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Taneja R, Szoke DJ, Hynes Z, Jones PM. Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study. Can J Anaesth 2023; 70:219-227. [PMID: 36471142 DOI: 10.1007/s12630-022-02364-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Excess protamine contributes to coagulopathy following cardiopulmonary bypass (CPB) and may increase blood loss and transfusion requirements. The primary aim of this study was to find the least amount of protamine necessary to neutralize residual heparin following CPB using the gold standard assays of anti-IIa and anti-Xa activity. Secondary objectives were to evaluate whether the post-CPB activated clotting time could be used as a surrogate marker for quantifying heparin neutralization. METHODS Twenty-eight consecutive patients undergoing elective cardiac surgery were enrolled. Protamine administration was standardized through an infusion pump at 25 mg·min-1. Blood samples were withdrawn prior to and following administration of 150, 200, 250, and 300 mg protamine and analyzed for activated clotting time and anti-IIa and -Xa activity. RESULTS Following a mean (standard deviation) cumulative heparin dose of 67,700 (19,400) units and a CPB duration of 113 (71) min, protamine requirements varied widely. Eight out of 25 (32%) patients showed complete neutralization of anti-IIa and -Xa activity at the first sampling point (150 mg protamine; protamine:heparin ratio, 0.3 [0.1]). A protamine:heparin ratio of 0.5 (0.2) was sufficient for heparin neutralization in > 90% of patients. After CPB, a low to mid-range activated clotting time correlated well with anti-IIa and -Xa activity. CONCLUSIONS The protamine:heparin ratio required to neutralize residual unfractionated heparin (UFH) following CPB is variable. A protamine:heparin ratio of 0.3 was sufficient to neutralize UFH in some patients, while a ratio of 0.5 is sufficient to neutralize both residual anti-IIa and -Xa activity in most patients. Larger studies are necessary to confirm these findings and evaluate their clinical implications. STUDY REGISTRATION ClinicalTrials.gov (NCT03787641); registered 26 December 2018.
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Affiliation(s)
- Ravi Taneja
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada.
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Daniel J Szoke
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Zachary Hynes
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
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2
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Song P, Holmes M, Mackensen GB. Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00031-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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3
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SORAN TÜRKCAN B, ÜNAL EU, KİRİŞ E, AYTEKİN B, AKKAYA B, DEMİR Z, AYKUT A, AKSÖYEK A, BIRINCIOĞLU L. Heparin titration protocol with tranexamic acid in cardiac surgery: a pilot study. ACTA MEDICA ALANYA 2021. [DOI: 10.30565/medalanya.956769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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4
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Elassal AA, Al-Ebrahim KE, Debis RS, Ragab ES, Faden MS, Fatani MA, Allam AR, Abdulla AH, Bukhary AM, Noaman NA, Eldib OS. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg 2021; 16:166. [PMID: 34099003 PMCID: PMC8183590 DOI: 10.1186/s13019-021-01545-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
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Affiliation(s)
- Ahmed Abdelrahman Elassal
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | | | - Ragab Shehata Debis
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ehab Sobhy Ragab
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | | | | | - Amr Ragab Allam
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Department of Cardiac Surgery, Naser Institute of Research and Treatment, Cairo, Egypt
| | - Ahmed Hasan Abdulla
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Alahrar Hospital, Zagazig, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Saber Eldib
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
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Knapik P, Cieśla D, Saucha W, Knapik M, Zembala MO, Przybyłowski P, Kapelak B, Kuśmierczyk M, Jasiński M, Tobota Z, Maruszewski BJ, Zembala M. Outcome Prediction After Coronary Surgery and Redo Surgery for Bleeding (From the KROK Registry). J Cardiothorac Vasc Anesth 2019; 33:2930-2937. [DOI: 10.1053/j.jvca.2019.04.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/29/2019] [Accepted: 04/29/2019] [Indexed: 11/11/2022]
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6
