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Al-Attar N, Gaer J, Giordano V, Harris E, Kirk A, Loubani M, Meybohm P, Sayeed R, Stock U, Travers J, Whiteman B. Multidisciplinary paper on patient blood management in cardiothoracic surgery in the UK: perspectives on practice during COVID-19. J Cardiothorac Surg 2023; 18:96. [PMID: 37005650 PMCID: PMC10066978 DOI: 10.1186/s13019-023-02195-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 03/29/2023] [Indexed: 04/04/2023] Open
Abstract
The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.
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Affiliation(s)
- Nawwar Al-Attar
- Golden Jubilee National Hospital, University of Glasgow, Agamemnon Street, Clydebank, Glasgow, G81 4DY, Scotland, UK.
| | - Jullien Gaer
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Vincenzo Giordano
- Department of Cardiothoracic Surgery, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Emma Harris
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Alan Kirk
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Würzburg, Germany
| | - Rana Sayeed
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ulrich Stock
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Jennifer Travers
- West of Scotland Cancer Centre, Golden Jubilee National Hospital, Glasgow, UK
| | - Becky Whiteman
- Cluster Medical Manager Advanced Surgery - UKI and Nordics Worldwide Medical, Baxter Healthcare Limited, Berkshire, UK
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Im C, Park YS, Min SH, Kang SH, Lee S, Lee E, Yoo M, Hwang D, Ahn SH, Suh YS, Park DJ, Kim HH. Postoperative major bleeding risk in patients using oral antiplatelets and/or anticoagulants after laparoscopic gastric cancer surgery. Ann Surg Treat Res 2023; 104:80-89. [PMID: 36816732 PMCID: PMC9929431 DOI: 10.4174/astr.2023.104.2.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/16/2022] [Accepted: 12/05/2022] [Indexed: 02/09/2023] Open
Abstract
Purpose The use of antiplatelet and/or anticoagulant therapies has become common. In rare cases, these therapies may increase the risk of dangerous postoperative bleeding. We investigated the association of antiplatelets and/or anticoagulants with postoperative major bleeding risk in laparoscopic gastric cancer surgery. Methods We retrospectively enrolled 3,663 gastric cancer patients (antiplatelet/anticoagulant group, 518; control group, 3,145) who had undergone laparoscopic surgery between January 2012 and December 2017. To minimize selection bias, 508 patients in each group were matched using propensity score matching (PSM) method. The primary outcome was postoperative major bleeding. Secondary outcomes were intraoperative, postoperative transfusion and early complications. Results After PSM, postoperative major bleeding occurred in 10 (2.0%) and 3 cases (0.6%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.090). Intraoperative and postoperative transfusions were not significantly different between 2 groups (2.4% vs. 1.4%, P = 0.355 and 5.5% vs. 4.3%, P = 0.469). Early complications developed in 58 (11.4%) and 43 patients (8.5%) in the antiplatelets/anticoagulants and control groups, respectively (P = 0.142). The mean amounts of intraoperative and postoperative transfusions were not significantly different between the groups (366.67 ± 238.68 mL vs. 371.43 ± 138.01 mL, P = 0.962; 728.57 ± 642.25 mL vs. 508.09 ± 468.95 mL, P = 0.185). In multivariable analysis, male (P = 0.008) and advanced stage (III, IV) (P = 0.024) were independent significant risk factors for postoperative major bleeding. Conclusion Preoperative antiplatelets and/or anticoagulants administration did not significantly increase the risk of postoperative major bleeding after laparoscopic gastric cancer surgery.
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Affiliation(s)
- Chami Im
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sa-Hong Min
- Department of Surgery, Asan Medical Center, Seoul, Korea
| | - So Hyun Kang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sangjun Lee
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Eunju Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mira Yoo
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Duyeong Hwang
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yun Suhk Suh
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Hospital, Seoul, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Kao FC, Chang YC, Chen TS, Liu PH, Tu YK. Risk factors for unplanned return to the operating room within 24 hours: A 9-year single-center observational study. Medicine (Baltimore) 2021; 100:e28053. [PMID: 34889250 PMCID: PMC8663871 DOI: 10.1097/md.0000000000028053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 11/08/2021] [Indexed: 01/05/2023] Open
Abstract
The purpose of the retrospective case-control study was to identify the causes of and risk factors for unplanned return to the operating room (uROR) within 24 hours in surgical patients.We examined 275 cases of 24-hour uROR in our hospital from January 2010 to December 2018. The reasons for 24-hour uROR were classified into several categories. Controls were randomly matched to cases in a 1:1 ratio with the selection criteria set for the same surgeon and operation code in the same corresponding year.The mortality rate was significantly higher in patients with 24-hour uROR (11.63% vs 5.23%). Bleeding was the most common etiology (172/275; 62.55%) and technical error (14.5%) also contributed to 24-hour uROR. The clinical factors that led to bleeding included a history of liver disease (P = .032), smoking (P = .002), low platelet count in preoperative screening (P = .012), and preoperative administration of antiplatelet or anticoagulant agents (P = .014).Clinicians should recognize the risk factors for bleeding and minimize errors to avoid the increase in patient morbidity and mortality that is associated with 24-hour uROR.Level of Evidence: Level IV.
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Affiliation(s)
- Feng-Chen Kao
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
| | - Yun-Chi Chang
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
- Department of Anesthesia, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzu-Shan Chen
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
- Department of Medical Research, E-Da Hospital, Kaohsiung, Taiwan
| | - Ping-Hsin Liu
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
- Department of Anesthesia, E-Da Hospital, Kaohsiung, Taiwan
| | - Yuan-Kun Tu
- Department of Orthopedics, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, I-Shou University, Kaohsiung, Taiwan
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Vieira SD, da Cunha Vieira Perini F, de Sousa LCB, Buffolo E, Chaccur P, Arrais M, Jatene FB. Autologous blood salvage in cardiac surgery: clinical evaluation, efficacy and levels of residual heparin. Hematol Transfus Cell Ther 2021; 43:1-8. [PMID: 31791879 PMCID: PMC7910157 DOI: 10.1016/j.htct.2019.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/21/2019] [Accepted: 08/20/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. METHOD Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. RESULTS Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81g/dl and 6.84×106/mm3, respectively (p<0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were ≤0.1IU/ml in all post-treatment analyses (p=0.003). No related adverse events were observed. CONCLUSION The reduced residual heparin values (≤0.1IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature.
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Affiliation(s)
- Sérgio Domingos Vieira
- Banco de Sangue de São Paulo, São Paulo, SP, Brazil; Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil.
| | | | | | - Enio Buffolo
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
| | - Paulo Chaccur
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
| | - Magaly Arrais
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
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DeAnda A, Levy G, Kinsky M, Sanjoto P, Garcia M, Avandsalehi KR, Diaz G, Yates SG. Comparison of the Quantra QPlus System With Thromboelastography in Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 35:1030-1036. [PMID: 33384230 DOI: 10.1053/j.jvca.2020.11.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Use of viscoelastic testing, such as thromboelastography (TEG), is recommended in cardiac surgery to monitor coagulation and to guide the transfusion of blood products. The Quantra QPlus System is a novel point-of-care platform that uses ultrasonic pulses to characterize dynamic changes in viscoelastic properties of a blood sample during coagulation. Despite the ability to assess similar aspects of clot formation, limited studies addressing the interchangeability of viscoelastic testing parameters exist. The primary aim of the present study was to assess the correlation and agreement between Quantra and TEG5000 results using blood samples from cardiac surgery patients. DESIGN Tertiary care, academic medical center. SETTING Prospective observational study. PARTICIPANTS Twenty-eight patients undergoing elective cardiac surgery undergoing cardiopulmonary bypass were evaluated. MEASUREMENTS AND MAIN RESULTS Perioperative blood samples were collected and assessed using Quantra, and results were compared with TEG and conventional coagulation testing. Method comparison analysis demonstrated that Quantra parameters (Quantra clot time, clot stiffness, and fibrinogen contribution to clot stiffness) significantly correlated with TEG R and TEG G after induction of anesthesia, during cardiopulmonary bypass, and after rewarming (rs = 0.83, rs = 0.84, and rs = 0.73, respectively). However, Quantra parameters demonstrated poor agreement compared with equivalent TEG5000 parameters. CONCLUSIONS The Quantra QPlus System significantly correlated with TEG5000, suggesting that this test may be used in a similar clinical context. Despite the strength of correlation between Quantra and TEG parameters, measurements are not interchangeable.
