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Coccolini F, Shander A, Ceresoli M, Moore E, Tian B, Parini D, Sartelli M, Sakakushev B, Doklestich K, Abu-Zidan F, Horer T, Shelat V, Hardcastle T, Bignami E, Kirkpatrick A, Weber D, Kryvoruchko I, Leppaniemi A, Tan E, Kessel B, Isik A, Cremonini C, Forfori F, Ghiadoni L, Chiarugi M, Ball C, Ottolino P, Hecker A, Mariani D, Melai E, Malbrain M, Agostini V, Podda M, Picetti E, Kluger Y, Rizoli S, Litvin A, Maier R, Beka SG, De Simone B, Bala M, Perez AM, Ordonez C, Bodnaruk Z, Cui Y, Calatayud AP, de Angelis N, Amico F, Pikoulis E, Damaskos D, Coimbra R, Chirica M, Biffl WL, Catena F. Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper. World J Emerg Surg 2024; 19:26. [PMID: 39010099 PMCID: PMC11251377 DOI: 10.1186/s13017-024-00554-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 07/01/2024] [Indexed: 07/17/2024] Open
Abstract
Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.
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Affiliation(s)
- Federico Coccolini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy.
| | - Aryeh Shander
- Anesthesiology and Critical Care, Rutgers University, Newark, NJ, USA
| | - Marco Ceresoli
- General Emergency and Trauma Surgery Department, Monza University Hospital, Monza, Italy
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center, University of Colorado, Denver, CO, USA
| | - Brian Tian
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
| | - Dario Parini
- General Surgery Department, Rovigo Hospital, Rovigo, Italy
| | | | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Medical University, Plovdiv, Bulgaria
| | - Krstina Doklestich
- Clinic of Emergency Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Fikri Abu-Zidan
- The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Tal Horer
- Vascular and Trauma Surgery, Orebro Hospital, Orebro, Sweden
| | - Vishal Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Timothy Hardcastle
- Department of Trauma and Burns, Inkosi Albert Luthuli Central Hospital and Department of Surgical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elena Bignami
- Anesthesia Department, Parma University Hospital, Parma, Italy
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB, Canada
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Igor Kryvoruchko
- Department of Surgery No. 2, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Ari Leppaniemi
- General Surgery Department, Melahiti Hospital, Helsinki, Finland
| | - Edward Tan
- Emergency Surgery Department, Radboud Medical Centre, Nijmegen, The Netherlands
| | - Boris Kessel
- Hillel Yaffe Medical Center, Rappaport Medical School, Haifa, Israel
| | - Arda Isik
- Division of General Surgery, School of Medicine, Istanbul Medeniyet University, Kadikoy, Istanbul, Turkey
| | - Camilla Cremonini
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | | | - Lorenzo Ghiadoni
- Emergency Medicine Department, Pisa University Hospital, Pisa, Italy
| | - Massimo Chiarugi
- General Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia, 56124, Pisa, Italy
| | - Chad Ball
- Trauma and Acute Care Surgery, Foothills Medical Center, Calgary, AB, Canada
| | - Pablo Ottolino
- Unidad de Trauma y Urgencias, Hospital Dr. Sótero del Río, Santiago de Chile, Chile
| | - Andreas Hecker
- Department of General, Thoracic and Transplant Surgery, University Hospital of Giessen, Giessen, Germany
| | - Diego Mariani
- General Surgery Department, Legnano Hospital, Legnano, Italy
| | - Ettore Melai
- ICU Department, Pisa University Hospital, Pisa, Italy
| | - Manu Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Vanessa Agostini
- Medicina Trasfusionale, IRCCS-Ospedale Policlinico San Martino, Genoa, Italy
| | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Yoram Kluger
- General, Emergency and Trauma Surgery Department, Rambam Medical Centre, Tel Aviv, Israel
| | | | - Andrey Litvin
- Department of Surgical Diseases No. 3, University Clinic, Gomel State Medical University, Gomel, Belarus
| | - Ron Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | | | - Belinda De Simone
- Department of Digestive and Emergency Surgery, Infermi Hospital, Rimini, Italy
| | - Miklosh Bala
- Trauma and Acute Care Surgery Unit Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Aleix Martinez Perez
- Faculty of Health Sciences, Valencian International University (VIU), Valencia, Spain
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Zenon Bodnaruk
- Hospital Information Services for Jehovah's Witnesses, Tuxedo Park, NY, USA
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | | | - Nicola de Angelis
- General Surgery Department, Ferrara University Hospital, Ferrara, Italy
| | - Francesco Amico
- Discipline of Surgery, The University of Newcastle, Newcastle, Australia
| | - Emmanouil Pikoulis
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Raul Coimbra
- General Surgery Department, Riverside University Health System Medical Center, Loma Linda, CA, USA
| | - Mircea Chirica
- General Surgery Department, Grenoble University Hospital, Grenoble, France
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- General Emergency and Trauma Surgery Department, Cesena Hospital, Cesena, Italy
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Bartoszko J, Peer M, Grewal D, Ansari S, Callum J, Karkouti K. Delayed cold-stored vs. room temperature stored platelet transfusions in bleeding adult cardiac surgery patients-a randomized multicentre pilot study (PLTS-1). Pilot Feasibility Stud 2024; 10:90. [PMID: 38879518 PMCID: PMC11179374 DOI: 10.1186/s40814-024-01518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 06/06/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND Platelets stored at 1-6 °C are hypothesized to be more hemostatically active than standard room temperature platelets (RTP) stored at 20-24 °C. Recent studies suggest converting RTP to cold-stored platelets (Delayed Cold-Stored Platelets, DCSP) may be an important way of extending platelet lifespan and increasing platelet supply while also activating and priming platelets for the treatment of acute bleeding. However, there is little clinical trial data supporting the efficacy and safety of DCSP compared to standard RTP. METHODS This protocol details the design of a multicentre, two-arm, parallel-group, randomized, active-control, blinded, internal pilot trial to be conducted at two cardiac surgery centers in Canada. The study will randomize 50 adult (≥ 18 years old) patients undergoing at least moderately complex cardiac surgery with cardiopulmonary bypass and requiring platelet transfusion to receive either RTP as per standard of care (control group) or DCSP (intervention group). Patients randomized to the intervention group will receive ABO-identical, buffy-coat, pathogen-reduced, platelets in platelet additive solution maintained at 22 °C for up to 4 days then placed at 4 °C for a minimum of 24 h, with expiration at 14 days after collection. The duration of the intervention is from the termination of cardiopulmonary bypass to 24 h after, with a maximum of two doses of DCSP. Thereafter, all patients will receive RTP. The aim of this pilot is to assess the feasibility of a future RCT comparing the hemostatic effectiveness of DCSP to RTP (defined as the total number of allogeneic blood products transfused within 24 h after CPB) as well as safety. Specifically, the feasibility objectives of this pilot study are to determine (1) recruitment of ≥ 15% eligible patients per center per month); (2) appropriate platelet product available for ≥ 90% of patients randomized to the cold-stored platelet group; (3) Adherence to randomization assignment (> 90% of patients administered assigned product). DISCUSSION DCSP represents a promising logistical solution to address platelet supply shortages and a potentially more efficacious option for the management of active bleeding. No prospective clinical studies on this topic have been conducted. This proposed internal pilot study will assess the feasibility of a larger definitive study. TRIAL REGISTRATION NCT06147531 (clinicaltrials.gov).
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Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
| | - Miki Peer
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
| | - Deep Grewal
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Saba Ansari
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Jeannie Callum
- University of Toronto Quality in Utilization, Education and Safety in Transfusion Research Program, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Lobdell KW, Perrault LP, Drgastin RH, Brunelli A, Cerfolio RJ, Engelman DT. Drainology: Leveraging research in chest-drain management to enhance recovery after cardiothoracic surgery. JTCVS Tech 2024; 25:226-240. [PMID: 38899104 PMCID: PMC11184673 DOI: 10.1016/j.xjtc.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/18/2024] [Accepted: 04/01/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Kevin W. Lobdell
- Sanger Heart & Vascular Institute, Wake Forest University School of Medicine, Advocate Health, Charlotte, NC
| | - Louis P. Perrault
- Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | | | - Alessandro Brunelli
- Department of Thoracic Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom
| | | | - Daniel T. Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical, School-Baystate, Springfield, Mass
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Besnier E, Schmidely P, Dubois G, Lemonne P, Todesco L, Aludaat C, Caus T, Selim J, Lorne E, Abou-Arab O. POBS-Card, a new score of severe bleeding after cardiac surgery: Construction and external validation. JTCVS OPEN 2024; 19:183-199. [PMID: 39015466 PMCID: PMC11247224 DOI: 10.1016/j.xjon.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 04/09/2024] [Accepted: 04/13/2024] [Indexed: 07/18/2024]
Abstract
Objective Bleeding after cardiac surgery leads to poor outcomes. The objective of the study was to build the PeriOperative Bleeding Score in Cardiac surgery (POBS-Card) to predict bleeding after cardiac surgery. Methods We conducted a retrospective cohort study in 2 academic hospitals (2016-2019). Inclusion criteria were adult patients after cardiac surgery under cardiopulmonary bypass. Exclusion criteria were heart transplantation, assistance, aortic dissection, and preoperative hemostasis diseases. Bleeding was defined by the universal definition for perioperative bleeding score ≥2. POBS-Card score was built using multivariate regression (derivation cohort, one center). The performance diagnosis was assessed using the area under the curve in a validation cohort (2 centers) and compared with other scores. Results In total, 1704 patients were included in the derivation cohort, 344 (20%) with bleeding. Preoperative factors were body mass index <25 kg/m2 (odds ratio [OR], 1.48 [1.14-1.93]), type of surgery (redo: OR, 1.76 [1.07-2.82]; combined: OR, 1.81 [1.19-2.74]; ascendant aorta: OR, 1.56 [1.02-2.38]), ongoing antiplatelet therapy (single: OR, 1.50 [1.09-2.05]; double: OR, 2.00 [1.15-3.37]), activated thromboplastin time ratio >1.2 (OR, 1.44 [1.03-1.99]), prothrombin ratio <60% (OR, 1.91 [1.21-2.97]), platelet count <150 g/L (OR, 1.74 [1.17-2.57]), and fibrinogen <3 g/L (OR, 1.33 [1.02-1.73]). In the validation cohort of 597 patients, the area under the curve was 0.645 [0.605-0.683] and was superior to other scores (WILL-BLEED, Papworth, TRUST, TRACK). A threshold >14 predicted bleeding with a sensitivity of 50% and a specificity of 73%. Conclusions POBS-Card score was superior to other scores in predicting severe bleeding after cardiac surgery. Performances remained modest, questioning the place of these scores in the perioperative strategy of bleeding-sparing.