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Ponce R, Armstrong K, Andrews K, Hensler J, Waggie K, Heffernan J, Reynolds T, Rogge M. Safety of Recombinant Human Factor XIII in a Cynomolgus Monkey Model of Extracorporeal Blood Circulation. Toxicol Pathol 2017; 33:702-10. [PMID: 16243775 DOI: 10.1080/15459620500330625] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Factor XIII (FXIII) is a thrombin-activated plasma coagulation factor critical for blood clot stabilization and longevity. Administration of exogenous FXIII to replenish depleted stores after major surgery, including cardiopulmonary bypass, may reduce bleeding complications and transfusion requirements. Thus, a model of extracorporeal circulation (ECC) was developed in adult male cynomolgus monkeys ( Macaca fascicularis) to evaluate the nonclinical safety of recombinant human FXIII (rFXIII). The hematological and coagulation profile in study animals during and after 2 h of ECC was similar to that reported for humans during and after cardiopulmonary bypass, including observations of anemia, thrombocytopenia, and activation of coagulation and platelets. Intravenous slow bolus injection of 300 U/kg (2.1 mg/kg) or 1000 U/kg (7 mg/kg) rFXIII after 2 h of ECC was well tolerated in study animals, and was associated with a dose-dependent increase in FXIII activity. No clinically significant effects in respiration, ECG, heart rate, blood pressure, body temperature, clinical chemistry, hematology (including platelet counts), or indicators of thrombosis (thrombin:antithrombin complex and D-Dimer) or platelet activation (platelet factor 4 and beta-thromboglobulin) were related to rFXIII administration. Specific examination of brain, heart, lung, liver, and kidney from rFXIII-treated animals provided no evidence of histopathological alterations suggestive of subclinical hemorrhage or thrombosis. Taken as a whole, the results demonstrate the ECC model suitably replicated the clinical presentation reported for humans during and after cardiopulmonary bypass surgery, and do not suggest significant concerns regarding use of rFXIII in replacement therapy after extracorporeal circulation.
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Affiliation(s)
- R Ponce
- ZymoGenetics, Inc, Seattle, Washington 98102, USA.
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Association Between Preoperative Aspirin-dosing Strategy and Mortality After Coronary Artery Bypass Graft Surgery. Ann Surg 2015; 262:1150-6. [DOI: 10.1097/sla.0000000000000951] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Nearman H, Klick JC, Eisenberg P, Pesa N. Perioperative Complications of Cardiac Surgery and Postoperative Care. Crit Care Clin 2014; 30:527-55. [DOI: 10.1016/j.ccc.2014.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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10
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Wahr JA, Abernathy JH. Improving Patient Safety in the Cardiac Operating Room: Doing the Right Thing the Right Way, Every Time. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0052-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Trummer G. Blutungsmenge und Gerinnung, Gabe von Blut, Transfusionstrigger. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1040-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Wahr JA, Prager RL, Abernathy JH, Martinez EA, Salas E, Seifert PC, Groom RC, Spiess BD, Searles BE, Sundt TM, Sanchez JA, Shappell SA, Culig MH, Lazzara EH, Fitzgerald DC, Thourani VH, Eghtesady P, Ikonomidis JS, England MR, Sellke FW, Nussmeier NA. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association. Circulation 2013; 128:1139-69. [PMID: 23918255 DOI: 10.1161/cir.0b013e3182a38efa] [Citation(s) in RCA: 167] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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13
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Optimal treatment of ACS patients: Issues and considerations for upstream antiplatelet therapy. Int J Cardiol 2013; 163:19-25. [DOI: 10.1016/j.ijcard.2011.10.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/18/2011] [Indexed: 11/21/2022]
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Vivacqua A, Koch CG, Yousuf AM, Nowicki ER, Houghtaling PL, Blackstone EH, Sabik JF. Morbidity of Bleeding After Cardiac Surgery: Is It Blood Transfusion, Reoperation for Bleeding, or Both? Ann Thorac Surg 2011; 91:1780-90. [DOI: 10.1016/j.athoracsur.2011.03.105] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/16/2022]
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Mataraci I, Polat A, Toker ME, Tezcan O, Erkin A, Kirali K. Postoperative Revision Surgery for Bleeding in a Tertiary Heart Center. Asian Cardiovasc Thorac Ann 2010; 18:266-71. [DOI: 10.1177/0218492310369030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We analyzed cases of re-exploration for bleeding after 19,680 open heart operations performed between January 1995 and January 2009 to determine the risk factors for mortality and morbidity. Half of the 282 patients reexplored had nonsurgical causes of bleeding. The patients were grouped according to the timing of reoperation, early reexploration being on the day of the operation. Mortality, total morbidity, and the need for transfusion of any blood product were compared between the early and late reexploration groups. Most patients (77.7%) were reexplored early. Overall mortality was 8.5% (24 patients). Mortality, total morbidity, renal, gastrointestinal, neurologic and infectious complications, and low cardiac output differed significantly between the 2 groups. Significant predictors of mortality were old age, female sex, left ventricular dysfunction, noncoronary operations, and delayed reoperation. Predictors of morbidity were old age, preoperative dialysis, tobacco use, chronic lung disease, and delayed reoperation. No factors were found to be associated with the need for transfusion.