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Affiliation(s)
- Abe DeAnda
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Gal Levy
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Michael Kinsky
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Peni Sanjoto
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX
| | - Mary Garcia
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, TX
| | - Kurosh R Avandsalehi
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, TX
| | - Gabriel Diaz
- Department of Pathology, Division of Transfusion Medicine, University of Texas Medical Branch, Galveston, TX
| | - Sean G Yates
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Surgery, University of Texas Medical Branch, Galveston, TX.
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Lin C, Fu Y, Huang S, Zhou S, Shen C. Rapid thrombelastography predicts perioperative massive blood transfusion in patients undergoing coronary artery bypass grafting: A retrospective study. Medicine (Baltimore) 2020; 99:e21833. [PMID: 32925720 PMCID: PMC7489729 DOI: 10.1097/md.0000000000021833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Massive blood transfusion (MBT) is a relatively common complication of cardiac surgery, which is independently associated with severe postoperative adverse events. However, the value of using rapid thrombotomography (r-TEG) to predict MBT in perioperative period of cardiac surgery has not been explored. This study aimed to identify the effect of r-TEG in predicting MBT for patients undergoing coronary artery bypass grafting (CABG).This retrospective study included consecutive patients first time undergoing CABG at the Zhongnan Hospital of Wuhan University between March 2015 and November 2017. All the patients had done r-TEG tests before surgery. The MBT was defined as receiving at least 4 units of red blood cells intra-operatively and 5 units postoperatively (1 unit red blood cells from 200 mL whole blood).Lower preoperative hemoglobin level (P = .001) and longer cardiopulmonary bypass time (P = .001) were the independent risk factors for MBT during surgery, and no components of the r-TEG predicted MBT during surgery. Meanwhile, longer activated clotting time (P < .001), less autologous blood transfusion (P = .001), and older age (P = .008) were the independent risk factors for MBT within 24 hours of surgery.Preoperative r-TEG activated clotting time can predict the increase of postoperative MBT in patients undergoing CABG. We recommend the careful monitoring of coagulation system with r-TEG, which allows rapid diagnosis of coagulation abnormalities even before the start of surgery.
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Affiliation(s)
- Chenyao Lin
- Department of Laboratory Mediciney, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Yourong Fu
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuang Huang
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuimei Zhou
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Changxin Shen
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
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Therapeutic potential of fibrinogen γ-chain peptide-coated, ADP-encapsulated liposomes as a haemostatic adjuvant for post-cardiopulmonary bypass coagulopathy. Sci Rep 2020; 10:11308. [PMID: 32647296 PMCID: PMC7347858 DOI: 10.1038/s41598-020-68307-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022] Open
Abstract
Fibrinogen γ-chain peptide-coated, adenosine 5'-diphosphate (ADP)-encapsulated liposomes (H12-ADP-liposomes) are a potent haemostatic adjuvant to promote platelet thrombi. These liposomes are lipid particles coated with specific binding sites for platelet GPIIb/IIIa and encapsulating ADP. They work at bleeding sites, facilitating haemostasis by promoting aggregation of activated platelets and releasing ADP to strongly activate platelets. In this study, we investigated the therapeutic potential of H12-ADP-liposomes on post-cardiopulmonary bypass (CPB) coagulopathy in a preclinical setting. We created a post-CPB coagulopathy model using male New Zealand White rabbits (body weight, 3 kg). One hour after CPB, subject rabbits were intravenously administered H12-ADP-liposomes with platelet-rich plasma (PRP) collected from donor rabbits (H12-ADP-liposome/PRP group, n = 8) or PRP alone (PRP group, n = 8). Ear bleeding time was greatly reduced for the H12-ADP-liposome/PRP group (263 ± 111 s) compared with the PRP group (441 ± 108 s, p < 0.001). Electron microscopy showed platelet thrombus containing liposomes at the bleeding site in the H12-ADP-liposome/PRP group. However, such liposome-involved platelet thrombi were not observed in the end organs after H12-ADP-liposome administration. These findings suggest that H12-ADP-liposomes could help effectively and safely consolidate platelet haemostasis in post-CPB coagulopathy and may have potential for reducing bleeding complications after cardiovascular surgery with CPB.
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Akkoc A, Aydin C, Ucar M, Topcuoglu M. Can antibiotic preference affect bleeding in percutaneous nephrolithotomy? Retrospective comparative study of two commonly used antibiotics. Pak J Med Sci 2020; 36:621-626. [PMID: 32494244 PMCID: PMC7260928 DOI: 10.12669/pjms.36.4.1977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Bleeding is one of the most common and alarming complication of percutaneous nephrolithotomy (PCNL). In this study, we aimed to compare the effects of ciprofloxacin and cefuroxime on the bleeding in PCNL procedures. Methods The study was a retrospective analysis of 97 patients who underwent PCNL between February 2011 and June 2017. We just included the patients who had single tract lower pole PCNL for more objective evaluation of bleeding in the study. The patients were divided into two groups as ciprofloxacin group (Group-I, n:40) and cefuroxime group (Group-II, n:56) according to the type of antibiotic used in the operation. Patient age, gender, body mass index, stone size, preoperative INR, preoperative and postoperative platelet counts and difference, operative time, need for blood transfusion, postoperative fever, hospital stay, postoperative hemoglobin and hematocrit drop were analyzed. Results There was no statistically significant difference in patients' gender distribution, body mass index, preoperative INR, preoperative and postoperative platelet counts, preoperative and postoperative platelet difference, duration of operation, hospital stay, postoperative fever and need for postoperative blood transfusion between two antibiotic groups (p > 0.05). Mean patient age was 42,75±16,97 in Group-I and 35,54±14,71 in Group-II (p < 0.05). The mean stone size of Group-I and Group-II were 27,23±7,05 mm and 30,59±8,20, respectively (p < 0.05). The mean postoperative hemoglobin and hematocrit drop were significantly higher in Group-I than in Group-II. The mean hemoglobin drop was 1,73±0,95 for Group-I and 1,28±0,67 for Group-II (p < 0.05). The mean hematocrit drop was 5,17±2,76 for Group-I and 3,80±1,99 for Group-II (p < 0.05). Conclusion On the basis of the results of the initial study, the antibiotic preference in patients undergoing surgery may be one of the bleeding factors during and after PCNL.
