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Which factors have a great impact on coagulopathy and hemostatic impairment after cardiopulmonary bypass in cardiovascular surgery? An analysis based on rotational thromboelastometry. Gen Thorac Cardiovasc Surg 2021; 70:230-238. [PMID: 34386904 DOI: 10.1007/s11748-021-01688-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/31/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to investigate which factors have a great impact on coagulopathy after cardiopulmonary bypass (CPB) using rotational thromboelastometry (ROTEM). METHODS Ninety-eight patients undergoing cardiovascular surgery using CPB were enrolled. Data of amplitude 10 min after clotting time (A10) of ROTEM measured routinely before and after CPB were retrospectively collected. ROTEM has some assays by which we can evaluate the capacity of extrinsic coagulation (EXTEM), intrinsic coagulation (INTEM), fibrin polymerization (FIBTEM), and the effect of heparin (HEPTEM). The platelet component, defined as PLTEM, can be calculated by subtracting FIBTEM from EXTEM. Age, sex, total plasma volume, pre-CPB A10, lowest body temperature, in-out balance during CPB, intraoperative bleeding amount, and type of pumps were considered as possible factors. Univariate and multivariate analyses were performed for the rate of change of A10. RESULTS The change rate of each A10 had a significant negative correlation with bleeding amount (p < 0.01 for EXTEM, p < 0.01 for INTEM, p = 0.02 for FIBTEM, p < 0.01 for PLTEM). Female sex was a significant contributive predictor for the greater decline of EXTEM (p < 0.01) and INTEM (p < 0.01), positive balance for EXTEM (p < 0.01), FIBTEM (p = 0.01), and PLTEM (p < 0.01), long CPB time for INTEM (p = 0.01), centrifugal pump for FIBTEM (p < 0.01), and large pre-CPB A10 for PLTEM (p < 0.01). CONCLUSION In perioperative hemostatic management using ROTEM, attention should be given to the effects of these multiple factors.
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Madhu Krishna NR, Nagaraja PS, Singh NG, Nanjappa SN, Kumar KN, Prabhakar V, Manjunatha N. Evaluation of risk scores in predicting perioperative blood transfusions in adult cardiac surgery. Ann Card Anaesth 2020; 22:73-78. [PMID: 30648683 PMCID: PMC6350431 DOI: 10.4103/aca.aca_18_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Objective: Allogeneic blood product transfusions are associated with an increased morbidity and mortality risk in cardiac surgery. At present, a few transfusion risk scores have been proposed for cardiac surgery patients. The present study is aimed to develop a new score and to compare with preexisting scores – Transfusion Risk and Clinical Knowledge (TRACK) and Transfusion Risk Understanding Scoring Tool (TRUST) score. Methodology: A total of 1014 adult patients undergoing cardiac surgery were enrolled in the retrospective study. Independent predictors of allogeneic blood transfusions were selected from TRACK and TRUST scores. A predictive score was developed from six variables using logistic regression analysis, and new score was compared to the other existing scores – TRACK and TRUST. Results: The new score had following predictors: age >58 years, weight <63 kg for males and <49 kg for females, gender (female), complex surgery, hemoglobin <13.5 g/dl, and creatinine >1.36 mg/dl. Validation of new score demonstrated an acceptable predictive power (area under the curve [AUC] 0.749) and a good calibration at the Hosmer–Lemeshow test. New score was comparable with TRACK score with P = 0.578 (AUC of TRACK 0.756 and AUC of new score 0.749). There was a significant difference between new score and TRUST score, P = 0.01 (AUC of TRUST 0.72 and AUC of new score 0.749). Conclusion: New score is a simple risk model based on six predictors having a similar accuracy and calibration in predicting the transfusion rate in cardiac surgery as compared to TRACK score.
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Affiliation(s)
- N R Madhu Krishna
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Naveen G Singh
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - S N Nanjappa
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Karthik Narendra Kumar
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - V Prabhakar
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - N Manjunatha
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Akintoye E, Sethi P, Harris WS, Thompson PA, Marchioli R, Tavazzi L, Latini R, Pretorius M, Brown NJ, Libby P, Mozaffarian D. Fish Oil and Perioperative Bleeding. Circ Cardiovasc Qual Outcomes 2018; 11:e004584. [PMID: 30571332 PMCID: PMC6376981 DOI: 10.1161/circoutcomes.118.004584] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background Fish oil is among the most common natural supplements for treatment of hypertriglyceridemia or prevention of cardiovascular disease. However, concerns about theoretical bleeding risk have led to recommendations that patients should stop taking fish oil before surgery or delay in elective procedures for patients taking fish oil by some health care professionals. Methods and Results We tested the effect of fish oil supplementation on perioperative bleeding in a multinational, placebo-controlled trial involving 1516 patients who were randomized to perioperative fish oil (eicosapentaenoic acid+docosahexaenoic acid; 8-10 g for 2-5 days preoperatively, and then 2 g/d postoperatively) or placebo. Primary outcome was major perioperative bleeding as defined by the Bleeding Academic Research Consortium. Secondary outcomes include perioperative bleeding per thrombolysis in myocardial infarction and International Society on Thrombosis and Hemostasis definitions, chest tube output, and total units of blood transfused. Participants' mean (SD) age was 63 (13) years, and planned surgery included coronary artery bypass graft (52%) and valve surgery (50%). The primary outcome occurred in 92 patients (6.1%). Compared with placebo, risk of Bleeding Academic Research Consortium bleeding was not higher in the fish oil group: odds ratio, 0.81; 95% CI, 0.53-1.24; absolute risk difference, 1.1% lower (95% CI, -3.0% to 1.8%). Similar findings were seen for secondary bleeding definitions. The total units of blood transfused were significantly lower in the fish oil group compared with placebo (mean, 1.61 versus 1.92; P<0.001). Evaluating achieved plasma phospholipid omega-3 polyunsaturated fatty acids levels with supplementation (on the morning of surgery), higher levels were associated with lower risk of Bleeding Academic Research Consortium bleeding, with substantially lower risk in the third (odds ratio, 0.30 [95% CI, 0.11-0.78]) and fourth (0.36 [95% CI, 0.15-0.87]) quartiles, compared with the lowest quartile. Conclusions Fish oil supplementation did not increase perioperative bleeding and reduced the number of blood transfusions. Higher achieved n-3-PUFA levels were associated with lower risk of bleeding. These novel findings support the need for reconsideration of current recommendations to stop fish oil or delay procedures before cardiac surgery. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00970489.