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Affiliation(s)
- Emmanuel Besnier
- Department of Anesthesiology and Critical Care, Univ Rouen Normandie, Inserm U1096, CHU Rouen, Rouen, France
| | - Pierre Schmidely
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Guillaume Dubois
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
| | - Prisca Lemonne
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Lucie Todesco
- Department of Anesthesiology and Critical Care, CHU Rouen, Rouen, France
| | - Chadi Aludaat
- Department of Cardiac Surgery, Rouen University Hospital, Rouen, France
| | - Thierry Caus
- Department of Cardiac Surgery, Amiens University Hospital, Amiens, France
| | - Jean Selim
- Department of Anesthesiology and Critical Care, Univ Rouen Normandie, Inserm U1096, CHU Rouen, Rouen, France
| | - Emmanuel Lorne
- Anesthesia and Critical Care Medicine, Clinique du Millénaire, Cedex 2, Montpellier, France
| | - Osama Abou-Arab
- Anesthesia and Critical Care Department, Amiens Hospital University, Amiens, France
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Schmoeckel M, Thielmann M, Hassan K, Geidel S, Schmitto J, Meyer AL, Vitanova K, Liebold A, Marczin N, Bernardi MH, Tandler R, Lindstedt S, Matejic-Spasic M, Wendt D, Deliargyris EN, Storey RF. Intraoperative haemoadsorption for antithrombotic drug removal during cardiac surgery: initial report of the international safe and timely antithrombotic removal (STAR) registry. J Thromb Thrombolysis 2024:10.1007/s11239-024-02996-x. [PMID: 38709456 DOI: 10.1007/s11239-024-02996-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/07/2024]
Abstract
Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y12 inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81% male) operated at a mean time of 33.2 h from the last P2Y12 inhibitor dose with a mean CPB duration of 117.1 ± 62.0 min. Group 2 included 51 patients (68.4 ± 9.4years, 53% male), operated at a mean time of 44.6 h after the last DOAC dose, with a CPB duration of 128.6 ± 48.4 min. In Group 1, 15 patients experienced a BARC-4 bleeding event (13%), including 3 reoperations (2.6%). The mean 24-hour CTD was 651 ± 407mL. In Group 2, 8 patients experienced a BARC-4 bleeding event (16%) including 4 reoperations (7.8%). The mean CTD was 675 ± 363mL. This initial report of the ongoing STAR registry shows that the intraoperative use of a haemoadsorption device is simple and safe, and may potentially mitigate the expected high bleeding risk of patients on antithrombotic drugs undergoing cardiac surgery before completion of the recommended washout period.Clinical registration number: ClinicalTrials.gov identifier: NCT05077124.
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Affiliation(s)
- Michael Schmoeckel
- Department of Cardiac Surgery, Klinikum Grosshadern, Ludwig-Maximilians-University, Marchioninistr. 15, Munich, D-81377, Germany.
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Kambiz Hassan
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Jan Schmitto
- Department of Cardiac-, Thoracic-, Transplantation- and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Anna L Meyer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Keti Vitanova
- Department of Cardiovascular Surgery, German Heart Centre, Munich, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Medical Center, Ulm, Germany
| | - Nandor Marczin
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Martin H Bernardi
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Rene Tandler
- Department of Cardiac Surgery, University Hospital Erlangen, Erlangen, Germany
| | - Sandra Lindstedt
- Department of Cardiothoracic Surgery and Transplantation, Skåne University Hospital, Lund, Sweden
| | | | - Daniel Wendt
- Department of Thoracic- and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
- CytoSorbents Europe GmbH, Berlin, Germany
| | | | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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dos Santos LL, dos Santos CL, Hu NKT, Datrino LN, Tavares G, Tristão LS, Orlandini MF, Serafim MCA, Tustumi F. Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis. Braz J Cardiovasc Surg 2023; 38:e20220326. [PMID: 37801640 PMCID: PMC10552558 DOI: 10.21470/1678-9741-2022-0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/16/2023] [Indexed: 10/08/2023] Open
Abstract
INTRODUCTION Chylothorax after thoracic surgery is a severe complication with high morbidity and mortality rate of 0.10 (95% confidence interval [CI] 0.06 - 0.02). There is no agreement on whether nonoperative treatment or early reoperation should be the initial intervention. This systematic review and meta-analysis aimed to evaluate the outcomes of the conservative approach to treat chyle leakage after cardiothoracic surgeries. METHODS A systematic review was conducted in PubMed®, Embase, Cochrane Library Central, and LILACS (Biblioteca Virtual em Saúde) databases; a manual search of references was also done. The inclusion criteria were patients who underwent cardiothoracic surgery, patients who received any nonoperative treatment (e.g., total parenteral nutrition, low-fat diet, medium chain triglycerides), and studies that evaluated chylothorax resolution, length of hospital stay, postoperative complications, infection, morbidity, and mortality. CENTRAL MESSAGE Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates. RESULTS Twenty-two articles were selected. Pulmonary complications, infections, and arrhythmia were the most common complications after surgical procedures. The incidence of chylothorax in cardiothoracic surgery was 1.8% (95% CI 1.7 - 2%). The mean time of maintenance of the chest tube was 16.08 days (95% CI 12.54 - 19.63), and the length of hospital stay was 23.74 days (95% CI 16.08 - 31.42) in patients with chylothorax receiving nonoperative treatment. Among patients that received conservative treatment, the morbidity event was 0.40 (95% CI 0.23 - 0.59), and reoperation rate was 0.37 (95% CI 0.27 - 0.49). Mortality rate was 0.10 (95% CI 0.06 - 0.02). CONCLUSION Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.
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Affiliation(s)
- Laura Lucato dos Santos
- Departament of Gastroenterology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Clara Lucato dos Santos
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Natasha Kasakevic Tsan Hu
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Leticia Nogueira Datrino
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Guilherme Tavares
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Luca Schiliró Tristão
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Marina Feliciano Orlandini
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
- Departament of Evidence-Based Medicine, Oya Care, São Paulo,
São Paulo, Brazil
| | | | - Francisco Tustumi
- Departament of Gastroenterology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Departament of Health Sciences, Faculdade de Medicina, Hospital
Israelita Albert Einstein, São Paulo, São Paulo, Brazil
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Intensivmedizinisches Management von postoperativen Komplikationen nach Herzoperationen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023. [DOI: 10.1007/s00398-023-00555-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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8
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Perioperative transcutaneous electrical acupoint stimulation (pTEAS) in pain management in major spinal surgery patients. BMC Anesthesiol 2022; 22:342. [PMID: 36348477 PMCID: PMC9641754 DOI: 10.1186/s12871-022-01875-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/19/2022] [Indexed: 11/10/2022] Open
Abstract
Background Lumbar disc herniation is seen in 5–15% of patients with lumbar back pain and is the most common spine disorder demanding surgical correction. Spinal surgery is one of the most effective management for these patients. However, current surgical techniques still present complications such as chronic pain in 10–40% of all patients who underwent lumbar surgery, which has a significant impact on patients’ quality of life. Research studies have shown that transcutaneous electrical acupoint stimulation (TEAS) may reduce the cumulative dosage of intraoperative anesthetics as well as postoperative pain medications in these patients. Objective To investigate the effect of pTEAS on pain management and clinical outcome in major spinal surgery patients. Methods We conducted a prospective, randomized, double-blind study to verify the effect of pTEAS in improving pain management and clinical outcome after major spinal surgery. Patients (n = 90) who underwent posterior lumbar fusion surgery were randomized into two groups: pTEAS, (n = 45) and Control (n = 45). The pTEAS group received stimulation on acupoints Zusanli (ST.36), Sanyinjiao (SP.6), Taichong (LR.3), and Neiguan (PC.6). The Control group received the same electrode placement but with no electrical output. Postoperative pain scores, intraoperative outcome, perioperative hemodynamics, postoperative nausea and vomiting (PONV), and dizziness were recorded. Results Intraoperative outcomes of pTEAS group compared with Control: consumption of remifentanil was significantly lower (P < 0.05); heart rate was significantly lower at the end of the operation and after tracheal extubation (P < 0.05); and there was lesser blood loss (P < 0.05). Postoperative outcomes: lower pain visual analogue scale (VAS) score during the first two days after surgery (P < 0.05); and a significantly lower rate of PONV (on postoperative Day-5) and dizziness (on postoperative Day-1 and Day-5) (P < 0.05). Conclusion pTEAS could manage pain effectively and improve clinical outcomes. It could be used as a complementary technique for short-term pain management, especially in patients undergoing major surgeries. Trial registration ChiCTR1800014634, retrospectively registered on 25/01/2018. http://medresman.org/uc/projectsh/projectedit.aspx?proj=183 Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01875-3
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Ushimaru Y, Odagiri K, Akeo K, Ban N, Hosaka M, Yamashita K, Saito T, Tanaka K, Yamamoto K, Makino T, Takahashi T, Kurokawa Y, Eguchi H, Doki Y, Nakajima K. Efficacy of electrocoagulation hemostasis: a study on the optimal usage of the very-low-voltage mode. Surg Endosc 2022; 36:8592-8599. [PMID: 35931893 DOI: 10.1007/s00464-022-09492-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/16/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The very-low-voltage (VLV) mode in electrosurgery can stably and deeply energize tissues even if the local electrical resistance changes with energization. Therefore, in electrosurgical hemostasis, the VLV mode is more reliable than other coagulation modes. In clinical practice, the appropriate use of combined saline drip and blood suction under the VLV mode can further enhance coagulation ability. However, the detailed mechanism is not known. The current study aimed to evaluate the association between electrosurgical activation time (ET) and hemostatic tissue effect (HTE) under the VLV mode. Further, the effect of saline drip and suction on power consumption and HTE was validated. METHODS Twelve female pigs weighing 35 kg were included in the experiment. A liver hemorrhage model was established via an open abdominal procedure, and hemostasis in the hemorrhagic lesion was attempted using the VLV mode under different conditions (ET: 3, 6, 9, and 12 s, with/without saline drip and/or continuous suction). Electrical data (such as voltage, current, and resistance) during coagulation were extracted. Then, the vertical/horizontal extent of HTE was assessed, and the hemostasis outcome (successful or failed) was recorded. RESULTS The vertical/horizontal HTE, power consumption, and integrated current value were positively correlated with the ET. The coagulation depth deepened with saline drip (p < 0.01). However, it was not affected by continuous suction (p = 0.20). The HTE area increased with saline drip (p < 0.01) and decreased with suction (p < 0.01). The power consumption and integrated current increased with saline drip (p < 0.01) and decreased with suction (p < 0.01). The success rate of hemostasis decreased with saline drip alone (31of 48 trials [success rate = 64.5%] in the saline drip group and 44/48 trials (success rate = 91.7%) in the control group). However, it improved with continuous suction (46/48 trials [success rate = 95.8%]). CONCLUSION The electrosurgical activation time was positively correlated with hemostatic tissue effect. Saline drip increased heat transfer efficiency but decreased the success rate of hemostasis. Therefore, the use of continuous suction in addition to saline drip increased hemostatic efficiency.