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Affiliation(s)
| | - Adil Polat
- Cardiovascular Surgery, JFK Hospital Istanbul, Turkey
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Grinberg R, Helling TS. A Betrayal of Our Handiwork: Postoperative Hemorrhage and the Need for Reoperation. Am Surg 2009. [DOI: 10.1177/000313480907501218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Postoperative hemorrhage (PH) that requires reoperation to control bleeding represents a potentially life-threatening and avoidable complication that could have serious implications for recovery. All surgical patients were reviewed who developed PH and required reoperation for control of hemorrhage over a 12-year period, to examine contributing factors possibly related to surgeon misadventure. Of 89,663 operations during this period, there were 1,031 patients (1.2%) who developed PH. Of these, 36 patients required reoperation for control of PH (0.04%), including, general surgery (17), otolaryngologic (9), cardiovascular (9), and gynecologic (1) patients. In 27 general, cardiovascular, and gynecologic patients (29 reoperations), the age ranged from 6 to 91 years. Almost one-half of patients (56%) developing PH were on preoperative anticoagulation. Estimated operative blood loss (EBL) was moderate (EBL = 100-500 mL, 48%). Most patients were normothermic (80%) and normotensive (93%) intraoperatively. The decision to reoperate was not made for at least 8 hours in 55 per cent of patients. At reoperation 10/29 patients were hypotensive. In 20/36 patients (56%) the reoperation note did not identify a single source of bleeding. PH is a distinctly uncommon complication of surgery and often not due to obvious surgeon misadventure. Reoperation for PH is even rarer and embarked upon with reluctance, frequently not yielding a discernible cause for hemorrhage.
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Affiliation(s)
- Roman Grinberg
- From the Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania
| | - Thomas S. Helling
- From the Department of Surgery, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania
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Mehta RH, Sheng S, O'Brien SM, Grover FL, Gammie JS, Ferguson TB, Peterson ED. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: incidence, risk factors, time trends, and outcomes. Circ Cardiovasc Qual Outcomes 2009; 2:583-90. [PMID: 20031896 DOI: 10.1161/circoutcomes.109.858811] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Reoperation for bleeding represents an important complication in patients undergoing coronary artery bypass surgery (CABG). Yet, few studies have characterized risk factors and patient outcomes of this event. METHODS AND RESULTS We evaluated 528 686 CABG patients at >800 hospitals in the Society of Thoracic Surgeons National Cardiac Database (2004 to 2007). Clinical features and in-hospital outcomes were evaluated in patients with and without reoperation for bleeding after CABG. Logistic regression was used to identify predictors of risk of this event and to estimate weights for an additive risk score. A total of 12 652 CABG patients (2.4%) required reoperation for bleeding. These rates remained fairly stable over time (2.2%, 2.3%, 2.5%, and 2.4% from 2004 to 2007, respectively). Although overall operative mortality was 4.5-fold higher in patients requiring reoperation for bleeding versus those who did not (2.0% versus 9.1%), this mortality risk declined significantly over time (11.3%, 9.5%, 8.8%, and 8.2% from 2004 to 2007, respectively, P for trend=0.0006). Factors associated with higher risk for reoperation were identified by multivariable analysis (c statistic=0.60) and summarized into a simple bedside risk score. The risk-score performed well when tested in the validation set (Hosmer-Lemeshow P=0.16). CONCLUSIONS Reoperation for bleeding remains an important morbid event after CABG. Nonetheless, death in patients with this complication has decreased over time. Our risk tool should allow estimation of patients risk for reoperation for bleeding and promote preventive measures when feasible in this at-risk group.
