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Akca O. Perioperative blood transfusion-how do I interpret the evidence concerning transfusion triggers? J Clin Anesth 2024; 96:111395. [PMID: 38342636 DOI: 10.1016/j.jclinane.2024.111395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/13/2024] [Indexed: 02/13/2024]
Affiliation(s)
- Ozan Akca
- Department of Anesthesiology & Critical Care Medicine (ACCM), Neuro-anesthesia & Neuro-critical care, Johns Hopkins Medicine, United States of America; Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, United States of America.
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Monaco F, Guarracino F, Vendramin I, Lei C, Zhang H, Lomivorotov V, Osinsky R, Efremov S, Gürcü ME, Mazzeffi M, Pasyuga V, Kotani Y, Biondi-Zoccai G, D'Ascenzo F, Romagnoli E, Nigro Neto C, Do Nascimento VTNDS, Ti LK, Lorsomradee S, Farag A, Bukamal N, Brizzi G, Lobreglio R, Belletti A, Arangino C, Paternoster G, Bonizzoni MA, Tucciariello MT, Kroeller D, Di Prima AL, Mantovani LF, Ajello V, Gerli C, Porta S, Ferrod F, Giardina G, Santonocito C, Ranucci M, Lembo R, Pisano A, Morselli F, Nakhnoukh C, Oriani A, Pieri M, Scandroglio AM, Kırali K, Likhvantsev V, Longhini F, Yavorovskiy A, Bellomo R, Landoni G, Zangrillo A. Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial. Contemp Clin Trials 2024; 143:107605. [PMID: 38866095 DOI: 10.1016/j.cct.2024.107605] [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: 01/31/2024] [Revised: 05/12/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain. METHODS This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions. RESULTS The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications. CONCLUSION The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB. STUDY REGISTRATION This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Igor Vendramin
- Division of Cardiac Surgery, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; Department of Medicine, University of Udine, Udine, Italy
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Xi'an, China
| | - Vladimir Lomivorotov
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia; Penn State Milton S. Hershey Medical Center, Department of Anesthesiology and Perioperative Medicine, Hershey, PA, USA
| | - Roman Osinsky
- E. Meshalkin National Medical Research Center, Department of Anesthesiology and Intensive Care, Novosibirsk, Russia
| | - Sergey Efremov
- Saint Petersburg State University Hospital, Saint-Petersburg, Russian Federation
| | - Mustafa Emre Gürcü
- Koşuyolu High Specialization Education and Research Hospital, Istanbul, Turkey
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - Vadim Pasyuga
- Department of Anesthesiology and Intensive Care, Federal Center for Cardiovascular Surgery Astrakhan, Astrakhan, Russian Federation
| | - Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Japan
| | | | - Fabrizio D'Ascenzo
- Cardiovascular and Thoracic Department, A.O.U. Città della Salute e della Scienza, Turin, Italy; Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via Pineta Sacchetti, 217, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Campus di Roma, Largo Francesco Vito, 1, 00168, Rome, Italy
| | | | | | | | | | - Ahmed Farag
- King Abdullah Medical City - Holy Capital (KAMC-HC), Makkah, Saudi Arabia
| | - Nazar Bukamal
- Cardiothoracic ICU and Anesthesia Department, Mohammed Bin Khalifa Specialist Cardiac Center, Awali 183261, Bahrain
| | - Giulia Brizzi
- Department of Cardiothoracic Anesthesia and ICU, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Rosetta Lobreglio
- Department of Anesthesia, Intensive Care and Emergency, Citta della Salute e della Scienza University Hospital, Turin, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Arangino
- Department of Cardiothoracic Anesthesia and Intensive Care, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Gianluca Paternoster
- Cardiovascular Anesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | - Matteo Aldo Bonizzoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Daniel Kroeller
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Ambra Licia Di Prima
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Valentina Ajello
- Department of Cardio Thoracic anesthesia and Intensive Care, Hospital Tor Vergata Roma, Italy
| | - Chiara Gerli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sabrina Porta
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Federica Ferrod
- Department of Cardiovascular Anestesia, Azienda Ospedaliera Umberto I Mauriziano, Turin, Italy
| | - Giuseppe Giardina
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Santonocito
- Anaesthesia and Intensive Care Medicine III, Policlinico University Hospital, Catania, Italy
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Pisano
- Cardiac Anesthesia and Intensive Care Unit, Azienda Ospedaliera Dei Colli, Monaldi Hospital, Naples, Italy
| | - Federica Morselli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Nakhnoukh
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Mara Scandroglio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Kaan Kırali
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Valery Likhvantsev
- Department of Clinical Trials, V. Negovsky Reanimatology Research Institute, Moscow, Russian Federation; Department of Anesthesiology and Resuscitation, First Moscow State Medical University, Moscow, Russian Federation
| | - Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University of Catanzaro, Italy
| | - Andrey Yavorovskiy
- I.M. Sechenov First Moscow State Medical University, Ministry of Public Health of Russia, Moscow, Russia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Yoshinaga K, Iizuka Y, Chiba Y, Sasabuchi Y, Sanui M. In vitro protamine addition for coagulation assessment using TEG 6s system during cardiopulmonary bypass: a pilot study. Gen Thorac Cardiovasc Surg 2024:10.1007/s11748-024-02061-7. [PMID: 39017825 DOI: 10.1007/s11748-024-02061-7] [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: 02/19/2024] [Accepted: 07/08/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE Systemic heparinization during cardiopulmonary bypass (CPB) can significantly affect thromboelastography (TEG). This study investigated the feasibility of adding protamine in vitro to allow assessment of coagulation status using the TEG 6s system during CPB. METHODS In this prospective observational study, 21 patients undergoing elective cardiac valve surgery were evaluated. During CPB, protamine was added in vitro to the heparinized blood of these patients at a concentration of 0.05 mg/mL and analyzed with the TEG 6s (Pre). The TEG parameters were compared to those analyzed after CPB withdrawal and systemic protamine administration (Post). RESULTS The citrated kaolin maximal amplitude (CK-MA) and the citrated functional fibrinogen maximal amplitude (CFF-MA) exhibited strong correlations between Pre and Post measurements (r = 0.790 and 0.974, respectively, P < 0.001 for both), despite significant mean differences (-2.23 mm for CK-MA and -0.68 mm for CFF-MA). Bland-Altman analysis showed a clinically acceptable agreement between Pre and Post measurement of CK-MA and CFF-MA (the percentage error was 10.6% and 12.2%, respectively). In contrast, the citrated kaolin reaction time (CK-R) showed no significant correlation between Pre and Post measurements (r = 0.328, P = 0.146), with a mean difference of 1.42 min (95% CI: -0.45 to 3.29). CONCLUSIONS In vitro protamine addition allows assessment of coagulation status during CPB using the TEG 6s system. CK-MA and CFF-MA measured during CPB using this method revealed a strong correlation and agreement with post-CPB measurements, suggesting that our method potentially facilitates early prediction of post-CPB coagulation status and decision-making on transfusion strategies. CLINICAL TRIAL REGISTRATION The study was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR, registration number: UMIN000041097, date of registration: July 13, 2020, https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000046925 ) before the recruitment of participants.
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Affiliation(s)
- Koichi Yoshinaga
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-Cho, Omiya-Ku, Saitama-Shi, Saitama, 330-8503, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-Cho, Omiya-Ku, Saitama-Shi, Saitama, 330-8503, Japan.
| | - Yoshihiko Chiba
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-Cho, Omiya-Ku, Saitama-Shi, Saitama, 330-8503, Japan
| | - Yusuke Sasabuchi
- Department of Real-World Evidence, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-Cho, Omiya-Ku, Saitama-Shi, Saitama, 330-8503, Japan
- Division of Critical Care, Department of Anesthesiology and Critical Care Medicine, Jichi Medical University, 3311-1, Yakushiji, Shimotsuke-Shi, Tochigi, 329-0498, Japan
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Jia B, Ding C, Deng J, Qi W, Yao Y. The association between heparin sensitivity index and postoperative blood loss in Chinese patients undergoing elective off-pump coronary artery bypass grafting: a single center retrospective study. J Cardiothorac Surg 2024; 19:426. [PMID: 38978097 PMCID: PMC11229182 DOI: 10.1186/s13019-024-02966-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 06/30/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND The heparin sensitivity index (HSI) is closely associated with perioperative ischemic events and increased blood loss in cardiac surgery. Previous studies have produced conflicting results. Therefore, this study aimed to investigate the relationship between HSI and postoperative blood loss specifically in Chinese patients undergoing elective off-pump coronary artery bypass grafting (OPCAB). METHODS Patients underwent OPCAB between March 2021 and July 2022 were retrospectively included. Enrolled patients were classified into Low-HSI (HSILOW; HSI < 1.3) and Normal-HSI (HSINORM; HSI ≥ 1.3) groups. HSI = [(activated clotting time (ACT) after heparin) - (baseline ACT)] / [loading dose of heparin (IU/kg)]. Primary outcome included postoperative blood loss at 24 h. Secondary outcomes were total postoperative blood loss, transfusion requirement of red blood cell (RBC), fresh frozen plasma (FFP), platelet concentrates (PC), and other complications. RESULTS We retrospectively analyzed 303 Chinese OPCAB patients. HSILOW group had higher preoperative platelet (PLT) count (221 × 109/L vs. 202 × 109/L; P = 0.041) and platelet crit (PCT) value (0.23% vs. 0.22%; P = 0.040) compared to HSINORM group. Two groups showed no significant differences in postoperative blood loss at 24 h (460 mL vs. 470 mL; P = 0.252), total blood loss (920 mL vs. 980 mL; P = 0.063), RBC transfusion requirement (3.4% vs. 3.1%; P = 1.000), FFP transfusion requirement (3.4% vs. 6.2%; P = 0.380), and other complications. Preoperative high PLT count was associated with low intraoperative HSI value (odds ratio: 1.006; 95% confidence interval: 1.002, 1.011; P = 0.008). CONCLUSIONS Intraoperative HSI value was not associated with postoperative blood loss in Chinese patients undergoing OPCAB. Preoperative high PLT count was an independent predictor of low intraoperative HSI value.