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Affiliation(s)
- Ali Akkoc
- Ali Akkoc, Department of Urology, Faculty of Medicine, Alanya Alaaddin Keykubat University, Alanya, Turkey
| | - Cemil Aydin
- Cemil Aydin, Department of Urology, Faculty of Medicine, Hitit University, Corum, Turkey
| | - Murat Ucar
- Murat Ucar, Department of Urology, Faculty of Medicine, Alanya Alaaddin Keykubat University, Alanya, Turkey
| | - Murat Topcuoglu
- Murat Topcuoglu, Department of Urology, Faculty of Medicine, Alanya Alaaddin Keykubat University, Alanya, Turkey
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Changes in MicroRNA Expression Level of Circulating Platelets Contribute to Platelet Defect After Cardiopulmonary Bypass. Crit Care Med 2019; 46:e761-e767. [PMID: 29742582 DOI: 10.1097/ccm.0000000000003197] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Platelet defect mechanisms after cardiopulmonary bypass remain unclear. Our hypothesis microRNA expressions in circulating platelets significantly change between pre and post cardiopulmonary bypass, and consequent messenger RNA and protein expression level alterations cause postcardiopulmonary bypass platelet defect. DESIGN Single-center prospective observational study. SETTING Operating room of Kyoto Prefectural University of Medicine. PATIENTS Twenty-five adult patients scheduled for elective cardiac surgeries under cardiopulmonary bypass. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In the initial phase, changes in microRNA expression between pre and post cardiopulmonary bypass underwent next generation sequencing analysis (10 patients). Based on the results, we focused on changes in mir-10b and mir-96, which regulate glycoprotein 1b and vesicle-associated membrane protein 8, respectively, and followed them until messenger RNA and protein syntheses (15 patients) using quantitative polymerase chain reaction and Western blotting. Seven microRNAs including mir-10b and mir-96 exhibited significant differences in the initial phase. In the subsequent phase, mir-10b-5p and mir-96-5p overexpressions were confirmed, and glycoprotein 1b and vesicle-associated membrane protein 8 messenger RNA levels were significantly decreased after cardiopulmonary bypass: fold differences (95% CI): mir-10b-5p: 1.35 (1.05-2.85), p value equals to 0.01; mir-96-5p: 1.59 (1.06-2.13), p value equals to 0.03; glycoprotein 1b messenger RNA: 0.46 (0.32-0.60), p value of less than 0.001; and vesicle-associated membrane protein messenger RNA: 0.70 (0.56-0.84), p value of less than 0.001. Glycoprotein 1b and vesicle-associated membrane protein 8 were also significantly decreased after cardiopulmonary bypass: glycoprotein 1b: 82.6% (71.3-93.8%), p value equals to 0.005; vesicle-associated membrane protein 8: 79.0% (70.7-82.3%), p value of less than 0.001. CONCLUSIONS Expressions of several microRNAs in circulating platelets significantly changed between pre and post cardiopulmonary bypass. Overexpressions of mir-10b and mir-96 decreased glycoprotein 1b and vesicle-associated membrane protein 8 messenger RNA as well as protein, possibly causing platelet defect after cardiopulmonary bypass.
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Basavarajegowda A, Pokhrel B, Chandran S, Basu D, Rehman T. Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study. GLOBAL JOURNAL OF TRANSFUSION MEDICINE 2019. [DOI: 10.4103/gjtm.gjtm_47_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Slatter DA, Percy CL, Allen-Redpath K, Gajsiewicz JM, Brooks NJ, Clayton A, Tyrrell VJ, Rosas M, Lauder SN, Watson A, Dul M, Garcia-Diaz Y, Aldrovandi M, Heurich M, Hall J, Morrissey JH, Lacroix-Desmazes S, Delignat S, Jenkins PV, Collins PW, O'Donnell VB. Enzymatically oxidized phospholipids restore thrombin generation in coagulation factor deficiencies. JCI Insight 2018; 3:98459. [PMID: 29563336 PMCID: PMC5926910 DOI: 10.1172/jci.insight.98459] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
Hemostatic defects are treated using coagulation factors; however, clot formation also requires a procoagulant phospholipid (PL) surface. Here, we show that innate immune cell–derived enzymatically oxidized phospholipids (eoxPL) termed hydroxyeicosatetraenoic acid–phospholipids (HETE-PLs) restore hemostasis in human and murine conditions of pathological bleeding. HETE-PLs abolished blood loss in murine hemophilia A and enhanced coagulation in factor VIII- (FVIII-), FIX-, and FX-deficient human plasma . HETE-PLs were decreased in platelets from patients after cardiopulmonary bypass (CPB). To explore molecular mechanisms, the ability of eoxPL to stimulate individual isolated coagulation factor/cofactor complexes was tested in vitro. Extrinsic tenase (FVIIa/tissue factor [TF]), intrinsic tenase (FVIIIa/FIXa), and prothrombinase (FVa/FXa) all were enhanced by both HETE-PEs and HETE-PCs, suggesting a common mechanism involving the fatty acid moiety. In plasma, 9-, 15-, and 12-HETE-PLs were more effective than 5-, 11-, or 8-HETE-PLs, indicating positional isomer specificity. Coagulation was enhanced at lower lipid/factor ratios, consistent with a more concentrated area for protein binding. Surface plasmon resonance confirmed binding of FII and FX to HETE-PEs. HETE-PEs increased membrane curvature and thickness, but not surface charge or homogeneity, possibly suggesting increased accessibility to cations/factors. In summary, innate immune-derived eoxPL enhance calcium-dependent coagulation factor function, and their potential utility in bleeding disorders is proposed. Innate immune-derived enzymatically oxidized phospholipids enhance calcium-dependent coagulation factor function.
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Affiliation(s)
- David A Slatter
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Charles L Percy
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Keith Allen-Redpath
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Joshua M Gajsiewicz
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Nick J Brooks
- Faculty of Natural Science, Department of Chemistry, Imperial College London, London, United Kingdom
| | - Aled Clayton
- Institute of Cancer and Genetics, Velindre Cancer Centre, School of Medicine, and
| | - Victoria J Tyrrell
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Marcela Rosas
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Sarah N Lauder
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Andrew Watson
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Maria Dul
- School of Pharmacy and Pharmaceutical Sciences, Cardiff University, Cardiff, United Kingdom
| | - Yoel Garcia-Diaz
- School of Chemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Maceler Aldrovandi
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Meike Heurich
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Judith Hall
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - James H Morrissey
- Departments of Biological Chemistry and Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | | | - P Vincent Jenkins
- Haematology Department, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter W Collins
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
| | - Valerie B O'Donnell
- Systems Immunity Research Institute and Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
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Baryshnikova E, Tripodi A, Schlimp CJ, Schöchl H, Cadamuro J, Winstedt D, Asmis L, Ranucci M, Solomon C. Fibrinogen measurement in cardiac surgery with cardiopulmonary bypass: Analysis of repeatability and agreement of Clauss method within and between six different laboratories. Thromb Haemost 2017; 112:109-17. [DOI: 10.1160/th13-12-0997] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 02/16/2014] [Indexed: 11/05/2022]
Abstract
SummaryPlasma fibrinogen concentration is important for coagulopathy assessment, and is most commonly measured using the Clauss method. Several factors, including device type and reagent, have been shown to affect results. The study objective was to evaluate performance and repeatability of the Clauss method and to assess differences between measurements performed during and after cardiopulmonary bypass (CPB), by testing plasma samples from patients undergoing cardiac surgery with CPB. Samples were collected from 30 patients before surgery, approximately 20 minutes before weaning from CPB, and 5 minutes after CPB and protamine. Fibrinogen concentration was determined using the Clauss method at six quality-controlled specialised laboratories, according to accredited standard operating procedures. Regarding within-centre agreement for Clauss measurement, mean differences between duplicate measurements were between 0.00 g/l and 0.15 g/l, with intervals for 95% limits of agreement for mean Bland-Altman differences up to 1.3 g/l. Regarding between-centre agreement, some mean differences between pairs of centres were above 0.5 g/l. Differences of up to ∼2 g/l were observed with individual samples. Increased variability was observed between centres, with inter-class correlation values below 0.5 suggesting only fair agreement. There were no significant differences in fibrinogen concentration before weaning from CPB and after CPB for most centres and methods. In conclusion, considerable differences exist between Clauss-based plasma fibrinogen measured using different detection methods. Nevertheless, the similarity between measurements shortly before weaning from CPB and after CPB within centres suggests that on-pump measurements could provide an early estimation of fibrinogen deficit after CPB and thus guidance for haemostatic therapy.