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Affiliation(s)
- Emmanuel Akintoye
- Division of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa, IA, USA
| | - Prince Sethi
- Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - William S. Harris
- Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
- OmegaQuant, LLC. Sioux Falls, SD, USA
| | - Paul A. Thompson
- Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Roberto Marchioli
- Cardiovascular Renal Metabolic (CVRM) Therapeutic Area, Medical Strategy and Science, Therapeutic Science and Strategy Unit (TSSU), IQVIA, Milan, Italy
| | - Luigi Tavazzi
- Department of Cardiology and LTTA Centre, University of Ferrara, Ferrara, Italy; Maria Cecilia Hospital- GVM Care & Research, and E.S. Health Science Foundation, Cotignola, Italy
| | - Roberto Latini
- Department of Cardiovascular Research, Istituto di Ricerche Farmacologiche “Mario Negri”-IRCCS, Milan, Italy
| | - Mias Pretorius
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nancy J. Brown
- Department of Pharmacology and Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | - Peter Libby
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Doshi R, Shlofmitz E, Meraj P. Comparison of Outcomes and Complications of Transcatheter Aortic Valve Implantation in Women Versus Men (from the National Inpatient Sample). Am J Cardiol 2018; 121:73-77. [PMID: 29103601 DOI: 10.1016/j.amjcard.2017.09.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/11/2017] [Accepted: 09/14/2017] [Indexed: 01/09/2023]
Abstract
Transcatheter aortic valve implantation (TAVI) is a rapidly emerging procedure for the treatment of intermediate and high-surgical-risk patients with severe aortic stenosis. The impact of gender on in-hospital outcomes has not been studied on a large scale. The aim of this study was to examine gender differences in in-hospital outcomes after TAVI. The National Inpatient Sample (2012 to 2014) using the International Classification of Diseases, 9th Revision, Clinical Modification procedure codes for TAVI (35.05 and 35.06) were used to form this database. Propensity score matching (1:1) was performed and in-hospital outcomes were compared. The primary outcome was in-hospital mortality. Statistical analysis was performed using SAS 9.4 (SAS Institute Inc., Cary, North Carolina). A total of 41,050 (weighted) patients were included in our study. Women accounted for 47.7% (n = 19,570) in our study and presented with older age (81.7 years vs 80.5 years, p ≤ 0.0001). The population was predominantly white (87.4%). After performing propensity score-matched analysis (1:1), no difference in the primary outcome was noted between men and women. The secondary outcomes including stroke, hemorrhage requiring transfusion, and pericardial complications were higher in women. The composite end point of death and stroke occurred more frequently in women than in men. Acute renal failure was higher in men. The post-TAVI length of stay was higher in women (8.3 days vs 7.7 days, p = 0.0007). In conclusion, this large, retrospective registry analysis of patients with severe aortic stenosis who underwent TAVI suggests women may experience higher rates of in-hospital morbidity compared with men.
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Affiliation(s)
- Rajkumar Doshi
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Evan Shlofmitz
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
| | - Perwaiz Meraj
- Department of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York.
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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de Boer WJ, Visser C, Ganushchak YM. Preoperative hemoglobin level: the best predictor of transfusion of packed red cells. Perfusion 2016; 31:691-698. [DOI: 10.1177/0267659116657864] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Blood transfusions could have serious consequences for patients. A reduction in the transfusion rate could be accomplished by an optimized blood management. Clear guidelines and awareness among all employees at a single institution have resulted in a reduction in transfusion rates in recent years. Identification of the group of patients who still received a blood transfusion in recent years could result in a further reduction. This study enrolled 4022 patients undergoing cardiothoracic surgery between 2008 and 2013. Patients were divided into three groups: “no blood transfusion”, “transfusion of packed red cells only” and “any other combinations of blood transfusion”. In total, 16 variables were tested for their association with the administration of homologous blood. The variables associated with blood transfusion were included in a stepwise multinomial logistic regression analysis to find the variables with the strongest association. For the transfusion of packed red cells only and any other combinations of blood transfusion, the following predictors are found: gender, age, weight, type of surgery, reoperation, unstable angina pectoris, endocarditis, recent myocardial infarction, preoperative creatinine level, preoperative hemoglobin level and preoperative platelet count. The best predictor for the transfusion of packed red cells is preoperative hemoglobin level (4.1 to 7.8 mmol/l). For other blood products, the strongest association was found with type of surgery (aortic surgery, ventricular septal rupture and intracardiac tumour).
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Affiliation(s)
- Wiebe J. de Boer
- Department of Cardio-Thoracic Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Cornelis Visser
- Department of Cardio-Thoracic Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Yuri M. Ganushchak
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
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Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care. Crit Care Med 2015; 43:1477-97. [PMID: 25962078 DOI: 10.1097/ccm.0000000000001059] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient. DATA SOURCE AND SYNTHESIS Narrative review of relevant English-language peer-reviewed medical literature. CONCLUSIONS Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.