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Affiliation(s)
- Yuki Ushimaru
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Gastroenterological Surgery, Sakai City Medical Center, Osaka, Japan
| | - Kazuki Odagiri
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | | | - Makoto Hosaka
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Osaka, Japan
- Yamashina Seiki Co. Ltd, Shiga, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takuro Saito
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koji Tanaka
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuyoshi Yamamoto
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yukinori Kurokawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Suite 0912, Center of Medical Innovation and Translational Research, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Hassan K, Thielmann M, Easo J, Kamler M, Wendt D, Haidari Z, Deliargyris E, El Gabry M, Ruhparwar A, Geidel S, Schmoeckel M. Removal of Apixaban during Emergency Cardiac Surgery Using Hemoadsorption with a Porous Polymer Bead Sorbent. J Clin Med 2022; 11:5889. [PMID: 36233756 PMCID: PMC9572487 DOI: 10.3390/jcm11195889] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Patients on direct oral anticoagulants are at high risk of perioperative bleeding complications. We analyzed the results of intraoperative hemoadsorption (HA) in patients undergoing cardiac surgery who were also on concurrent therapy with apixaban. Methods: we included 25 consecutive patients on apixaban who underwent cardiac surgery with the use of cardio-pulmonary bypass (CPB) at three sites. The first 12 patients underwent surgery without hemoadsorption (controls), while the next 13 consecutive patients were operated with the Cytosorb® (Princeton, NJ, USA) device integrated into the CPB circuit (HA group). The primary outcome was perioperative bleeding assessed by the Bleeding Academic Research Consortium (BARC) definition and secondary outcomes included 24 h chest-tube-drainage (CTD) and need for 1-deamino-8-d-arginine-vasopressin (desmopressin (DDAVP)) administration to achieve hemostasis. Results: Preoperative mean daily dose of apixaban was higher in the HA group (8.5 ± 2.4 vs. 5.6 ± 2.2 mg, p = 0.005), while time since last apixaban dose was longer in the controls (1.3 ± 0.9 vs. 0.6 ± 1.2 days, p < 0.001). No BARC-4 bleeding events and no repeat-thoracotomies occurred in the HA group compared with 3 and 1, respectively, in the controls. Postoperative 24 h CTD volume was significantly lower in the HA group (510 ± 152 vs. 893 ± 579 mL, p = 0.03) and there was no need for DDAVP compared to controls, who received an average of 10 ± 13.6 mg (p = 0.01). Conclusions: In patients on apixaban undergoing emergent cardiac surgery, the intraoperative use of hemoadsorption was feasible and safe. Compared to patients operated on without hemoadsorption, BARC-4 bleeding complications did not occur and the need for 24 h CTD and DDAVP was significantly lower.
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Affiliation(s)
- Kambiz Hassan
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, 20099 Hamburg, Germany
| | - Matthias Thielmann
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Jerry Easo
- Department of Cardiac Surgery Essen-Huttrop, University of Essen, 45138 Essen, Germany
| | - Markus Kamler
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
- Department of Cardiac Surgery Essen-Huttrop, University of Essen, 45138 Essen, Germany
| | - Daniel Wendt
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
- CytoSorbents, Princeton, NJ 08540, USA
| | - Zaki Haidari
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | | | - Mohamed El Gabry
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic- and Cardiovascular Surgery, West-German Heart and Vascular Center, University Duisburg-Essen, 45147 Essen, Germany
| | - Stephan Geidel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, 20099 Hamburg, Germany
| | - Michael Schmoeckel
- Department of Cardiac Surgery, Asklepios Klinik St. Georg, 20099 Hamburg, Germany
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11
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Datzmann T, Völtl T, Ortner N, Wieder V, Liebold A, Reinelt H, Hoenicka M. Effects of colloid-based (hydroxyethylstarch 6% 130/0.42, gelafundin 4%) and crystalloid-based volume regimes in cardiac surgery: a retrospective analysis. J Thorac Dis 2022; 14:3782-3800. [PMID: 36389310 PMCID: PMC9641334 DOI: 10.21037/jtd-22-450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/19/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The restriction of hydroxyethylstarch (HES) necessitated changes in volume management in cardiac surgery, increasing the use of gelatin (GELA) and crystalloid (CRYS) mono strategies. METHODS This retrospective study evaluated the effects of changed volume replacement management to a GELA or CRYS mono therapy on mortality, acute kidney injury (AKI), blood loss, and transfusion in cardiac surgery patients with at least one coronary artery bypass grafting (CABG) at a university hospital. Three groups (HES n=938, GELA n=397, CRYS n=205) were derived from 1,540 patients with complete data sets. Data were analyzed by multiple regression models. RESULTS Patients had similar risk profiles, comorbidities, and preoperative routine diagnostics prior to surgery. No difference was observed in mortality and AKI. HES treated patients showed highest blood loss, followed by GELA while CRYS patients had the lowest (P<0.0001). Patients in the HES group had highest transfusion of packed red blood cells (PRBCs) and platelet concentrates (PCs), followed by GELA, whereas CRYS had the lowest (P<0.0001). Fresh frozen plasma (FFP) transfusion, administration of fibrinogen, and prothrombin complex concentrates (PCCs) were highest in HES group. CRYS showed the shortest time of mechanical ventilation (P<0.0001) and left the intensive care unit (ICU) significantly earlier (P<0.0001). Multivariable regression analysis found that colloid volume significantly predicted hospital mortality and renal replacement therapy (RRT), but not AKI. CONCLUSIONS Administration of crystalloids without any colloid showed no differences in mortality or AKI, but less blood loss and transfusion. Colloids should be considered critically and further studies should investigate effects of GELA in cardiac surgery.
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Affiliation(s)
- Thomas Datzmann
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany;,Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Hospital Ulm, Ulm, Germany
| | - Theresa Völtl
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Nicola Ortner
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Victoria Wieder
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, University Hospital Ulm, Ulm, Germany
| | - Helmut Reinelt
- Department of Anesthesiology, University Hospital Ulm, Ulm, Germany
| | - Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, University Hospital Ulm, Ulm, Germany
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12
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De La Porte VM, De Meyer GRA, Schepens T, Verbrugghe W, Laga S, Allegaert M, Mertens P, Rodrigus I, Jorens PG. Reoperation for bleeding after cardiac surgery. Acta Chir Belg 2022; 122:312-320. [PMID: 33150853 DOI: 10.1080/00015458.2020.1847463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative cardio-surgical haemostatic management is centre-specific and experience-based, which leads to a variability in patient care. This study aimed to identify which postoperative haemostatic interventions may reduce the need for reoperation after cardiac surgery in adults. METHODS A retrospective case-control study in a tertiary centre. Adult, elective, primary cardiac surgical patients were selected (n = 2098); cases (n = 42) were patients who underwent reoperation within 72 h after the initial surgery. Interventions administered to control surgical bleeding were compared for the need to re-operate using multiple logistic regression. RESULTS Rate of cardiac surgical reoperation was 2% in the study population. Three variables were found to be associated with cardiac reoperation: preoperative administration of fresh frozen plasma (OR 5.45, CI 2.34-12.35), cumulative volume of chest tube drainage and cumulative count of packed red blood cells transfusion on ICU (OR 1.98, CI 1.56-2.51). CONCLUSION No significant difference among specific types of postoperative haemostatic interventions was found between patients who needed reoperation and those who did not. Perioperative transfusion of fresh frozen plasma, postoperative transfusion of packed cells and cumulative volume of chest tube drainage were associated with reoperation after cardiac surgery. These variables could help predict the need for reoperation.
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Affiliation(s)
| | - Gregory R A De Meyer
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Tom Schepens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Walter Verbrugghe
- Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Steven Laga
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiac Surgery, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Mathias Allegaert
- Department of Patient Care, Subdivision of Perfusion, Antwerp University Hospital, Edegem, Belgium
| | - Pieter Mertens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Inez Rodrigus
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiac Surgery, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Philippe G Jorens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
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13
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Zhang CH, Ge YP, Zhong YL, Hu HO, Qiao ZY, Li CN, Zhu JM. Massive Bleeding After Surgical Repair in Acute Type A Aortic Dissection Patients: Risk Factors, Outcomes, and the Predicting Model. Front Cardiovasc Med 2022; 9:892696. [PMID: 35898275 PMCID: PMC9309227 DOI: 10.3389/fcvm.2022.892696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMassive bleeding throughout aortic repair in acute type A aortic dissection (ATAAD) patients is a common but severe condition that can cause multiple serious clinical problems. Here, we report our findings regarding risk factors, short-term outcomes, and predicting model for massive bleeding in ATAAD patients who underwent emergent aortic repair.MethodsA universal definition of perioperative bleeding (UDPB) class 3 and 4 were used to define massive bleeding and comprehensively evaluate patients. A total of 402 consecutive patients were enrolled in this retrospective study during 2019. Surgical strategies used to perform aortic arch procedures included total arch and hemiarch replacements. In each criterion, patients with massive bleeding were compared with remaining patients. Multivariable regression analyses were used to identify independent risk factors for massive bleeding. Logistic regression was used to build the model, and the model was evaluated with its discrimination and calibration.ResultsIndependent risk factors for massive bleeding included male sex (OR = 6.493, P < 0.001), elder patients (OR = 1.029, P = 0.05), low body mass index (BMI) (OR = 0.879, P = 0.003), emergent surgery (OR = 3.112, P = 0.016), prolonged cardiopulmonary bypass time (OR = 1.012, P = 0.002), lower hemoglobin levels (OR = 0.976, P = 0.002), increased D-dimer levels (OR = 1.000, P = 0.037), increased fibrin degradation products (OR = 1.019, P = 0.008), hemiarch replacement (OR = 5.045, P = 0.037), total arch replacement (OR = 14.405, P = 0.004). The early-stage mortality was higher in massive bleeding group (15.9 vs. 3.9%, P = 0.001). The predicting model showed a well discrimination (AUC = 0.817) and calibration (χ2 = 5.281, P = 0.727 > 0.05).ConclusionMassive bleeding in ATAAD patients who underwent emergent aortic repair is highly associated with gender, emergent surgery, increased D-dimer levels, longer CPB time, anemia, and use of a complex surgical strategy. Since massive bleeding may lead to worse outcomes, surgeons should choose suitable surgical strategies in patients who are at a high risk of massive bleeding.
