3.17; 95% confidence interval [CI], 2.37-4.22). The adjusted odds of VTE doubled for transfused patients compared to non-transfused patients (aOR, 2.19; 95% CI, 1.86-2.57). CONCLUSIONS Rates of RBC transfusion and VTE rates hepatectomy have minimally changed in the recent years. VTE prevention is challenging in extended surgeries at increased risk of bleeding and RBC transfusions. Patient-level data on coagulation and thromboprophylaxis can potentially refine risk assessment for postoperative VTE.
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Affiliation(s)
- Monica Ha
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenneth E Stewart
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amir L Butt
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kofi B Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Sydany Tran
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Ajay Jain
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Barish Edil
- Department of Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Rasmussen SB, Boyko Y, Ranucci M, de Somer F, Ravn HB. Cardiac surgery-Associated acute kidney injury - A narrative review. Perfusion 2023:2676591231211503. [PMID: 37905794 DOI: 10.1177/02676591231211503] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Cardiac Surgery-Associated Acute Kidney Injury (CSA-AKI) is a serious complication seen in approximately 20-30% of cardiac surgery patients. The underlying pathophysiology is complex, often involving both patient- and procedure related risk factors. In contrast to AKI occurring after other types of major surgery, the use of cardiopulmonary bypass comprises both additional advantages and challenges, including non-pulsatile flow, targeted blood flow and pressure as well as the ability to manipulate central venous pressure (congestion). With an increasing focus on the impact of CSA-AKI on both short and long-term mortality, early identification and management of high-risk patients for CSA-AKI has evolved. The present narrative review gives an up-to-date summary on definition, diagnosis, underlying pathophysiology, monitoring and implications of CSA-AKI, including potential preventive interventions. The review will provide the reader with an in-depth understanding of how to identify, support and provide a more personalized and tailored perioperative management to avoid development of CSA-AKI.
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Affiliation(s)
- Sebastian Buhl Rasmussen
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Yuliya Boyko
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesiology and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Hanne Berg Ravn
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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3
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Schwann TA, Vekstein AM, Engoren M, Grau-Sepulveda M, O'Brien S, Engelman D, Lobdell KW, Gaudino MF, Salenger R, Habib RH. Perioperative Anemia and Transfusions and Late Mortality in Coronary Artery Bypass Patients. Ann Thorac Surg 2023; 115:759-769. [PMID: 36574523 DOI: 10.1016/j.athoracsur.2022.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/14/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Perioperative anemia and transfusions are associated with adverse operative outcomes after coronary artery bypass graft surgery (CABG). Their individual association with long-term outcomes is unclear. METHODS Patients aged 65 years and older who had undergone CABG and were in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (n = 504,596) from 2011 to 2018 were linked to Centers for Medicare and Medicaid Service data to assess long-term survival. The association of intraoperative anemia defined by intraoperative nadir hematocrit (nHct) and red blood cell (RBC) transfusions, and their interactions, on long-term mortality were assessed with Kaplan-Meier estimates and multivariable Cox regression. Restricted cubic splines were used to explore the association between nHct as a continuous variable and long-term mortality. RESULTS 258,398 on-pump CABG STS Adult Cardiac Surgery Database patients surviving the perioperative period were linked to Centers for Medicare and Medicaid Service claims files. Per World Health Organization criteria, 41% had preoperative anemia. Mean intraoperative nHct was 24%; RBC transfusion rate was 43.7%. Univariable analysis associated both RBC transfusion and lower nHct with worse survival. Lower nHct was only marginally associated with risk-adjusted mortality: adjusted hazard ratio (AHR) 1.04 (95% CI, 1.01-1.06) and 1.07 (95% CI, 1.00-1.14) at nHct 20% and at nHct 14%, respectively. RBC transfusion was associated with significantly higher adjusted mortality irrespective of timing of transfusion: AHR intraoperative 1.21 (95% CI, 1.18-1.27); AHR postoperative 1.26 (95% CI, 1.22-1.30); AHR both 1.46 (95% CI, 1.40-1.52) and across all levels of nHct. RBC transfusion was not associated with improved survival at any level of nHct. CONCLUSIONS Among Medicare CABG patients, RBC transfusions were associated with increased risk-adjusted late mortality across all levels of nHct whereas intraoperative anemia was only marginally so. Tolerance of lower intraoperative nHct than currently accepted may be preferable to transfusions.