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Ranaweera PS, Bigelow BC, Leary MC, de la Torre R, Sellke F, Garcia LA. Endovascular carotid artery stenting and early coronary artery bypass grafting for asymptomatic carotid artery stenosis: Long-term outcomes and neurologic events. Catheter Cardiovasc Interv 2009; 73:139-42. [DOI: 10.1002/ccd.21824] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Herz-Kreislauf-Stillstand und kardiopulmonale Reanimation auf der herzchirurgischen Intensivstation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Yavuz S, Eris C, Türk T. Re-exploration for excessive bleeding after coronary artery bypass surgery: how early is better? Eur J Cardiothorac Surg 2007; 32:819-20; author reply 820. [PMID: 17768063 DOI: 10.1016/j.ejcts.2007.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Revised: 06/06/2007] [Accepted: 08/06/2007] [Indexed: 11/24/2022] Open
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Hajjar LA, Auler Junior JOC, Santos L, Galas F. Blood tranfusion in critically ill patients: state of the art. Clinics (Sao Paulo) 2007; 62:507-24. [PMID: 17823715 DOI: 10.1590/s1807-59322007000400019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2007] [Accepted: 04/24/2007] [Indexed: 11/22/2022] Open
Abstract
Anemia is one of the most common abnormal findings in critically ill patients, and many of these patients will receive a blood transfusion during their intensive care unit stay. However, the determinants of exactly which patients do receive transfusions remains to be defined and have been the subject of considerable debate in recent years. Concerns and doubts have emerged regarding the benefits and safety of blood transfusion, in part due to the lack of evidence of better outcomes resulting from randomized studies and in part related to the observations that transfusion may increase the risk of infection. As a result of these concerns and of several studies suggesting better or similar outcomes with a lower transfusion trigger, there has been a general tendency to decrease the transfusion threshold from the classic 10 g/dL to lower values. In this review, we focus on some of the key studies providing insight into current transfusion practices and fueling the current debate on the ideal transfusion trigger.
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Affiliation(s)
- Ludhmila Abrahão Hajjar
- Heart Institute, Division of Anesthesia, Intensive Care Unit, Heart Institute INCOR, Medical School Hospital, São Paulo University, São Paulo, Brazil.
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Wolfe R, Bolsin S, Colson M, Stow P. Monitoring the rate of re-exploration for excessive bleeding after cardiac surgery in adults. Qual Saf Health Care 2007; 16:192-6. [PMID: 17545345 PMCID: PMC2464986 DOI: 10.1136/qshc.2004.012435] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The monitoring of adverse events in clinical care can be an important part of quality assurance. There is little evidence on the monitoring of re-exploration after cardiac surgery. OBJECTIVE To apply statistical monitoring techniques to the rate of re-exploration for excessive bleeding in adult patients undergoing cardiac surgery procedures using cardiopulmonary bypass at Geelong Hospital, Victoria, Australia, between 1997 and 2003. METHODS Shewhart charts, moving average plots and cumulative sum (CUSUM) charts were used to demonstrate changes in the rate of re-exploration over time. RESULTS A CUSUM chart was used retrospectively at a time of perceived deteriorating clinical outcomes in patients of the cardiac surgery service. At this time, an intervention aimed at reducing the re-exploration rate was performed, and subsequent CUSUM charts indicated an improvement in this rate. The CUSUM chart has become an important part of the quality feedback of clinical care outcomes within the Anaesthesia & Pain Management unit of Geelong Hospital. CONCLUSION Statistical monitoring techniques for quality assurance can identify important changes in clinical performance, and their adoption by clinicians is recommended.
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Affiliation(s)
- Rory Wolfe
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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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: 610] [Impact Index Per Article: 35.9] [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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Steiner ME, Despotis GJ. Transfusion Algorithms and How They Apply to Blood Conservation: The High-risk Cardiac Surgical Patient. Hematol Oncol Clin North Am 2007; 21:177-84. [PMID: 17258126 DOI: 10.1016/j.hoc.2006.11.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Considerable blood product support is administered to the cardiac surgery population. Due to the multifactorial etiology of bleeding in the cardiac bypass patient, blood products frequently and empirically are infused to correct bleeding, with varying success. Several studies have demonstrated the benefit of algorithm-guided transfusion in reducing blood loss, transfusion exposure, or rate of surgical re-exploration for bleeding. Some transfusion algorithms also incorporate laboratory-based decision points in their guidelines. Despite published success with standardized transfusion practices, generalized change in blood use has not been realized, and it is evident that current laboratory-guided hemostasis measures are inadequate to define and address the bleeding etiology in these patients.
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Affiliation(s)
- Marie E Steiner
- Department of Pediatrics, Division of Hematology/Oncology/Blood & Marrow Transplantation, 420 Delaware Street, MMC 484, University of Minnesota, Minneapolis, MN 55455, USA.