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14
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Lavoie P, Lapierre A, Maheu-Cadotte MA, Rodriguez D, Lavallée A, Mailhot T. Improving the recognition and management of hemorrhage: A scoping review of nursing and midwifery education. NURSE EDUCATION TODAY 2022; 113:105361. [PMID: 35429750 DOI: 10.1016/j.nedt.2022.105361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/16/2022] [Accepted: 04/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hemorrhage is a frequent complication that nurses and midwives must recognize and manage to avoid life-threatening consequences for patients. There is currently no synthesis of evidence on educational interventions in nursing and midwifery regarding hemorrhage, thus limiting the definition of best practices. OBJECTIVE To map the literature on nursing and midwifery education regarding the recognition and management of hemorrhage. DESIGN Scoping review based on the Joanna Briggs Institute guidelines. DATA SOURCES Quantitative studies evaluating the effect of educational interventions with students, nurses, or midwives published in English or French, with no time limit. REVIEW METHODS Study selection, data extraction, and quality assessment were conducted by two independent reviewers. We characterized educational interventions based on the Guideline for Reporting Evidence-Based Practice Educational Interventions and Teaching. We categorized learning outcomes using the New World Kirkpatrick Model. Methodological quality appraisal was performed with tools from the Joanna Briggs Institute. Findings were synthesized using descriptive statistics and graphical methods RESULT: Most of the 38 studies used a single-group design (n = 26, 68%) and were conducted with professionals (n = 28, 74%) in hospital settings (n = 20, 53%). Most were of low (n = 14; 37%) or moderate (n = 18, 47%) methodological quality. Most interventions focused on postpartum hemorrhage (n = 34, 89%) and combined two or more teaching strategies (n = 25, 66%), often pairing an informational segment (e.g., lecture, readings) with a practical session (e.g., workshop, simulation). Learning outcomes related to the management (n = 27; 71%) and recognition of hemorrhage (n = 19, 50%), as well as results for patients and organizations (n = 9, 24%). CONCLUSION Considerable heterogeneity in interventions and learning outcomes precluded conducting a systematic review of effectiveness. High-quality, controlled studies are needed, particularly in surgery and trauma. Reflection on the contribution of nurses and midwives to the detection, monitoring, and management of hemorrhage could enrich the content and expected outcomes of hemorrhage education.
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Affiliation(s)
- Patrick Lavoie
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, Quebec H1T 1C8, Canada.
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada
| | - Marc-André Maheu-Cadotte
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, Quebec H1T 1C8, Canada
| | - Dora Rodriguez
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada
| | - Andréane Lavallée
- Department of Pediatrics, Columbia University Medical Center, 51 Audubon Ave, Suite 100, New York, NY 10032, United States
| | - Tanya Mailhot
- Faculty of Nursing, Université de Montréal, 2375 Chemin De la Côte-Sainte-Catherine, Montreal, Quebec H3C 3J7, Canada; Montreal Heart Institute Research Center, 5000 rue Bélanger, Montreal, Quebec H1T 1C8, Canada
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15
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6555495. [DOI: 10.1093/ejcts/ezac208] [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: 09/19/2021] [Revised: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
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16
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Hoghooghy A, Honarmand A, Bagheri K, Rezaei K. Evaluation of plasma fibrinogen levels before and after coronary artery bypass graft surgery and its association with the need for blood products. Adv Biomed Res 2022; 11:25. [PMID: 35720218 PMCID: PMC9201223 DOI: 10.4103/abr.abr_22_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/12/2022] Open
Abstract
Background: The present study investigated the plasma level of fibrinogen before and after removing the pump in coronary artery bypass graft (CABG) surgery and its relationship with the need for blood products. Materials and Methods: The present study was performed on 60 patients who were candidates for CABG surgery. The fibrinogen level of these patients was assessed and recorded before surgery and immediately after removing the pump. In addition, their hemoglobin level was recorded before the operation and 2 h after. In addition, the number and type of blood products transfusion were recorded intraoperatively and postoperatively and also at the intensive care unit. Results: Patients’ fibrinogen level after removing the pump with the mean of 130.53 ± 122.01 mg/dl decreased significantly compared to before surgery with the mean of mg/dl 224.95 ± 132.88 mg/dl (P < 0.001). In addition, the prognostic value of fibrinogen after removing the pump in determining the postoperative need of blood transfusion showed that the cut-off value of fibrinogen was < 196 mg/dl with a sensitivity of 16.82% and specificity of 80%, but it was not statistically significant (area under the curve [95% confidence interval]: 0.519 [0.350–0.689]; P = 0.825). Conclusion: According to the results of the present study, due to significant changes in fibrinogen levels after removing the pump compared to preoperation, it seems that this factor can play an important role in prognosis of the need to postoperative blood transfusion, although the prognostic value and the critical point mentioned in our study was not significant and it is required to do further studies.
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The association of thrombin generation with bleeding outcomes in cardiac surgery: a prospective observational study. Can J Anaesth 2021; 69:311-322. [PMID: 34939141 DOI: 10.1007/s12630-021-02165-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/15/2021] [Accepted: 10/04/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with coagulopathic bleeding. Impaired thrombin generation may be an important cause of coagulopathic bleeding but is poorly measured by existing hemostatic assays. We examined thrombin generation during cardiac surgery, using calibrated automated thrombography, and its association with bleeding outcomes. METHODS We conducted a prospective observational study in 100 patients undergoing cardiac surgery with CPB. Calibrated automated thrombography parameters were expressed as a ratio of post-CPB values divided by pre-CPB values. The association of thrombin generation parameters for bleeding outcomes was compared with conventional tests of hemostasis, and the outcomes of patients with the most severe post-CPB impairment in thrombin generation (≥ 80% drop from baseline) were compared with the rest of the cohort. RESULTS All 100 patients were included in the final analysis, with a mean age of 63 (12) yr, 31 (31%) female, and 94 (94%) undergoing bypass and/or valve surgery. Post-CPB, peak thrombin decreased by a median of 73% (interquartile range [IQR], 49-91%) (P < 0.001) and total thrombin generation, expressed as the endogenous thrombin potential (ETP), decreased 56% [IQR, 30-83%] (P < 0.001). In patients with ≥ 80% decrease in ETP, 21% required re-exploration for bleeding compared with 7% in the rest of the cohort (P = 0.04), and 48% required medical or surgical treatment for hemostasis compared with 27% in the rest of the cohort (P = 0.04). CONCLUSIONS Thrombin generation is significantly impaired by CPB and associated with higher bleeding severity. Clinical studies aimed at the identification and treatment of patients with impaired thrombin generation are warranted.
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Nuttall GA, Smith MM, Smith BB, Christensen JM, Santrach PJ, Schaff HV. A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients. Ann Thorac Cardiovasc Surg 2021; 28:204-213. [PMID: 34937821 PMCID: PMC9209891 DOI: 10.5761/atcs.oa.21-00222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy. Materials and Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements. Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups. Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paula J Santrach
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Mazur P, Litwinowicz R, Tchantchaleishvili V, Natorska J, Ząbczyk M, Bochenek M, Przybylski R, Iwaniec T, Kȩdziora A, Filip G, Kapelak B. Left Internal Mammary Artery Skeletonization Reduces Bleeding—A Randomized Controlled Trial. Ann Thorac Surg 2021; 112:794-801. [DOI: 10.1016/j.athoracsur.2020.10.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/03/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
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Xu X, Zhang Y, Gan J, Ye X, Yu X, Huang Y. Association between perioperative allogeneic red blood cell transfusion and infection after clean-contaminated surgery: a retrospective cohort study. Br J Anaesth 2021; 127:405-414. [PMID: 34229832 DOI: 10.1016/j.bja.2021.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/08/2021] [Accepted: 05/08/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Allogeneic red blood cell (RBC) transfusion can induce immunosuppression, which can then increase the susceptibility to postoperative infection. However, studies in different types of surgery show conflicting results regarding this effect. METHODS In this retrospective cohort study conducted in a tertiary referral centre, we included adult patients undergoing clean-contaminated surgery from 2014 to 2018. Patients who received allogeneic RBC transfusion from preoperative Day 30 to postoperative Day 30 were included into the transfusion group. The control group was matched for the type of surgery in a 1:1 ratio. The primary outcome was infection within 30 days after surgery, which was defined by healthcare-associated infection, and identified mainly based on antibiotic regimens, microbiology tests, and medical notes. RESULTS Among the 8098 included patients, 1525 (18.8%) developed 1904 episodes of postoperative infection. Perioperative RBC transfusion was associated with an increased risk of postoperative infection after controlling for 27 confounders by multivariable regression analysis (odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.39-1.84; P<0.001) and propensity score weighing (OR: 1.64; 95% CI: 1.45-1.85; P<0.001) and matching (OR: 1.70; 95% CI: 1.43-2.01; P<0.001), and a dose-response relationship was observed. The transfusion group also showed higher risks of surgical site infection, pneumonia, bloodstream infection, multiple infections, intensive care admission, unplanned reoperation, prolonged postoperative length of hospital stay, and all-cause death. CONCLUSIONS Perioperative allogeneic RBC transfusion is associated with an increased risk of infection after clean-contaminated surgery in a dose-response manner. Close monitoring of infections and enhanced prophylactic strategies should be considered after transfusion.
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Affiliation(s)
- Xiaohan Xu
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Centre, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Jia Gan
- Department of Blood Transfusion, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiangyang Ye
- Department of Information Management, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuerong Yu
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
| | - Yuguang Huang
- Department of Anaesthesiology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.
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21
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Senay S, Cacur O, Bastopcu M, Gullu AU, Kocyigit M, Alhan C. Robotic mitral valve operations can be safely performed in obese patients. J Card Surg 2021; 36:3126-3130. [PMID: 34148263 DOI: 10.1111/jocs.15758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/19/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Robotic cardiac surgery offers mitigated risks for obese patients requiring mitral valve surgery. We aimed to study the safety of robotic mitral surgery in the obese patient population by analyzing the outcomes of mitral surgery patients in our center for robotic cardiac surgery. METHOD This study retrospectively included 123 consecutive patients who underwent robotic mitral valve operations in a single center for robotic cardiac surgery. Patients with body mass index (BMI) ≥ 30 were compared against patients with BMI < 30 for demographic and operative parameters as well as postoperative outcomes. RESULTS Mean BMI was 33.9 ± 2.8 in the obesity group (n = 87) and 25.4 ± 2.7 in the no-obesity group (n = 36). Female gender (80.6% vs. 52.9%, p = .004), diabetes (25.0% vs. 10.3%, p = .036), and hypertension (48.6% vs. 26.4%, p = .018) were more common in patients with obesity. The obesity group was operated with similar cardiopulmonary bypass and total operative times with the no-obesity group. Postoperative drainage and blood transfusion requirements were similar between the groups. Mechanical ventilation times (6.1 ± 2.2 vs. 8.0 ± 4.4 h, p = .003) and intensive care unit stay (20.4 ± 1.6 vs. 29.4 ± 3.7, p = .027) were shorter in the obesity group. Other postoperative outcomes of infection, atrial fibrillation, hospital stay duration, and readmission rates were similar between the groups. CONCLUSION Robotic mitral surgery is safe to perform in obese patients. Obesity should not be a contraindication for robotic mitral surgery as obese patients have outcomes similar to nonobese patients despite increased challenges and risk-factors.
