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Sunthankar SD, Moore RP, Byrne DW, Domenico HJ, Wheeler AP, Walker SC, Kannankeril PJ. Assessment of the CLOT (children's likelihood of thrombosis) real-time risk prediction model of hospital-associated venous thromboembolism in children with congenital heart disease. Am Heart J 2024; 272:37-47. [PMID: 38521193 DOI: 10.1016/j.ahj.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) are at high risk for hospital-associated venous thromboembolism (HA-VTE). The children's likelihood of thrombosis (CLOT) trial validated a real-time predictive model for HA-VTE using data extracted from the EHR for pediatric inpatients. We tested the hypothesis that addition of CHD specific data would improve model prediction in the CHD population. METHODS Model performance in CHD patients from 2010 to 2022, was assessed using 3 iterations of the CLOT model: 1) the original CLOT model, 2) the original model refit using only data from the CHD cohort, and 3) the model updated with the addition of cardiopulmonary bypass time, STAT Mortality Category, height, and weight as covariates. The discrimination of the three models was quantified and compared using AUROC. RESULTS Our CHD cohort included 1457 patient encounters (median 2.0 IQR [0.5-5.2] years-old). HA-VTE was present in 5% of our CHD cohort versus 1% in the general pediatric population. Several features from the original model were associated with thrombosis in the CHD cohort including younger age, thrombosis history, infectious disease consultation, and EHR coding of a central venous line. Lower height and weight were associated with thrombosis. HA-VTE rate was 12% (18/149) amongst those with STAT Category 4-5 operation versus 4% (49/1256) with STAT Category 1-3 operation (P < .001). Longer cardiopulmonary bypass time (124 [92-205] vs. 94 [65-136] minutes, P < .001) was associated with thrombosis. The AUROC for the original (0.80 95% CI [0.75-0.85]), refit (0.85 [0.81-0.89]), and updated (0.86 [0.81-0.90]) models demonstrated excellent discriminatory ability within the CHD cohort. CONCLUSION The automated approach with EHR data extraction makes the applicability of such models appealing for ease of clinical use. The addition of cardiac specific features improved model discrimination; however, this benefit was marginal compared to refitting the original model to the CHD cohort. This suggests strong predictive generalized models, such as CLOT, can be optimized for cohort subsets without additional data extraction, thus reducing cost of model development and deployment.
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Affiliation(s)
- Sudeep D Sunthankar
- Thomas P. Graham Jr. Division of Pediatric Cardiology and Center for Pediatric Precision Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN.
| | - Ryan P Moore
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Henry J Domenico
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Allison P Wheeler
- Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, TN; Divisions of Pediatric Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Shannon C Walker
- Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center, Nashville, TN; Divisions of Pediatric Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Prince J Kannankeril
- Thomas P. Graham Jr. Division of Pediatric Cardiology and Center for Pediatric Precision Medicine, Department of Pediatrics, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN
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2
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Reachi B, Negrelli J, Rapier M, Hickman A. 4-Factor Prothrombin Complex Concentrate Dosing Strategies: A Retrospective Evaluation. J Pharm Pract 2024; 37:287-295. [PMID: 36206169 DOI: 10.1177/08971900221131924] [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] [Indexed: 11/16/2022]
Abstract
ObjectivesDetermine indication specific 4-Factor prothrombin complex concentrate (4FPCC) dosing strategies within a hospital system and subsequent effectiveness. Background: 4FPCC is FDA approved for reversal of vitamin K antagonists (VKA) for acute major bleeding or need for urgent surgery/invasive procedure. Since its approval, off label use has expanded to include direct oral anticoagulant reversal and perioperative hemostasis. Optimal dosing strategies remain controversial, and recent studies have evaluated fixed-dose regimens with lower doses than those recommended in product labeling. Methods/Materials: Retrospective cohort with manual chart review for patients who received 4FPCC spanning 2 years. Primary outcome was to characterize dosing. Secondary outcomes were INR normalization, hemostatic efficacy, in-hospital mortality, and renal function change. Results: Of the 300 patients evaluated, 80% received 4FPCC for anticoagulant reversal, with 66% of those for VKA and 34% for DOAC. The remaining 20% received 4FPCC for a non-reversal indication. Of the patients requiring anticoagulation reversal, 25% received doses lower than recommended and 6% received higher. 71% of patients received 4FPCC for life-threatening bleed, and 45% of them had intracranial hemorrhage. Higher mortality with higher than recommended doses was the only statistically significant secondary outcome (P = .018). Conclusion: We found that lower doses than recommended were used in a significant number of patients. The higher than recommended doses group constituted a small proportion of patients and the higher mortality was attributed to patient acuity on presentation. Additional studies evaluating dosing approach are required to determine lowest effective dosing for various indications.
