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Downey LA, Moiseiwitsch N, Nellenbach K, Xiang Y, Brown AC, Guzzetta NA. Effect of In Vivo Administration of Fibrinogen Concentrate Versus Cryoprecipitate on Ex Vivo Clot Degradation in Neonates Undergoing Cardiac Surgery. Anesth Analg 2024:00000539-990000000-00899. [PMID: 39116012 DOI: 10.1213/ane.0000000000007123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024]
Abstract
BACKGROUND Neonates undergoing cardiac surgery require fibrinogen replacement to restore hemostasis after cardiopulmonary bypass (CPB). Cryoprecipitate is often the first-line treatment, but recent studies demonstrate that fibrinogen concentrate (RiaSTAP; CSL Behring) may be acceptable in this population. This investigator-initiated, randomized trial compares cryoprecipitate to fibrinogen concentrate in neonates undergoing cardiac surgery (ClinicalTrials.gov NCT03932240). The primary end point was the percent change in ex vivo clot degradation from baseline at 24 hours after surgery between groups. Secondary outcomes included intraoperative blood transfusions, coagulation factor levels, and adverse events. METHODS Neonates were randomized to receive cryoprecipitate (control group) or fibrinogen concentrate (study group) as part of a post-CPB transfusion algorithm. Blood samples were drawn at 4 time points: presurgery (T1), after treatment (T2), arrival to the intensive care unit (ICU) (T3), and 24 hours postsurgery (T4). Using the mixed-effect models, we analyzed the percent change in ex vivo clot degradation from a patient's presurgery baseline at each time point. Intraoperative blood product transfusions, coagulation factor levels, perioperative laboratory values, and adverse events were collected. RESULTS Thirty-six neonates were enrolled (intent to treat [ITT]). Thirteen patients in the control group and seventeen patients in the study group completed the study per protocol (PP). After normalizing to the patient's own baseline (T1), no significant differences were observed in clot degradation at T2 or T3. At T4, patients in the study group had greater degradation when compared to those in the control group (826.5%, 95% confidence interval [CI], 291.1-1361.9 vs -545.9%, 95% CI, -1081.3 to -10.4; P < .001). Study group patients received significantly less median post-CPB transfusions than control group patients (ITT, 27.2 mL/kg [19.0-36.9] vs 41.6 [29.2-52.4]; P = .043; PP 26.7 mL/kg [18.8-32.2] vs 41.2 mL/kg [29.0-51.4]; P < .001). No differences were observed in bleeding or thrombotic events. CONCLUSIONS Neonates who received fibrinogen concentrate, as compared to cryoprecipitate, have similar perioperative ex vivo clot degradation with faster degradation at 24 hours postsurgery, less post-CPB blood transfusions, and no increased bleeding or thrombotic complications. Our findings suggest that fibrinogen concentrate adequately restores hemostasis and reduces transfusions in neonates after CPB without increased bleeding or thrombosis risk.