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Affiliation(s)
- Bin Jia
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Chenying Ding
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
- Department of Anesthesiology, The First Hospital of Hohhot, Hohhot, 010020, China
| | - Jinhe Deng
- Department of Anesthesiology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, 510006, China
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Wenhui Qi
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China
- Department of Anesthesiology, Harrison International Peace Hospital, Hengshui, 053000, China
| | - Yuntai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167, Beilishi Road, Xicheng District, Beijing, 100037, China.
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Kim HJ, Shin HJ, Lee SW, Heo S, Lee SH, Kim JE, Son HS, Jung JS. Improvement of Transfusion Practice in Cardiothoracic Surgery Through Implementing a Patient Blood Management Program. J Chest Surg 2024; 57:390-398. [PMID: 38584377 PMCID: PMC11240097 DOI: 10.5090/jcs.23.160] [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: 11/09/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 04/09/2024] Open
Abstract
Background In this study, we examined the impact of a patient blood management (PBM) program on red blood cell (RBC) transfusion practices in cardiothoracic surgery. Methods The PBM program had 3 components: monitoring transfusions through an order communication system checklist, educating the medical team about PBM, and providing feedback to ordering physicians on the appropriateness of transfusion. The retrospective analysis examined changes in the hemoglobin levels triggering transfusion and the proportions of appropriate RBC transfusions before, during, and after PBM implementation. Further analysis was focused on patients undergoing cardiac surgery, with outcomes including 30-day mortality, durations of intensive care unit and hospital stays, and rates of pneumonia, sepsis, and wound complications. Results The study included 2,802 patients admitted for cardiothoracic surgery. After the implementation of PBM, a significant decrease was observed in the hemoglobin threshold for RBC transfusion. This threshold dropped from 8.7 g/dL before PBM to 8.3 g/dL during the PBM education phase and 8.0 g/dL during the PBM feedback period. Additionally, the proportion of appropriate RBC transfusions increased markedly, from 23.9% before PBM to 34.9% and 58.2% during the education and feedback phases, respectively. Among the 381 patients who underwent cardiac surgery, a significant reduction was noted in the length of hospitalization over time (p<0.001). However, other clinical outcomes displayed no significant differences. Conclusion PBM implementation effectively reduced the hemoglobin threshold for RBC transfusion and increased the rate of appropriate transfusion in cardiothoracic surgery. Although transfusion practices improved, clinical outcomes were comparable to those observed before PBM implementation.
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Affiliation(s)
- Hee Jung Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hyeon Ju Shin
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Suk Woo Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seonyeong Heo
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seung Hyong Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ji Eon Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ho Sung Son
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
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Gautam N, Tran V, Griffin E, Elliott J, Rydalch E, Kerr K, Wilkinson AJ, Zhang X, Saroukhani S. A single-center, retrospective analysis to compare measurement of fibrinogen using the TEG6 analyzer to the Clauss measurement in children undergoing heart surgery. Paediatr Anaesth 2024; 34:619-627. [PMID: 38071737 DOI: 10.1111/pan.14820] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/26/2023] [Accepted: 11/28/2023] [Indexed: 06/07/2024]
Abstract
BACKGROUND Newer generation viscoelastic tests, TEG6s, offer point-of-care hemostatic therapy in adult patients. However, their efficacy in estimating fibrinogen levels in pediatric patients undergoing cardiac surgery is not well established. AIMS This study evaluates TEG6s for estimating fibrinogen levels in pediatric cardiac surgery patients and its predictive capability for post-bypass hypofibrinogenemia. METHODS A single-center, retrospective study on pediatric patients (under 18 years) who underwent cardiac surgery with cardiopulmonary bypass from August 2020 and November 2022. Blood samples for estimated whole blood functional fibrinogen level via TEG6s (Haemonetics Inc.) and concurrent laboratory-measured plasma fibrinogen via von Clauss assay were collected at pre- and post-cardiopulmonary bypass. RESULTS Paired data for TEG6s estimated functional fibrinogen levels and plasma fibrinogen were analyzed for 432 pediatric patients pre-bypass. It was observed that functional fibrinogen consistently overestimated plasma fibrinogen across all age groups with a mean difference of 138 mg/dL (95% confidence interval [CI]: 128-149 mg/dL). This positive bias in the pre-bypass data was confirmed by Bland-Altman analysis. Post-bypass, functional fibrinogen estimates were comparable to plasma fibrinogen in all patient groups with a mean difference of -6 mg/dL (95% CI: -20-8 mg/dL) except for neonates, where functional fibrinogen levels underestimated plasma fibrinogen with a mean difference of -38 mg/dL (95% CI: -64 to -12 mg/dL). The predictive accuracy of functional fibrinogen for detecting post-bypass hypofibrinogenemia (plasma fibrinogen ≤250 mg/dL) demonstrated overall fair accuracy in all patients, indicated by an area under the curve of 0.73 (95% CI: 0.65-0.80) and good accuracy among infants, with an area under the curve of 0.80 (95% CI: 0.70-0.90). Similar performance was observed in predicting critical post-bypass hypofibrinogenemia (plasma fibrinogen ≤200 mg/dL). Based on these analyses, optimal cutoffs for predicting post-bypass hypofibrinogenemia were established as a functional fibrinogen level ≤270 mg/dL and MAFF ≤15 mm. CONCLUSION This study demonstrates that whole blood functional fibrinogen, as estimated by TEG6s, tends to overestimate baseline plasma fibrinogen levels in pediatric age groups but aligns more accurately post-cardiopulmonary bypass, particularly in neonates and infants, suggesting its potential as a point-of-care tool in pediatric cardiac surgery. However, the variability in TEG6s performance before and after bypass highlights the need for careful interpretation of its results in clinical decision-making. Despite its contributions to understanding TEG6s in pediatric cardiac surgery, the study's design and inherent biases warrant cautious application of these findings in clinical settings.
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Affiliation(s)
- Nischal Gautam
- Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Vy Tran
- Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Evelyn Griffin
- Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Jehan Elliott
- Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Eric Rydalch
- Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | - Kelbie Kerr
- Department of Anesthesiology, McGovern Medical School, UT Health Houston, Houston, Texas, USA
| | | | - Xu Zhang
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Biostatistics/Epidemiology/Research Design (BERD) component, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sepideh Saroukhani
- Division of Clinical and Translational Sciences, Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA
- Biostatistics/Epidemiology/Research Design (BERD) component, Center for Clinical and Translational Sciences (CCTS), The University of Texas Health Science Center at Houston, Houston, Texas, USA
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7
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Shou BL, Schena S. Early Reexploration for Postoperative Bleeding in Cardiac Surgery Is Beneficial Regardless of Bleeding Site, Even When Undetectable. Ann Thorac Surg 2024; 117:484. [PMID: 37178859 DOI: 10.1016/j.athoracsur.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefano Schena
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226.
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Navarro R, Bojic S, Fatima R, El-Tahan M, El-Diasty M. Recombinant Activated Factor VII (rFVIIa) for Bleeding After Thoracic Aortic Surgery: A Scoping Review of Current Literature. J Cardiothorac Vasc Anesth 2024; 38:275-284. [PMID: 38036397 DOI: 10.1053/j.jvca.2023.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Bleeding after surgery on the thoracic aorta is a frequent complication, and can be associated with a significant increase in morbidity and mortality. Recombinant activated factor VII (rFVIIa) was developed initially for treating patients with hemophilia; however, it has been used increasingly "off-label" to achieve hemostasis after thoracic aortic procedures. OBJECTIVE This scoping review aimed to present the available literature on the role of rFVIIa in the management of refractory postoperative bleeding after thoracic aortic surgery. METHODS/RESULTS An electronic database search was conducted using Medline, Embase, Cochrane Library, and Google Scholar in June 2023. The authors included studies that reported the use of rFVIIa in patients undergoing surgical repair of ascending or descending aortic aneurysm or dissection. Single-case reports were excluded. Ten publications with a pooled number of 649 patients (319 patients received rFVIIa and 330 in the control groups) were identified: 3 case series, 6 retrospective studies, and 1 nonrandomized clinical trial. All studies reported the potential role of rFVIIa in correcting coagulopathy and reducing postoperative blood loss in this group of patients. Overall, there was not enough evidence to suggest that rFVIIa was associated with higher rates of thromboembolic complications or mortality. CONCLUSION Limited evidence suggests that rFVIIa may be useful in managing postoperative refractory bleeding in patients undergoing thoracic aortic surgery. However, the impact of rFVIIa on thromboembolic complications and mortality rates remains unclear.
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Affiliation(s)
- Ryan Navarro
- Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Sandra Bojic
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rubab Fatima
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Mohamed El-Tahan
- Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammad El-Diasty
- Cardiac Surgery Department, Harrington Heart Institute, University Hospitals, Cleveland, Ohio, USA.
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Bloch EM, Tobian AAR. Optimizing Blood Transfusion in Patients with Acute Myocardial Infarction. N Engl J Med 2023; 389:2483-2485. [PMID: 38157506 DOI: 10.1056/nejme2312741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Evan M Bloch
- From the Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
| | - Aaron A R Tobian
- From the Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore
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10
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Fletcher CM, Hinton JV, Xing Z, Perry LA, Karamesinis A, Shi J, Penny-Dimri JC, Ramson D, Liu Z, Smith JA, Segal R, Coulson TG, Bellomo R. Fresh frozen plasma transfusion after cardiac surgery. Perfusion 2023:2676591231221715. [PMID: 38085647 DOI: 10.1177/02676591231221715] [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: 12/22/2023]
Abstract
INTRODUCTION Fresh frozen plasma (FFP) transfusion in the intensive care unit (ICU) is commonly used to treat coagulopathy and bleeding in cardiac surgery, despite suggestion that it may increase the risk of morbidity and mortality through mechanisms such as fluid overload and infection. METHODS We retrospectively studied consecutive adults undergoing cardiac surgery from the Medical Information Mart for Intensive Care III and IV databases. We applied propensity score matching to investigate the independent association of within-ICU FFP transfusion with mortality and other key clinical outcomes. RESULTS Of our 12,043 adults who met inclusion criteria, 1585 (13.2%) received perioperative FFP with a median of 2.48 units per recipient (interquartile range [IQR]: 2.04, 4.33) at a median time of 1.83 h (IQR: 0.75, 3.75) after ICU admission. After propensity matching of 952 FFP recipients to 952 controls, we found no significant association between FFP use and hospital mortality (odds ratio (OR): 1.58; 99% confidence interval (CI): 0.57, 3.71), suspected infection (OR: 0.72; 99% CI: 0.49, 1.08), or acute kidney injury (OR: 1.23; 99% CI: 0.91, 1.67). However, FFP was associated with increased days in hospital (adjusted mean difference (AMD): 1.28; 99% CI: 0.27, 2.41; p = .0050), days in intensive care (AMD: 1.28; 99% CI: 0.27, 2.28; p = .0011), and chest tube output in millilitres up to 8 h after transfusion (AMD: 92.98; 99% CI: 52.22, 133.74; p < .0001). CONCLUSIONS After propensity matching, FFP transfusion was not associated with increased hospital mortality, but was associated with increased length of stay and no decrease in bleeding in the early post-transfusion period.