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Cannon CP, Mehta SR, Aranki SF. Balancing the benefit and risk of oral antiplatelet agents in coronary artery bypass surgery. Ann Thorac Surg 2006; 80:768-79. [PMID: 16039260 DOI: 10.1016/j.athoracsur.2004.09.058] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2004] [Revised: 09/24/2004] [Accepted: 09/29/2004] [Indexed: 10/25/2022]
Abstract
Concern about possible hemorrhagic complications arising from use of oral antiplatelet agents in immediate proximity to coronary artery bypass graft (CABG) surgery leads many clinicians to avoid or discontinue these agents preoperatively. Recent evidence suggests that aspirin and clopidogrel can be used with relative safety in the preoperative period; dual antiplatelet therapy in the 5 days immediately preceding CABG surgery results in a moderate and variable increase in the risk of procedural bleeding. This modest hemorrhagic risk may be acceptable, given the clinical benefits of sustained antiplatelet therapy in preventing graft occlusion and ischemic complications pre- and post-CABG. Because the bleeding risk with aspirin is dose dependent, use of a low dose is preferred post-CABG.
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Affiliation(s)
- Christopher P Cannon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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26
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Abstract
OBJECTIVE To describe the physiologic alterations, evaluation, and hemodynamic management of patients in the first 24 hrs after cardiac surgery. DESIGN A brief review of preoperative and intraoperative events, postoperative physiology, and a discussion of the evaluation and hemodynamic management of cardiac surgery patients postoperatively based on a review of the literature, known physiology, and clinical experience. RESULTS After cardiac surgery, patients undergo alterations in cardiac performance related to co-morbid conditions, preoperative myocardial insults and interventions, the surgical procedure, and intraoperative management. Predictable responses evolve rapidly in the first 24 hrs after surgery. Monitoring, diagnostic regimens, and therapeutic regimens exist to address the patterns of response and occasional complications. CONCLUSION By understanding preoperative and intraoperative events and their evolution in the intensive care unit, clinicians can effectively manage patients who experience cardiac surgery.
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Affiliation(s)
- Arthur C St André
- Surgical Critical Care, Washington Hospital Center, Washington, DC, USA
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27
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Dial S, Delabays E, Albert M, Gonzalez A, Camarda J, Law A, Menzies D. Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg 2005; 130:654-61. [PMID: 16153909 DOI: 10.1016/j.jtcvs.2005.02.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2004] [Revised: 02/08/2005] [Accepted: 02/15/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We sought to determine the incidence of and risk factors for the development of low intraoperative hematocrit levels and of excessive postoperative bleeding in patients undergoing coronary artery bypass grafting, whether the risk factors are the same, and their effect on blood product transfusions. METHODS We performed a prospective cohort study of 613 adult patients who underwent coronary artery bypass grafting in 3 tertiary, university-affiliated hospitals during the period from October 1, 2000, to March 31, 2001. RESULTS Low intraoperative hematocrit levels (<19%) were found in 131 (24%) patients who had operations performed with extracorporeal circulation compared with in 3 (4%) patients with operations performed off pump. In multivariate analysis this was associated with older age, female sex, lower preoperative hemoglobin levels, lower body surface area, longer duration on bypass, and use of higher total volumes with more hydroxyethyl starch in the circuit. Low intraoperative hematocrit levels did not predict excessive postoperative hemorrhage (>1 L of mediastinal drainage in the first 12 hours). This occurred in 26% (n = 140) of patients undergoing on-pump operations and in 25% of patients undergoing off-pump operations and in multivariate analysis was associated with male sex, longer pump times, not receiving aprotinin, and operations performed by certain surgeons but not with total circuit or hydroxyethyl starch volume. CONCLUSIONS We observed that the risk factors for the development of a low intraoperative hematocrit level and excessive postoperative bleeding differed. Our results suggest that decreasing these outcomes in patients undergoing cardiac surgery requires a comprehensive approach, including limiting hemodilution, particularly in female subjects with lower preoperative hemoglobin levels, and careful attention to surgical hemostasis.