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Affiliation(s)
- Thomas A Schwann
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts.
| | - Andrew M Vekstein
- Department of Surgery, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Milo Engoren
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Sean O'Brien
- Duke Clinical Research Institute, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Daniel Engelman
- Department of Surgery, University of Massachusetts-Baystate, Springfield, Massachusetts
| | - Kevin W Lobdell
- Department of Surgery, Atrium Health, Charlotte, North Carolina
| | - Mario F Gaudino
- Department of Surgery, Weill-Cornell Health, New York, New York
| | - Rawn Salenger
- Department of Surgery, University of Maryland, Baltimore, Maryland
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4
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Pal N, Nelson M. Prothrombin Complex Concentrate and Cardiac Surgery. JAMA Surg 2023; 158:222-223. [PMID: 36449283 DOI: 10.1001/jamasurg.2022.5801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Nirvik Pal
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Virginia Commonwealth University, Richmond
| | - Mark Nelson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Virginia Commonwealth University, Richmond
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Sultan I, Bianco V, Aranda-Michel E, Kilic A, Serna-Gallegos D, Navid F, Wang Y, Gleason TG. The use of blood and blood products in aortic surgery is associated with adverse outcomes. J Thorac Cardiovasc Surg 2023; 165:544-551.e3. [PMID: 33838909 DOI: 10.1016/j.jtcvs.2021.02.096] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 02/08/2021] [Accepted: 02/23/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products. METHODS All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival. RESULTS A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001). CONCLUSIONS In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.
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Affiliation(s)
- Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
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Palomba H, Treml RE, Caldonazo T, Katayama HT, Gomes BC, Malbouisson LMS, Silva Junior JM. Intraoperative fluid balance and cardiac surgery-associated acute kidney injury: a multicenter prospective study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:688-694. [PMID: 35917847 PMCID: PMC9659999 DOI: 10.1016/j.bjane.2022.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/20/2022] [Accepted: 07/24/2022] [Indexed: 05/16/2023]
Abstract
BACKGROUND Recent data suggest the regime of fluid therapy intraoperatively in patients undergoing major surgeries may interfere in patient outcomes. The development of postoperative Acute Kidney Injury (AKI) has been associated with both Restrictive Fluid Balance (RFB) and Liberal Fluid Balance (LFB) during non-cardiac surgery. In patients undergoing cardiac surgery, this influence remains unclear. The study objective was to evaluate the relationship between intraoperative RFB vs. LFB and the incidence of Cardiac-Surgery-Associated AKI (CSA-AKI) and major postoperative outcomes in patients undergoing on-pump Coronary Artery Bypass Grafting (CABG). METHODS This prospective, multicenter, observational cohort study was set at two high-complexity university hospitals in Brazil. Adult patients who required postoperative intensive care after undergoing elective on-pump CABG were allocated to two groups according to their intraoperative fluid strategy (RFB or LFB) with no intervention. RESULTS The primary endpoint was CSA-AKI. The secondary outcomes were in-hospital mortality, cardiovascular complications, ICU Length of Stay (ICU-LOS), and Hospital LOS (H-LOS). After propensity score matching, 180 patients remained in each group. There was no difference in risk of CSA-AKI between the two groups (RR = 1.15; 95% CI, 0.85-1.56, p = 0.36). The in-hospital mortality, H-LOS and cardiovascular complications were higher in the LFB group. ICU-LOS was not significantly different between the two groups. ROCcurve analysis determined a fluid balance above 2500 mL to accurately predict in-hospital mortality. CONCLUSION Patients undergoing on-pump CABG with LFB when compared with patients with RFB present similar CSA-AKI rates and ICU-LOS, but higher in-hospital mortality, cardiovascular complications, and H-LOS.