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Affiliation(s)
- Sahin Senay
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Orkun Cacur
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Tatvan State Hospital, Tatvan, Turkey
| | - Ahmet Umit Gullu
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Muharrem Kocyigit
- Department of Anesthesiology, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Cem Alhan
- Department of Cardiovascular Surgery, Acibadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
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22
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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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23
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Nemeth E, Varga T, Soltesz A, Racz K, Csikos G, Berzsenyi V, Tamaska E, Lang Z, Molnar G, Benke K, Eory A, Merkely B, Gal J. Perioperative Factor Concentrate Use is Associated With More Beneficial Outcomes and Reduced Complication Rates Compared With a Pure Blood Product-Based Strategy in Patients Undergoing Elective Cardiac Surgery: A Propensity Score-Matched Cohort Study. J Cardiothorac Vasc Anesth 2021; 36:138-146. [PMID: 33941446 DOI: 10.1053/j.jvca.2021.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/12/2021] [Accepted: 03/22/2021] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The goal of this study was to compare factor concentrate (FC)-based and blood product-based hemostasis management of coagulopathy in cardiac surgical patients in terms of postoperative bleeding, required blood products, and outcome. DESIGN Retrospective, propensity score-matched analysis. SETTING Single, tertiary, academic medical center. PARTICIPANTS One hundred eighteen matched pairs of 433 consecutive patients scheduled for cardiac surgery in two isolated periods with distinct strategies of hemostasis management. INTERVENTIONS Patients received either blood product-based (period I) or FC-based (period II) hemostasis management to treat perioperative coagulopathy. MEASUREMENTS AND MAIN RESULTS Patients treated with FC management experienced less postoperative blood loss (907 v 1,153 mL, p = 0.014) and required less red blood cell and fresh frozen plasma transfusion (2.3 v 3.7 units p < 0.0001, and 2.0 v 3.4 units p < 0.0001, respectively) compared with subjects in the blood product-based management group. The frequency of Stage 3 acute kidney injury and 30-day mortality rate were significantly higher in the blood product-based group than in the FC management group (6.8% v 0.8%, p = 0.016, and 7.2% v 0.8%, p = 0.022, respectively). FC management-related thromboembolic events were not registered. The FC strategy was associated with a 2.19-fold decrease in the odds of massive postoperative bleeding (p < 0.0001), a 2.56-fold decrease in the odds of polytransfusion (p < 0.0001), and a 13.16-fold decrease in the odds of early postoperative death (p = 0.003). CONCLUSIONS FC-based versus blood product-based management is associated with reduced blood product needs and fewer complications, and was not linked to a higher frequency of thromboembolic events or a decrease in long-term survival in cardiac surgical patients developing perioperative coagulopathy and bleeding.
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Affiliation(s)
- Endre Nemeth
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
| | - Tamas Varga
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Adam Soltesz
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Kristof Racz
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Gergely Csikos
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Viktor Berzsenyi
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Eszter Tamaska
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Zsolt Lang
- Department of Biomathematics and Informatics, University of Veterinary Medicine, Budapest, Hungary
| | - Gabriella Molnar
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
| | - Kalman Benke
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Ajandek Eory
- Department of Family Medicine, Semmelweis University, Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Janos Gal
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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St-Onge S, Chauvette V, Hamad R, Bouchard D, Jeanmart H, Lamarche Y, Perrault LP, Demers P. Active clearance vs conventional management of chest tubes after cardiac surgery: a randomized controlled study. J Cardiothorac Surg 2021; 16:44. [PMID: 33757537 PMCID: PMC7986555 DOI: 10.1186/s13019-021-01414-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/10/2021] [Indexed: 01/10/2023] Open
Abstract
Background Chest tubes are routinely used after cardiac surgery to evacuate shed mediastinal blood. Incomplete chest drainage due to chest tube clogging can lead to retained blood after cardiac surgery. This can include cardiac tamponade, hemothorax, bloody effusions and postoperative atrial fibrillation (POAF). Prior published non randomized studies have demonstrated that active tube clearance (ATC) of chest tubes can reduce retained blood complications prompting the ERAS Cardiac Society guidelines to recommend this modality. Objective A randomized prospective trial to evaluate whether an ATC protocol aimed at improving chest tube patency without breaking the sterile field could efficiently reduce complications related to retained blood after cardiac surgery. Methods This was a pragmatic, single-blinded, parallel randomized control trial held from November 2015 to June 2017 including a 30-day post index surgery follow-up. The setting was two academic centers affiliated with the Université de Montréal School of Medicine; the Montreal Heart Institute and the Hôpital du Sacré-Coeur de Montréal. Adult patients admitted for non-emergent coronary bypass grafting and/or valvular heart surgery through median sternotomy, in sinus rhythm for a minimum of 30 days prior to the surgical intervention were eligible for inclusion. In the active tube clearance group (ATC), a 28F PleuraFlow device was positioned within the mediastinum. In the standard drainage group, a conventional chest tube (Teleflex Inc.) was used. Other chest tubes were left at the discretion of the operating surgeon. Results A total of 520 adult patients undergoing cardiac surgery were randomized to receive either ATC (n = 257) or standard drainage (n = 263). ATC was associated with a 72% reduction in re-exploration for bleeding (5.7% vs 1.6%, p = .01) and an 89% reduction in complete chest tube occlusion (2% vs 19%, p = .01). There was an 18% reduction in POAF between the ATC and control group that was not statistically significant (31% vs 38%, p = .08). Conclusions and relevance In this RCT, the implementation of active clearance of chest tubes reduced re-exploration and chest tube clogging in patients after cardiac surgery further supporting recommendations to consider this modality postoperatively. Trial registration Clinical Trials NCT02808897. Retrospectively registered 22 June 2016. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-021-01414-0.
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Affiliation(s)
- Samuel St-Onge
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada
| | - Vincent Chauvette
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada
| | - Raphael Hamad
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada
| | - Denis Bouchard
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada
| | - Hugues Jeanmart
- Department of Surgery, Faculty of Medicine, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada
| | - Louis P Perrault
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada
| | - Philippe Demers
- Department of Surgery, Faculty of Medicine, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, Montreal, Quebec, H1T1C8, Canada.
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25
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Bastopcu M, Özhan A, Erdoğan SB, Kehlibar T. Factors associated with excessive bleeding following elective on-pump coronary artery bypass grafting. J Card Surg 2021; 36:1277-1281. [PMID: 33484200 DOI: 10.1111/jocs.15364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Excessive bleeding following cardiac surgery is associated with worse outcomes. We aimed to analyze preoperative and operative factors associated with excessive bleeding in coronary artery bypass patients to better understand which patients are under increased risk. METHODS The study was conducted as an observational study in a tertiary center for cardiac surgery by retrospective analysis of the hospital database. Patients were grouped according to chest tube output within the postoperative 24 h. Patients in the 4th percentile of chest tube output per kilogram were categorized as having excessive bleeding. Patients with excessive bleeding were compared with the other patients for preoperative and operative factors. Factors significant in univariate analysis were carried onto the multivariate analysis. RESULTS Patients with excessive bleeding were more likely to be males (91.4% vs. 78.7%, p = .002), have lower body mass index (BMI) (27.4 vs. 29.2, p < .001), and low platelets (6.9% vs. 1.5%, p = .006). Cardiopulmonary bypass (101.8 vs. 110.9 min, p = .022) time was longer in the excessive bleeding group. Patients with excessive bleeding were more likely to have more than three vessels revascularized. Male sex, lower BMI, low platelets, and longer cardiopulmonary bypass time were independently associated with increased bleeding. CONCLUSION Male sex, lower BMI, low platelet count, and longer cardiopulmonary bypass time are associated with extensive bleeding after elective coronary artery bypass surgery (CABG). Patients with higher bleeding risk should be identified preoperatively to account for adverse outcomes after CABG.
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Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Abdulkerim Özhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç B Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tamer Kehlibar
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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26
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Fibrin clot susceptibility to lysis is impaired after on-pump coronary artery by-pass grafting with tranexamic acid: clinical implications. Blood Coagul Fibrinolysis 2021; 32:29-36. [PMID: 33196514 DOI: 10.1097/mbc.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Coronary artery bypass grafting (CABG) done on-pump may cause a significant blood loss. Low fibrinogen is associated with perioperative bleeding. The influence of cardiopulmonary bypass on fibrin clot properties is poorly investigated. We studied 55 patients with isolated coronary artery disease on aspirin undergoing on-pump CABG with tranexamic acid. Fibrinogen levels, fibrinolytic capacity expressed as clot lysis time (CLT), thrombin generation potential and platelet count were assessed before and after the surgery (prior to admission to the intensive care unit). A postoperative drop in haemoglobin (-30% from baseline), haematocrit (-31% from baseline) and platelet count (-42% from baseline) was observed (all, P < 0.0001). Postoperative fibrinogen level was lower by 57%, compared with preoperative value (1.5 [1.3-1.8] vs. 3.5 [2.8-3.9] g/l, P < 0.0001). Postoperative CLT was longer by 48 min, compared with preoperative (182 [170-218] vs. 134 [122-165] min, P < 0.0001). Thrombin generation was impaired postoperatively: both lag time and time to peak thrombin were prolonged by 44 and 45%, respectively, whereas endogenous thrombin potential and peak thrombin generation decreased by 45 and 78%, respectively (all P < 0.0001). Median postoperative drainage at 12 h was 400 [290-570] ml. Predictors of blood loss at 12 h identified in multivariable linear regression model adjusted for sex and preoperative fibrinogen level were: BMI (b = -23.4, P = 0.048) and postoperative CLT (b = -2.4, P = 0.042). Despite decreased fibrinogen levels after on-pump CABG with tranexamic acid, fibrin clot susceptibility to lysis is impaired, as reflected by prolonged CLT. Postoperative CLT is associated with mediastinal drainage at 12 h.
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27
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Mazur P, Natorska J, Ząbczyk M, Krzych Ł, Litwinowicz R, Kędziora A, Kapelak B, Undas A. Von Willebrand factor in aortic or mitral valve stenosis and bleeding after heart valve surgery. Thromb Res 2020; 198:190-195. [PMID: 33360153 DOI: 10.1016/j.thromres.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/05/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Low von Willebrand factor (VWF) increases the risk of bleeding. The objective was to assess the influence of VWF on bleeding after valvular surgery. METHODS We studied 82 consecutive patients in median age of 65.5 years with severe isolated aortic stenosis (AS, n = 62) or mitral stenosis (MS, n = 20), undergoing heart valve surgery in extracorporeal circulation. Preoperatively, we assessed VWF antigen (VWF:Ag) and activity (VWF:RCo), a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), and fibrinolysis inhibitors. RESULTS Compared with AS, MS patients were more frequently female (80 vs. 55%, p = 0.045) with atrial fibrillation (AF) (80 vs. 8%, p < 0.0001), with no difference in age or comorbidities. Median postoperative drainage was 420 ml for AS, and 425 ml for MS (p = 0.37). Patients with AS had lower VWF:RCo (125.8 [88.5-160.8] vs. 188.0 [140.3-207.3] IU/dl, p = 0.003) and VWF:Ag (135.8 [112.0-171.2] vs. 191.7 [147.3-236.4] IU/dl, p = 0.01) than MS patients. Mean VWF:RCo/Ag ratio was 0.88 ± 0.17, with no intergroup differences. ADAMTS13 levels and activity were similar in both groups. In AS, both VWF:RCo and VWF:Ag correlated inversely with maximal (r = -0.39, p = 0.0003 and r = -0.39, p = 0.0004, respectively) and mean (r = -0.40, p = 0.0004 and r = -0.39, p = 0.0006, respectively) transvalvular pressure gradients. There was no difference in perioperative bleeding between patients following mitral and aortic valve surgery, and bleeding was not associated with VWF:Ag or VWF:RCo. CONCLUSIONS In severe AS, VWF levels and activity correlate inversely with transvalvular pressure gradients, and are lower than in severe degenerative MS, but do not affect blood loss after valvular surgery in extracorporeal circulation.