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Affiliation(s)
- Calvin M Fletcher
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Jake V Hinton
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Zhongyue Xing
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Alexandra Karamesinis
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jenny Shi
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia
| | - Dhruvesh Ramson
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia
| | - Zhengyang Liu
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Julian A Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia
- Department of Cardiothoracic Surgery, Monash Health, Clayton, VIC, Australia
| | - Reny Segal
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Tim G Coulson
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
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11
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Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA, Murphy CH, Pavenski K, Prochaska MT, Raval JS, Salazar E, Saifee NH, Tobian AAR, So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA 2023; 330:1892-1902. [PMID: 37824153 DOI: 10.1001/jama.2023.12914] [Citation(s) in RCA: 45] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell transfusion is a common medical intervention with benefits and harms. Objective To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.
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Affiliation(s)
- Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- NHSBT, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom
| | - Gordon Guyatt
- Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester
| | - Jane Dennis
- Cochrane Injuries Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California, San Francisco
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | | | - Brenda J Grossman
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Gaurav K Gupta
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron S Hess
- Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison
| | - Jessica L Jacobson
- Department of Pathology, New York University Grossman School of Medicine, New York
- NYC Health + Hospitals/Bellevue, New York, New York
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care and Surgical Emergencies, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City
| | - Colin H Murphy
- Pathology Associates of Albuquerque, Albuquerque, New Mexico
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque
| | - Eric Salazar
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan Waters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erica M Wood
- Department of Haematology, Monash Health, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
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12
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Pagano MB, Dennis JA, Idemudia OM, Stanworth SJ, Carson JL. An analysis of quality of life and functional outcomes as reported in randomized trials for red cell transfusions. Transfusion 2023; 63:2032-2039. [PMID: 37723866 DOI: 10.1111/trf.17540] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/21/2023] [Accepted: 08/15/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Meta-analyses of randomized controlled trials (RCTs) evaluating thresholds for red blood cell (RBC) transfusion typically focus on mortality; however, other outcomes are highly relevant. The aim of this study is to summarize the effects of different transfusion thresholds on the outcomes of quality of life (QoL) and function. STUDY DESIGN We extracted data from RCTs identified in a recently published Cochrane systematic review. Primary analysis was descriptive. RESULTS A total of 23 RCTs with 13,743 adult participants were included. Fifteen RCTs included patients in the postoperative period, of which 9 RCTs were conducted in hip (n = 3024) and 6 (n = 8672) in cardiac surgeries; 5 RCTs (n = 489) were in patients with hematological malignancies; 2 in the setting of bleeding (gastrointestinal bleed [n = 936] and postpartum [n = 521]); and one RCT (n = 936) included critically ill patients. QoL and function were reported using a variety of questionnaires and tools. The timing of assessments varied between trials. No clear clinical differences in QoL outcomes were identified in comparisons between restrictive and liberal transfusion thresholds. DISCUSSION There is no evidence that a liberal transfusion strategy improves QoL and functional outcomes. However, the substantial limitations of many included studies indicate the need for further well-designed and adequately powered trials.
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Affiliation(s)
- Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Osaumwense M Idemudia
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Simon J Stanworth
- NHS Blood and Transplant, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
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13
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Anastasiadis K, Antonitsis P, Murkin J, Serrick C, Gunaydin S, El-Essawi A, Bennett M, Erdoes G, Liebold A, Punjabi P, Theodoropoulos KC, Kiaii B, Wahba A, de Somer F, Bauer A, Kadner A, van Boven W, Argiriadou H, Deliopoulos A, Baker RΑ, Breitenbach I, Ince C, Starinieri P, Jenni H, Popov V, Moorjani N, Moscarelli M, Di Eusanio M, Cale A, Shapira O, Baufreton C, Condello I, Merkle F, Stehouwer M, Schmid C, Ranucci M, Angelini G, Carrel T. 2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery. Perfusion 2023; 38:1360-1383. [PMID: 35961654 DOI: 10.1177/02676591221119002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.
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Affiliation(s)
- Kyriakos Anastasiadis
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - John Murkin
- Department of Anesthesia and Perioperative Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Cyril Serrick
- Department of Perfusion, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Mark Bennett
- Department of Anesthesia, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andreas Liebold
- Department of Cardio-thoracic Surgery, University Hospital Ulm, Ulm, Germany
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Bob Kiaii
- Division of Cardiothoracic Surgery, UC Davis Health, Sacramento, CA, USA
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway and Department of Circulation and Medical Imaging, University of Science and Technology, Trondheim, Norway
| | - Filip de Somer
- Department of Cardiac Surgery, University Hospital Ghent, Ghent, Belgium
| | - Adrian Bauer
- Department of Cardiovascular Perfusion, MediClin Heart Center, Coswig, Saxony-Anhalt, Germany
| | - Alexander Kadner
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Switzerland
| | | | - Helena Argiriadou
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Apostolos Deliopoulos
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Greece
| | - Robert Α Baker
- Cardiothoracic Surgery Quality and Outcomes, and Perfusion, Flinders Medical Centre and Flinders University, Adelaide, South Australia, Australia
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Can Ince
- Department of Intensive Care, Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | | | - Hansjoerg Jenni
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, Switzerland
| | - Vadim Popov
- Department of Cardio-Vascular Surgery, Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | - Marco Moscarelli
- Cardiac Surgery, Anthea Hospital Gvm Care & Research, Bari, Italy
| | - Marco Di Eusanio
- Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Alex Cale
- Department of Cardiac Surgery, Hull and East Yorkshire Hospitals NHS Trust, UK
| | - Oz Shapira
- Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | | | - Ignazio Condello
- Cardiac Surgery, Anthea Hospital Gvm Care & Research, Bari, Italy
| | - Frank Merkle
- Academy for Perfusion, German Heart Institute Berlin, Berlin, Germany
| | - Marco Stehouwer
- Department of Clinical Perfusion, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Gianni Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, University of Bristol, Bristol, UK
| | - Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zürich, Zurich, Switzerland
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14
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Wool GD, Carll T. Viscoelastic testing: Critical appraisal of new methodologies and current literature. Int J Lab Hematol 2023; 45:643-658. [PMID: 37559473 DOI: 10.1111/ijlh.14144] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023]
Abstract
United States Food and Drug Administration (FDA)-approved viscoelastic testing (VET) methodologies have significantly changed in the last 10 years, with the availability of cartridge-based VET. Some of these cartridge-based methodologies use harmonic resonance-based clot detection. While VET has always allowed for the evaluation of real-time clot formation, cartridge-based VET provides increased ease of use as well as greater portability and robustness of results in out-of-laboratory environments. Here we review the use of VET in a variety of clinical contexts, including cardiac surgery, trauma, liver transplant, obstetrics, and hypercoagulable states such as COVID-19. As of now, high quality randomized trial evidence for new generation VET (TEG 6s, HemoSonics Quantra, ROTEM sigma) is limited. Nevertheless, the use of VET-guided transfusion algorithms appears to result in reduced blood usage without worsening of patient outcomes. Future work comparing the new generation VET instruments and continuing to validate clinically important cut-offs will help move the field of point-of-care coagulation monitoring forward and increase the quality of transfusion management in bleeding patients.
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Affiliation(s)
- Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Timothy Carll
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
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15
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Gkiouliava A, Argiriadou H, Antonitsis P, Goulas A, Papapostolou E, Sarridou D, Karapanagiotidis GT, Anastasiadis K. Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery on minimal invasive extracorporeal circulation; A prospective randomized study. Perfusion 2023:2676591231204284. [PMID: 37776194 DOI: 10.1177/02676591231204284] [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: 10/02/2023]
Abstract
INTRODUCTION Individualized heparin and protamine management is increasingly used as a strategy to reduce coagulation activation and bleeding complications. While it is associated with increased heparin requirements during Cardiopulmonary Bypass (CPB), the impact on protamine administration remains controversial. We aim to investigate the effect of heparin level-guided monitoring on protamine dosing during cardiac surgery where low-anticoagulation protocols are implemented. METHODS This is a prospective, randomized, controlled trial. A total of 132 patients undergoing elective full-spectrum cardiac surgery with Minimal Invasive Extracorporeal Circulation (MiECC) were recruited. All patients were managed by the same anaesthetic, surgical and perfusion team. Patients were randomly allocated in two groups; the individualized heparin-protamine titration (IHPT) group and the conventional heparinization and reversal group by using ACT (cACT) with a 0.75:1, protamine: heparin ratio. Titration was accomplished with the Hepcon HMS Plus (Medtronic, Minneapolis, MN) system. The primary outcome of the study was the total protamine dose used. Secondary outcomes comprised of the total heparin dose, the percentage of patients achieving target ACT, 24-h transfusion requirements, postoperative bleeding, duration of mechanical ventilation, major morbidity and length of hospital stay. Patients in each group were divided in two subgroups according to the target ACT; those operated for coronary artery bypass grafting (CABG) using a target ACT >300 s and the rest (non-CABG) patients operated with a target ACT >400 s, respectively. RESULTS Protamine requirements were significantly reduced when IHPT was implemented; CABG (118 ± 24 mg vs 163 ± 61 mg; p < 0.001) and non-CABG cases (151 ± 46 mg vs 197 ± 45 mg; p < 0.001). Moreover, heparin requirements were significantly higher in the non-CABG subgroup managed with IHPT (34,539 ± 7658 IU vs 29,893 ± 9037 IU; p = 0.02). In overall, no significant differences were detected with respect to postoperative bleeding, transfusion of RBC or other blood products. CONCLUSIONS Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery with MiECC implementing reduced anticoagulation strategy. TRIAL REGISTRATION clinicaltrials.gov; NCT04215588.