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14
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Bashaw M, Triplett S. Coagulopathy In and Outside the Intensive Care Unit. Crit Care Nurs Clin North Am 2017; 29:353-362. [DOI: 10.1016/j.cnc.2017.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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15
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Tang M, Fenger-Eriksen C, Wierup P, Greisen J, Ingerslev J, Hjortdal V, Sørensen B. Rational and timely haemostatic interventions following cardiac surgery - coagulation factor concentrates or blood bank products. Thromb Res 2017; 154:73-79. [DOI: 10.1016/j.thromres.2017.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 02/18/2017] [Accepted: 04/04/2017] [Indexed: 01/08/2023]
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16
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Abstract
Platelet transfusions play an important role in the treatment of critically ill patients. Like any blood component, however, there are various aspects of platelet transfusion therapy that need be considered by the intensivist. These include the proper dose and type of platelet component to infuse, as well as the route and method of administration. Methods to reduce the volume of the transfused platelets, for example, must ensure that the infused platelets will be functional and viable, posttransfusion. Treatment and diagnosis of the HLA alloimmunized recipient can pose a serious challenge to the clinician and an obstacle to adequate platelet therapy. An ICU patient for whom an adequate posttransfusion platelet increment cannot be achieved is at great risk of suffering a fatal hemorrhage. The ICU physician should be aware of the techniques used in modern transfusion practice to avoid having to deal with this complication. Adverse reactions to platelet transfusion include not only serologic ones, but those related to febrile and allergic complications, as well as infectious complications. The latter group includes diseases caused by infection with cytomegalovirus, bacteria, and a cadre of viruses including HIV and hepatitis. The clinical approach to thrombocytopenia in the ICU will be covered in some detail in an effort to review many of the conditions associated with recipient thrombocytopenia, including ITP, TTP, dilutional thrombocytopenia, DIC, surgery, HELLP syndrome, and drug-induced thrombocytopenia. Unfortunately the treatment approaches traditionally used are not always derived from evidence-based studies. This review covers many of these topics in an attempt to help physicians become better able to manage thrombocytopenia in the ICU and thus provide the best transfusion therapy for their patients.
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Affiliation(s)
- Jean-Pierre Gelinas
- Department of Anesthesiology and Critical Care, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Lanu V. Stoddart
- Blood Bank/Apheresis Service, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Edward L. Snyder
- Department of Laboratory Medicine, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT.
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17
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Abstract
Thrombocytopenia is a common laboratory finding in the intensive care unit (ICU) patient. Because the causes can range from laboratory artifact to life-threatening processes such as thrombotic thrombocytopenic purpura (TTP), identifying the cause of thrombocytopenia is important. In the evaluation of the thrombocytopenia patient, one should incorporate all clinical clues such as why the patient is in the hospital, medications the patient is on, and other abnormal laboratory findings. One should ensure that the patient does not suffer from heparin-induced thrombocytopenia (HIT) or one of the thrombotic microangiopathies (TMs). HIT can present in any patient on heparin and requires specific testing and antithrombotic therapy. TMs cover a spectrum of disease ranging from TTP to pregnancy complications and can have a variety of presentations. Management of disseminated intravascular coagulation depends on the patient’s condition and complication. Other causes of ICU thrombocytopenia include sepsis, medication side effects, post-transfusion purpura, catastrophic anti phospholipid antibody disease, and immune thrombocytopenia.
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Abstract
PURPOSE OF REVIEW Blood coagulation exists to halt excessive blood loss. It is paradoxical that surgery and trauma simultaneously represent major risk factors for both hemorrhagic and thrombotic complications. A summary of the available evidence used to guide contemporary approaches to perioperative care will be reviewed. RECENT FINDINGS Although the advent of factor-specific products has safely allowed for intervention on patients with congenital hemostatic defects, the presence of an increasingly complex surgical population (chronic liver disease, traumatic injuries, and requirements for chronic anticoagulation) has renewed concerns about hemorrhagic risks. However, the past three decades of clinical sciences have supported a re-emphasis on the prevention of venous thromboembolism (VTE), a major cause of morbidity and mortality in hospitalized surgical patients. There is now an abundance of data confirming the robust risk:benefit ratio of antithrombotic prophylaxis in the vast majority of surgical patients, regardless of their medical comorbidities. SUMMARY Perioperative hemorrhage is a natural risk of any surgical intervention and deserves careful evaluation and prompt intervention. However, in order to support ongoing efforts in the prevention of medical errors, the application of evidence-based guidelines for the prophylaxis of VTE in surgical patients must become a standard part of daily practice.
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19
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Curnow J, Pasalic L, Favaloro EJ. Why Do Patients Bleed? Surg J (N Y) 2016; 2:e29-e43. [PMID: 28824979 PMCID: PMC5553458 DOI: 10.1055/s-0036-1579657] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/01/2016] [Indexed: 12/19/2022] Open
Abstract
Patients undergoing surgical procedures can bleed for a variety of reasons. Assuming that the surgical procedure has progressed well and that the surgeon can exclude surgical reasons for the unexpected bleeding, then the bleeding may be due to structural (anatomical) anomalies or disorders, recent drug intake, or disorders of hemostasis, which may be acquired or congenital. The current review aims to provide an overview of reasons that patients bleed in the perioperative setting, and it also provides guidance on how to screen for these conditions, through consideration of appropriate patient history and examination prior to surgical intervention, as well as guidance on investigating and managing the cause of unexpected bleeding.