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Affiliation(s)
- Piotr Mazur
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; The John Paul II Hospital, Krakow, Poland.
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; The John Paul II Hospital, Krakow, Poland
| | - Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; The John Paul II Hospital, Krakow, Poland
| | - Łukasz Krzych
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Radosław Litwinowicz
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; The John Paul II Hospital, Krakow, Poland
| | | | - Bogusław Kapelak
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; The John Paul II Hospital, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; The John Paul II Hospital, Krakow, Poland
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Koponen T, Musialowicz T, Lahtinen P. Gelatin and the risk of bleeding after cardiac surgery. Acta Anaesthesiol Scand 2020; 64:1438-1445. [PMID: 32735701 DOI: 10.1111/aas.13677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/11/2020] [Accepted: 07/12/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Gelatins has been used in cardiac surgery because of their ability to preserve intravascular volume better than crystalloids. Unfortunately, gelatin has been associated with impaired coagulation and hemostasis, that may cause increased bleeding. We investigated whether the administration of gelatin increases postoperative bleeding after cardiac surgery. METHODS Retrospective, observational single-center cohort study in the intensive care unit of a tertiary teaching hospital. Postoperative bleeding, chest tube drainage volume and consumption of blood products were compared between groups. RESULTS Cohort included 3067 consecutive patients who underwent cardiac surgery. First 1698 patients received gelatin (gelatin group), and 1369 patients did not (crystalloid group). The characteristics of the patients in the gelatin and crystalloid groups were comparable. Postoperative chest tube drainage was 18% (95% CI 11%-20%) greater during the first 12 hours (P < .001) and 15% (95% CI 7%-17%) greater during the first 24 hours (P < .001) in the gelatin group compared to the crystalloid group. Severe and massive postoperative bleeding was more common in the gelatin group compared to the crystalloid group (21% vs 16%, P < .001). Patients in the gelatin group received red blood cells (40% vs 20%, P < .001) and platelets (12% vs 8%, P < .001) more frequently than patients in the crystalloid group. However, the number of administered fresh-frozen plasma transfusions did not differ between the groups. CONCLUSION Gelatin may increase postoperative bleeding and the need for blood product transfusions after cardiac surgery.
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Affiliation(s)
- Timo Koponen
- Department of Anesthesia and Intensive Care Medicine North Karelia Central Hospital Joensuu Finland
| | - Tadeusz Musialowicz
- Department of Anesthesia and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | - Pasi Lahtinen
- Department of Anesthesia and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
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29
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Saour M, Zeroual N, Aubry E, Blin C, Gaudard P, Colson PH. Blood Loss Kinetics During the First 12 Hours After On-Pump Cardiac Surgical Procedures. Ann Thorac Surg 2020; 111:1308-1315. [PMID: 32896545 DOI: 10.1016/j.athoracsur.2020.06.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/04/2020] [Accepted: 06/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anemia and coagulation management and a restrictive transfusion strategy are key points of blood management in patients undergoing cardiac surgical procedures. However, little consideration has been given to the kinetics of postoperative bleeding. This prospective observational study investigated bleeding kinetics from chest tubes to assess whether it was possible to predict, within the early postoperative hours, major bleeding at 12 postoperative hours. METHODS Adult cardiac surgical patients who were admitted consecutively to the postoperative intensive care unit in a tertiary academic hospital from January to June 2016 were included. Blood volume was collected from the chest drains, and major bleeding was defined as bleeding exceeding the 90th percentile of the volume distribution at 12 postoperative hours. Receiver operating characteristics curve analysis was performed with hourly bleeding thresholds to determine the best predictor of major bleeding. RESULTS In 292 patients, bleeding at 12 postoperative hours ranged from 60 to 2190 mL (median, 350 mL), and 30 patients had major bleeding, with a threshold of 675 mL. Bleeding volume declined logarithmically, 54% [IQR, 45% to 63%] within the first 4 hours. Patients with major bleeding had a higher bleeding volume every hour (P < .004). A good predictive value was observed within the first 2 hours (2.73 mL/kg; receiver operating characteristics area under the curve, 0.87 ± 0.04 [IQR, 0.79 to 0.94]; P< .001). CONCLUSIONS The hourly rate of chest tube blood loss seems to be relevant to predict, within the first postoperative hours after cardiac surgical procedures, major bleeding at 12 postoperative hours. Early detection of blood loss may help to improve a patient's blood conservation strategy because it may prompt preemptive treatments.
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Affiliation(s)
- Marine Saour
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Emmanuelle Aubry
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Cinderella Blin
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; Department of Physiology and Experimental Medicine Heart Muscles, National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Montpellier University, Montpellier, France
| | - Pascal H Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; Institute for Functional Genomics, National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Montpellier University, Montpellier, France.
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30
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Gunertem E, Urcun S, Pala AA, Budak AB, Ercisli MA, Gunaydin S. Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery. Perfusion 2020; 36:277-284. [DOI: 10.1177/0267659120941327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. Methods: The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. Results: Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. Conclusion: Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.
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Affiliation(s)
- Eren Gunertem
- Department of Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Salim Urcun
- Department of Cardiovascular Surgery, Adiyaman Training and Research Hospital, Adiyaman, Turkey
| | - Arda Aybars Pala
- Department of Cardiovascular Surgery, Adiyaman Training and Research Hospital, Adiyaman, Turkey
| | - Ali Baran Budak
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | | | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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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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32
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Karimov JH, Dessoffy R, Fukamachi K, Okano S, Idzior L, Lobosky M, Horvath D. Development and Evaluation of Motion-activated System for Improved Chest Drainage: Bench, In Vivo Results, and Pilot Clinical Use of Technology. Surg Innov 2020; 27:507-514. [PMID: 32490739 DOI: 10.1177/1553350620927579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. The aim of this study was to evaluate a motion-activated system (MAS) that applies motion-activated energy (vibration) to prevent chest tube clogging and maintain tube patency. We performed chest tube blood flow analysis in vitro, studied MAS effects on intraluminal clot deposition in vivo, and conducted a pilot clinical test. Background. Chest tube clogging is known to adversely contribute to postoperative cardiac surgery outcomes. Methods. The MAS was tested in vitro with a blood-filled chest tube model for device acceleration and performance. In vivo acute hemothorax studies (n = 5) were performed in healthy pigs (48.0 ± 2 kg) to evaluate the drainage in MAS versus control (no device) groups. Using a high-speed camera (FASTCAM Mini AX200, 100 mm Zeiss lens) in an additional animal study (n = 1), intraluminal whole-blood activation imaging of the chest tube (32 Fr) was made. The pilot clinical study (n = 12) consisted of up to a 30 minutes device tolerance test. Results. In vitro MAS testing suggested optimal device performance. The 2-hour in vivo evaluation showed a longer incremental drainage in the MAS group versus control. The total drainage in the MAS group was significantly higher than that in the control group (379 ± 144 mL vs 143 ± 40 mL; P = .0097), indicating tube patency. The high-speed camera images showed a characteristic intraluminal blood "swirling" pattern. Clinical data showed no discomfort with the MAS use (pleural = 4; mediastinal = 8). Conclusions. The MAS showed optimal performance at bench and better drainage profile in vivo. The clinical trial showed patients' tolerance to the MAS and device safety.
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Affiliation(s)
- Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, 2569Cleveland Clinic, OH, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, 2569Cleveland Clinic, OH, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, 2569Cleveland Clinic, OH, USA
| | - Shinji Okano
- Transplant Center, Department of General Surgery, 2569Cleveland Clinic, OH, USA
| | - Laura Idzior
- Cardiothoracic Intensive Care Unit, Nursing Institute, 2569Cleveland Clinic, OH, USA
| | - Mark Lobosky
- Department of Biomedical Engineering, Lerner Research Institute, 2569Cleveland Clinic, OH, USA
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Bogdanić D, Bogdanić N, Karanović N. Evaluation of platelet count and platelet function analyzer - 100 testing for prediction of platelet transfusion following coronary bypass surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:296-302. [PMID: 32125177 DOI: 10.1080/00365513.2020.1731847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Platelet transfusions are commonly administered to treat bleeding in cardiac surgery. The aim of this study was to compare platelet (PLT) count and values of collagen adenosine diphosphate closure time (cADP-CT) measured by Platelet Function Analyzer (PFA) for prediction of PLT transfusion therapy following coronary bypass surgery. For this prospective observational study, 66 patients scheduled for coronary artery bypass grafting (CABG) who received early PLT transfusions (within 60 min after the operation) were enrolled. To assess changes in platelets, count and function, two time points were selected: 15 min before and 30 - 60 min after the end of PLT transfusion. The patients were divided into transfused and non-transfused with further PLT in the 48 h postoperatively. We used the receiver operating characteristics (ROC) curve to investigate whether the PLT count and cADP-CT values were predictors of PLT transfusion. The positive predictive values (PPV) of PLT count and cADP-CT after PLT transfusion for further PLT transfusion were 33% and 86% respectively, with a PLT count threshold of ≤200 × 109/L and cADP-CT threshold of ≥118 s. The comparison among the ROC curves showed a statistical difference (p = .0002). In multiple regression analysis, cADP-CT was the strongest predictor for the number of PLT transfusion doses in the 48 h postoperatively. In CABG patients, the results of cADP-CT after PLT transfusion have a better predictive capacity for further PLT transfusions than the PLT count.
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Affiliation(s)
- Dejana Bogdanić
- Department of Transfusion Medicine, University Hospital Center Split, Split, Croatia
| | - Nikolina Bogdanić
- University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | - Nenad Karanović
- Department of Anesthesiology and Intensive Care, University Hospital Center Split, Split, Croatia
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34
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Shah A, Palmer AJR, Klein AA. Strategies to minimize intraoperative blood loss during major surgery. Br J Surg 2020; 107:e26-e38. [DOI: 10.1002/bjs.11393] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Abstract
Background
Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies.
Methods
This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient.
Results
Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays.
Conclusion
Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high-quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.
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Affiliation(s)
- A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
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35
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Mazur P, Litwinowicz R, Krzych Ł, Bochenek M, Wasilewski G, Hymczak H, Bartuś K, Filip G, Przybylski R, Kapelak B. Absence of perioperative excessive bleeding in on-pump coronary artery bypass grafting cases performed by residents. Interact Cardiovasc Thorac Surg 2019; 29:836-843. [PMID: 31435666 DOI: 10.1093/icvts/ivz195] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES On-pump coronary artery bypass grafting (CABG) is associated with elevated bleeding risk. Our aim was to evaluate the role of surgical experience in postoperative blood loss. METHODS A propensity score-matched analysis was employed to compare on-pump CABG patients operated on by residents and specialists. End points included drainage volume and bleeding severity, as assessed by the Universal Definition of Perioperative Bleeding in cardiac surgery and E-CABG scale. RESULTS A total of 212 matched pairs (c-statistics 0.693) were selected from patients operated on by residents (n = 294) and specialists (n = 4394) between October 2012 and May 2018. Patients did not differ in bleeding risk. There were no statistically significant differences in postoperative 6-, 12- and 24-h drainages between subjects operated on by residents and specialists, and there was no between-group difference in rethoracotomy or transfusion rate. There were no differences in Universal Definition of Perioperative Bleeding or E-CABG grades. In June 2018, after a median follow-up of 2.8 years (range 0.1-5.7 years), the overall survival was 94%, with no differences between the patients operated on by residents (95%) and specialists (92%) (P = 0.27). CONCLUSIONS Patients undergoing on-pump CABG, when operated on by a resident, are not exposed to an elevated bleeding risk, as compared with patients operated on by experienced surgeons.