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Affiliation(s)
- Sandra Dial
- Department of Critical Care, SMBD Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
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28
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Morawski W, Sanak M, Cisowski M, Szczeklik M, Szczeklik W, Dropinski J, Waclawczyk T, Ulczok R, Bochenek A. Prediction of the excessive perioperative bleeding in patients undergoing coronary artery bypass grafting: Role of aspirin and platelet glycoprotein IIIa polymorphism. J Thorac Cardiovasc Surg 2005; 130:791-6. [PMID: 16153930 DOI: 10.1016/j.jtcvs.2005.02.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2004] [Revised: 02/12/2005] [Accepted: 02/24/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The presence of the glycoprotein IIIa allele PlA2 is associated with enhanced thrombin formation and an impaired antithrombotic action of aspirin, which could favor coronary thrombosis. We wondered whether PlA1/A2 genetic polymorphism could affect the postoperative bleeding in patients undergoing coronary artery bypass grafting. We also aimed to assess the effects of aspirin pretreatment and to ascertain the value of platelet function studies as predictors of postoperative bleeding. METHODS In a randomized, double-blind study, patients undergoing coronary artery bypass grafting were pretreated with a 150-mg dose of aspirin orally 12 and 3 hours before surgery (n = 51, 41 elective) or with placebo (n = 51, 43 elective). The hemostasis was monitored by Simplate (bioMérieux, Inc, Durham, NC) bleeding time and capillary closure time (platelet function analyzer PFA 100; Sysmex UK Ltd, Milton Keynes, United Kingdom). Postoperative bleeding and blood products transfusions were recorded. The glycoprotein IIIa polymorphism was analyzed. RESULTS Bleeding was significantly greater in PlA1 homozygotes from control group. Blood loss was significantly greater (by 25%) in aspirin group. The volume of blood products transfusions in aspirin patients was significantly larger (by 137%). When subjects were stratified accordingly to blood platelet glycoprotein IIb/IIIa genotype, in the aspirin group PlA2 carriers had greater blood loss than PlA1 homozygotes (1858 +/- 932 mL vs 1216 +/- 525 mL, P < .05). CONCLUSION PlA1 homozygotes normally had a greater risk of perioperative bleeding. Capillary closure time had no advantage relative to Simplate bleeding time in predicting postoperative blood loss. Aspirin pretreatment revealed no beneficial effects and resulted in increased postoperative bleeding and requirement for blood product transfusions after coronary artery bypass grafting in patients with stable angina. It was most unfavorable for PlA2 carriers.
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Affiliation(s)
- W Morawski
- First Cardiac Surgery Department, Medical University of Silesia, Katowice, Poland.
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29
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Bybee KA, Powell BD, Valeti U, Rosales AG, Kopecky SL, Mullany C, Wright RS. Preoperative Aspirin Therapy Is Associated With Improved Postoperative Outcomes in Patients Undergoing Coronary Artery Bypass Grafting. Circulation 2005; 112:I286-92. [PMID: 16159833 DOI: 10.1161/circulationaha.104.522805] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Aspirin is beneficial in the setting of atherosclerotic cardiovascular disease. There are limited data evaluating preoperative aspirin administration preceding coronary artery bypass grafting and associated postoperative outcomes.
Methods and Results—
Using prospectively collected data from 1636 consecutive patients undergoing first-time isolated coronary artery bypass surgery at our institution from January 2000 through December 2002, we evaluated the association between aspirin usage within the 5 days preceding coronary bypass surgery and risk of adverse in-hospital postoperative events. A logistic regression model, which included propensity scores, was used to adjust for remaining differences between groups. Overall, there were 36 deaths (2.2%) and 48 adverse cerebrovascular events (2.9%) in the postoperative hospitalization period. Patients receiving preoperative aspirin (n=1316) had significantly lower postoperative in-hospital mortality compared with those not receiving preoperative aspirin [1.7% versus 4.4%; adjusted odds ratio (OR), 0.34; 95% CI, 0.15 to 0.75;
P
=0.007]. Rates of postoperative cerebrovascular events were similar between groups (2.7% versus 3.8%; adjusted OR, 0.67; 95% CI, 0.32 to 1.50;
P
=0.31). Preoperative aspirin therapy was not associated with an increased risk of reoperation for bleeding (3.5% versus 3.4%;
P
=0.96) or requirement for postoperative blood product transfusion (adjusted OR, 1.17; 95% CI, 0.88 to 1.54;
P
=0.28).
Conclusions—
Aspirin usage within the 5 days preceding coronary artery bypass surgery is associated with a lower risk of postoperative in-hospital mortality and appears to be safe without an associated increased risk of reoperation for bleeding or need for blood product transfusion.