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Affiliation(s)
- Henrique Palomba
- Hospital Alemão Oswaldo Cruz, Departamento de Medicina Intensiva, São Paulo, SP, Brazil
| | - Ricardo E Treml
- Friedrich-Schiller-University, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany
| | - Tulio Caldonazo
- Friedrich-Schiller-University, Department of Cardiothoracic Surgery, Jena, Germany
| | - Henrique T Katayama
- Universidade de São Paulo, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | - Brenno C Gomes
- Universidade Federal do Paraná, Departamento de Medicina Integrada, Setor de Ciências da Saúde, Curitiba, PR, Brazil
| | - Luiz M S Malbouisson
- Universidade de São Paulo, Departamento de Anestesiologia, São Paulo, SP, Brazil
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Utilizing Total Blood Volume and Red Cell Volume to Clarify Adverse Outcomes in Patients With High Hematocrit During Cardiac Surgery. Anesth Analg 2022; 135:e5-e6. [PMID: 35709459 DOI: 10.1213/ane.0000000000006023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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8
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Blood loss estimation during posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2022; 10:581-588. [PMID: 34784000 DOI: 10.1007/s43390-021-00440-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Blood loss (BL) during posterior spinal fusion for adolescent idiopathic scoliosis (AIS) may be estimated using a variety of unproven techniques. Patient care and research on BL are likely impacted by a lack of standardization. A novel FDA-approved blood volume (BV) analysis system (BVA-100 Blood Volume Analyzer) allows rapid processing with > 97% accuracy. The purpose of this study was to investigate common methods for BL estimation. METHODS BV assessment was performed with the BVA-100. After obtaining a baseline sample of 5 mL of blood, 1 mL of I-131-labeled albumin was injected intravenously over 1 min. Five milliliter blood samples were then collected at 12, 18, 24, 30, and 36 min post-injection. Intravenous fluid was minimized to maintain euvolemia. Salvaged blood was not administered during surgery. BL was estimated using several common techniques and compared to the BV measurements provided by the BVA-100 (BVABL). RESULTS Thirty AIS patients were prospectively enrolled with major curves of 54° and underwent fusions of 10 levels. BL based on the BVA-100 (BVABL) was 519.2 [IQR 322.9, 886.2] mL. Previously published formulas all failed to approximate BVABL. Multiplying the cell saver volume return by 3 (CS3) approximates BVABL well with a Spearman correlation coefficient and ICC of 0.80 and 0.72, respectively. An extrapolated cell salvage-based estimator also showed high intraclass correlation coefficient (ICC) and Spearman coefficients with less bias than CS3. CONCLUSION Published formulaic approaches do not approximate true blood loss. Multiplying the cell saver volume by 3 or using the cell salvage-based estimator had the highest correlation coefficient and ICC. LEVEL OF EVIDENCE Prospective cohort Level 2.
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9
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Pal N, Weitzel N, Kertai MD. The Year 2020 in Review: Coronavirus Disease 2019 Cloud and Its Impact Excelling the Clinical Practice. Semin Cardiothorac Vasc Anesth 2021; 25:85-93. [PMID: 34000905 PMCID: PMC8689102 DOI: 10.1177/10892532211016152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Nirvik Pal
- Virginia Commonwealth University, Richmond, VA, USA
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10
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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11
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Katabi LJ, Pu X, Yilmaz HO, Jia Y, Leung S, Duncan AE. Prognostic Utility of KDIGO Urine Output Criteria After Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:2991-3000. [PMID: 33744114 DOI: 10.1053/j.jvca.2021.02.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Kidney Disease: Improving Global Outcomes (KDIGO) guidelines include assessment of creatinine and urine output to identify acute kidney injury (AKI). Whether urine output is an accurate indicator of AKI after cardiac surgery, however, is unclear. The authors' goal was to examine whether cardiac surgery patients who fulfilled criteria for AKI by KDIGO urine output criteria also demonstrated kidney injury by elevated creatinine, other kidney biomarkers, or had worse clinical outcomes. DESIGN Secondary analysis of prospectively collected data from a clinical trial, "6% Hydroxyethyl starch 130/0.4 in Cardiac Surgery (NCT02192502)." SETTING Academic, quaternary care hospital. PARTICIPANTS Patients undergoing elective aortic valve replacement INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: One hundred forty-one patients were classified into AKI stage by KDIGO urine output criteria within 24 hours after surgery. Kidney biomarkers (serum creatinine, urinary neutrophil gelatinase-associated lipocalin [NGAL], urinary interleukin-18 [IL-18]) and hospital and intensive care unit length of stay were analyzed across AKI stages. Urine output criteria classified four times as many patients with AKI than creatinine criteria (95 [67%] v 21 [15%]). Most patients meeting KDIGO urine output criteria for AKI postoperatively did not satisfy KDIGO creatinine criteria for AKI within one week (77 of 95 [81%]) or six-to-12 months (27 of 29 [93%]). Higher AKI stage assessed by urine output was not associated with higher NGAL, IL-18, or longer hospital or intensive care unit stays. CONCLUSIONS Acute kidney injury classified by KDIGO urine output criteria was not associated with other biomarkers of kidney injury or worse patient outcomes. These data suggested that KDIGO urine output criteria after cardiac surgery may overclassify AKI stage; further research is needed.