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Onorati F, D’Errigo P, Barbanti M, Rosato S, Covello RD, Maraschini A, Ranucci M, Santoro G, Tamburino C, Grossi C, Santini F, Menicanti L, Seccareccia F. Different impact of sex on baseline characteristics and major periprocedural outcomes of transcatheter and surgical aortic valve interventions: Results of the multicenter Italian OBSERVANT Registry. J Thorac Cardiovasc Surg 2014; 147:1529-39. [DOI: 10.1016/j.jtcvs.2013.05.039] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 05/02/2013] [Accepted: 05/10/2013] [Indexed: 10/26/2022]
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Dixon B, Reid D, Collins M, Newcomb AE, Rosalion A, Yap CH, Santamaria JD, Campbell DJ. The operating surgeon is an independent predictor of chest tube drainage following cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28:242-6. [PMID: 24439890 DOI: 10.1053/j.jvca.2013.09.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Bleeding into the chest is a major cause of blood transfusion and adverse outcomes following cardiac surgery. The authors investigated predictors of bleeding following cardiac surgery to identify potentially correctable factors. DESIGN Data were retrieved from the medical records of patients undergoing cardiac surgery over the period of 2002 to 2008. Multivariate analysis was used to identify the independent predictors of chest tube drainage. SETTING Tertiary hospital. PARTICIPANTS Two thousand five hundred seventy-five patients. INTERVENTIONS Cardiac surgery. RESULTS The individual operating surgeon was independently associated with the extent of chest tube drainage. Other independent factors included internal mammary artery grafting, cardiopulmonary bypass time, urgency of surgery, tricuspid valve surgery, redo surgery, left ventricular impairment, male gender, lower body mass index and higher preoperative hemoglobin levels. Both a history of diabetes and administration of aprotinin were associated with reduced levels of chest tube drainage. CONCLUSIONS The individual operating surgeon was an independent predictor of the extent of chest tube drainage. Attention to surgeon-specific factors offers the possibility of reduced bleeding, fewer transfusions, and improved patient outcomes.
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Affiliation(s)
- Barry Dixon
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia.
| | - David Reid
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Marnie Collins
- Department of Statistics, Peter MacCallum Hospital, Melbourne, Australia
| | - Andrew E Newcomb
- Department of Cardiothoracic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Alexander Rosalion
- Department of Cardiothoracic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Cheng-Hon Yap
- Department of Cardiothoracic Surgery, Geelong Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - John D Santamaria
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Duncan J Campbell
- St. Vincent's Institute of Medical Research, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia
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Onorati F, D'Errigo P, Grossi C, Barbanti M, Ranucci M, Covello DR, Rosato S, Maraschini A, Santoro G, Tamburino C, Seccareccia F, Santini F, Menicanti L. Effect of severe left ventricular systolic dysfunction on hospital outcome after transcatheter aortic valve implantation or surgical aortic valve replacement: results from a propensity-matched population of the Italian OBSERVANT multicenter study. J Thorac Cardiovasc Surg 2013; 147:568-75. [PMID: 24263007 DOI: 10.1016/j.jtcvs.2013.10.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 09/17/2013] [Accepted: 10/06/2013] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Despite demonstration of the superior outcomes of transcatheter aortic valve implantation (TAVI) versus optimal medical therapy for severe left ventricular systolic dysfunction, studies comparing TAVI and surgical aortic valve replacement (AVR) in this high-risk group have been lacking. METHODS We performed propensity matching for age, gender, baseline comorbidities, previous interventions, priority at hospital admission, frailty score, New York Heart Association class, EuroSCORE, and associated cardiac diseases. Next, the 30-day mortality and procedure-related morbidity of 162 patients (81 TAVI vs 81 AVR) with severe left ventricular systolic dysfunction (ejection fraction ≤ 35%) were analyzed at the Italian National Institute of Health. RESULTS The 30-day mortality was comparable (P = .37) between the 2 groups. The incidence of periprocedural acute myocardial infarction (P = .55), low output state (P = .27), stroke (P = .36), and renal dysfunction (peak creatinine level, P = .57) was also similar between the 2 groups. TAVI resulted in significantly greater postprocedural permanent pacemaker implantation (P = .01) and AVR in more periprocedural transfusions (P < .01) despite a similar transfusion rate per patient (2.8 ± 3.7 for TAVI vs 4.4 ± 3.8 for AVR; P = .08). The postprocedural intensive care unit stay (median, 2 days after TAVI vs 3 days after AVR; P = .34), intermediate care unit stay (median, 0 days after both TAVI and AVR; P = .94), and hospitalization (median, 11 days after TAVI vs 14 days after AVR; P = .51) were comparable. CONCLUSIONS In patients with severe left ventricular systolic dysfunction, both TAVI and AVR are valid treatment options, with comparable hospital mortality and periprocedural morbidity. Comparisons of the mid- to long-term outcomes are mandatory.
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Affiliation(s)
- Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy.