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Affiliation(s)
- Anna Gkiouliava
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Helena Argiriadou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Antonis Goulas
- First Laboratory of Pharmacology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Evangelia Papapostolou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Despoina Sarridou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Georgios T Karapanagiotidis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Kyriakos Anastasiadis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
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16
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Bolliger D, Tanaka KA, Steiner LA. Patient blood management programmes: keeping the ball rolling. Br J Anaesth 2023; 131:426-428. [PMID: 37394325 DOI: 10.1016/j.bja.2023.06.031] [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: 05/02/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 07/04/2023] Open
Abstract
Patient blood management programmes have been endorsed by the World Health Organization and multiple medical societies. It seems important to review the progress and results of patient blood management programmes so necessary modifications or new initiatives can be added to achieve their major goals. In this issue of the British Journal of Anaesthesia, Meybohm and colleagues show that a nationwide patient blood management programme had an impact and was potentially cost-effective in centres that previously utilised large amounts of allogeneic blood transfusions. Before implementing a programme, each institution might need to identify the area(s) of deficiency with respect to established patient blood management methods, which will warrant specific focus in subsequent clinical practice reviews.
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Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Luzius A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
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17
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Tibi P, Thompson J, Attaran S, Black E. Retrospective study assessing outcomes in cardiac surgery after implementation of Quantra. J Cardiothorac Surg 2023; 18:149. [PMID: 37069685 PMCID: PMC10109219 DOI: 10.1186/s13019-023-02245-x] [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: 08/26/2022] [Accepted: 04/02/2023] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND The Quantra QPlus System is a cartridge-based device with a unique ultrasound technology that can measure the viscoelastic properties of whole blood during coagulation. These viscoelastic properties correlate directly with hemostatic function. The primary objective of this study was to assess blood product utilization in cardiac surgery patients before and after the implementation of the Quantra QPlus System. METHODS Yavapai Regional Medical Center implemented the Quantra QPlus System to aid in their efforts to reduce the transfusion of allogenic blood products and improve outcomes in patients undergoing cardiac surgery. A total of 64 patients were enrolled prior to the utilization of the Quantra (pre-Quantra cohort), and 64 patients were enrolled after (post-Quantra cohort). The pre-Quantra cohort had been managed via standard laboratory assays along with physician discretion for transfusion decisions. The utilization of blood products and frequency of transfusions were compared and analyzed between the two cohorts. (using the Student's t-test) RESULTS: The implementation of the Quantra resulted in a change in the pattern of blood product utilization leading to a demonstrated decrease in the amount of blood products transfused and the associated costs. The amount of FFP transfused was significantly decreased by 97% (P = 0.0004), whereas cryoprecipitate decreased by 67% (P = 0.3134), platelets decreased by 26% (P = 0.4879), and packed red blood cells decreased by 10% (P = 0.8027) however these trends did not reach statistical significance. The acquisition cost of blood products decreased by 41% for total savings of roughly $40,682. CONCLUSIONS Use of the Quantra QPlus System has the potential to improve patient blood management and decrease costs. STUDY REGISTERED AT CLINICALTRIALS.GOV: NCT05501730.
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Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA.
| | - Jess Thompson
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA
| | - Saina Attaran
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA
| | - Elizabeth Black
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, 811 Ainsworth Drive, Suite 109, Prescott, AZ, 86301, USA
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Sanfilippo S, Buisson L, Rouabehi H, Dujaric ME, Donnet T, de Raucourt E, Dumont B, Peynaud-Debayle E. The qLabs® FIB system, a novel point-of-care technology for a rapid and accurate quantification of functional fibrinogen concentration from a single drop of citrated whole blood. Thromb Res 2023; 226:159-164. [PMID: 37178638 DOI: 10.1016/j.thromres.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/13/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
Hypofibrinogenemia is often associated with excessive bleeding and requires immediate treatment. The qLabs FIB® is a handheld and easy-to-use point-of-care (POC) device designed for the rapid measurement of functional fibrinogen concentration from a single drop of citrated whole blood. The aim of this study was to evaluate the analytical performances of the qLabs FIB system. Fibrinogen concentrations from 110 citrated whole blood specimen were measured by both the qLabs FIB and the Clauss laboratory reference methods (STA®-Liquid Fib assay on STA-R® Max from Stago). A three-laboratories comparison study was conducted to assess reproducibility and repeatability of the qLabs FIB using plasma quality control material. In addition, single-site assays were conducted to assess the repeatability from citrated whole blood specimen covering the qLabs FIB reportable range. A very strong correlation between the qLabs FIB and the Clauss laboratory reference method was observed (r = 0.95). Using a clinical cut-off value of 2.0 g/L, the area under the receiver operating characteristic curve (ROC) of citrated whole blood was 0.99 and sensibility and specificity were 100 % and 93.5 %, respectively. Percent CVs for reproducibility and repeatability assessed from quality control material, were both <5 %. Repeatability assessed from citrated whole blood specimen showed a CV of 2.6 to 6.5 %. In conclusion, the qLabs FIB system enables a rapid and reliable measurement of functional fibrinogen levels from citrated whole blood and exhibits a strong prediction power at the 2 g/L clinical cut-off when compared to the Clauss laboratory reference. Further clinical studies should demonstrate its ability to quickly confirm the diagnosis of acquired hypofibrinogenemia and help identify patients who may benefit from targeted hemostatic treatment.
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Kloeser R, Buser A, Bolliger D. Treatment Strategies in Anemic Patients Before Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:266-275. [PMID: 36328926 DOI: 10.1053/j.jvca.2022.09.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 01/14/2023]
Abstract
Both preoperative anemia and the transfusion of red blood cells have been associated with increased morbidity and mortality after cardiac surgery. To reduce the need for blood transfusion during surgery and improve patient outcomes, patient blood management programs have been developed. A primary focus of patient blood management in the preoperative period is the identification, diagnosis, and treatment of preoperative anemia, as anemia is associated with an increased risk of preoperative blood transfusion. In this narrative review, the authors focus on the laboratory screening of anemia before surgery and the evidence and limitations of different treatment strategies in anemic patients scheduled for cardiac surgery. To accurately correct preoperative anemia, the timely detection and definition of the etiology of anemia before elective cardiac surgery are crucial. Multiple randomized studies have been performed using preoperative iron supplementation and/or administration of erythropoiesis-stimulating agents in patients undergoing cardiac surgery. Although preoperative iron substitution in patients with iron deficiency is recommended, the evidence of its effectiveness is limited. In patients with nonpure iron deficiency anemia, combined therapy with erythropoiesis-stimulating agents and intravenous iron is recommended. Combined therapy might effectively reduce the need for red blood cell transfusion, even if applied shortly before cardiac surgery. The therapeutic effect on morbidity and mortality remains unclear. Nonetheless, the timely preoperative assessment of anemia and determination of iron status, eventually leading to targeted therapy, should become a standard of care and might potentially improve patient outcomes.
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Affiliation(s)
- Raphael Kloeser
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Andreas Buser
- Regional Blood Transfusion Service, Swiss Red Cross, Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland.
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Tanaka KA, Alejo D, Ghoreishi M, Salenger R, Fonner C, Ad N, Whitman G, Taylor BS, Mazzeffi MA. Impact of Preoperative Hematocrit, Body Mass Index, and Red Cell Mass on Allogeneic Blood Product Usage in Adult Cardiac Surgical Patients: Report From a Statewide Quality Initiative. J Cardiothorac Vasc Anesth 2023; 37:214-220. [PMID: 35644751 DOI: 10.1053/j.jvca.2022.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/22/2022] [Accepted: 03/30/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The study aims were to evaluate current blood transfusion practice in cardiac surgical patients and to explore associations between preoperative anemia, body mass index (BMI), red blood cell (RBC) mass, and allogeneic transfusion. DESIGN Multicenter retrospective study. SETTING Academic and non-academic centers. PARTICIPANTS AND INTERVENTIONS After Institutional Review Board approval, 26,499 patients who underwent coronary artery bypass grafting ± valve replacement/repair between 2011 and 2019 were included from the Maryland Cardiac Surgery Quality Initiative database. Patients were stratified into BMI categories (<25, 25 to <30, and ≥30 kg/m2), and a multivariable logistic regression model was fit to determine if preoperative hematocrit, BMI, and RBC mass were associated independently with allogeneic transfusion. RESULTS Preoperative anemia was found in 55.4%, and any transfusion was administered to 49.3% of the entire cohort. Females and older patients had lower BMI and RBC mass. Increased RBC and cryoprecipitate transfusions occurred more frequently after surgery in the lower BMI group. After adjustments, increased transfusion was associated with a BMI <25 relative to a BMI ≥30 at an odds ratio (OR) of 1.26 (95% confidence interval [CI]: 1.08-1.39). For each 1% increase in preoperative hematocrit, transfusion was decreased by 9% (OR: 0.91; 95% CI: 0.90-0.92). For every 500 mL increase in RBC mass, there was a 43% reduction of transfusion (OR: 0.57; 95% CI: 0.55-0.58). CONCLUSIONS Transfusion probability modeling based on calculated RBC mass eliminated sex differences in transfusion risk based on preoperative hematocrit, and may better delineate which patients may benefit from more rigorous perioperative blood conservation strategy.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
| | - Diane Alejo
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mehrdad Ghoreishi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rawn Salenger
- Department of Cardiothoracic Surgery, St. Joseph Medical Center, University of Maryland, Towson, MD
| | | | - Niv Ad
- Department of Cardiothoracic Surgery, Adventist Healthcare, Silver Spring, MD
| | - Glenn Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bradley S Taylor
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A Mazzeffi
- George Washington University School of Medicine and Health Sciences, Washington, D.C
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21
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Taneja R, Szoke DJ, Hynes Z, Jones PM. Minimum protamine dose required to neutralize heparin in cardiac surgery: a single-centre, prospective, observational cohort study. Can J Anaesth 2023; 70:219-227. [PMID: 36471142 DOI: 10.1007/s12630-022-02364-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 08/10/2022] [Accepted: 08/12/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Excess protamine contributes to coagulopathy following cardiopulmonary bypass (CPB) and may increase blood loss and transfusion requirements. The primary aim of this study was to find the least amount of protamine necessary to neutralize residual heparin following CPB using the gold standard assays of anti-IIa and anti-Xa activity. Secondary objectives were to evaluate whether the post-CPB activated clotting time could be used as a surrogate marker for quantifying heparin neutralization. METHODS Twenty-eight consecutive patients undergoing elective cardiac surgery were enrolled. Protamine administration was standardized through an infusion pump at 25 mg·min-1. Blood samples were withdrawn prior to and following administration of 150, 200, 250, and 300 mg protamine and analyzed for activated clotting time and anti-IIa and -Xa activity. RESULTS Following a mean (standard deviation) cumulative heparin dose of 67,700 (19,400) units and a CPB duration of 113 (71) min, protamine requirements varied widely. Eight out of 25 (32%) patients showed complete neutralization of anti-IIa and -Xa activity at the first sampling point (150 mg protamine; protamine:heparin ratio, 0.3 [0.1]). A protamine:heparin ratio of 0.5 (0.2) was sufficient for heparin neutralization in > 90% of patients. After CPB, a low to mid-range activated clotting time correlated well with anti-IIa and -Xa activity. CONCLUSIONS The protamine:heparin ratio required to neutralize residual unfractionated heparin (UFH) following CPB is variable. A protamine:heparin ratio of 0.3 was sufficient to neutralize UFH in some patients, while a ratio of 0.5 is sufficient to neutralize both residual anti-IIa and -Xa activity in most patients. Larger studies are necessary to confirm these findings and evaluate their clinical implications. STUDY REGISTRATION ClinicalTrials.gov (NCT03787641); registered 26 December 2018.