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Affiliation(s)
- Jennifer Curnow
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia
| | - Leonardo Pasalic
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia.,Pathology West, NSW Health Pathology, Westmead, Australia
| | - Emmanuel J Favaloro
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia.,Pathology West, NSW Health Pathology, Westmead, Australia
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20
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Changes in thrombin generation in children after cardiac surgery and ex-vivo response to blood products and haemostatic agents. Blood Coagul Fibrinolysis 2016; 27:24-30. [DOI: 10.1097/mbc.0000000000000379] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Desborough M, Sandu R, Brunskill SJ, Doree C, Trivella M, Montedori A, Abraha I, Stanworth S. Fresh frozen plasma for cardiovascular surgery. Cochrane Database Syst Rev 2015; 2015:CD007614. [PMID: 26171897 PMCID: PMC8406941 DOI: 10.1002/14651858.cd007614.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Fresh frozen plasma (FFP) is a blood component containing procoagulant factors, which is sometimes used in cardiovascular surgery with the aim of reducing the risk of bleeding. The purpose of this review is to assess the risk of mortality for patients undergoing cardiovascular surgery who receive FFP. OBJECTIVES To evaluate the risk to benefit ratio of FFP transfusion in cardiovascular surgery for the treatment of bleeding patients or for prophylaxis against bleeding. SEARCH METHODS We searched 11 bibliographic databases and four ongoing trials databases including the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2015), MEDLINE (OvidSP, 1946 to 21 April 2015), EMBASE (OvidSP, 1974 to 21 April 2015), PubMed (e-publications only: searched 21 April 2015), ClinicalTrials.gov, World Health Organization (WHO) ICTRP and the ISRCTN Register (searched 21 April 2015). We also searched the references of all identified trials and relevant review articles. We did not limit the searches by language or publication status. SELECTION CRITERIA We included randomised controlled trials in patients undergoing major cardiac or vascular surgery who were allocated to a FFP group or a comparator (no plasma or an active comparator, either clinical plasma (any type) or a plasma-derived blood product). We included participants of any age (neonates, children and adults). We excluded studies of plasmapheresis and plasma exchange. DATA COLLECTION AND ANALYSIS Two authors screened all electronically derived citations and abstracts of papers identified by the review search strategy. Two authors assessed risk of bias in the included studies and extracted data independently. We took care to note whether FFP was used therapeutically or prophylactically within each trial. MAIN RESULTS We included 15 trials, with a total of 755 participants for analysis in the review. Fourteen trials compared prophylactic use of FFP against no FFP. One study compared therapeutic use of two types of plasma. The timing of intervention varied, including FFP transfusion at the time of heparin neutralisation and stopping cardiopulmonary bypass (CPB) (seven trials), with CPB priming (four trials), after anaesthesia induction (one trial) and postoperatively (two trials). Twelve trials excluded patients having emergency surgery and nine excluded patients with coagulopathies.Overall the trials were small, with only four reporting an a priori sample size calculation. No trial was powered to determine changes in mortality as a primary outcome. There was either high risk of bias, or unclear risk, in the majority of trials included in this review.There was no difference in the number of deaths between the intervention arms in the six trials (with 287 patients) reporting mortality (very low quality evidence). There was also no difference in blood loss in the first 24 hours for neonatal/paediatric patients (four trials with 138 patients; low quality evidence): mean difference (MD) -1.46 ml/kg (95% confidence interval (CI) -4.7 to 1.78 ml/kg); or adult patients (one trial with 120 patients): MD -12.00 ml (95% CI -101.16 to 77.16 ml).Transfusion with FFP was inferior to control for preventing patients receiving any red cell transfusion: Peto odds ratio (OR) 2.57 (95% CI 1.30 to 5.08; moderate quality evidence). There was a difference in prothrombin time within two hours of FFP transfusion in eight trials (with 210 patients; moderate quality evidence) favouring the FFP arm: MD -0.71 seconds (95% CI -1.28 to -0.13 seconds). There was no difference in the risk of returning to theatre for reoperation (eight trials with 398 patients; moderate quality evidence): Peto OR 0.81 (95% CI 0.26 to 2.57). Only one included study reported adverse events as an outcome and reported no significant adverse events following FFP transfusion. AUTHORS' CONCLUSIONS This review has found no evidence to support the prophylactic administration of FFP to patients without coagulopathy undergoing elective cardiac surgery. There was insufficient evidence about treatment of patients with coagulopathies or those who are undergoing emergency surgery. There were no reported adverse events attributable to FFP transfusion, although there was a significant increase in the number of patients requiring red cell transfusion who were randomised to FFP. Variability in outcome reporting between trials precluded meta-analysis for many outcomes across all trials, and there was evidence of a high risk of bias in most of the studies. Further adequately powered studies of FFP, or comparable pro-haemostatic agents, are required to assess whether larger reductions in prothrombin time translate into clinical benefits. Overall the evidence from randomised controlled trials for the safety and efficacy of prophylactic transfusion of FFP for cardiac surgery is insufficient.
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22
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Radulovic V, Laffin A, Hansson KM, Backlund E, Baghaei F, Jeppsson A. Heparin and Protamine Titration Does Not Improve Haemostasis after Cardiac Surgery: A Prospective Randomized Study. PLoS One 2015; 10:e0130271. [PMID: 26134993 PMCID: PMC4489911 DOI: 10.1371/journal.pone.0130271] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/18/2015] [Indexed: 11/18/2022] Open
Abstract
Background Bleeding complications are common in cardiac surgery. Perioperative handling of heparin and protamine may influence the haemostasis. We hypothesized that heparin and protamine dosing based on individual titration curves would improve haemostasis in comparison to standard dosing. Subjects and Methods Sixty patients scheduled for first time elective coronary artery bypass grafting or valve surgery were included in a prospective randomized study. The patients were randomized to heparin and protamine dosing with Hepcon HMS Plus device or to standard weight and activated clotting time (ACT) based dosing. Blood samples were collected before and 10 minutes, 2 hours and 4 hours after cardiopulmonary bypass. Primary endpoint was endogenous thrombin potential in plasma 2 hours after surgery as assessed by calibrated automated thrombography. Secondary endpoints included total heparin and protamine doses, whole blood clot formation (thromboelastometry) and post-operative bleeding volume and transfusions. Heparin effect was assessed by measuring anti-Xa activity. Results Endogenous thrombin potential and clot formation deteriorated in both groups after surgery without statistically significant intergroup difference. There were no significant differences between the groups in total heparin and protamine doses, heparin effect, or postoperative bleeding and transfusions at any time point. Significant inverse correlations between anti-Xa activity and endogenous thrombin potential were observed 10 min (r = -0.43, p = 0.001), 2 hours (r = -0.66, p<0.001) and 4 hours after surgery (r = -0.58, p<0.001). Conclusion In conclusion, the results suggest that perioperative heparin and protamine dosing based on individual titration curves does not improve haemostasis after cardiac surgery. Postoperative thrombin generation capacity correlates to residual heparin effect. Trial Registration www.isrctn.comISRCTN14201041.
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Affiliation(s)
- Vladimir Radulovic
- Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna Laffin
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Erika Backlund
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fariba Baghaei
- Department of Medicine/Hematology and Coagulation Disorders, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- * E-mail:
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23
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Abstract
Cryoprecipitate, originally developed as a therapy for patients with antihaemophilic factor deficiency, or haemophilia A, has been in use for almost 50 yr. However, cryoprecipitate is no longer administered according to its original purpose, and is now most commonly used to replenish fibrinogen levels in patients with acquired coagulopathy, such as in clinical settings with haemorrhage including cardiac surgery, trauma, liver transplantation (LT), or obstetric haemorrhage. Cryoprecipitate is a pooled product that does not undergo pathogen inactivation, and its administration has been associated with a number of adverse events, particularly transmission of blood-borne pathogens and transfusion-related acute lung injury. As a result of these safety concerns, along with emerging availability of alternative fibrinogen preparations, cryoprecipitate has been withdrawn from use in a number of European countries. Compared with the plasma from which it is prepared, cryoprecipitate contains a high concentration of coagulation factor VIII, coagulation factor XIII, and fibrinogen. Cryoprecipitate is usually licensed by regulatory authorities for the treatment of hypofibrinogenaemia, and recommended for supplementation when plasma fibrinogen levels decrease below 1 g litre(-1); however, this threshold is empiric and is not based on solid clinical evidence. Consequently, there is uncertainty over the appropriate dosing and optimal administration of cryoprecipitate, with some guidelines from professional societies to guide clinical practice. Randomized, controlled trials are needed to determine the clinical efficacy of cryoprecipitate, compared with the efficacy of alternative preparations. These trials will allow the development of evidence-based guidelines in order to inform physicians and guide clinical practice.