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Affiliation(s)
- Leila J Katabi
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Xuan Pu
- Departments of Cardiothoracic Anesthesiology & Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Huseyin Oguz Yilmaz
- Departments of Cardiothoracic Anesthesiology & Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Yuan Jia
- Departments of Cardiothoracic Anesthesiology & Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Steve Leung
- Departments of Cardiothoracic Anesthesiology & Outcomes Research, Cleveland Clinic, Cleveland, OH
| | - Andra E Duncan
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH.
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12
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Roman MA, Abbasciano RG, Pathak S, Oo S, Yusoff S, Wozniak M, Qureshi S, Lai FY, Kumar T, Richards T, Yao G, Estcourt L, Murphy GJ. Patient blood management interventions do not lead to important clinical benefits or cost-effectiveness for major surgery: a network meta-analysis. Br J Anaesth 2021; 126:149-156. [PMID: 32620259 PMCID: PMC7844348 DOI: 10.1016/j.bja.2020.04.087] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/22/2020] [Accepted: 04/25/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patient blood management (PBM) interventions aim to improve clinical outcomes by reducing bleeding and transfusion. We assessed whether existing evidence supports the routine use of combinations of these interventions during and after major surgery. METHODS Five systematic reviews and a National Institute of Health and Care Excellence health economic review of trials of common PBM interventions enrolling participants of any age undergoing surgery were updated. The last search was on June 1, 2019. Studies in trauma, burns, gastrointestinal haemorrhage, gynaecology, dentistry, or critical care were excluded. The co-primary outcomes were: risk of receiving red cell transfusion and 30-day or hospital all-cause mortality. Treatment effects were estimated using random-effects models and risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity assessments used I2. Network meta-analyses used a frequentist approach. The protocol was registered prospectively (PROSPERO CRD42018085730). RESULTS Searches identified 393 eligible randomised controlled trials enrolling 54 917 participants. PBM interventions resulted in a reduction in exposure to red cell transfusion (RR=0.60; 95% CI 0.57, 0.63; I2=77%), but had no statistically significant treatment effect on 30-day or hospital mortality (RR=0.93; 95% CI 0.81, 1.07; I2=0%). Treatment effects were consistent across multiple secondary outcomes, sub-groups and sensitivity analyses that considered clinical setting, type of intervention, and trial quality. Network meta-analysis did not demonstrate additive benefits from the use of multiple interventions. No trial demonstrated that PBM was cost-effective. CONCLUSIONS In randomised trials, PBM interventions do not have important clinical benefits beyond reducing bleeding and transfusion in people undergoing major surgery.
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Affiliation(s)
- Marius A. Roman
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Riccardo G. Abbasciano
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Shwe Oo
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Syabira Yusoff
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Saqib Qureshi
- Department of Cardiothoracic Surgery, University Hospitals of Nottingham, Nottingham, UK
| | - Florence Y. Lai
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
| | - Toby Richards
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Guiqing Yao
- Biostatistics Research Group, Department of Health Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Lise Estcourt
- Haematology/Transfusion Medicine, NHS Blood, and Transplant, John Radcliffe Hospital, Headington, Oxford, UK
| | - Gavin J. Murphy
- Department of Cardiovascular Sciences and National Institute for Health Research Leicester Biomedical Research Unit in Cardiovascular Medicine, College of Life Sciences, University of Leicester, Leicester, UK
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13
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Gibbs NM, Weightman WM. Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review. Anaesth Intensive Care 2020; 48:339-353. [DOI: 10.1177/0310057x20948868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Hypofibrinogenaemia during cardiac surgery may increase blood loss and bleeding complications. Viscoelastic point-of-care tests provide more rapid diagnosis than laboratory measurement, allowing earlier treatment. However, their diagnostic test accuracy for hypofibrinogenaemia has never been reviewed systematically. We aimed to systematically review their diagnostic test accuracy for the identification of hypofibrinogenaemia during cardiac surgery. Two reviewers assessed relevant articles from seven electronic databases, extracted data from eligible articles and assessed quality. The primary outcomes were sensitivity, specificity and positive and negative predictive values. A total of 576 articles were screened and 81 full texts were assessed, most of which were clinical agreement or outcome studies. Only 10 diagnostic test accuracy studies were identified and only nine were eligible (ROTEM delta 7; TEG5000 1; TEG6S 1, n = 1820 patients) (ROTEM, TEM International GmbH, Munich, Germany; TEG, Haemonetics, Braintree, MA, USA). None had a low risk of bias. Four ROTEM studies with a fibrinogen threshold less than 1.5–1.6 g/l and FIBTEM threshold A10 less than 7.5–8 mm had point estimates for sensitivity of 0.61–0.88; specificity 0.54–0.94; positive predictive value 0.42–0.70; and negative predictive value 0.74–0.98 (i.e. false positive rate 30%–58%; false negative rate 2%–26%). Two ROTEM studies with higher thresholds for both fibrinogen (<2 g/l) and FIBTEM A10 (<9.5 mm) had similar false positive rates (25%–46%), as did the two TEG studies (15%–48%). This review demonstrates that there have been few diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients. The studies performed so far report false positive rates of up to 58%, but low false negative rates. Further diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia are required to guide their better use during cardiac surgery.