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Affiliation(s)
- Ravi Taneja
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada.
- Division of Critical Care, Department of Medicine, London Health Sciences Centre, University Hospital, B2-223, 339 Windermere Road, London, ON, N6A 5A5, Canada.
| | - Daniel J Szoke
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Zachary Hynes
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
| | - Philip M Jones
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre, London, ON, Canada
- Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada
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22
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Volod O, Viola F. The Quantra System: System Description and Protocols for Measurements. Methods Mol Biol 2023; 2663:743-761. [PMID: 37204750 DOI: 10.1007/978-1-0716-3175-1_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Over the past two decades, the TEG 5000 (Haemonetics Corp, Braintree, MA) and ROTEM delta (Werfen, Bedford, MA) have been the principal viscoelastic (VET) technologies. These legacy technologies are based on the "cup and pin" principle. The Quantra System (HemoSonics, LLC, Durham, NC) is a new device that assesses blood viscoelastic properties by ultrasound (SEER Sonorheometry). It is cartridge based, automated device that provides simplified specimen management and increased results reproducibility. In the present chapter, we provide a description of the Quantra and its principle of operation, currently available cartridges/assays with their respective clinical indications, device operation, and results interpretation.
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Affiliation(s)
- Oksana Volod
- Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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23
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Hayes K, Fernando MC, Jordan V. Prothrombin complex concentrate in cardiac surgery for the treatment of coagulopathic bleeding. Cochrane Database Syst Rev 2022; 11:CD013551. [PMID: 36408876 PMCID: PMC9677522 DOI: 10.1002/14651858.cd013551.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Coagulopathy following cardiac surgery is associated with considerable blood product transfusion and high morbidity and mortality. The treatment of coagulopathy following cardiac surgery is challenging, with the replacement of clotting factors being based on transfusion of fresh frozen plasma (FFP). Prothrombin complex concentrate (PCCs) is an alternative method to replace clotting factors and warrants evaluation. PCCs are also an alternative method to treat refractory ongoing bleeding post-cardiac surgery compared to recombinant factor VIIa (rFVIIa) and also warrants evaluation. OBJECTIVES: Assess the benefits and harms of PCCs in people undergoing cardiac surgery who have coagulopathic non-surgical bleeding. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science on 20 April 2021. We searched Clinicaltrials.gov (www. CLINICALTRIALS gov), and the World Health Organisation (WHO) International Clinical Trials Registry Platform (ICTRP; apps.who.int/trialsearch/), for ongoing or unpublished trials. We checked the reference lists for additional references. We did not limit the searches by language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised trials (NRSs). DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: Eighteen studies were included (4993 participants). Two were RCTs (151 participants) and 16 were NRSs. Both RCTs had low risk of bias (RoB) in almost all domains. Of the 16 NRSs, 14 were retrospective cohort analyses with one prospective study and one case report. The nine studies used in quantitative analysis were judged to have critical RoB, three serious and three moderate. 1. PCC versus standard treatment Evidence from RCTs showed PCCs are likely to reduce the number of units transfused compared to standard care (MD -0.89, 95% CI -1.78 to 0.00; participants = 151; studies = 2; moderate-quality evidence). Evidence from NRSs agreed with this, showing that PCCs may reduce the mean number of units transfused compared to standard care but the evidence is uncertain (MD -1.87 units, 95% CI -2.53 to -1.20; participants = 551; studies = 2; very low-quality evidence). There was no evidence from RCTs showing a difference in the incidence of red blood cell (RBC) transfusion compared to standard care (OR 0.53, 95% CI 0.20 to 1.40; participants = 101; studies = 1; low-quality evidence). Evidence from NRSs disagreed with this, showing that PCCs may reduce the mean number of units transfused compared to standard care but the evidence is uncertain (OR 0.54, 95% CI 0.30 to 0.98; participants = 1046; studies = 4; low-quality evidence). There was no evidence from RCTs showing a difference in the number of thrombotic events with PCC compared to standard care (OR 0.68 95% CI 0.20 to 2.31; participants = 152; studies = 2; moderate-quality evidence). This is supported by NRSs, showing that PCCs may have no effect on the number of thrombotic events compared to standard care but the evidence is very uncertain (OR 1.32, 95% CI 0.87 to 1.99; participants = 1359; studies = 7; very low-quality evidence). There was no evidence from RCTs showing a difference in mortality with PCC compared to standard care (OR 0.53, 95% CI 0.12 to 2.35; participants = 149; studies = 2; moderate-quality evidence). This is supported by evidence from NRSs, showing that PCCs may have little to no effect on mortality compared to standard care but the evidence is very uncertain (OR 1.02, 95% CI 0.69 to 1.51; participants = 1334; studies = 6; very low-quality evidence). Evidence from RCTs indicated that there was little to no difference in postoperative bleeding (MD -107.05 mLs, 95% CI -278.92 to 64.83; participants = 151, studies = 2; low-quality evidence). PCCs may have little to no effect on intensive care length of stay (RCT evidence: MD -0.35 hours, 95% CI -19.26 to 18.57; participants = 151; studies = 2; moderate-quality evidence) (NRS evidence: MD -18.00, 95% CI -43.14 to 7.14; participants = 225; studies = 1; very low-quality evidence) or incidence of renal replacement therapy (RCT evidence: OR 0.72, 95% CI 0.14 to 3.59; participants = 50; studies = 1; low-quality evidence) (NRS evidence: OR 1.46, 95% CI 0.71 to 2.98; participants = 684; studies = 2; very low-quality evidence). No studies reported on additional adverse outcomes. 2. PCC versus rFVIIa For this comparison, all evidence was provided from NRSs. PCC likely results in a large reduction of RBCs transfused intra-operatively in comparison to rFVIIa (MD-4.98 units, 95% CI -6.37 to -3.59; participants = 256; studies = 2; moderate-quality evidence). PCC may have little to no effect on the incidence of RBC units transfused comparative to rFVIIa; evidence is very uncertain (OR 0.16, 95% CI 0.02 to 1.56; participants = 150; studies = 1; very low-quality evidence). PCC may have little to no effect on the number of thrombotic events comparative to rFVIIa; evidence is very uncertain (OR 0.51, 95% CI 0.23 to 1.16; participants = 407; studies = 4; very low-quality evidence). PCC may have little to no effect on the incidence of mortality (OR 1.07, 95% CI 0.38 to 3.03; participants = 278; studies = 3; very low-quality evidence) or intensive care length of stay comparative to rFVIIa (MD -40 hours, 95% CI -110.41 to 30.41; participants = 106; studies = 1; very low-quality evidence); evidence is very uncertain . PCC may reduce bleeding (MD -674.34 mLs, 95% CI -906.04 to -442.64; participants = 150; studies = 1; very low-quality evidence) and incidence of renal replacement therapy (OR 0.29, 95% CI 0.12 to 0.71; participants = 106; studies = 1; very low-quality evidence) comparative to rFVIIa; evidence is very uncertain. No studies reported on other adverse events. AUTHORS' CONCLUSIONS: PCCs could potentially be used as an alternative to standard therapy for coagulopathic bleeding post-cardiac surgery compared to FFP as shown by moderate-quality evidence and it may be an alternative to rFVIIa in refractory non-surgical bleeding but this is based on moderate to very low quality of evidence.