| | - Paola D'Errigo
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| | - Claudio Grossi
- Department of Cardiovascular Surgery, S. Croce e Carle Hospital, Cuneo, Italy
| | - Marco Barbanti
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy, and Excellence Through Newest Advances Foundation, Catania, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia-Intensive Care Unit and Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Daniel Remo Covello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele, Milan, Italy
| | - Stefano Rosato
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| | - Alice Maraschini
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| | | | - Corrado Tamburino
- Division of Cardiology, Ferrarotto Hospital, University of Catania, Italy, and Excellence Through Newest Advances Foundation, Catania, Italy
| | - Fulvia Seccareccia
- National Centre for Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Rome, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, University Hospital San Martino, Genoa, Italy
| | - Lorenzo Menicanti
- Department of Cardiothoracic and Vascular Anesthesia-Intensive Care Unit and Department of Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Brauer SD, Applegate RL, Jameson JJ, Hay KL, Lauer RE, Herrmann PC, Bull BS. Association of Plasma Dilution With Cardiopulmonary Bypass-Associated Bleeding and Morbidity. J Cardiothorac Vasc Anesth 2013; 27:845-52. [DOI: 10.1053/j.jvca.2013.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Indexed: 11/11/2022]
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12
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Vretzakis G, Georgopoulou S, Stamoulis K, Tassoudis V, Mikroulis D, Giannoukas A, Tsilimingas N, Karanikolas M. Monitoring of brain oxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial. J Cardiothorac Surg 2013; 8:145. [PMID: 23758929 PMCID: PMC3691733 DOI: 10.1186/1749-8090-8-145] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 05/30/2013] [Indexed: 11/10/2022] Open
Abstract
Background Blood transfusions are common in cardiac surgery, but have been associated with increased morbidity and long-term mortality. Efforts to reduce blood product use during cardiac surgery include fluid restriction to minimize hemodilution, and protocols to guide transfusion decisions. INVOS is a modality that monitors brain tissue oxygen saturation, and could be useful in guiding decisions to transfuse. However, the role of INVOS (brain tissue oxygen saturation) as part of an algorithm to direct blood transfusions during cardiac surgery has not been evaluated. This study was conducted to investigate the value of INVOS as part of a protocol for blood transfusions during cardiac surgery. Methods Prospective, randomized, blinded clinical trial, on 150 (75 per group) elective cardiac surgery patients. The study was approved by the Institution Ethics committee and all patients gave written informed consent. Data were initially analyzed based on “intention to treat”, but subsequently were also analyzed “per protocol”. Results When protocol was strictly followed (“per protocol analysis”), compared to the control group, significantly fewer patients monitored with INVOS received any blood transfusions (46 of 70 patients in INVOS group vs. 55 of 67 patients in the control group, p = 0.029). Similarly, patients monitored with INVOS received significantly fewer units of red blood cell transfusions intraoperatively (0.20 ± 0.50 vs. 0.52 ± 0.88, p = 0.008) and overall during hospital stay (1.31 ± 1.20 vs. 1.82 ± 1.46, p = 0.024). When data from all patients (including patient with protocol violation) were analyzed together (“intention to treat analysis”), the observed reduction of blood transfusions in the INVOS group was still significant (51 of 75 patients transfused in the INVOS group vs. 63 of 75 patients transfused in the control group, p = 0.021), but the overall number of units transfused per patient did not differ significantly between the groups (1.55 ± 1.97 vs. 1.84 ± 1.41, p = 0.288). Conclusions Our data suggest that INVOS could be a useful tool as part of an algorithm to guide decisions for blood transfusion in cardiac surgery. Additional data from rigorous, well designed studies are needed to further evaluate the role of INVOS in guiding blood transfusions in cardiac surgery, and circumvent the limitations of this study. Trial registration ClinicalTrials.gov: NCT00879463
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Affiliation(s)
- George Vretzakis
- Cardiac Anesthesia Unit, Anesthesiology Clinic, University of Thessaly, Biopolis, Larissa, Greece
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Tan NL, Corbineau H, Phu BD, Verhoye JP. Is a cell saver necessary in off-pump coronary artery bypass surgery? Asian Cardiovasc Thorac Ann 2012; 20:539-43. [PMID: 23087296 DOI: 10.1177/0218492312439479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Off-pump coronary artery bypass surgery should have a significantly lower risk of postoperated bleeding than on-pump surgery. However, the use of a cell saver has been considered necessary, with significant additional cost incurred. Can we consider performing off-pump coronary artery bypass surgery without a cell saver? PATIENTS AND METHODS A prospective observational study was performed in 68 consecutive patients operated on for 2- or 3-vessel coronary lesions by the off-pump technique. RESULTS The mean number of distal anastomoses was 2.7 ± 0.7. Both internal thoracic arteries were used in 45 patients, and sequential revascularization was performed in 27, with 140 (77.8%) arterial grafts. Cell savers were used in 21 (30.9%) patients. In these 21 patients, the mean volume retransfused after treatment was 315 ± 177 mL. Postoperatively, 11 (16.2%) patients were transfused with packed red blood cells, with a mean volume of 636 ± 234 mL per patient. The 2 factors identified as associated with a higher risk of autotransfusion were female sex and a lower preoperative hemoglobin. CONCLUSIONS The use of a cell saver in off-pump surgery is useless in most cases. Careful surgical hemostasis is essential to limit hypovolemia.
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Affiliation(s)
- Nguyen Luong Tan
- Cardiovascular and Thoracic Surgery Department, Hue Central Hospital, Vietnam.
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Rodriguez RA, Bussière M, Bourke M, Mesana T, Nathan HJ. Predictors of Duration of Unconsciousness in Patients With Coma After Cardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:961-7. [DOI: 10.1053/j.jvca.2010.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Indexed: 11/11/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Vretzakis G, Kleitsaki A, Aretha D, Karanikolas M. Management of intraoperative fluid balance and blood conservation techniques in adult cardiac surgery. Heart Surg Forum 2011; 14:E28-39. [PMID: 21345774 DOI: 10.1532/hsf98.2010111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Blood transfusions are associated with adverse physiologic effects and increased cost, and therefore reduction of blood product use during surgery is a desirable goal for all patients. Cardiac surgery is a major consumer of donor blood products, especially when cardiopulmonary bypass (CPB) is used, because hematocrit drops precipitously during CPB due to blood loss and blood cell dilution. Advanced age, low preoperative red blood cell volume (preoperative anemia or small body size), preoperative antiplatelet or antithrombotic drugs, complex or re-operative procedures or emergency operations, and patient comorbidities were identified as important transfusion risk indicators in a report recently published by the Society of Cardiovascular Anesthesiologists. This report also identified several pre- and intraoperative interventions that may help reduce blood transfusions, including off-pump procedures, preoperative autologous blood donation, normovolemic hemodilution, and routine cell saver use.A multimodal approach to blood conservation, with high-risk patients receiving all available interventions, may help preserve vital organ perfusion and reduce blood product utilization. In addition, because positive intravenous fluid balance is a significant factor affecting hemodilution during cardiac surgery, especially when CPB is used, strategies aimed at limiting intraoperative fluid balance positiveness may also lead to reduced blood product utilization.This review discusses currently available techniques that can be used intraoperatively in an attempt to avoid or minimize fluid balance positiveness, to preserve the patient's own red blood cells, and to decrease blood product utilization during cardiac surgery.