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Affiliation(s)
- B Nascimento
- Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - L T Goodnough
- Departments of Pathology and Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - J H Levy
- Departments of Anesthesiology and Surgery, Duke University School of Medicine, 2301 Erwin Road, 5691H HAFS, Box 3094, Durham, NC 27710, USA
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Kozek-Langenecker S, Fries D, Spahn D, Zacharowski K. III. Fibrinogen concentrate: clinical reality and cautious Cochrane recommendation. Br J Anaesth 2014; 112:784-7. [DOI: 10.1093/bja/aeu004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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25
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Bosch YP, Al Dieri R, ten Cate H, Nelemans PJ, Bloemen S, de Laat B, Hemker C, Weerwind PW, Maessen JG, Mochtar B. Measurement of thrombin generation intra-operatively and its association with bleeding tendency after cardiac surgery. Thromb Res 2014; 133:488-94. [DOI: 10.1016/j.thromres.2013.12.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 11/22/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
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26
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Davidson S. State of the Art - How I manage coagulopathy in cardiac surgery patients. Br J Haematol 2014; 164:779-89. [DOI: 10.1111/bjh.12746] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Simon Davidson
- Department of Haematology; Royal Brompton Hospital; London UK
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27
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Pekelharing J, Furck A, Banya W, Macrae D, Davidson SJ. Comparison between thromboelastography and conventional coagulation tests after cardiopulmonary bypass surgery in the paediatric intensive care unit. Int J Lab Hematol 2013; 36:465-71. [DOI: 10.1111/ijlh.12171] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 10/21/2013] [Indexed: 11/28/2022]
Affiliation(s)
- J. Pekelharing
- Department of Paediatric Cardiac Intensive Care; Royal Brompton Hospital & Harefield NHS Foundation Trust; London UK
| | - A. Furck
- Department of Paediatric Cardiac Intensive Care; Royal Brompton Hospital & Harefield NHS Foundation Trust; London UK
| | - W. Banya
- Department of Research and Development; Royal Brompton Hospital & Harefield NHS Foundation Trust; London UK
| | - D. Macrae
- Department of Paediatric Cardiac Intensive Care; Royal Brompton Hospital & Harefield NHS Foundation Trust; London UK
| | - S. J. Davidson
- Department of Haematology; Royal Brompton Hospital & Harefield NHS Foundation Trust; London UK
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28
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Levy JH, Welsby I, Goodnough LT. Fibrinogen as a therapeutic target for bleeding: a review of critical levels and replacement therapy. Transfusion 2013; 54:1389-405; quiz 1388. [DOI: 10.1111/trf.12431] [Citation(s) in RCA: 213] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 08/14/2013] [Accepted: 08/14/2013] [Indexed: 12/12/2022]
Affiliation(s)
- Jerrold H. Levy
- Department of Anesthesiology; Duke University School of Medicine; Durham North Carolina
| | - Ian Welsby
- Department of Anesthesiology; Duke University School of Medicine; Durham North Carolina
| | - Lawrence T. Goodnough
- Department of Pathology; Stanford University School of Medicine, Stanford Medical Center; Palo Alto California
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Said R, Regnault V, Hacquard M, Carteaux JP, Lecompte T. Platelet-dependent thrombography gives a distinct pattern of in vitro thrombin generation after surgery with cardio-pulmonary bypass: potential implications. Thromb J 2012; 10:15. [PMID: 22909275 PMCID: PMC3522546 DOI: 10.1186/1477-9560-10-15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 08/02/2012] [Indexed: 11/10/2022] Open
Abstract
Background Bleeding remains a potentially lethal complication of cardio-pulmonary bypass (CPB) surgery. The purpose of this study was to obtain a better insight into in vitro thrombin generation in the context of CPB. Methods We used Calibrated Automated Thrombography to assess blood coagulation of 10 low-risk patients operated for valve replacement with CPB, under 2 experimental conditions, one implicating platelets as platelet dysfunction has been described to occur during CPB. Results Our main finding was that CPB-induced coagulopathy was differently appreciated depending on the presence or absence of platelets: the decrease in thrombin generation was much less pronounced in their presence (mean endogenous thrombin potential change values before and after CPB were -3.9% in the presence of platelets and -39.6% in their absence). Conclusion Our results show that experimental conditions have a profound effect in the study of in vitro thrombin generation in the context of CPB.
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Affiliation(s)
- Rose Said
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,Inserm U961, Nancy Université, Nancy, France
| | - Véronique Regnault
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,Inserm U961, Nancy Université, Nancy, France
| | - Marie Hacquard
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,EFS Lorraine Champagne, Nancy, France
| | - Jean-Pierre Carteaux
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France
| | - Thomas Lecompte
- Laboratoire d'Hématologie et Institut Cardiovasculaire Nancy, Centre Hospitalier Universitaire, Nancy, France.,Inserm U961, Nancy Université, Nancy, France.,EFS Lorraine Champagne, Nancy, France.,Haematology Laboratory, CHU Nancy, Rue du Morvan, 54511, Vandoeuvre les Nancy Cedex, France
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30
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Ranucci M, Solomon C. Supplementation of fibrinogen in acquired bleeding disorders: experience, evidence, guidelines, and licences. Br J Anaesth 2012; 109:135-7. [DOI: 10.1093/bja/aes227] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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31
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Noui N, Zogheib E, Walczak K, Werbrouck A, Amar AB, Dupont H, Caus T, Remadi JP. Anticoagulation monitoring during extracorporeal circulation with the Hepcon/HMS device. Perfusion 2012; 27:214-20. [DOI: 10.1177/0267659112436632] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective: The objective of our study was to compare the standard protocol of anticoagulation to the Hepcon/HMS. Method: This study included forty-four patients who underwent coronary bypass grafting surgery (CABG), or biological aortic valve replacement (AVR). Unfractionated heparin (UH) was used for patients who underwent operations in the control group (n = 22) (300U/Kg of UH with a goal of an ACT of 400s). The heparin was antagonized dose/dose by protamine. For the patients who underwent operations in the HMS group (n = 22), the heparin and protamine doses were assessed by the Hepcon/HMS device. Results: The sex ratio amounted to 1.93 (29 men and 15 women) and the mean age was 70 ± 11 years. The patients in the HMS group had a chest closure time that was significantly shorter than patients in the control group. The times were, respectively, 42 ± 15 minutes and 68 ± 27 minutes (p = 0.001). The protamine/heparin ratio was significantly lower in the HMS group (0.62 ± 0.13 vs. 1 ± 0.11) (p = 0.0001). The postoperative bleeding amounted to 804 ± 729 ml in the HMS group versus 1416 ± 1103 in the control group (p = 0.016). In multivariate linear regression analysis, only two independent factors were significantly associated with bleeding: the Hepcon/HMS (OR = 0.1-p = 0.03) and the preoperative hemoglobin rate (OR = 1.4 - p = 0.05). Postoperatively, within 72 hours, the red blood cell transfusion was 1.04 ± 1.5 units for the HMS group and 2.1 ± 1.87 units for the control group (p = 0.05). Conclusion: During cardiac surgery under CPB, heparin and protamine titration with the Hepcon/HMS device could predict a lower protamine dose and lower postoperative bleeding without higher thromboembolic events, and lower perioperative red blood cell transfusion with a shorter chest closure time.