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Affiliation(s)
- Katia Hayes
- Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Malindra C Fernando
- Department of Cardiothoracic and ORL Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Vanessa Jordan
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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24
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Platelet Transfusion and In-Hospital Mortality in Veno-Arterial Extracorporeal Membrane Oxygenation Patients. ASAIO J 2022; 68:1249-1255. [PMID: 34967786 DOI: 10.1097/mat.0000000000001643] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Thrombocytopenia is common during extracorporeal membrane oxygenation (ECMO), and platelets are sometimes transfused to meet arbitrary goals. We performed a retrospective cohort study of veno-arterial (VA) ECMO patients from a single academic medical center and explored the relationship between platelet transfusion and in-hospital mortality using multivariable logistic regression. One hundred eighty-eight VA ECMO patients were included in the study. Ninety-one patients (48.4%) were transfused platelets during ECMO. Patients who received platelet transfusion had more coronary artery disease, lower platelet counts at cannulation, higher predicted mortality, lower nadir platelet counts, more ECMO days, and more red blood cell (RBC) and plasma transfusion. Mortality was 19.6% for patients who received no platelets, 40.8% for patients who received 1-3 platelets, and 78.6% for patients who received 4 or more platelets ( P < 0.001). After controlling for confounding variables including baseline severity of illness, central cannulation, postcardiotomy status, RBC and plasma transfusion, major bleeding, and total ECMO days, transfusion of 4 or more platelets remained associated with in-hospital mortality; OR = 4.68 (95% CI = 1.18-27.28), P = 0.03. Our findings highlight the need for randomized controlled trials that compare different platelet transfusion triggers, so that providers can better understand when platelet transfusion is indicated in VA ECMO patients.
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25
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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26
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Li H, Bartoszko J, Serrick C, Rao V, Karkouti K. Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial. Can J Anaesth 2022; 69:1117-1128. [PMID: 35799088 DOI: 10.1007/s12630-022-02278-1] [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: 06/20/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management. METHODS We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort. RESULTS A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did. CONCLUSIONS The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT03347201); first submitted 12 October 2017.
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Affiliation(s)
- Han Li
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - 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
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Cardiovascular Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, 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
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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27
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Irabor BE, Kothari A, Hong J, Burnette-Chiang B, Kent D, Duhamel T, Arora RC. Use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery: a scoping review protocol. BMJ Open 2022; 12:e064098. [PMID: 36002220 PMCID: PMC9413285 DOI: 10.1136/bmjopen-2022-064098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION A major complication of cardiac surgery is bleeding which can require surgical re-exploration and the transfusion of allogeneic blood products. Re-operative procedures for bleeding have been associated with higher rates of mortality and morbidity, therefore an intervention to reduce this complication would be important. Previous investigation has demonstrated that low-cost solutions, such as the use of an intraoperative haemostatic checklist may result in the reduction of bleeding and subsequent transfusion. The goals of this scoping review aim to assess the efficacy of the use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery. Specifically, the objective is to understand if the use of intraoperative haemostatic checklists has been associated with a reduction in bleeding and blood product utilisation in patients undergoing non-emergent cardiac surgery. METHODS AND ANALYSIS A scoping review of literature identifying randomised control and observational trials, reporting on haemostatic checklists in cardiac surgery, will be undertaken. The proposed review will be guided by the methodological framework proposed by Arksey and O'Malley. A search will be conducted for published and unpublished (grey) literature. Published literature will be searched in the following electronic databases: Scopus, MEDLINE, EMBASE and the Cochrane Library. Relevant grey literature will be identified through conference abstracts. Outcomes chosen are patient centred to ensure reduced bleeding and overall positive experience that reduces complications intraoperatively. ETHICS AND DISSEMINATION This study does not require ethical approval as the data used are from available publications. Our dissemination strategy includes peer-review publication, presentation at conferences and relevant stakeholders.
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Affiliation(s)
| | - Asha Kothari
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jonathan Hong
- Department of Cardiac Surgery, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | | | - David Kent
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Todd Duhamel
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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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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29
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Malleeswaran S, Sivajothi S, Reddy MS. Viscoelastic Monitoring in Liver Transplantation. Liver Transpl 2022; 28:1090-1102. [PMID: 34724319 DOI: 10.1002/lt.26352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022]
Abstract
Cirrhosis and liver transplantation (LT) surgery are associated with substantial alterations to the patient's coagulation status. Accurate monitoring of these changes during LT can help manage bleeding proactively and potentially reduce transfusion requirements. Unlike conventional coagulation tests (CCTs), viscoelastic monitoring (VEM) can provide an accurate, real-time, point-of-care assessment of coagulation status during LT and hence has become an invaluable tool for anesthetists and intensive care physicians. However, it remains an enigmatic subject for transplantation surgeons who are more conversant with CCTs. This review discusses the principles of VEM, provides a primer to understanding and interpreting its output, and explains how it can be used to make real-world clinical decisions during LT.
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Affiliation(s)
- Selvakumar Malleeswaran
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Sivanesan Sivajothi
- Department of Liver Anesthesia and Critical Care, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
| | - Mettu Srinivas Reddy
- Department of Hepatobiliary Surgery and Liver Transplantation, Institute of Liver Diseases and Transplantation, Gleneagles Global Health City, Chennai, India
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Khoury W, Servito M, Wang L, Baranchuk A, Callum J, Payne D, El-Diasty M. The use of FEIBA for refractory bleeding in cardiac surgery - a systematic review. Expert Rev Cardiovasc Ther 2022; 20:403-408. [PMID: 35514246 DOI: 10.1080/14779072.2022.2074838] [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] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Significant blood loss during cardiac surgery is associated with a significant increase in morbidity and mortality. Factor Eight Inhibitor Bypassing Activity (FEIBA), a hemostatic bypassing agent mainly used in hemophiliac patients, has also been used for intractable surgical bleeding during cardiac surgical procedures in non-hemophiliac patients. However, concerns exist that its use may be linked to increased incidence of perioperative adverse effects including thrombotic complications. AREAS COVERED A systematic literature search was performed on MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for all studies that reported the administration of FEIBA for treatment of bleeding during adult cardiac surgery in non-hemophiliac patients. After selecting of title and abstracts, two authors assessed the methodological quality of the full-text articles prior to final inclusion in the manuscript. EXPERT OPINION The safety profile of FEIBA was determined through an aggregate count of adverse events. Major complications included renal failure, re-operation for unresolved bleeding, postoperative mortality, and thromboembolic events. Overall, there is insufficient robust evidence to make a definitive conclusion about the safety or efficacy of using of FEIBA as a hemostatic agent in the setting of cardiac surgery.
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Affiliation(s)
- William Khoury
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Maria Servito
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Louie Wang
- Department of Anesthesiology, Queen's University, Kingston, ON, Canada
| | - Adrian Baranchuk
- Division of Cardiology, Queen's University, Kingston, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Queen's University, Kingston, ON, Canada
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31
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Vandenheuvel M, VAN Gompel C, Vandewiele K, DE Kesel PM, Wyffels P, DE Somer F, Devreese KM, Wouters PF. Comparison of coagulation monitoring using ROTEM and Sonoclot devices in cardiac surgery. A single-centre prospective observational study. Minerva Anestesiol 2022; 88:680-689. [PMID: 35315620 DOI: 10.23736/s0375-9393.22.16119-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Viscoelastic tests (VETs) are recommended during cardiac surgery to monitor coagulation status and guide transfusion. We compared the results of two VETs, the Sonoclot Analyzer and the ROTEM Sigma. Agreement between viscoelastic tests' subdiagnoses and overall diagnosis severity was assessed. Correlations with conventional coagulation tests (CCT) and the discriminatory potential of numerical VET outputs for transfusion thresholds was determined. METHODS Single-centre, prospective observational study in a tertiary academic centre. In fifty adult patients undergoing elective cardiac surgery, parallel Sonoclot, ROTEM and CCT analysis was performed before heparin, or after protamine or coagulation product administration. All patients completed the study, resulting in 139 data points. RESULTS Agreement on the severity of coagulation disorders was acceptable (83%), but poor (27%) on the differentiation of the underlying causes. Correlations between ROTEM parameters and CCT were good (post-protamine: FIBTEM A5 (r2 = 0.90 vs fibrinogen) and EXTEM-FIBTEM A5 difference (r2 = 0.81 vs platelet count) ). Sonoclot correlated less (Clot Rate (r2 = 0.25 vs fibrinogen) and Platelet Function (r2 = 0.43 vs platelet count)). This was reflected in the discriminatory potential of these parameters as found by linear mixed modelling. We suggest clinically useful grey zones for VET cutoff interpretation. CONCLUSIONS ROTEM and Sonoclot accord well on the detection of severity of coagulation dysfunction, but not on the diagnosis of the underlying cause. ROTEM correlated more closely with CCT then Sonoclot. We propose a testing strategy that could lead to a cost-effective approach to the bleeding cardiac surgery patient.
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Affiliation(s)
| | - Carla VAN Gompel
- Department of Anaesthesia, University Hospital Ghent, Ghent, Belgium
| | | | - Pieter M DE Kesel
- Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium
| | - Piet Wyffels
- Department of Anaesthesia, University Hospital Ghent, Ghent, Belgium
| | - Filip DE Somer
- Department of Perfusion, University Hospital Ghent, Ghent, Belgium
| | - Katrien M Devreese
- Department of Laboratory Medicine, University Hospital Ghent, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Patrick F Wouters
- Department of Anaesthesia, University Hospital Ghent, Ghent, Belgium
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Abstract
Mechanical properties have been extensively studied in pure elastic or viscous materials; however, most biomaterials possess both physical properties in a viscoelastic component. How the biomechanics of a fibrin clot is related to its composition and the microenvironment where it is formed is not yet fully understood. This review gives an outline of the building mechanisms for blood clot mechanical properties and how they relate to clot function. The formation of a blood clot in health conditions or the formation of a dangerous thrombus go beyond the mere polymerization of fibrinogen into a fibrin network. The complex composition and localization of in vivo fibrin clots demonstrate the interplay between fibrin and/or fibrinogen and blood cells. Studying these protein–cell interactions and clot mechanical properties may represent new methods for the evaluation of cardiovascular diseases (the leading cause of death worldwide), creating new possibilities for clinical diagnosis, prognosis, and therapy. Expected final online publication date for the Annual Review of Biophysics, Volume 51 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Marco M. Domingues
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Filomena A. Carvalho
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Nuno C. Santos
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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Nath S, Pandey C, Kumar S. Clinical application of viscoelastic point-of-care tests of coagulation-shifting paradigms. Ann Card Anaesth 2022; 25:1-10. [PMID: 35075014 PMCID: PMC8865353 DOI: 10.4103/aca.aca_319_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Bleeding during cardiac surgery, liver transplant, trauma and post partum hemorrhage are often multifactorial and these factors are dynamic as new factors crop up during the course of management. Conventional tests of coagulation offer information of a part of the coagulation system and also is time consuming. Viscoelastic point of care tests (VE POCTs) like rotational thromboelastometry, thromboelastogram and Sonoclot, are based on analysis of the viscoelastic properties of clotting blood and provide information for the entire coagulation pathway. In this comprehensive review being presented here, we have examined the pros and cons of VE POCTs including clinical, cost and survival benefits. The recommendations of the various guidelines regarding use of VE POCTs in various scenarios have been discussed. The review also tried to offer suggestions as to their optimal role in management of bleeding during cardiac surgeries, extracorporeal membrane oxygenation, left ventricular assist devices, liver transplant and briefly in trauma and postpartum hemorrhage.