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Affiliation(s)
- George Vretzakis
- Cardiac Anaesthesia Unit, University Hospital of Larissa, Greece
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The Papworth Bleeding Risk Score: a stratification scheme for identifying cardiac surgery patients at risk of excessive early postoperative bleeding. Eur J Cardiothorac Surg 2011; 39:924-30. [DOI: 10.1016/j.ejcts.2010.10.003] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 10/01/2010] [Accepted: 10/04/2010] [Indexed: 11/23/2022] Open
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Preoperative fibrinogen plasma concentration is associated with perioperative bleeding and transfusion requirements in scoliosis surgery. Spine (Phila Pa 1976) 2011; 36:549-55. [PMID: 21079540 DOI: 10.1097/brs.0b013e3181d952dc] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective observational study. OBJECTIVE To investigate the potential association between fibrinogen, bleeding, and transfusion requirements after scoliosis surgery. SUMMARY OF BACKGROUND DATA Bleeding complications during and after orthopedic surgery are associated with increased morbidity and mortality. Early identification of patients with increased risk of excessive bleeding offers the possibility to initiate countermeasures. Fibrinogen is a key protein in the coagulation cascade, and thus a potential biomarker for bleeding risk. METHODS A total of 82 otherwise healthy patients (mean age: 15 ± 3 years, 85% girls) undergoing surgery for adolescent idiopathic scoliosis were included in the study. Patient variables (age, gender, operation time, and thrombosis prophylaxis), preoperative laboratory variables (hemoglobin, platelet count, activated partial thromboplastin time [aPTT], prothrombin time [PT], and fibrinogen), peroperative and postoperative bleeding volume, and transfusions were registered. Correlations between laboratory variables and bleeding volume were calculated with Pearson test. Patient variables and laboratory variables were compared with Student t test between patients with bleeding volume in the upper quartile ("bleeders") and the remaining patients, and between patients with extensive transfusion (defined as >2 U of packed red cells) and no or limited transfusions (≤ 2 U). RESULTS Mean fibrinogen concentration was 3.0 ± 0.7 g/L (range, 1.3- 4.9). Mean total perioperative bleeding volume was 1552 ± 1019 mL (range, 100-5800 mL). Total bleeding volume correlated significantly with preoperative fibrinogen concentration (r = -0.31, P = 0.005) but neither with platelet count, aPTT, nor PT (P = 0.61, 0.46, and 0.57, respectively). Bleeders had significantly lower preoperative fibrinogen plasma concentration (2.6 ± 0.6 vs. 3.1 ± 0.6 g/L, P = 0.002). Of total, 16% (13/82) of the patients were transfused with >2 U of packed red cells. Patients with extensive transfusions had significantly lower preoperative fibrinogen plasma concentration (2.5 ± 0.7 vs. 3.1 ± 0.6 g/L, P = 0.002), while preoperative platelet count, aPTT, and PT did not differ. CONCLUSION The results indicate that preoperative fibrinogen concentration is a limiting factor for postoperative hemostasis during and after scoliosis surgery. Preoperative measurement of fibrinogen concentration provides more information about bleeding volume and transfusion requirements than standard screening tests.
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Kipps AK, Wypij D, Thiagarajan RR, Bacha EA, Newburger JW. Blood transfusion is associated with prolonged duration of mechanical ventilation in infants undergoing reparative cardiac surgery. Pediatr Crit Care Med 2011; 12:52-6. [PMID: 20453699 PMCID: PMC3697008 DOI: 10.1097/pcc.0b013e3181e30d43] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Perioperative transfusion has adverse effects in adults undergoing cardiac surgery. We sought to investigate whether greater use of blood and blood products might be an independent predictor of prolonged postoperative recovery, indicated by duration of mechanical ventilation (DMV), after reparative infant heart surgery. DESIGN Secondary analysis of prospectively collected data from two randomized trials of hematocrit strategy during cardiopulmonary bypass in infant heart surgery to explore the association of DMV with perioperative transfusion and other variables. SETTING Tertiary pediatric hospital. PATIENTS Two hundred seventy infants undergoing two ventricle corrective cardiac surgery without aortic arch reconstruction. MEASUREMENTS AND MAIN RESULTS In univariable analyses, longer DMV was associated with younger age and lower weight at surgery, diagnostic group, and higher intraoperative and postoperative blood product transfusion (each p < .001). In multivariable proportional hazard regression, longer total support time and greater intraoperative and early postoperative blood products per kg were the strongest predictors of longer DMV. Patients in the highest tertile of intraoperative blood products per kg had an instantaneous risk of being extubated approximately half that of patients in the lowest tertile (hazard ratio, 0.51; 95% confidence interval, 0.35, 0.73). Patients who received any blood products on postoperative day 1, compared with those who did not, had a hazard ratio for extubation of 0.65 (95% confidence interval, 0.50, 0.85). CONCLUSIONS In this exploratory secondary analysis of infants undergoing two ventricular repair of congenital heart disease without aortic arch obstruction, greater intraoperative and early postoperative blood transfusion emerged as potential important risk factors for longer DMV. Future prospective clinical trials are needed to determine whether reduction in blood product administration hastens postoperative recovery after infant heart surgery.