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Affiliation(s)
- N Noui
- Anesthesiology Unit, South Hospital, Amiens, France
| | - E Zogheib
- Anesthesiology Unit, South Hospital, Amiens, France
| | - K Walczak
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Werbrouck
- Anesthesiology Unit, South Hospital, Amiens, France
| | - A Ben Amar
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - H Dupont
- Anesthesiology Unit, South Hospital, Amiens, France
| | - T Caus
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
| | - JP Remadi
- Cardio-vascular Surgery Unit, University Hospital, CHU Amiens, France
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Kozek-Langenecker S, Sørensen B, Hess J, Spahn DR. Emotional or evidence-based medicine--is there a moral tragedy in haemostatic therapy? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:462. [PMID: 22236360 PMCID: PMC3388669 DOI: 10.1186/cc10583] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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33
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Coakley M, Hall JE, Evans C, Duff E, Billing V, Yang L, McPherson D, Stephens E, Macartney N, Wilkes AR, Collins PW. Assessment of thrombin generation measured before and after cardiopulmonary bypass surgery and its association with postoperative bleeding. J Thromb Haemost 2011; 9:282-92. [PMID: 21091865 DOI: 10.1111/j.1538-7836.2010.04146.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bleeding after cardiopulmonary bypass (CPB) is a major cause of morbidity and mortality and consumes large amounts of blood. Identifying patients at increased risk of bleeding secondary to hemostatic impairment may improve clinical outcomes by allowing early intervention. METHODS This present study recruited 77 patients undergoing CPB and measured coagulation screens, coagulation factors, TEG(®), Rotem(®) and thrombin generation (TG) before surgery and 30 min after heparin reversal. The tests were analyzed to investigate whether they identified patients at increased risk of excess bleeding (defined as > 1000 mL) in the first 24 h postoperatively. RESULTS Patients who bled > 1000 mL had a lower: platelet count (P < 0.02), factors (F)IX, X and XI (P < 0.005), endogenous thrombin potential (ETP) and an initial rate of TG (P < 0.02) and higher activated partial thromboplastin time (aPTT) (P < 0.001) than patients who bled < 1000 mL. Receiver operating characteristic (ROC) analysis was significant for post-operative TG and aPTT (P < 0.001). Furthermore, reduced pre-operative TG was associated with increased postoperative bleeding (P < 0.02). Pre- and postoperative TG were correlated (ρ = 0.7, P < 0.001). TEG(®), Rotem(®) and prothrombin time (PT) at either time point were not associated with increased bleeding. CONCLUSION These data suggest that pre-operative defects in the propagation phase of hemostasis are exacerbated during CPB, contributing to bleeding post-CPB. TG taken both pre- and postoperatively could potentially be used to identify patients at an increased risk of bleeding post-CPB.
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Affiliation(s)
- M Coakley
- Department of Anaesthetics, Intensive Care and Pain Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, UK
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Sørensen B, Bevan D. A critical evaluation of cryoprecipitate for replacement of fibrinogen. Br J Haematol 2010; 149:834-43. [DOI: 10.1111/j.1365-2141.2010.08208.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Solomon C, Pichlmaier U, Schoechl H, Hagl C, Raymondos K, Scheinichen D, Koppert W, Rahe-Meyer N. Recovery of fibrinogen after administration of fibrinogen concentrate to patients with severe bleeding after cardiopulmonary bypass surgery. Br J Anaesth 2010; 104:555-62. [PMID: 20348140 PMCID: PMC2855672 DOI: 10.1093/bja/aeq058] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Normalization of plasma fibrinogen levels may be associated with satisfactory haemostasis and reduced bleeding. The aim of this retrospective study was to assess fibrinogen recovery parameters after administration of fibrinogen concentrate (Haemocomplettan P) to patients with diffuse bleeding in cardiovascular surgery. Data on transfusion and patient outcomes were also collected. METHODS Patient characteristic and clinical data were obtained from patient records. RESULTS of the thromboelastometry (FIBTEM)and of the standard coagulation tests, including plasma fibrinogen level, measured before surgery, before and after haemostatic therapy, and on the following day, were retrieved from laboratory records. Results Thirty-nine patients receiving fibrinogen concentrate for diffuse bleeding requiring haemostatic therapy after cardiopulmonary bypass were identified. The mean fibrinogen concentrate dose administered was 6.5 g. The mean fibrinogen level increased from 1.9 to 3.6 g litre(-1) (mean increment of 0.28 g litre(-1) per gram of concentrate administered); maximum clot firmness increased from 10 to 21 mm. The mean fibrinogen increase was 2.29 (sd 0.7) mg dl(-1) per mg kg(-1) bodyweight of concentrate administered. Thirty-five patients received no transfusion of fresh-frozen plasma (FFP) or platelet concentrate after receiving fibrinogen concentrate; the remaining four patients received platelet concentrate intraoperatively. Eleven patients received platelets, FFP, or both during the first postoperative day. No venous thromboses, arterial ischaemic events, or deaths were registered during hospitalization. CONCLUSIONS In this retrospective study, fibrinogen concentrate was effective in increasing plasma fibrinogen level, and contributed to the correction of bleeding after cardiovascular surgery.
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Affiliation(s)
- C Solomon
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625 Hannover, Germany.
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Al-Ruzzeh S, Navia JL. The “Off-Label” Role of Recombinant Factor VIIa in Surgery: Is the Problem Deficient Evidence or Defective Concept? J Am Coll Surg 2009; 209:659-67. [DOI: 10.1016/j.jamcollsurg.2009.07.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2009] [Revised: 07/20/2009] [Accepted: 07/22/2009] [Indexed: 01/31/2023]
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Plasma frais congelé et apport transfusionnel en chirurgie cardiaque. Ing Rech Biomed 2009. [DOI: 10.1016/s1959-0318(09)74601-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Elevated activated partial thromboplastin time does not correlate with heparin rebound following cardiac surgery. Can J Anaesth 2009; 56:489-96. [DOI: 10.1007/s12630-009-9098-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 03/04/2009] [Accepted: 03/15/2009] [Indexed: 10/20/2022] Open
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PAI-1 gene: pharmacogenetic association of 4G/4G genotype with bleeding after cardiac surgery – pilot study. Eur J Anaesthesiol 2009; 26:404-11. [DOI: 10.1097/eja.0b013e3283240412] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wood EM, Stanworth S, Doree C, Hyde C, Silvani CM, Montedori A, Abraha I. Fresh frozen plasma for cardiovascular surgery. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Anticoagulant therapy during cardiopulmonary bypass. J Thromb Thrombolysis 2008; 26:218-28. [DOI: 10.1007/s11239-008-0280-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2008] [Accepted: 09/19/2008] [Indexed: 10/21/2022]
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Al-Ruzzeh S, Ibrahim K, Navia JL. Con: The Role of Recombinant Factor VIIa in the Control of Bleeding After Cardiac Surgery. J Cardiothorac Vasc Anesth 2008; 22:783-5. [DOI: 10.1053/j.jvca.2008.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Indexed: 11/11/2022]
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Becker RC. Emerging constructs to maintain safety among patients with acute coronary syndromes requiring surgical coronary revascularization. Eur Heart J Suppl 2008. [DOI: 10.1093/eurheartj/sun006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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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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McCall P, Story DA, Karalapillai D, Karapillai D. Audit of factor VIIa for bleeding resistant to conventional therapy following complex cardiac surgery. Can J Anaesth 2006; 53:926-33. [PMID: 16960271 DOI: 10.1007/bf03022836] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE There are an increasing number of anecdotal reports and trials of recombinant activated factor VII (rFVIIa) for bleeding during surgery. The reports of rFVIIa during cardiac surgery are limited. We report our experience using rFVIIa, in the operating room; to treat bleeding that prevented chest closure, despite appropriate conventional treatment, following complex cardiac surgery. METHODS Retrospective chart review, at an Australian University hospital and associated private hospital, of cardiac surgery patients given rFVIIa (usual dose 90 microg.kg(-1)). We used rFVIIa for bleeding that prevented closure of the chest despite administration of blood products, protamine, and surgical attempts to secure hemostasis. RESULTS Recombinant activated factor VII was administered on 55 occasions to 53 patients. Most patients had complex aortic or valve surgery. Median bypass time was 266 min. Before administering rFVIIa, patients received (median): packed red cells four units; platelets 15 units; fresh frozen plasma eight units; and cryoprecipitate ten units. After administering rFVIIa the median doses of donor blood products up to 12 hr after intensive care unit admission were: packed red cells one unit; platelets zero units; fresh frozen plasma zero units; and cryoprecipitate zero units. The decrease in doses of all blood products was significant (P < 0.001). We could not determine if rFVIIa played a role in significant mortality (19%) and morbidity (17%). CONCLUSION Use of rFVIIa in cardiac surgery may be effective, but definitive clinical trials are needed to clarify its role in clinical practice and safety. We present an rFVIIa guideline developed during the audit period.