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Affiliation(s)
- Breyanna Reachi
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
| | - Jenna Negrelli
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Marie Rapier
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
| | - Abby Hickman
- Department of Pharmacy, Intermountain Medical Center, Murray, UT, USA
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3
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De La Porte VM, De Meyer GRA, Schepens T, Verbrugghe W, Laga S, Allegaert M, Mertens P, Rodrigus I, Jorens PG. Reoperation for bleeding after cardiac surgery. Acta Chir Belg 2022; 122:312-320. [PMID: 33150853 DOI: 10.1080/00015458.2020.1847463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative cardio-surgical haemostatic management is centre-specific and experience-based, which leads to a variability in patient care. This study aimed to identify which postoperative haemostatic interventions may reduce the need for reoperation after cardiac surgery in adults. METHODS A retrospective case-control study in a tertiary centre. Adult, elective, primary cardiac surgical patients were selected (n = 2098); cases (n = 42) were patients who underwent reoperation within 72 h after the initial surgery. Interventions administered to control surgical bleeding were compared for the need to re-operate using multiple logistic regression. RESULTS Rate of cardiac surgical reoperation was 2% in the study population. Three variables were found to be associated with cardiac reoperation: preoperative administration of fresh frozen plasma (OR 5.45, CI 2.34-12.35), cumulative volume of chest tube drainage and cumulative count of packed red blood cells transfusion on ICU (OR 1.98, CI 1.56-2.51). CONCLUSION No significant difference among specific types of postoperative haemostatic interventions was found between patients who needed reoperation and those who did not. Perioperative transfusion of fresh frozen plasma, postoperative transfusion of packed cells and cumulative volume of chest tube drainage were associated with reoperation after cardiac surgery. These variables could help predict the need for reoperation.
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Affiliation(s)
| | - Gregory R A De Meyer
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Tom Schepens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Walter Verbrugghe
- Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Steven Laga
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiac Surgery, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Mathias Allegaert
- Department of Patient Care, Subdivision of Perfusion, Antwerp University Hospital, Edegem, Belgium
| | - Pieter Mertens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Inez Rodrigus
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiac Surgery, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Philippe G Jorens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
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4
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Nemeth E, Varga T, Soltesz A, Racz K, Csikos G, Berzsenyi V, Tamaska E, Lang Z, Molnar G, Benke K, Eory A, Merkely B, Gal J. Perioperative Factor Concentrate Use is Associated With More Beneficial Outcomes and Reduced Complication Rates Compared With a Pure Blood Product-Based Strategy in Patients Undergoing Elective Cardiac Surgery: A Propensity Score-Matched Cohort Study. J Cardiothorac Vasc Anesth 2021; 36:138-146. [PMID: 33941446 DOI: 10.1053/j.jvca.2021.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/12/2021] [Accepted: 03/22/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The goal of this study was to compare factor concentrate (FC)-based and blood product-based hemostasis management of coagulopathy in cardiac surgical patients in terms of postoperative bleeding, required blood products, and outcome. DESIGN Retrospective, propensity score-matched analysis. SETTING Single, tertiary, academic medical center. PARTICIPANTS One hundred eighteen matched pairs of 433 consecutive patients scheduled for cardiac surgery in two isolated periods with distinct strategies of hemostasis management. INTERVENTIONS Patients received either blood product-based (period I) or FC-based (period II) hemostasis management to treat perioperative coagulopathy. MEASUREMENTS AND MAIN RESULTS Patients treated with FC management experienced less postoperative blood loss (907 v 1,153 mL, p = 0.014) and required less red blood cell and fresh frozen plasma transfusion (2.3 v 3.7 units p < 0.0001, and 2.0 v 3.4 units p < 0.0001, respectively) compared with subjects in the blood product-based management group. The frequency of Stage 3 acute kidney injury and 30-day mortality rate were significantly higher in the blood product-based group than in the FC management group (6.8% v 0.8%, p = 0.016, and 7.2% v 0.8%, p = 0.022, respectively). FC management-related thromboembolic events were not registered. The FC strategy was associated with a 2.19-fold decrease in the odds of massive postoperative bleeding (p < 0.0001), a 2.56-fold decrease in the odds of polytransfusion (p < 0.0001), and a 13.16-fold decrease in the odds of early postoperative death (p = 0.003). CONCLUSIONS FC-based versus blood product-based management is associated with reduced blood product needs and fewer complications, and was not linked to a higher frequency of thromboembolic events or a decrease in long-term survival in cardiac surgical patients developing perioperative coagulopathy and bleeding.