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Affiliation(s)
- Kevin A Bybee
- Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
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30
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Harrington DK, Lilley JP, Rooney SJ, Bonser RS. Nonneurologic morbidity and profound hypothermia in aortic surgery. Ann Thorac Surg 2005; 78:596-601. [PMID: 15276529 DOI: 10.1016/j.athoracsur.2004.01.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Use of profoundly hypothermic cardiopulmonary bypass may increase the risk of postoperative bleeding and lung and renal dysfunction. The aim of this study was to analyze postoperative blood loss and indices of pulmonary and renal dysfunction in patients undergoing proximal aortic surgery with and without the use of profound hypothermia to determine risk factors for nonneurologic morbidity. METHODS Risk factors for blood loss, transfusion requirement, and pulmonary and renal dysfunction were studied in 116 patients undergoing thoracic aortic surgery with profoundly or moderately hypothermic cardiopulmonary bypass. RESULTS Overall mortality was 8.6%. Mean (+/- standard deviation) cardiopulmonary bypass times were 191 +/- 53 minutes (profoundly hypothermic group) and 131 +/- 48 minutes (moderately hypothermic group; p < 0.0001). The incidence of blood loss more than 1 L or resternotomy for bleeding was 25% (29 patients). Fifteen patients (12.9%) experienced postoperative pulmonary dysfunction, and 25 patients (21.6%) had postoperative renal dysfunction. Forty-one patients (35.3%) had a prolonged intensive therapy unit length of stay. Multivariate analysis demonstrated that prolonged cardiopulmonary bypass time was the only predictor of postoperative hemorrhage and resternotomy for bleeding (p = 0.03). Increased intensive therapy unit length of stay was predicted by total arch replacement (p = 0.01) and low 6-hour ratio of partial pressure of arterial oxygen to inspired fraction of oxygen (p = 0.05). Increased preoperative creatinine (p = 0.002) and emergency status (p = 0.015) predicted postoperative renal dysfunction. Low 6-hour ratio of partial pressure of arterial oxygen to inspired fraction of oxygen was predicted by increased preoperative creatinine (p = 0.03) and prolonged cardiopulmonary bypass time (p = 0.03). CONCLUSIONS Profound hypothermia may cause a coagulopathy, but procedure extent is the primary determinant of postoperative bleeding. Profoundly hypothermic cardiopulmonary bypass does not appear to be a risk factor for renal or early pulmonary dysfunction or intensive therapy unit length of stay.
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Affiliation(s)
- Deborah K Harrington
- Cardiothoracic Surgical Unit, University Hospital Birmingham, Queen Elizabeth Medical Centre, Birmingham B15 2TH, United Kingdom
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31
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Abstract
PURPOSE OF REVIEW Severe bleeding after cardiac surgery is a potential problem that poses major risks and challenges. Severe bleeding after cardiac surgery still occurs despite many pharmacological approaches to decrease bleeding and reduce transfusion requirements. Activated recombinant factor VII may be a therapy that is potentially useful in the management of refractory bleeding after cardiac surgery and in other postoperative bleeding states. RECENT FINDINGS Several small, uncontrolled case series have suggested that activated recombinant factor VII may be useful in the management of some patients with intractable bleeding after cardiopulmonary bypass in both pediatric and adult populations. Blood loss or transfusion requirements have been reported to be substantially reduced in some patients who receive activated recombinant factor VII perioperatively. However, these reports have not established the optimal dosing or ideal timing of the administration of activated recombinant factor VII, or determined the frequency of serious adverse events related to its use. SUMMARY Current reports summarized in this review suggest that activated recombinant factor VII may be a promising agent in the management of uncontrolled bleeding after cardiopulmonary bypass, but additional randomized, placebo-controlled trials are needed to support this use.