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34
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Hill SE, Nonaka DF. Perioperative Management of Bleeding and Transfusion. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00027-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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35
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Peña Borras JJ, Pajares Moncho A, Puig J, Mateo Rodríguez E, López Forte C, Peña Pérez L, Moreno Pachón J, Gabaldón Conejos T, Pérez Artacho J, Ferrer Gómez C, Férez Martí A, López Cantero M, de Andrés Ibáñez J. Tranexamic acid in cardiac surgery: Are low doses enough? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:576-583. [PMID: 34857506 DOI: 10.1016/j.redare.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 02/09/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.
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Affiliation(s)
- J J Peña Borras
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Pajares Moncho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J Puig
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, Spain.
| | - E Mateo Rodríguez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - C López Forte
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - L Peña Pérez
- Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J Moreno Pachón
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - T Gabaldón Conejos
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - J Pérez Artacho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - C Ferrer Gómez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - A Férez Martí
- Servicio de Análisis Clínicos, Hospital General Universitario de Valencia, Valencia, Spain
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - J de Andrés Ibáñez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, Spain; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, Spain
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36
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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37
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Salenger R, Mazzeffi MA. The 7 Pillars of Blood Conservation in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 16:504-509. [PMID: 34821153 DOI: 10.1177/15569845211051683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Rawn Salenger
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Saint Joseph Medical Center, Towson, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, 43989George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Michael A Mazzeffi
- Division of Cardiac Surgery, 12264University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Saint Joseph Medical Center, Towson, MD, USA.,Departments of Anesthesiology and Critical Care Medicine, 43989George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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38
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Abstract
Red blood cell (RBC) transfusions are necessary to increase a patient's oxygen carrying capacity. The optimal transfusion trigger remains elusive, but a restrictive transfusion trigger of 7 g/dL has been shown in studies to reduce RBC transfusions without adversely affecting patient outcomes. Patient blood management programs have been shown effective at reducing RBC transfusions. Hemoglobin-based oxygen carriers and induced pluripotent stem cell derived RBCs are being developed to help mitigate RBC shortages and RBC transfusion limitations. Numerous challenges still exist that need to be overcome before they can have widespread clinical use.
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Affiliation(s)
- Yvette C Tanhehco
- Division of Transfusion Medicine, Department of Pathology and Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, Harkness Pavilion 4-418A, New York, NY 10032, USA. https://twitter.com/YTanhehcoPhDMD
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39
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Arjmand B, Khodadoost M, Jahani Sherafat S, Rezaei Tavirani M, Ahmadi N, Okhovatian F, Rezaei Tavirani M. Low-Level Laser Therapy Effects on Rat Blood Hemostasis Via Significant Alteration in Fibrinogen and Plasminogen Expression Level. J Lasers Med Sci 2021; 12:e59. [PMID: 35155144 PMCID: PMC8837859 DOI: 10.34172/jlms.2021.59] [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] [Received: 05/17/2021] [Accepted: 07/03/2021] [Indexed: 01/20/2024]
Abstract
Introduction: There are many documents about the significant role of low-level laser therapy (LLLT) in different processes such as regenerator medicine and bone formation. The aim of this study is to assess the role of LLLT in blood hemostasis in rats via bioinformatic investigation. Methods: The differentially expressed plasma proteins of treated rats via LLLT from the literature and the added 50 first neighbors were investigated via network analysis to find the critical dysregulated proteins and biological processes by using Cytoscape software, the STRING database, and ClueGO. Results: A scale-free network including 55 nodes was constructed from queried and added first neighbor proteins. Fibrinogen gamma, fibrinogen alpha, and plasminogen were highlighted as the central genes of the analyzed network. Fibrinolysis was determined as the main group of biological processes that were affected by LLLT. Conclusion: Findings indicate that LLLT affects blood hemostasis which is an important point in approving the therapeutic application of LLLT and also in preventing its possible complication.
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Affiliation(s)
- Babak Arjmand
- Cell Therapy and Regenerative Medicine Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahmood Khodadoost
- School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Somayeh Jahani Sherafat
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mostafa Rezaei Tavirani
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nayebali Ahmadi
- Proteomics Research Center, Faculty of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farshad Okhovatian
- Physiotherapy Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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40
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Peña Borras JJ, Pajares Moncho A, Puig J, Mateo Rodríguez E, López Forte C, Peña Pérez L, Moreno Pachón J, Gabaldón Conejos T, Pérez Artacho J, Ferrer Gómez C, Férez Martí A, López Cantero M, de Andrés Ibáñez J. Tranexamic acid in cardiac surgery: Are low doses enough? REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:S0034-9356(21)00105-5. [PMID: 34538453 DOI: 10.1016/j.redar.2021.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/04/2020] [Accepted: 02/09/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia. MATERIALS AND METHODS A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID. RESULTS There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P=.014) and ID (P=.040) but more fresh frozen plasma than group ID (P=.0002). CONCLUSIONS Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.
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Affiliation(s)
- J J Peña Borras
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Pajares Moncho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J Puig
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España.
| | - E Mateo Rodríguez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - C López Forte
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - L Peña Pérez
- Centre for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Suecia
| | - J Moreno Pachón
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón Conejos
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - J Pérez Artacho
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - C Ferrer Gómez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - A Férez Martí
- Servicio de Análisis Clínicos, Hospital General Universitario de Valencia, Valencia, España
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - J de Andrés Ibáñez
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España; Departamento de Cirugía, Facultad de Medicina y Odontología, Universidad de Valencia, Valencia, España
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41
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Cohen T, Haas T, Cushing MM. The strengths and weaknesses of viscoelastic testing compared to traditional coagulation testing. Transfusion 2021; 60 Suppl 6:S21-S28. [PMID: 33089934 DOI: 10.1111/trf.16073] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 06/05/2020] [Indexed: 12/25/2022]
Abstract
Optimized acute bleeding management requires timely and reliable laboratory testing to detect and diagnose coagulopathies and guide transfusion therapy. Conventional coagulation tests (CCT) are inexpensive with minimal labor requirements, but CCTs may have delayed turnaround times. In addition, abnormal CCT values may not reflect in vivo coagulopathies that require treatment and may lead to overtransfusion. The use of viscoelastic testing (VET) has been rapidly expanding and is recommended by several recent bleeding guidelines. This review is intended to compare CCT to VET, review the strengths and weaknesses of both approaches, and evaluate and summarize the clinical studies that compared CCT-based and VET-based transfusion algorithms. Most studies of CCT vs VET transfusion algorithms favor the use of VET in the management of massively bleeding patients due to reductions in blood product utilization, bleeding, costs, and lengths of stay.
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Affiliation(s)
- Tobias Cohen
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Transfusion Medicine, NewYork-Presbyterian Hospital-Weill Cornell, New York, New York, USA
| | - Thorsten Haas
- Department of Anesthesiology, University Children's Hospital, Zurich, Switzerland
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA.,Department of Transfusion Medicine, NewYork-Presbyterian Hospital-Weill Cornell, New York, New York, USA
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42
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Tantry US, Hartmann J, Neal MD, Schöechl H, Bliden KP, Agarwal S, Mason D, Dias JD, Mahla E, Gurbel PA. The role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. Platelets 2021; 33:520-530. [PMID: 34369848 DOI: 10.1080/09537104.2021.1961709] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We carried out a literature search in MEDLINE (PubMed) and EMBASE literature databases to provide a concise review of the role of viscoelastic testing in assessing peri-interventional platelet function and coagulation. The search identified 130 articles that were relevant for the review, covering the basic science of VHA and VHA in clinical settings including cardiac surgery, cardiology, neurology, trauma, non-cardiac surgery, obstetrics, liver disease, and COVID-19. Evidence from these articles is used to describe the important role of VHAs and platelet function testing in various peri-interventional setups. VHAs can help us to comprehensively assess the contribution of platelets and coagulation dynamics to clotting at the site-of-care much faster than standard laboratory measures. In addition to standard coagulation tests, VHAs are beneficial in reducing allogeneic transfusion requirements and bleeding, in predicting ischemic events, and improving outcomes in several peri-interventional care settings. Further focused studies are needed to confirm their utility in the peri-interventional case.