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Affiliation(s)
- Endre Nemeth
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
| | - Tamas Varga
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Kristof Racz
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Viktor Berzsenyi
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eszter Tamaska
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Zsolt Lang
- Department of Biomathematics and Informatics, University of Veterinary Medicine, Budapest, Hungary
| | - Gabriella Molnar
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Kalman Benke
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ajandek Eory
- Department of Family Medicine, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Janos Gal
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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5
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Zadeh FJ, Mohammadtaghizadeh M, Bahadori H, Saki N, Rezaeeyan H. The role of exogenous Fibrinogen in cardiac surgery: stop bleeding or induce cardiovascular disease. Mol Biol Rep 2020; 47:8189-8198. [PMID: 33026614 DOI: 10.1007/s11033-020-05880-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 09/29/2020] [Indexed: 12/18/2022]
Abstract
The surgical treatment contributes to broad variety of cardiovascular diseases (CVD). Due to many involved factors in preoperative bleeding, it is almost difficult to perform better Haemostatic approach. Fibrinogen is a major blood glycoprotein and a coagulation factor which decreases postoperative bleeding. It has a potential role in platelet activation and bleeding inhibition; it may reflect the inflammatory responses and be related to the endothelial dysfunction. Fibrinogen can act as a pro-inflammatory element via increasing some inflammatory markers including IL-6, tumor necrosis factor-α (TNF-α), monocyte chemo attractant protein (MCP-1), macrophage inflammatory protein-1 (MIP-1a and b), matrix metalloproteinase (MMP-1 and MMP-9) and Toll-like Receptors (TLRs); through activation of these factors, fibrinogen may induce some inflammatory mechanisms such as focal adhesion kinase (FAK), mitogen-activated protein kinases (MAPK) and nuclear factor κB (NF-κB) pathways. It may cause endothelial dysfunction by increasing P and E-selection, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) levels which activate MAPK and NF-κB pathways. This factor is also associated with increased exocytosed von Willebrand factor (vWF) as well as activation of Rho-GTPase mechanism. All of these data demonstrate the dual role of fibrinogen in cardiac surgeries, bleeding inhibition and CVD. Therefore, identifying the CVD factors is helpful for designing preventive strategies and alternative drugs.
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Affiliation(s)
- Fatemeh Javaherforoosh Zadeh
- Department of Cardiac Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Hojatolah Bahadori
- Department of Cardiac Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Najmaldin Saki
- Thalassemia and Hemoglobinopathy Research Center, Research Institute of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hadi Rezaeeyan
- Thalassemia and Hemoglobinopathy Research Center, Research Institute of Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. .,High Institute for Education and Research in Transfusion Medicine, Tehran, Iran.
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6
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van den Brink DP, Wirtz MR, Neto AS, Schöchl H, Viersen V, Binnekade J, Juffermans NP. Effectiveness of prothrombin complex concentrate for the treatment of bleeding: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2457-2467. [PMID: 32638483 PMCID: PMC7589201 DOI: 10.1111/jth.14991] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/23/2020] [Accepted: 06/26/2020] [Indexed: 01/02/2023]
Abstract
Prothrombin complex concentrate (PCC) is increasingly being used as a treatment for major bleeding in patients who are not taking anticoagulants. The aim of this systematic review and meta-analysis is to evaluate the effectiveness of PCC administration for the treatment of bleeding in patients not taking anticoagulants. Studies investigating the effectivity of PCC to treat bleeding in adult patients and providing data on either mortality or blood loss were eligible. Data were pooled using Mantel-Haenszel random effects meta-analysis or inverse variance random effects meta-analysis. From 4668 identified studies, 17 observational studies were included. In all patient groups combined, PCC administration was not associated with mortality (odds ratio = 0.83; 95% confidence interval [CI], 0.66-1.06; P = .13; I2 = 0%). However, in trauma patients, PCC administration, in addition to fresh frozen plasma, was associated with reduced mortality (odds ratio = 0.64; CI, 0.46-0.88; P = .007; I2 = 0%). PCC administration was associated with a reduction in blood loss in cardiac surgery patients (mean difference: -384; CI, -640 to -128, P = .003, I2 = 81%) and a decreased need for red blood cell transfusions when compared with standard care across a wide range of bleeding patients not taking anticoagulants (mean difference: -1.80; CI, -3.22 to -0.38; P = .01; I2 = 92%). In conclusion, PCC administration was not associated with reduced mortality in the whole cohort but did reduce mortality in trauma patients. In bleeding patients, PCC reduced the need for red blood cell transfusions when compared with treatment strategies not involving PCC. In bleeding cardiac surgery patients, PCC administration reduced blood loss.