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Affiliation(s)
- Marie E Steiner
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Karthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg 2004; 78:527-34; discussion 534. [PMID: 15276512 DOI: 10.1016/j.athoracsur.2004.02.088] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND We aimed to identify risk factors for reexploration for bleeding after surgical revascularization in our practice. We also looked at the impact of resternotomy and the effect of time delay on mortality and other in-hospital outcomes. METHODS In all, 2,898 consecutive patients undergoing coronary artery bypass grafting between April 1999 and March 2002 were retrospectively analyzed from our cardiac surgery registry. Multivariate logistic regression analysis was used to identify risk factors for reexploration for bleeding. To assess the effect of preoperative aspirin and heparin, reexploration patients were propensity matched with unique patients not requiring reexploration. We carried out a casenote review to ascertain the timing and causes for bleeding in patients undergoing resternotomy. RESULTS Eighty-nine patients (3.1%) underwent reexploration for bleeding. Multivariate analysis revealed smaller body mass index (p = 0.003), nonelective surgery (p = 0.022), 5 or more distal anastomoses (p = 0.035), and increased age (p = 0.041) to have increased risks. Propensity-matched analysis showed that preoperative use of aspirin (p = 0.004) and heparin (p = 0.001) were associated with increased risk in the on-pump coronary surgery group only. Patients requiring resternotomy had a significantly greater need for inotropic agents (p < 0.001), and longer intensive care unit stay (p < 0.001) and postoperative stay (p < 0.001) than their propensity-matched controls. However, there was no significant difference in the mortality rate. Adverse outcomes were significantly higher when patients waited more than 12 hours after return to the intensive care unit for resternotomy. CONCLUSIONS Risk factors for reexploration for bleeding after coronary artery bypass grafting include older age, smaller body mass index, nonelective cases, and 5 or more distal anastomoses. Preoperative aspirin and heparin were risk factors for the on-pump coronary artery surgery group. Patients needing reexploration are at higher risk of complications if the time to reexploration is prolonged. Policies that promote early return to the operating theater for reexploration should be encouraged.
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Affiliation(s)
- Shishir Karthik
- Department of Cardiothoracic Surgery, The Cardiothoracic Centre-Liverpool, Liverpool, United Kingdom.
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Govindaswamy S, Chandler J, Latimer R, Vuylsteke A. Management of the patient with coagulation disorders. Curr Opin Anaesthesiol 2002; 15:19-25. [PMID: 17019180 DOI: 10.1097/00001503-200202000-00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Understanding normal haemostasis and the pathophysiology of its disorders is essential for providing optimal care and ensuring judicious usage of blood products, as is keeping abreast of novel therapeutic modalities in a rapidly evolving field. The growing availability of synthetic coagulation factors has (at least in the western hemisphere) helped to reduce morbidity and therapeutic complications, while expanding the indications and usage of these agents. Promising advances in gene therapy may indeed introduce a sea change in the next decade or two.
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Abstract
OBJECTIVE Platelet dysfunction is a common cause of bleeding after coronary artery bypass graft surgery. This study explores the effects of clopidogrel on bleeding complications after coronary artery bypass graft surgery. DESIGN Prospective observational study of patients undergoing coronary artery bypass graft. SETTING Tertiary care center. PATIENTS A total of 247 patients undergoing coronary artery bypass graft surgery. INTERVENTIONS None. MEASUREMENTS Primary end point was need for reexploration secondary to bleeding. Secondary end points included need for transfusion of blood products and chest tube output. MAIN RESULTS Eight (3.3%) of 247 patients required reexploration secondary to bleeding. Clopidogrel recipients had higher incidence of reexploration for bleeding (9.8 vs. 1.6, p =.01) with an odds ratio of 6.9 (95% confidence interval, 1.6-30). Clopidogrel also increased the percentage of patients receiving packed red blood cell transfusion (72.6 vs. 51.6%, p =.007), the number of packed red blood cell units (3 vs. 1.6, p =0.0004), and the number of cryoprecipitate units (2.4 vs. 1.2, p =.04) transfused after coronary artery bypass graft surgery. Among clopidogrel recipients, a trend for increased transfusion of platelet units (4.3 vs. 1.7, p =.05) and fresh frozen plasma units (1.1 vs. 0.6, p =.08) also was found. CONCLUSIONS Preoperative use of clopidogrel in combination with aspirin is associated with increased need for surgical reexploration as well as risk of packed red blood cell and cryoprecipitate transfusions after coronary artery bypass graft surgery.
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Affiliation(s)
- S Yende
- Physician Research Network, Methodist Healthcare, Memphis, TN, USA
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35
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36
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Peragallo RA, Cheng DC. Con: tracheal extubation should not occur routinely in the operating room after cardiac surgery. J Cardiothorac Vasc Anesth 2000; 14:611-3. [PMID: 11052450 DOI: 10.1053/jcan.2000.9497] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- R A Peragallo
- Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, Ontario, Canada
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