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Affiliation(s)
- Neville M Gibbs
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
- The University of Western Australia, Nedlands, Australia
| | - William M Weightman
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
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Stammers AH, Tesdahl EA, Mongero LB, Stasko A. The effect of various blood management strategies on intraoperative red blood cell transfusion in first-time coronary artery bypass graft patients. Perfusion 2019; 35:217-226. [PMID: 31431120 DOI: 10.1177/0267659119867004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Effective blood management during cardiac surgery requires a multifactorial effort to limit exposure to allogeneic blood products. The present study evaluated the distribution of intraoperative interventions in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass. Records from patients undergoing non-reoperative surgery at 120 hospitals between January 2017 and December 2017 were reviewed, and red blood cell transfusion quartiles established. The 31 hospitals with the lowest transfusion rates fell into the first quartile (low transfusion group, n = 3,186 patients), while 29 hospitals with the highest transfusion were in the fourth quartile (high transfusion group, n = 2,561). A survey was sent to assess the blood management techniques: acute normovolemic hemodilution, autologous prime, fluid management, intraoperative autotransfusion, ultrafiltration, and transfusion triggers. All data are presented as mean (standard deviation). Patients in the low transfusion group had red blood cell transfusion rate of 5.5%, while the high transfusion group was 28.3%. There was no difference in gender or age. Fluid management was reduced in the low transfusion group with smaller prime volumes and anesthesia volumes, but higher crystalloid use during cardiopulmonary bypass. The low transfusion group did not use acute normovolemic hemodilution as often and had lower sequestered volumes when used. When ultrafiltration was used, the low transfusion quartile group removed more volume (1,555.9 ± 955.2 vs. 1,326.1 ± 918.9 mL, p ⩽ 0.001). In the low transfusion group, nadir hematocrit on-cardiopulmonary bypass averaged 1.6% lower and 3.0% lower for transfusion post-cardiopulmonary bypass. Intraoperative red blood cell units averaged 0.11 ± 0.50 U in low transfusion group compared to 0.63 ± 1.14 U in the high transfusion group. Mixed-effects logistic regression identified first in operating room and first on cardiopulmonary bypass hematocrit, estimated blood volume and nadir hematocrit transfusion trigger as the strongest predictors for red blood cell transfusion. Significant variation exists in the transfusion of red blood cell in coronary artery bypass graft patients undergoing cardiopulmonary bypass which may be related to the application of intraoperative blood management techniques.
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Affiliation(s)
- Alfred H Stammers
- Clinical Quality and Outcomes Research, SpecialtyCare, Brentwood, TN, USA
| | - Eric A Tesdahl
- Clinical Quality and Outcomes Research, SpecialtyCare, Brentwood, TN, USA
| | - Linda B Mongero
- Clinical Quality and Outcomes Research, SpecialtyCare, Brentwood, TN, USA
| | - Andrew Stasko
- Clinical Quality and Outcomes Research, SpecialtyCare, Brentwood, TN, USA
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Affiliation(s)
- Mark Nelson
- Virginia Commonwealth University, Richmond, VA
| | | | - Nirvik Pal
- Virginia Commonwealth University, Richmond, VA
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