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Affiliation(s)
- Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jan Hartmann
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Matthew D Neal
- Department of General Surgery, The University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert Schöechl
- Department of Anesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria.,AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Kevin P Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Seema Agarwal
- Department of Anaesthesia, Manchester University Foundation Trust, Manchester, UK
| | - Dan Mason
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Joao D Dias
- Medical Affairs and Clinical Development, Haemonetics Corporation, Boston, MA, USA
| | - Elisabeth Mahla
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
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43
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de Boer WJ, Visser C, van Kuijk SMJ, de Jong K. A prognostic model for the preoperative identification of patients at risk for receiving transfusion of packed red blood cells in cardiac surgery. Transfusion 2021; 61:2336-2346. [PMID: 34292607 DOI: 10.1111/trf.16438] [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: 07/04/2020] [Revised: 02/02/2021] [Accepted: 04/01/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Patients undergoing cardiothoracic surgery are at substantial risk for blood transfusion. Increased awareness and patient blood management have resulted in a significant reduction over the past years. The next step is preoperative treatment of patients at high risk for packed red blood cells (RBC) transfusion, with the ultimate goal to eventually prevent RBC transfusion. A prediction model was developed to select patients at high risk for RBC transfusion. MATERIALS AND METHODS Data of all patients that underwent cardiac surgery in our center between 2008 and 2013 (n = 2951) were used for model development, and between 2014 and 2016 for validation (n = 1136). Only preoperative characteristics were included in a multinomial regression model with three outcome categories (no, RBC, other transfusion). The accuracy of the estimated risks and discriminative ability of the model were assessed. Clinical usefulness was explored. RESULTS Risk factors included are sex, type of surgery, redo surgery, age, height, body mass index, preoperative hemoglobin level, and preoperative platelet count. The model has excellent discriminative ability for predicting RBC transfusion versus no transfusion (area under the curve [AUC] = 94%) and good discriminative ability for RBC transfusion versus other transfusion (AUC = 84%). With a cut-off value of RBC risk of 16.8% and higher, the model is well able to identify a high proportion of patients at risk for RBC transfusion (sensitivity = 87.1%, specificity = 82.3%). CONCLUSION In the current study, a prediction tool was developed to be used for risk stratification of patients undergoing elective cardiac surgery at risk for blood transfusions.
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Affiliation(s)
- Wiebe J de Boer
- Heart Center, Department Extra Corporeal Circulation, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Cornelis Visser
- Heart Center, Department Extra Corporeal Circulation, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Sander M J van Kuijk
- Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht UMC+, Maastricht, The Netherlands
| | - Kim de Jong
- Department of Epidemiology, MCL Academy, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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44
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Clendenen N, Ahlgren B, Robitaille MJ, Christensen E, Morabito J, Grae L, Lyman M, Weitzel N. Year in Review 2020: Noteworthy Literature in Cardiothoracic Anesthesiology. Semin Cardiothorac Vasc Anesth 2021; 25:94-106. [PMID: 33938302 PMCID: PMC10088871 DOI: 10.1177/10892532211013614] [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: 12/15/2022]
Abstract
The year 2020 was marred by the emergence of a deadly pandemic that disrupted every aspect of life. Despite the disruption, notable research accomplishments in the practice of cardiothoracic anesthesiology occurred in 2020 with an emphasis on optimizing care, improving outcomes, and expanding what is possible for patients undergoing cardiac surgery. This year's edition of Noteworthy Literature Review will focus on specific themes in cardiac anesthesiology that include preoperative anemia, predictors of acute kidney injury following cardiac surgery, pain management modalities, anticoagulation strategies after transcatheter aortic valve replacement, mechanical circulatory support, and future directions in research.
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Affiliation(s)
| | - Bryan Ahlgren
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mark J Robitaille
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Joseph Morabito
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Lyndsey Grae
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Matthew Lyman
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nathaen Weitzel
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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45
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Viscoelastic Coagulation Testing: Use and Current Limitations in Perioperative Decision-making. Anesthesiology 2021; 135:342-349. [PMID: 33979438 DOI: 10.1097/aln.0000000000003814] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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46
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Hensley NB, Grant MC, Cho BC, Suffredini G, Abernathy JA. How Do We Use Dashboards to Enhance Quality in Cardiac Anesthesia? J Cardiothorac Vasc Anesth 2021; 35:2969-2976. [PMID: 34059439 DOI: 10.1053/j.jvca.2021.04.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 02/04/2023]
Abstract
The use of clinical dashboards has expanded significantly in healthcare in recent years in a variety of settings. The ability to analyze data related to quality metrics in one screen is highly desirable for cardiac anesthesiologists, as they have considerable influence on important clinical outcomes. Building a robust quality program within cardiac anesthesia relies on consistent access and review of quality outcome measures, process measures, and operational measures through a clinical dashboard. Signals and trends in these measures may be compared to other cardiac surgical programs to analyze gaps and areas for quality improvement efforts. In this article, the authors describe how they designed a clinical cardiac anesthesia dashboard for quality efforts at their institution.
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Affiliation(s)
- Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giancarlo Suffredini
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James A Abernathy
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, MD
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47
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Clinical impact of rotational thromboelastometry in cardiac surgery. Transfus Clin Biol 2021; 28:276-282. [PMID: 33839299 DOI: 10.1016/j.tracli.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 03/25/2021] [Accepted: 03/27/2021] [Indexed: 11/22/2022]
Abstract
Patients undergoing cardiac surgery are at high risk of postoperative bleeding, which is related to worse prognosis and survival. The use of ROTEM®, together with the implementation of a specific treatment algorithm, to reduce the risk of postoperative bleeding. An observational, comparative, cross-case study with historical controls. A total of 1772 consecutive patients admitted to intensive care unit after having undergone cardiac surgery, was divided into 3 groups: Group 1: Coagulation was only monitored by the classical coagulation test (control group). Group 2: Monitorization was done by ROTEM®, according to a protocol designed in our center. Group 3: VerifyNow® was added to ROTEM®, implementing a specific treatment algorithm. We observed a decreased of red blood cell transfusion (Group 1 55.5%, Group 2 52.7%, Group 3 46.6%, P<0.01). Postoperative results include a significant reduction in complications with a marked improvement in overall survival in the ROTEM® - guided groups. Conclusions: Monitoring of hemostasis by POCT'S (ROTEM® and VerifyNow®) in patients undergoing cardiac surgery and cardiac transplantation was associated with a decreased incidence of blood transfusion, postoperative clinical complications, and mortality.
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48
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Kidd B, Sutherland L, Jabaley CS, Flynn B. Efficacy, Safety, and Strategies for Recombinant-Activated Factor VII in Cardiac Surgical Bleeding: A Narrative Review. J Cardiothorac Vasc Anesth 2021; 36:1157-1168. [PMID: 33875351 DOI: 10.1053/j.jvca.2021.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 02/25/2021] [Accepted: 03/14/2021] [Indexed: 11/11/2022]
Abstract
As perioperative bleeding continues to be a major source of morbidity and mortality in cardiac surgery, the search continues for an ideal hemostatic agent for use in this patient population. Transfusion of blood products has been associated both with increased costs and risks, such as infection, prolonged mechanical ventilation, increased length of stay, and decreased survival. Recombinant-activated factor VII (rFVIIa) first was approved for the US market in 1999 and since that time has been used in a variety of clinical settings. This review summarizes the existing literature pertaining to perioperative rFVIIa, in addition to society recommendations and current guidelines regarding its use in cardiac surgery.
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Affiliation(s)
- Brent Kidd
- Division of Critical Care Medicine, Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS.
| | - Lauren Sutherland
- Division of Critical Care Medicine, Department of Anesthesiology, Columbia University, New York, NY
| | - Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University, Atlanta, GA; Emory Critical Care Center, Atlanta, GA
| | - Brigid Flynn
- Division of Critical Care Medicine, Department of Anesthesiology, University of Kansas Medical Center, Kansas City, KS
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49
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Argiriadou H, Antonitsis P, Gkiouliava A, Papapostolou E, Deliopoulos A, Anastasiadis K. Minimal invasive extracorporeal circulation preserves coagulation integrity. Perfusion 2021; 37:257-265. [PMID: 33637025 DOI: 10.1177/0267659121998544] [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: 11/17/2022]
Abstract
INTRODUCTION Coagulopathy after cardiac surgery is a serious multifactorial complication that results in postoperative bleeding requiring transfusion of red blood cells and procoagulant products. Use of cardiopulmonary bypass represents the major contributing factor affecting coagulation. We sought to prospectively investigate the effect of contemporary minimal invasive extracorporeal circulation (MiECC) on coagulation parameters using point-of-care (POC) rotational thromboelastometry and the relation to postoperative bleeding. METHODS Patients undergoing elective cardiac surgery on MiECC were prospectively recruited. Anticoagulation strategy was based on individualized heparin management and heparin level-guided protamine titration. Rotational thromboelastometry testing was performed before induction of anesthesia and after aortic cross-clamp release. A strict POC-guided transfusion protocol was implemented. The primary endpoint was the assessment of viscoelastic properties of the coagulating blood at the end of surgery compared to preoperative values and the relation to postoperative bleeding and 24-hour transfusion requirements. RESULTS Fifty patients were included in the study with a significant proportion having complex surgery. Thirteen patients (26%) required blood transfusion (mean rate: 0.5 ± 1 units per patient), 5/50 (10%) received coagulation factors while no patient received fresh frozen plasma, platelets or fibrinogen. Thromboelastometry analysis showed that the major derangement was CT EXTEM > 100 seconds in 28/50 (56%) and A10 EXTEM < 40 mm in one (2%) patient without clinical significance. Platelet function was preserved throughout surgery. A10-FIBTEM was found predictive of postoperative bleeding at 12 hours. CONCLUSIONS MiECC preserves clot quality throughout surgery acting in both key determinants of clot strength; fibrinogen and platelets. This is clinically translated into minimal postoperative bleeding and restricted use of blood products and coagulation factors.
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Affiliation(s)
- Helena Argiriadou
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Anna Gkiouliava
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Evangelia Papapostolou
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Apostolos Deliopoulos
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Kyriakos Anastasiadis
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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50
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Klompas AM, Boswell MR, Plack DL, Smith MM. Thrombocytopenia: Perioperative Considerations for Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:893-905. [PMID: 33707107 DOI: 10.1053/j.jvca.2021.02.009] [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: 01/29/2021] [Accepted: 02/01/2021] [Indexed: 11/11/2022]
Abstract
The etiologies of thrombocytopenia in patients presenting for cardiac surgery are extensive, but clinically relevant conditions generally can be categorized by those related to decreased platelet production or increased platelet destruction. Many causes require mere acknowledgment and availability of allogeneic platelet transfusion; others have unique considerations for which providers should be familiar. The purpose of this review is to provide an overview of the common causes of thrombocytopenia, summarize the literature, and discuss perioperative considerations for patients undergoing cardiac surgery.
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Affiliation(s)
- Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN
| | - Michael R Boswell
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN
| | - Daniel L Plack
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, 200 First St SW, Rochester, MN.
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