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Affiliation(s)
- Alaina K. Kipps
- Pediatric Division of Cardiology, UCSF Children’s Hospital, and Department of Pediatrics, University of California, San Francisco
| | - David Wypij
- Department of Cardiology, Children’s Hospital, Boston, and Department of Pediatrics, Harvard Medical School, Boston, MA,Department of Biostatistics, Harvard School of Public Health, Boston, MA
| | - Ravi R. Thiagarajan
- Department of Cardiology, Children’s Hospital, Boston, and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Emile A. Bacha
- Department of Cardiovascular Surgery, Children’s Hospital, Boston and Department of Surgery, Harvard Medical School, Boston, MA
| | - Jane W. Newburger
- Department of Cardiology, Children’s Hospital, Boston, and Department of Pediatrics, Harvard Medical School, Boston, MA
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Thorarinsdottir HR, Sigurbjornsson FT, Hreinsson K, Onundarson PT, Gudbjartsson T, Sigurdsson GH. Effects of fibrinogen concentrate administration during severe hemorrhage. Acta Anaesthesiol Scand 2010; 54:1077-82. [PMID: 20887409 DOI: 10.1111/j.1399-6576.2010.02289.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fibrinogen concentrate has been shown to improve coagulation in dilutional coagulopathy in experimental studies, but clinical experience is still scarce. The aim of this study was to evaluate laboratory data and the clinical outcome of fibrinogen administration in patients suffering from severe hemorrhage. MATERIALS AND METHODS A retrospective study over a 3-year observation period of consecutive patients who received a single dose of fibrinogen concentrate but not recombinant factor VIIa as part of their treatment of severe hemorrhage, defined as >6 U of packed red blood cells (PRBCs). RESULTS Thirty-seven patients were included, most of them suffering from severe hemorrhage following open heart surgery (68%). After a median fibrinogen dose of 2 g (range 1-6 g), an absolute increase in the plasma fibrinogen concentration of 0.6 g/l was observed (P<0.001). The activated partial thromboplastin time (APTT) decreased significantly (P<0.001), from 52 to 43 s and the prothrombin time (PT) decreased from 20 to 17 s, respectively. The transfusion requirement for PRBCs decreased from 6 to 3 U (P<0.01) in the 24 h after fibrinogen administration, but fresh-frozen plasma and platelet concentrate transfusions did not change significantly. Eight patients (22%) died in intensive care unit and the pre-operative fibrinogen concentration was not significantly different in these patients. CONCLUSION Administration of fibrinogen for severe hemorrhage was associated with an increased fibrinogen concentration and a significant decrease in APTT, PT and the requirement for PRBCs.
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Affiliation(s)
- H R Thorarinsdottir
- Department of Anesthesia and Intensive Care, Landspitali-University Hospital, Reykjavik, Iceland
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22
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Vretzakis G, Kleitsaki A, Stamoulis K, Bareka M, Georgopoulou S, Karanikolas M, Giannoukas A. Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial. J Cardiothorac Surg 2010; 5:7. [PMID: 20181257 PMCID: PMC2845571 DOI: 10.1186/1749-8090-5-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 02/24/2010] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Cardiac surgery is a major consumer of blood products, and hemodilution increases transfusion requirements during cardiac surgery under CPB. As intraoperative parenteral fluids contribute to hemodilution, we evaluated the hypothesis that intraoperative fluid restriction reduces packed red-cell (PRC) use, especially in transfusion-prone adults undergoing elective cardiac surgery. METHODS 192 patients were randomly assigned to restrictive (group A, 100 pts), or liberal (group B, 92 pts) intraoperative intravenous fluid administration. All operations were conducted by the same team (same surgeon and perfusionist). After anesthesia induction, intravenous fluids were turned off in Group A (fluid restriction) patients, who only received fluids if directed by protocol. In contrast, intravenous fluid administration was unrestricted in group B. Transfusion decisions were made by the attending anesthesiologist, based on identical transfusion guidelines for both groups. RESULTS 137 of 192 patients received 289 PRC units in total. Age, sex, weight, height, BMI, BSA, LVEF, CPB duration and surgery duration did not differ between groups. Fluid balance was less positive in Group A. Fewer group A patients (62/100) required transfusion compared to group B (75/92, p < 0.04). Group A patients received fewer PRC units (113) compared to group B (176; p < 0.0001). Intraoperatively, the number of transfused units and transfused patients was lower in group A (31 u in 19 pts vs. 111 u in 62 pts; p < 0.001). Transfusions in ICU did not differ significantly between groups. Transfused patients had higher age, lower weight, height, BSA and preoperative hematocrit, but no difference in BMI or discharge hematocrit. Group B (p < 0.005) and female gender (p < 0.001) were associated with higher transfusion probability. Logistic regression identified group and preoperative hematocrit as significant predictors of transfusion. CONCLUSIONS Our data suggest that fluid restriction reduces intraoperative PRC transfusions without significantly increasing postoperative transfusions in cardiac surgery; this effect is more pronounced in transfusion-prone patients. TRIAL REGISTRATION NCT00600704, at the United States National Institutes of Health.