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Affiliation(s)
- Peter McCall
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia.
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Pätilä T, Kukkonen S, Vento A, Pettilä V, Suojaranta-Ylinen R. Relation of the Sequential Organ Failure Assessment Score to Morbidity and Mortality After Cardiac Surgery. Ann Thorac Surg 2006; 82:2072-8. [PMID: 17126112 DOI: 10.1016/j.athoracsur.2006.06.025] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Revised: 05/31/2006] [Accepted: 06/02/2006] [Indexed: 01/31/2023]
Abstract
BACKGROUND Organ dysfunction evaluation using Sequential Organ Failure Assessment (SOFA) has been shown to predict mortality and morbidity in adult cardiac surgical patients with prolonged recovery. The purpose of this study was to evaluate the utility of SOFA in prediction of mortality and morbidity in a cohort of heterogeneous consecutive adult cardiac surgical patients. METHODS A prospective study of 857 consecutive patients entering in a single cardiac postoperative intensive care unit was assigned during the year 2004. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) of each patient was assessed preoperatively. SOFA was calculated daily until intensive care unit discharge or for a maximum of 7 days. SOFA change between the first and the third postoperative day, maximum SOFA during the first 3 days, and maximal SOFA were calculated. Length of intensive care unit stay and 30-day mortality were assessed. RESULTS Maximum SOFA during the first 3 days and maximal SOFA-predicted 30-day mortality (area under the curve, 0.763 and 0.779, respectively) also correlated with the length of intensive care unit stay (p < 0.001 and p < 0.001, respectively). The EuroSCORE predicted both mortality and intensive care unit stay (p < 0.0001 and p < 0.0001). The correlation coefficient between the EuroSCORE and maximum SOFA during the first 3 days or maximal SOFA was low (r = 0.34 and 0.33, respectively, p < 0.0001 and p = 0.0001). CONCLUSIONS The SOFA score is an independent predictor of mortality and length of stay in cardiac surgical patients. The SOFA score is associated with mortality and morbidity even when assessed in the early postoperative period after adult cardiac surgery.
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Affiliation(s)
- Tommi Pätilä
- Department of Cardiothoracic Surgery, Helsinki University Meilahti Hospital, Helsinki, Finland.
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Beldowicz BC, McDonald JM, Needham CS. Confirmed graft flow following use of recombinant factor VIIa in coronary artery bypass grafting: a case report and literature review. J Card Surg 2006; 21:483-6. [PMID: 16948764 DOI: 10.1111/j.1540-8191.2006.00304.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We present our experience of a unique opportunity to survey coronary artery bypass graft (CABG) patency following the administration of recombinant factor VIIa in the early postoperative period. A review of the published literature on use of this medication in cardiothoracic surgery, specifically CABG, is included.
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Affiliation(s)
- Brian C Beldowicz
- Department of Cardiothoracic Surgery, Madigan Army Medical Center, Tacoma, WA 98431-1100, USA
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Abstract
Bleeding is a major surgical complication. Although mortality rates of 0.1% are observed for surgical procedures, it may be 5% to 8% for elective vascular surgery, and increase to 20% in the presence of severe bleeding. In major surgery for liver diseases, as well as in cardiac surgery, excessive blood loss is associated with increased mortality, morbidity, and intensive care stay. Approximately 75% to 90% of intraoperative and early postoperative bleeding is due to technical factors. However, in some cases either acquired or congenital coagulopathies may favor, if not directly cause, surgical hemorrhage. Uncontrolled bleeding leads to a combination of hemodilution, hypothermia, consumption of clotting factors, and acidosis, which in turn worsen the clotting process, further exacerbating the problem in a vicious bloody circle. At present, the standard treatment for surgical bleeding is the rapid control of the source of bleeding by either surgical or radiological techniques. Blood-derived products as well as hemostatic agents, such as aprotinin, tranexamic acid, and DDAVP, are widely used to improve hemostatic balance in bleeding patients. Recombinant activated factor VII (rFVIIa) has been reported to be effective for the treatment of surgical or traumatic massive bleeding unresponsive to conventional therapy. Although most reports are anecdotal, and therefore exposed to a "positive" selection bias, the number of cases is impressive, strongly suggesting that in such patients rFVIIa may afford a hemostatic advantage beyond that of conventional replacement therapy.
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Affiliation(s)
- M Marietta
- Department of Oncology and Hematology, Section Hematology, University of Modena and Reggio Emilia, Modena, Italy.
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Friesen RH, Perryman KM, Weigers KR, Mitchell MB, Friesen RM. A trial of fresh autologous whole blood to treat dilutional coagulopathy following cardiopulmonary bypass in infants. Paediatr Anaesth 2006; 16:429-35. [PMID: 16618298 DOI: 10.1111/j.1460-9592.2005.01805.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transfusion of fresh whole blood is superior to blood component therapy in correcting coagulopathies in children following cardiopulmonary bypass (CPB); however, a supply of fresh homologous whole blood is difficult to maintain. We hypothesized that transfusion of fresh autologous whole blood obtained prior to heparinization for CPB and infused following CPB would be associated with improved coagulation function when compared with standard therapy. METHODS A total of 32 infants 5-12 kg undergoing noncomplex open cardiac surgery were randomly assigned to either the treatment or control group. In the treatment group, 15 ml x kg(-1) of autologous whole blood was collected into a CPDA bag prior to heparinization while 15 ml x kg(-1) of 5% albumin was infused intravenously. After reversal of heparin, coagulation tests were drawn in both groups, and the autologous whole blood was infused over 20 min in the treatment group. RESULTS The treatment group had greater (P < 0.05) improvement in platelet count, prothrombin time, and fibrinogen than the control group. CONCLUSIONS We conclude that collection of fresh autologous whole blood prior to heparinization and reinfusion following CPB is associated with greater improvement of coagulation status after CPB in infants.
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Affiliation(s)
- Robert H Friesen
- Department of Anesthesiology, The Children's Hospital and the University of Colorado School of Medcine, Denver, CO 80218, USA.
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