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Affiliation(s)
- Daan P. van den Brink
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Mathijs R. Wirtz
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Trauma SurgeryAmsterdam UMCAmsterdamThe Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Department of Critical Care MedicineHospital Israelita Albert EinsteinSᾶo PauloBrazil
| | - Herbert Schöchl
- Department of Anesthesiology and Intensive Care MedicineAUVA Trauma Centre SalzburgAcademic Teaching Hospital of the Paracelsus Medical UniversitySalzburgAustria
- Institute for Experimental and Clinical TraumatologyAUVA Research CentreViennaAustria
| | - Victor Viersen
- Department of AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
| | - Jan Binnekade
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
| | - Nicole P. Juffermans
- Department of Intensive Care MedicineAmsterdam UMCAmsterdamThe Netherlands
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMCAmsterdamThe Netherlands
- Department of Intensive Care MedicineOLVG HospitalAmsterdamThe Netherlands
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7
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Terwindt L, Karlas A, Eberl S, Wijnberge M, Driessen A, Veelo D, Geerts B, Hollmann M, Vlaar A. Patient blood management in the cardiac surgical setting: An updated overview. Transfus Apher Sci 2019; 58:397-407. [DOI: 10.1016/j.transci.2019.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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8
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Hashmi NK, Ghadimi K, Srinivasan AJ, Li YJ, Raiff RD, Gaca JG, Root AG, Barac YD, Ortel TL, Levy JH, Welsby IJ. Three-factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis. Vox Sang 2019; 114:374-385. [PMID: 30937927 DOI: 10.1111/vox.12774] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Prothrombin complex concentrates (PCC) are increasingly administered off-label in the United States to treat bleeding in cardiovascular surgical patients and carry the potential risk for acquired thromboembolic side-effects after surgery. Therefore, we hypothesized that the use of low-dose 3-factor (3F) PCC (20-30 IU/kg), as part of a transfusion algorithm, reduces bleeding without increasing postoperative thrombotic/thromboembolic complications. MATERIALS/METHODS After IRB approval, we retrospectively analysed 114 consecutive, complex cardiovascular surgical patients (age > 18 years), between February 2014 and June 2015, that received low-dose 3F-PCC (Profilnine® ), of which seven patients met established exclusion criteria. PCC was dosed according to an institutional perioperative algorithm. Allogeneic transfusions were recorded before and after PCC administration (n = 107). The incidence of postoperative thromboembolic events was determined within 30 days of surgery, and Factor II levels were measured in a subset of patients (n = 20) as a quality control measure to avoid excessive PCC dosing. RESULTS Total allogeneic blood product transfusion reached a mean of 12·4 ± 9·9 units before PCC and 5·0 ± 6·3 units after PCC administration (P < 0·001). The mean PCC dose was 15·8 ± 7·1 IU/kg. Four patients (3·8%) each experienced an ischaemic stroke on postoperative day 1, 2, 4 and 27. Seven patients (6·5%) had acquired venous thromboembolic disease within 10 days of surgery. Median factor II level after transfusion algorithm adherence and PCC administration was 87%. CONCLUSIONS 3F-PCC use for refractory bleeding after cardiovascular surgery resulted in reduced transfusion of allogeneic blood and blood products. Adherence to this algorithmic approach was associated with an acceptable incidence of postoperative thrombotic/thromboembolic complications.