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Affiliation(s)
- Laura A Downey
- From the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
- Department of Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nina Moiseiwitsch
- Department of Biomedical Engineering of University of North Carolina-Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Kimberly Nellenbach
- Department of Biomedical Engineering of University of North Carolina-Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Yijin Xiang
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Ashley C Brown
- Department of Biomedical Engineering of University of North Carolina-Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
- Department of Material Science and Engineering, North Carolina State University, Raleigh, North Carolina
| | - Nina A Guzzetta
- From the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
- Department of Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
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Gomes M, Ângelo-Dias M, Duarte GS, Dias SS, Serra SS, Lima J. Safety of Fibrinogen Concentrate in Non-Trauma and Non-Obstetric Adult Patients during Perioperative Care: Systematic Review and Meta-Analysis. J Clin Med 2024; 13:3482. [PMID: 38930009 PMCID: PMC11204778 DOI: 10.3390/jcm13123482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/27/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Low fibrinogen levels are associated with an increased risk of perioperative bleeding. However, there is an ongoing debate over the ideal treatment threshold, the benefits of prophylactic supplementation with fibrinogen concentrate, and the best source of fibrinogen. While fibrinogen concentrate supplementation is being widely used to treat bleeding related to acquired haemostatic deficiencies, there is a lack of evidence regarding its dosage, effectiveness, and safety. This systematic review provides an up-to-date summary of the relationship between fibrinogen concentrate supplementation and safety measures in the perioperative care of non-trauma, non-obstetric adult patients. Methods: A comprehensive online search was conducted on PubMed/Medline, EMBASE, Scopus, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials. Results: This systematic review and meta-analysis encompasses ten studies involving 1391 patients. There was a decreased risk of total thromboembolic events in patients treated with fibrinogen compared to the control (OR 0.65, 95% CI 0.43 to 0.98, I2 = 0%). In addition, when fibrinogen was used prophylactically, it resulted in shorter ICU stays (MD -1.50, 95% CI -2.64 to -0.36), when set against its therapeutic use. A sensitivity analysis on cardiovascular surgery studies did not reveal any statistically significant difference. Conclusions: The use of fibrinogen concentrate in the perioperative care of non-trauma and non-obstetric adult patients may lead to potential benefits.
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Affiliation(s)
- Manuela Gomes
- Transfusion Medicine Department, Hemovida, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisboa, Portugal;
| | - Miguel Ângelo-Dias
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- Comprehensive Health Research Centre (CHRC), NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
| | - Gonçalo S. Duarte
- Clinical Pharmacology, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisboa, Portugal;
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, 1649-004 Lisboa, Portugal
| | - Sara Simões Dias
- Comprehensive Health Research Centre (CHRC), NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- ciTechCare—Centre for Innovative Care and Health Technology, Polytechnic of Leiria, 2411-901 Leiria, Portugal
| | - Sofia Silvério Serra
- Library, NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
| | - Jorge Lima
- NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- Comprehensive Health Research Centre (CHRC), NOVA Medical School (NMS), Faculdade de Ciências Médicas (FCM), Universidade Nova de Lisboa, 1099-085 Lisboa, Portugal;
- Department of Obstetrics and Gynecology, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisboa, Portugal
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Rahe-Meyer N, Neumann G, Schmidt DS, Downey LA. Long-Term Safety Analysis of a Fibrinogen Concentrate (RiaSTAP ®/Haemocomplettan ® P). Clin Appl Thromb Hemost 2024; 30:10760296241254106. [PMID: 38803191 PMCID: PMC11135097 DOI: 10.1177/10760296241254106] [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: 11/08/2023] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 05/29/2024] Open
Abstract
Fibrinogen concentrate treatment is recommended for acute bleeding episodes in adult and pediatric patients with congenital and acquired fibrinogen deficiency. Previous studies have reported a low risk of thromboembolic events (TEEs) with fibrinogen concentrate use; however, the post-treatment TEE risk remains a concern. A retrospective evaluation of RiaSTAP®/Haemocomplettan® P (CSL Behring, Marburg, Germany) post-marketing data was performed (January 1986-June 2022), complemented by a literature review of published studies. Approximately 7.45 million grams of fibrinogen concentrate was administered during the review period. Adverse drug reactions (ADRs) were reported in 337 patients, and 81 (24.0%) of these patients experienced possible TEEs, including 14/81 (17.3%) who experienced fatal outcomes. Risk factors and the administration of other coagulation products existed in most cases, providing alternative explanations. The literature review identified 52 high-ranking studies with fibrinogen concentrate across various clinical areas, including 26 randomized controlled trials. Overall, a higher number of comparative studies showed lower rates of ADRs and/or TEEs in the fibrinogen group versus the comparison group(s) compared with those that reported higher rates or no differences between groups. Post-marketing data and clinical studies demonstrate a low rate of ADRs, including TEEs, with fibrinogen concentrate treatment. These findings suggest a favorable safety profile of fibrinogen concentrate, placing it among the first-line treatments effective for managing intraoperative hemostatic bleeding.