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Affiliation(s)
- Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Łukasz Krzych
- Department of Anaesthesiology and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Bochenek
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Wasilewski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Hubert Hymczak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Filip
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Roman Przybylski
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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Erdoes G, Koster A, Meesters MI, Ortmann E, Bolliger D, Baryshnikova E, Ahmed A, Lance MD, Ravn HB, Ranucci M, Heymann C, Agarwal S. The role of fibrinogen and fibrinogen concentrate in cardiac surgery: an international consensus statement from the Haemostasis and Transfusion Scientific Subcommittee of the European Association of Cardiothoracic Anaesthesiology. Anaesthesia 2019; 74:1589-1600. [DOI: 10.1111/anae.14842] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/23/2022]
Affiliation(s)
- G. Erdoes
- Department of Anaesthesiology and Pain Medicine Inselspital, Bern University Hospital University of Bern Switzerland
| | - A. Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW Ruhr‐University Bochum Bad Oeynhausen Germany
| | - M. I. Meesters
- Department of Anaesthesiology University Medical Centre Utrecht The Netherlands
| | - E. Ortmann
- Department of Anaesthesia Kerckhoff Heart and Lung Centre Bad Nauheim Germany
| | - D. Bolliger
- Department of Anaesthesia Surgical Intensive Care Prehospital Emergency Medicine, and Pain Therapy University Hospital Basel Switzerland
| | - E. Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - A. Ahmed
- Department of Anaesthesia University Hospitals of Leicester NHS Trust LeicesterUK
| | - M. D. Lance
- Hamad Medical Corporation, HMC Anaesthesiology ICU and Peri‐operative Medicine Doha Qatar
| | - H. B. Ravn
- Department of Cardiothoracic Anaesthesiology Copenhagen University Hospital Copenhagen Denmark
| | - M. Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - C. Heymann
- Department of Anaesthesia Intensive Care Medicine, Emergency Medicine and Pain Therapy Vivantes Klinikum im Friedrichshain Berlin Germany
| | - S. Agarwal
- Department of Anaesthesia Manchester University Hospitals Manchester UK
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37
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Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery. JAMA Surg 2019; 154:755-766. [DOI: 10.1001/jamasurg.2019.1153] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel T. Engelman
- Heart and Vascular Program, Baystate Medical Center, Springfield, Massachusetts
| | | | | | | | - V. Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rakesh C. Arora
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
- Now with Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | | | - Ali Khoynezhad
- MemorialCare Heart and Vascular Institute, Los Angeles, California
| | - Marc Gerdisch
- Franciscan Health Heart Center, Indianapolis, Indiana
| | | | - Kevin Lobdell
- Atrium Health, Department of Cardiovascular and Thoracic Surgery, North Carolina
| | - Nick Fletcher
- St Georges University of London, London, United Kingdom
| | - Matthias Kirsch
- Centre Hospitalier Universitaire Vaudois Cardiac Surgery Centre, Lausanne, Switzerland
| | | | | | | | - Edward M. Boyle
- Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon
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38
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The design of an adaptive clinical trial to evaluate the efficacy of platelets stored at low temperature in surgical patients. J Trauma Acute Care Surg 2019. [PMID: 29521797 DOI: 10.1097/ta.0000000000001876] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Storage of platelets at 4°C compared with 22°C may increase both hemostatic activity and storage duration; however, the maximum duration of cold storage is unknown. We report the design of an innovative, prospective, randomized, Bayesian adaptive, "duration finding" clinical trial to evaluate the efficacy and maximum duration of storage of platelets at 4°C. METHODS Patients undergoing cardiac surgery and requiring platelet transfusions will be enrolled. Patients will be randomized to receive platelets stored at 22°C up to 5 days or platelets stored at 4°C up to 5 days, 10 days, or 15 days. Longer durations of cold storage will only be used if shorter durations at 4°C appear noninferior to standard storage, based on a four-level clinical hemostatic efficacy score with a NIM of a half level. A Bayesian linear model is used to estimate the hemostatic efficacy of platelet transfusions based on the actual duration of storage at 4°C. RESULTS The type I error rate, if platelets stored at 4°C are inferior, is 0.0247 with an 82% probability of early stopping for futility. With a maximum sample size of 1,500, the adaptive trial design has a power of over 90% to detect noninferiority and a high probability of correctly identifying the maximum duration of storage at 4°C that is noninferior to 22°C. CONCLUSION An adaptive, duration-finding trial design will generate Level I evidence and allow the determination of the maximum duration platelet storage at 4°C that is noninferior to standard storage at 22°C, with respect to hemostatic efficacy. The adaptive trial design helps to ensure that longer cold storage durations are only explored once substantial supportive data are available for the shorter duration(s) and that the trial stops early if continuation is likely to be futile.
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39
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Development and validation of a measurement system for continuously monitoring postoperative reservoir levels. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2019; 42:611-617. [PMID: 30868479 DOI: 10.1007/s13246-019-00746-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
Following cardiac surgical procedures, multiple drainage systems remain in place inside the patient's chest to prevent the development of pericardial effusion or pneumothorax. Therefore, postoperative bleeding must be diligently observed. Currently, observation of the exudate rate is performed through periodical visual inspection of the reservoir. To improve postoperative monitoring, a measurement system based on load cells was developed to automatically detect bleeding rates. A reservoir retaining bracket was instrumented with a load cell. The signal was digitized by a microcontroller and then processed and displayed on customized software written in LabView. In cases where bleeding rates reach critical levels, the device will automatically sound an alarm. Additionally, the bleeding rate is displayed on the screen with the status of the alarm, as well as the fluid level of the reservoir. These data are all logged to a file. The measurement system has been validated for gain stability and drift, as well as for sensor accuracy, with different in vitro examinations. Additionally, performance of the measurement device was tested in a clinical pilot study on patients recovering from cardiac surgical procedures. The in vitro investigation showed that the monitoring device had excellent gain and drift stability, as well as sensor accuracy, with a resolution of 2.6 mL/h for the bleeding rate. During the clinical examination, bleeding rates of all patients were correctly measured. Continuously recording drainage volume using the developed system was comparable to manual measurements performed every 30 min by a nurse. Implementation of continuous digital measurements could improve patient safety and reduce the workload of medical professionals working in intensive care units.
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40
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Lehmann F, Rau J, Malcolm B, Sander M, von Heymann C, Moormann T, Geyer T, Balzer F, Wernecke KD, Kaufner L. Why does a point of care guided transfusion algorithm not improve blood loss and transfusion practice in patients undergoing high-risk cardiac surgery? A prospective randomized controlled pilot study. BMC Anesthesiol 2019; 19:24. [PMID: 30777015 PMCID: PMC6379957 DOI: 10.1186/s12871-019-0689-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/25/2019] [Indexed: 12/15/2022] Open
Abstract
Background Adult cardiac surgery is often complicated by elevated blood losses that account for elevated transfusion requirements. Perioperative bleeding and transfusion of blood products are major risk factors for morbidity and mortality. Timely diagnostic and goal-directed therapies aim at the reduction of bleeding and need for allogeneic transfusions. Methods Single-centre, prospective, randomized trial assessing blood loss and transfusion requirements of 26 adult patients undergoing elective cardiac surgery at high risk for perioperative bleeding. Primary endpoint was blood loss at 24 h postoperatively. Random assignment to intra- and postoperative haemostatic management following either an algorithm based on conventional coagulation assays (conventional group: platelet count, aPTT, PT, fibrinogen) or based on point-of-care (PoC-group) monitoring, i.e. activated rotational thromboelastometry (ROTEM®) combined with multiple aggregometry (Multiplate®). Differences between groups were analysed using nonparametric tests for independent samples. Results The study was terminated after interim analysis (n = 26). Chest tube drainage volume was 360 ml (IQR 229-599 ml) in the conventional group, and 380 ml (IQR 310-590 ml) in the PoC-group (p = 0.767) after 24 h. Basic patient characteristics, results of PoC coagulation assays, and transfusion requirements of red blood cells and fresh frozen plasma did not differ between groups. Coagulation results were comparable. Platelets were transfused in the PoC group only. Conclusion Blood loss via chest tube drainage and transfusion amounts were not different comparing PoC- and central lab-driven transfusion algorithms in subjects that underwent high-risk cardiac surgery. Routine PoC coagulation diagnostics do not seem to be beneficial when actual blood loss is low. High risk procedures might not suffice as a sole risk factor for increased blood loss. Trial registration NCT01402739, Date of registration July 26, 2011.
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Affiliation(s)
- F Lehmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany.
| | - J Rau
- Division of Medical Biotechnology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Hessen, Germany
| | - B Malcolm
- Department of Internal Medicine, Hegau-Bodensee-Klinikum, Singen, Baden-Württemberg, Germany
| | - M Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain therapy, University Hospital Gießen UKGM, Justus-Liebig-University Giessen, Giessen, Hessen, Germany
| | - C von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - T Moormann
- Department of Anaesthesiology and Intensive Care Medicine, Martin-Luther-Krankenhaus, Berlin, Germany
| | - T Geyer
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - F Balzer
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - K D Wernecke
- CRO SOSTANA GmbH and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - L Kaufner
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Research into major bleeding during cardiac surgery is challenging due to variability in how it is scored. Two consensus-based clinical scores for major bleeding: the Universal definition of perioperative bleeding and the European Coronary Artery Bypass Graft (E-CABG) bleeding severity grade, were compared in this substudy of the Transfusion Avoidance in Cardiac Surgery (TACS) trial.
Methods
As part of TACS, 7,402 patients underwent cardiac surgery at 12 hospitals from 2014 to 2015. We examined content validity by comparing scored items, construct validity by examining associations with redo and complex procedures, and criterion validity by examining 28-day in-hospital mortality risk across bleeding severity categories. Hierarchical logistic regression models were constructed that incorporated important predictors and categories of bleeding.
Results
E-CABG and Universal scores were correlated (Spearman ρ = 0.78, P < 0.0001), but E-CABG classified 910 (12.4%) patients as having more severe bleeding, whereas the Universal score classified 1,729 (23.8%) as more severe. Higher E-CABG and Universal scores were observed in redo and complex procedures. Increasing E-CABG and Universal scores were associated with increased mortality in unadjusted and adjusted analyses. Regression model discrimination based on predictors of perioperative mortality increased with additional inclusion of the Universal score (c-statistic increase from 0.83 to 0.91) or E-CABG (c-statistic increase from 0.83 to 0.92). When other major postoperative complications were added to these models, the association between Universal or E-CABG bleeding with mortality remained.