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Affiliation(s)
- Nazish K Hashmi
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amudan J Srinivasan
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Robert D Raiff
- Center for Medication Policy, Department of Pharmacy, Duke University Hospital Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Adam G Root
- Center for Medication Policy, Department of Pharmacy, Duke University Hospital Durham, NC, USA
| | - Yaron D Barac
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Thomas L Ortel
- Departments of Pathology, Hematology, and Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jerrold H Levy
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Ian J Welsby
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
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9
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Biancari F, Ruggieri VG, Perrotti A, Gherli R, Demal T, Franzese I, Dalén M, Santarpino G, Rubino AS, Maselli D, Salsano A, Nicolini F, Saccocci M, Gatti G, Rosato S, D'Errigo P, Kinnunen EM, De Feo M, Tauriainen T, Onorati F, Mariscalco G. Comparative Analysis of Prothrombin Complex Concentrate and Fresh Frozen Plasma in Coronary Surgery. Heart Lung Circ 2018; 28:1881-1887. [PMID: 30709591 DOI: 10.1016/j.hlc.2018.10.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 10/30/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recent studies suggested that prothrombin complex concentrate (PCC) might be more effective than fresh frozen plasma (FFP) to reduce red blood cell (RBC) transfusion requirement after cardiac surgery. METHODS This is a comparative analysis of 416 patients who received FFP postoperatively and 119 patients who received PCC with or without FFP after isolated coronary artery bypass grafting (CABG). RESULTS Mixed-effects regression analyses adjusted for multiple covariates and participating centres showed that PCC significantly decreased RBC transfusion (67.2% vs. 87.5%, adjusted OR 0.319, 95%CI 0.136-0.752) and platelet transfusion requirements (11.8% vs. 45.2%, adjusted OR 0.238, 95%CI 0.097-0.566) compared with FFP. The PCC cohort received a mean of 2.7±3.7 (median, 2.0, IQR 4) units of RBC and the FFP cohort received a mean of 4.9±6.3 (median, 3.0, IQR 4) units of RBC (adjusted coefficient, -1.926, 95%CI -3.357-0.494). The use of PCC increased the risk of KDIGO (Kidney Disease: Improving Global Outcomes) acute kidney injury (41.4% vs. 28.2%, adjusted OR 2.300, 1.203-4.400), but not of KDIGO acute kidney injury stage 3 (6.0% vs. 8.0%, OR 0.850, 95%CI 0.258-2.796) when compared with the FFP cohort. CONCLUSIONS These results suggest that the use of PCC compared with FFP may reduce the need of blood transfusion after CABG.
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Affiliation(s)
- Fausto Biancari
- Heart Center, Turku University Hospital and Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland.
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Till Demal
- Hamburg University Heart Center, Hamburg, Germany
| | - Ilaria Franzese
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Antonino S Rubino
- Centro Clinico-Diagnostico "G.B. Morgagni", Centro Cuore, Pedara, Italy
| | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | | | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico - Fondazione Monzino IRCCS, Milan, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Stefano Rosato
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Paola D'Errigo
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Eeva-Maija Kinnunen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Marisa De Feo
- Department of Cardiothoracic Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Tuomas Tauriainen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
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10
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Roman M, Biancari F, Ahmed AB, Agarwal S, Hadjinikolaou L, Al-Sarraf A, Tsang G, Oo AY, Field M, Santini F, Mariscalco G. Prothrombin Complex Concentrate in Cardiac Surgery: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2018; 107:1275-1283. [PMID: 30458156 DOI: 10.1016/j.athoracsur.2018.10.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/28/2018] [Accepted: 10/01/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prothrombin complex concentrate (PCC) has recently emerged as an effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. This systematic review and meta-analysis evaluated the safety and efficacy of PCC administration as first-line treatment for coagulopathy after adult cardiac surgery. METHODS PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared with patients receiving FFP. RESULTS A total of 861 adult patients from four studies were retrieved. No randomized studies were identified. Pooled odds ratios (ORs) showed that the PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR, 2.22; 95% confidence interval [CI], 1.45 to 3.40) and units of RBC received (OR, 1.34; 95% CI, 0.78 to 1.90). No differences were observed between the groups for reexploration for bleeding (OR, 1.09; 95% CI, 0.66 to 1.82), chest drain output at 24 hours (OR, 66.36; 95% CI, -82.40 to 216.11), hospital mortality (OR, 0.94; 95% CI, 0.59 to 1.49), stroke (OR, 0.80; 95% CI, 0.41 to 1.56), and occurrence of acute kidney injury (OR, 0.80; 95% CI, 0.58 to 1.12). A trend toward increased risk of renal replacement therapy was observed in the PCC group (OR, 0.41; 95% CI, 0.16 to 1.02). CONCLUSIONS In patients with significant bleeding after cardiac surgery, PCC administration seems to be more effective than FFP in reducing perioperative blood transfusions. No additional risks of thromboembolic events or other adverse reactions were observed. Randomized controlled trials are needed to establish the safety of PCC in cardiac surgery definitively.
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Affiliation(s)
- Marius Roman
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland
| | - Aamer B Ahmed
- Department of Anesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Seema Agarwal
- Department of Anesthesia, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Leon Hadjinikolaou
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ali Al-Sarraf
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Geoff Tsang
- Cardiac Surgery Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Aung Y Oo
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Francesco Santini
- Department of Integrated Surgical and Diagnostic Sciences, Division of Cardiac Surgery, University of Genoa, Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom; Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
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