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Affiliation(s)
- George Vretzakis
- Cardiac Anesthesia Unit, Department of Anesthesiology, University Hospital of Larissa, Greece
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Makar M, Taylor J, Zhao M, Farrohi A, Trimming M, D’Attellis N. Perioperative Coagulopathy, Bleeding, and Hemostasis During Cardiac Surgery. ACTA ACUST UNITED AC 2010. [DOI: 10.1177/1944451609357759] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cardiac surgery patients use 10%-25% of the blood products transfused annually in the United States. The transfusion of red blood cells or blood products has been the subject of intense scrutiny over the past 10 years. Bleeding after cardiac surgery can be surgical or nonsurgical and lead to hemodynamic compromise and surgical reexploration. Because hemorrhage and blood product transfusions are associated with multiple negative outcomes, including increased mortality, it is prudent to understand the mechanisms responsible for nonsurgical bleeding. This review focuses on the physiology of the normal coagulation and fibrinolysis, risk factors associated with patients presenting for cardiac surgery, impairments of normal hemostasis associated with cardiac surgery and cardiopulmonary bypass (CPB), and potential interventions to reduce perioperative blood loss and blood transfusion.
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Affiliation(s)
- Moody Makar
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Jamie Taylor
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Maxnu Zhao
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ali Farrohi
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Trimming
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicola D’Attellis
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
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Karlsson M, Ternström L, Hyllner M, Baghaei F, Nilsson S, Jeppsson A. Plasma fibrinogen level, bleeding, and transfusion after on-pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion 2008; 48:2152-8. [DOI: 10.1111/j.1537-2995.2008.01827.x] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Yavari M, Becker RC. Coagulation and fibrinolytic protein kinetics in cardiopulmonary bypass. J Thromb Thrombolysis 2008; 27:95-104. [PMID: 18214639 DOI: 10.1007/s11239-007-0187-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 12/17/2007] [Indexed: 12/29/2022]
Abstract
The development of Cardiopulmonary Bypass (CPB) catopulted the field of cardiothoracic surgery into a new dimension--one that changed the lives of individuals with congenital and acquired heart disease worldwide. Despite its contributions, CPB has clear limitations and creates unique challenges for clinicians and patients alike, stemming from profound hemostatic pertubations and accompanying risk for bleeding and possibly thrombotic complications.
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Affiliation(s)
- Maryam Yavari
- Duke Cardiovascular Thrombosis Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
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Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RSD, Despotis G, Brown JR, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27-86. [PMID: 17462454 DOI: 10.1016/j.athoracsur.2007.02.099] [Citation(s) in RCA: 543] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2006] [Revised: 01/21/2007] [Accepted: 02/08/2007] [Indexed: 01/24/2023]
Abstract
BACKGROUND A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes. METHODS We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme. RESULTS Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions. CONCLUSIONS Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.
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Berroeta C, Benbara A, Provenchère S, Ajzenberg N, Benessiano J, Depoix JP, Desmonts JM, Iung B, Philip I. A Comparison of Bilateral with Single Internal Mammary Artery Grafts on Postoperative Mediastinal Drainage and Transfusion Requirement. Anesth Analg 2006; 103:1380-5. [PMID: 17122207 DOI: 10.1213/01.ane.0000242514.49621.0c] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The superiority of the left internal mammary artery (LIMA) graft over autogenous saphenous vein as a bypass conduit in coronary artery bypass surgery has been well established. Early and late patency rates of bilateral internal mammary artery (BIMA) grafts exceed those of vein grafts, and patients who receive BIMA have improved long-term survival rates and more freedom from reoperations and other cardiac events. But because of other concerns, particularly the question of increased risk of postoperative bleeding, controversy still surrounds the perioperative period. In the present study we sought to determine whether BIMA grafting was an independent risk factor of postoperative bleeding and of blood product use in patients undergoing primary elective coronary artery revascularization. For this purpose, 33 consecutive patients scheduled for BIMA grafting were matched with 66 patients operated on by single LIMA grafting. Patients in the LIMA group had significantly less postoperative mediastinal drainage than those in the BIMA group (median: 722 vs 920 mL, P = 0.0001). Fifty-six patients received blood products (56% vs 51% in LIMA and BIMA groups, respectively; P = 0.67). In multivariate analysis, BIMA and operative duration were independent predictors of increased postoperative drainage. Nevertheless, in logistic regression, BIMA was not significantly associated with blood product use, unlike precardiopulmonary bypass hematocrit and duration of surgery (OR and 95% CI: 0.89 [0.80-0.96] P = 0.01; 1.009 [1.001-1.019] P = 0.04, for an increase of 1% in hematocrit and 1 min in duration of surgery, respectively). In conclusion, these data support the idea that BIMA graft slightly increases postoperative drainage but not transfusion requirement.
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Murphy GJ, Angelini GD. Indications for Blood Transfusion in Cardiac Surgery. Ann Thorac Surg 2006; 82:2323-34. [PMID: 17126171 DOI: 10.1016/j.athoracsur.2006.06.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2006] [Revised: 06/09/2006] [Accepted: 06/12/2006] [Indexed: 01/29/2023]
Abstract
In addition to its life-saving effect in hemorrhagic shock, transfusion of allogenic packed red blood cells can be beneficial in situations where a critically low hematocrit is contributing to a state of oxygen-supply dependency. These benefits are countered by the risks of transfusion-associated lung injury, transfusion-associated immunomodulation, and cellular hypoxia after RBC transfusion. The critical hematocrit is patient and organ specific, and varies intraoperatively according to the duration and temperature of bypass, as well as for a variable postoperative period. Future randomized studies must prospectively evaluate regional indicators of tissue oxygenation in transfusion algorithms.
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Affiliation(s)
- Gavin J Murphy
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom.