Conclusions
Although each offers different advantages, both the Universal score and E-CABG performed well in the validity assessments, supporting their use as outcome measures in clinical trials.
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Braga DV, Brandão MAG. Diagnostic evaluation of risk for bleeding in cardiac surgery with extracorporeal circulation. Rev Lat Am Enfermagem 2018; 26:e3092. [PMID: 30517580 PMCID: PMC6280528 DOI: 10.1590/1518-8345.2523.3092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 09/17/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. METHOD case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. RESULTS variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). CONCLUSION such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.
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Affiliation(s)
- Damaris Vieira Braga
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Janeiro, RJ, Brazil
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Nam K, Jeon Y, Kim TK, Jo WY, Yoon S, Kwak J, Cho YJ. The velocity curve of the clotting waveform of rotational thromboelastometry predicts bleeding after cardiac surgery but conventional rotational thromboelastometric parameters do not. Minerva Anestesiol 2018; 85:505-513. [PMID: 30394063 DOI: 10.23736/s0375-9393.18.12960-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Early detection of a risk of postoperative bleeding is essential in cardiac surgery patients. The aim of the present study was to evaluate the utility of the first derivative curve (the V-curve) of the clotting waveform of rotational thromboelastometry (ROTEM) in terms of predicting bleeding after cardiac surgery. METHODS We retrospectively analysed 534 cardiac surgery patients. We used the chest tube output during the stay in the intensive care unit to divide patients into a higher blood loss group (HBL group; the fourth quartile) and a lower blood loss group (LBL group; the lower quartiles). We performed multivariable logistic regression using the V-curve parameters and potential confounders including conventional ROTEM parameters. RESULTS In the multivariable model, the adjusted odds ratios for HBL of patients with a lower maximum clotting velocity (MaxVel ≤9 mm*100 s-1) as revealed by extrinsically activated ROTEM (EXTEM), and the area under the velocity curve (AUC ≤988 mm*100) of the fibrin-based extrinsically activated ROTEM (FIBTEM), both measured at skin closure in the end of surgery, were 1.78 (95% CI 1.03 to 3.07) and 2.14 (95% CI 1.20 to 3.82), respectively. However, conventional ROTEM parameters were not included in the final model. Additionally, lower EXTEM MaxVel and FIBTEM AUC values were associated with the need for a higher transfusion volume, longer postoperative intensive care unit and hospital stays, and more frequent re-exploration to control bleeding. CONCLUSIONS The ROTEM V-curve parameters can predict postoperative bleeding and clinical outcomes after cardiac surgery.
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Tae K Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Woo Y Jo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Sehee Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Jooah Kwak
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Youn J Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, South Korea -
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Pereira KMFSM, de Assis CS, Cintra HNWL, Ferretti-Rebustini REL, Püschel VAA, Santana-Santos E, Rodrigues ARB, de Oliveira LB. Factors associated with the increased bleeding in the postoperative period of cardiac surgery: A cohort study. J Clin Nurs 2018; 28:850-861. [PMID: 30184272 DOI: 10.1111/jocn.14670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
AIMS AND OBJECTIVES To identify factors associated with the increased bleeding in patients during the postoperative period after cardiac surgery. BACKGROUND Bleeding is among the most frequent complications that occur in the postoperative period after cardiac surgery, representing one of the major factors in morbidity and mortality. Understanding the factors associated with the increased bleeding may allow nurses to anticipate and prioritise care, thus reducing the mortality associated with this complication. DESIGN Prospective cohort study. METHODS Adult patients in a cardiac hospital who were in the postoperative period following cardiac surgery were included. Factors associated with the increased bleeding were investigated by means of linear regression, considering time intervals of 6 and 12 hr. RESULTS The sample comprised 391 participants. The factors associated with the increased bleeding in the first 6 hr were male sex, body mass index, cardiopulmonary bypass duration, anoxia duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative period. Predictors in the first 12 hr were body mass index, cardiopulmonary bypass duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative. CONCLUSIONS This study identified factors associated with the increased postoperative bleeding from cardiac surgery that have not been reported in previous studies. The nurse is important in the vigilance, evaluation and registry of chest tube drainage and modifiable factors associated with the increased bleeding, such as metabolic acidosis and postoperative heart rate, and in discussions with the multiprofessional team. RELEVANCE TO CLINICAL PRACTICE Knowledge of the factors associated with the increased bleeding is critical for nurses so they can provide prophylactic interventions and early postoperative treatment when needed.
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Affiliation(s)
- Kárla M F S M Pereira
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Caroline S de Assis
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Haulcionne N W L Cintra
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Vilanice A A Püschel
- Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de Sao Paulo, SP, BR
| | | | - Adriano Rogério B Rodrigues
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Larissa B de Oliveira
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.,Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de Sao Paulo, SP, BR.,Nursing Department, Sociedade de Cardiologia do Estado de Sao Paulo, SP, BR
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St-Onge S, Lemoine É, Bouhout I, Rochon A, El-Hamamsy I, Lamarche Y, Demers P. Evaluation of the real-world impact of rotational thromboelastometry-guided transfusion protocol in patients undergoing proximal aortic surgery. J Thorac Cardiovasc Surg 2018; 157:1045-1054.e4. [PMID: 30195598 DOI: 10.1016/j.jtcvs.2018.07.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/12/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Complex aortic procedures are potentially associated with important blood loss and coagulopathy. The aim of this study was to assess the impact of rotational thromboelastometry (ROTEM, Tem International GmBH, Munich, Germany) on transfusion requirements after proximal aortic operations in a real-world setting. METHODS This single-center retrospective analysis based on 385 consecutive patients undergoing cardiac surgeries involving the aortic root, ascending aorta, or aortic arch compared 197 controls managed according to routine transfusion protocol before the introduction of the ROTEM in 2012 with 188 patients operated afterward. With the use of a 1:1 propensity score match, 224 patients were included in paired analysis (112 in each group). The primary end point was erythrocytes transfusion rate. The secondary end points comprised the transfusion of other allogeneic blood products, number of units transfused, postoperative blood loss, massive transfusion rate, and use of other hemostatic products. RESULTS ROTEM implementation was associated with a trend toward reduction in the rate of erythrocytes transfusion (57% vs 46%, P = .08) and a decreased median number of units transfused for erythrocytes (1.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .03) and plasma (0.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .04). After sensitivity analysis, ROTEM displayed a comparable rate of erythrocytes transfusion (58% vs 47%, P = .15). CONCLUSIONS In a real-world setting, ROTEM-based algorithm implementation could help reduce excess erythrocytes transfusion for complex aortic procedures. We advocate for a strict adherence and concerted team effort to maximize the benefits of such addition to patients' management.
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Affiliation(s)
- Samuel St-Onge
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Émile Lemoine
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesia, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Ismaïl El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Philippe Demers
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada.
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Dimberg A, Alström U, Ståhle E, Christersson C. Higher Preoperative Plasma Thrombin Potential in Patients Undergoing Surgery for Aortic Stenosis Compared to Surgery for Stable Coronary Artery Disease. Clin Appl Thromb Hemost 2018; 24:1282-1290. [PMID: 29768939 PMCID: PMC6714769 DOI: 10.1177/1076029618776374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aortic stenosis (AS) and coronary artery disease (CAD) influence the coagulation system, potentially affecting hemostasis during cardiac surgery. Our aim was to evaluate 2 preoperative global hemostasis assays, plasma thrombin potential and thromboelastometry, in patients with severe aortic valve stenosis compared to patients with CAD. A secondary aim was to test whether the assays were associated with postoperative bleeding. Calibrated automated thrombogram (CAT) in platelet-poor plasma and rotational thromboelastometry (ROTEM) in whole blood were analyzed in patients scheduled for elective surgery due to severe AS (n = 103) and stable CAD (n = 68). Patients with AS displayed higher plasma thrombin potential, both thrombin peak with median 252 nmol/L (interquartile range 187-319) and endogenous thrombin potential (ETP) with median 1552 nmol/L/min (interquartile range 1340-1838), when compared to patients with CAD where thrombin peak was median 174 nmol/L (interquartile range 147-229) and ETP median 1247 nmol/L/min (interquartile range 1034-1448; both P < .001). Differences persisted after adjustment for age, gender, comorbidity, and antithrombotic treatment. Differences observed in thromboelastometry between the groups did not persist after adjustment for baseline characteristics. Bleeding amount showed no relationship with plasma thrombin potential but weakly to thromboelastometry (R2 = .064, P = .001). Patients with AS exhibited preoperatively increased plasma thrombin potential compared to patients with CAD. Plasma thrombin potential was not predictive for postoperative bleeding in patients scheduled for elective surgery.
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Affiliation(s)
- Axel Dimberg
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ulrica Alström
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Elisabeth Ståhle
- 1 Section of Thoracic Surgery, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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How detrimental is reexploration for bleeding after cardiac surgery? J Thorac Cardiovasc Surg 2017; 154:927-935. [DOI: 10.1016/j.jtcvs.2016.04.097] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 03/28/2016] [Accepted: 04/05/2016] [Indexed: 11/22/2022]
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Tauriainen T, Kinnunen EM, Koski-Vähälä J, Mosorin MA, Airaksinen J, Biancari F. Outcome after procedures for retained blood syndrome in coronary surgery. Eur J Cardiothorac Surg 2017; 51:1078-1085. [DOI: 10.1093/ejcts/ezx015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Microvascular reactivity measured by vascular occlusion test is an independent predictor for postoperative bleeding in patients undergoing cardiac surgery. J Clin Monit Comput 2017; 32:295-301. [PMID: 28455779 DOI: 10.1007/s10877-017-0020-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/22/2017] [Indexed: 01/31/2023]
Abstract
The purpose of the study is to investigate the relationship between microvascular reactivity and postoperative bleeding in cardiac surgery. The authors retrospectively analyzed a prospectively collected registry of cardiac surgery patients. Data from 154 patients enrolled in the registry were analyzed. A linear mixed model was performed to evaluate the association between the amount of postoperative chest tube output (CTO, milliliter, repeatedly measured at 0-8, 8-24, and 24-48 h) and tissue oxygen saturation (StO2) recovery slope (%/s) measured by vascular occlusion test (VOT) at skin closure. A logistic regression was carried out to see the relationship between StO2 recovery slope and packed red blood cell (PRBC) transfusion during the 48-h postoperative period. In the multivariable adjusted model, the effect of StO2 recovery slope on postoperative CTO (log-transformed) was statistically significant, and the degree of StO2 recovery slope was inversely related to the amount of CTO (exp(estimate) = 0.935; exp(95% CI) 0.881-0.992; p = 0.027). StO2 recovery slope was also inversely associated with postoperative PRBC transfusion possibility (OR = 0.795; 95% CI 0.633-0.998; p = 0.048). Microvascular reactivity measured by VOT is independently and inversely associated with postoperative bleeding in patients undergoing cardiac surgery.
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