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Murphy GJ, Mango E, Lucchetti V, Battaglia F, Catapano D, Rogers CA, Angelini GD. A randomized trial of tranexamic acid in combination with cell salvage plus a meta-analysis of randomized trials evaluating tranexamic acid in off-pump coronary artery bypass grafting. J Thorac Cardiovasc Surg 2006; 132:475-80, 480.e1-8. [PMID: 16935098 DOI: 10.1016/j.jtcvs.2006.01.064] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2005] [Revised: 01/06/2006] [Accepted: 01/17/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES We sought to evaluate the effectiveness of tranexamic acid in off-pump coronary artery bypass grafting surgery, either when used in combination with mechanical cell salvage or when used alone. METHODS One hundred patients were randomized to either 2 g of tranexamic acid as an intravenous bolus before sternotomy or to placebo. Intraoperative and postoperative cell salvage was used in all patients. The primary end point was early postoperative blood loss (within 4 hours). To evaluate the efficacy of tranexamic acid in isolation, we also performed a meta-analysis of 4 randomized trials identified from a systematic literature search. The primary end point of the meta-analysis was red cell transfusion. RESULTS In our randomized trial patients in the tranexamic acid group had a significant reduction in early postoperative blood loss, (median difference, 50 mL; 95% confidence interval, 15-100 mL; P < .01); however, there was no reduction in the frequency of blood component transfusion. Patients in the placebo group received a significantly larger volume of autotransfused red cells (median difference, 120 mL; 95% confidence interval, 0-220 mL; P = .02). The meta-analysis demonstrated a significant reduction in red cell transfusions in patients receiving tranexamic acid compared with those receiving placebo (risk ratio, 0.48; 95% confidence interval, 0.24-0.97; P = .041). There was also a reduction in the frequency of any allogeneic blood component transfusion, as well as a highly significant reduction in postoperative blood loss, in patients receiving tranexamic acid (P < .001). CONCLUSIONS Tranexamic acid reduces blood loss and transfusion requirements in off-pump coronary artery bypass grafting surgery. A reduction in allogeneic blood transfusion was not evident in the presence of perioperative cell salvage. These data support the routine use of tranexamic acid in off-pump coronary artery bypass grafting surgery.
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Affiliation(s)
- Gavin J Murphy
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol, United Kingdom
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Karkouti K, Yau TM, Riazi S, Dattilo KM, Wasowicz M, Meineri M, McCluskey SA, Wijeysundera DN, van Rensburg A, Beattie WS. Determinants of complications with recombinant factor VIIa for refractory blood loss in cardiac surgery. Can J Anaesth 2006; 53:802-9. [PMID: 16873347 DOI: 10.1007/bf03022797] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Recombinant factor VIIa (rFVIIa) is being used for refractory, excessive blood loss (EBL) after cardiac surgery, but its safety for this indication is not known. METHODS The unadjusted and risk-adjusted adverse event (AE) rates were compared between 114 consecutive cardiac surgical patients who received rFVIIa for refractory EBL and 541 concurrent patients who developed EBL but did not receive rFVIIa. Similarly, timing of rFVIIa therapy was assessed by dichotomizing rFVIIa patients based on median number of red blood cell (RBC) units received before therapy. The measured AE was a composite of death, stroke, renal failure, myocardial infarction, and major vein thrombosis. For risk adjustment, logistic regression models for this outcome were constructed using known predictors of AEs. RESULTS The median RBC units transfused before rFVIIa therapy was eight. The AE rates in the untreated, early (< or = 8 U), and late (> 8 U) treated patients were 24% (129/541), 30% (20/66), and 60% (29/48). The risk-adjustment model included total RBC units, pump time, weaning difficulty, gender, weight, and age. The unadjusted and adjusted AE odds ratios (OR) in the treated vs untreated groups were 2.41 [confidence interval (CI) 1.58-3.67; P < 0.0001] and 1.04 (CI 0.60-1.81; P = 0.9). In the rFVIIa group, the adjusted AE OR was lower in the early treated group (OR 0.41; CI 0.18-0.92; P = 0.03). CONCLUSION In cardiac surgical patients with refractory hemorrhage, rFVIIa therapy is not associated with increased risk of AEs, and early treatment may be associated with better outcomes.
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Affiliation(s)
- Keyvan Karkouti
- University of Toronto, University Health Network, Department of Anesthesia, 3 Eaton North, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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Karkouti K, O'Farrell R, Yau TM, Beattie WS. Prediction of massive blood transfusion in cardiac surgery. Can J Anaesth 2006; 53:781-94. [PMID: 16873345 DOI: 10.1007/bf03022795] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE In cardiac surgery with cardiopulmonary bypass (CPB), excessive blood loss requiring the transfusion of multiple red blood cell (RBC) units is a common complication that is associated with significant morbidity and mortality. The objective of this study was to develop a prediction rule for massive blood transfusion (MBT) that could be used to optimize the management of, and research on, at-risk patients. METHODS Data were collected prospectively over the period from 2000 to 2005, on patients who underwent surgery with CPB at one hospital. Patients who received > or = five units of RBC within one day of surgery were classified as MBT. Logistic regression was used to appropriately select and weigh perioperative variables in the prediction rule, which was developed on the initial 60% of the sample and validated on the remaining 40%. RESULTS Of the 10,667 patients included, 925 (8.7%) had MBT. The clinical prediction rule included 12 variables (listed in order of predictive value: CPB duration, preoperative hemoglobin concentration, body surface area, nadir CPB hematocrit, previous sternotomy, preoperative shock, preoperative platelet count, urgency of surgery, age, surgeon, deep hypothermic circulatory arrest, and type of procedure) and was highly discriminative (c-index = 0.88). In the validation set, those classified as low-, moderate-, and high-risk by a simple risk score derived from the prediction rule had a 5%, 27%, and 58% chance of MBT, respectively. CONCLUSION A clinical prediction rule was developed that accurately identified patients at low-risk or high-risk for MBT. Studies are needed to determine the external generalizability and clinical utility of the prediction rule.
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Affiliation(s)
- Keyvan Karkouti
- University Health Network, Toronto General Hospital, Department of Anesthesia, EN 3-402, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada.
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