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Affiliation(s)
- Niels Rahe-Meyer
- Department for Anaesthesiology and Intensive Care Medicine, Franziskus Hospital Bielefeld, Bielefeld, Germany
- Department for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | | | | | - Laura A Downey
- Department of Anaesthesiology, Emory University Medical School, Atlanta, GA, USA
- Department of Paediatric Cardiac Anaesthesiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Al-Azri K, Goldstone K, Phillips J, Bhana J, Patel N, Warkentin TE. Severe autoimmune heparin-induced thrombocytopenia postcardiac surgery: Implications for subsequent cardiac surgery. Am J Hematol 2023; 98:1953-1958. [PMID: 37823557 DOI: 10.1002/ajh.27123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/19/2023] [Accepted: 09/25/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Khalid Al-Azri
- Hematology Department, Waikato Hospital, Hamilton, New Zealand
| | - Kate Goldstone
- Cardiac Anaesthesia Department, Waikato Hospital, Hamilton, New Zealand
| | - Julia Phillips
- Hematology Department, Waikato Hospital, Hamilton, New Zealand
| | - Jack Bhana
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Nishith Patel
- Department of Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Theodore E Warkentin
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Pathology & Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Service of Benign Hematology, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Ontario, Canada
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Schoerghuber M, Bärnthaler T, Prüller F, Mantaj P, Cvirn G, Toller W, Klivinyi C, Mahla E, Heinemann A. Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo. Br J Anaesth 2023; 131:452-462. [PMID: 37087333 PMCID: PMC10485366 DOI: 10.1016/j.bja.2023.03.010] [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: 09/04/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation. METHODS Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis. RESULTS Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline. CONCLUSIONS Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.
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Affiliation(s)
- Michael Schoerghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria.
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Polina Mantaj
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Cvirn
- Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 71] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Itagaki Y, Hayakawa M, Takahashi Y, Hirano S, Yamakawa K. Emergency administration of fibrinogen concentrate for haemorrhage: systematic review and meta-analysis. World J Emerg Surg 2023; 18:27. [PMID: 36998084 PMCID: PMC10061696 DOI: 10.1186/s13017-023-00497-5] [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: 01/15/2023] [Accepted: 03/26/2023] [Indexed: 04/01/2023] Open
Abstract
INTRODUCTION The occurrence of massive haemorrhages in various emergency situations increases the need for blood transfusions and increases the risk of mortality. Fibrinogen concentrate (FC) use may increase plasma fibrinogen levels more rapidly than fresh-frozen product or cryoprecipitate use. Previous several systematic reviews and meta-analyses have not effectively demonstrated FC efficacy in significantly improving the risk of mortality and reducing transfusion requirements. In this study, we investigated the use of FC for haemorrhages in emergency situations. METHODS AND ANALYSIS In this systematic review and meta-analysis, we included controlled trials, but excluded randomized controlled trials (RCTs) in elective surgeries. The study population consisted of patients with haemorrhages in emergency situations, and the intervention was emergency supplementation of FC. The control group was administered with ordinal transfusion or placebo. The primary and secondary outcomes were in-hospital mortality and the amount of transfusion and thrombotic events, respectively. The electronic databases searched included MEDLINE (PubMed), Web of Science, and the Cochrane Central Register of Controlled Trials. RESULTS Nine RCTs in the qualitative synthesis with a total of 701 patients were included. Results showed a slight increase in in-hospital mortality with FC treatment (RR 1.24, 95% CI 0.64-2.39, p = 0.52) with very low certainty of the evidence. There was no reduction in the use of red blood cells (RBC) transfusion in the first 24 h after admission with FC treatment (mean difference [MD] 0.0 Unit in the FC group, 95% CI - 0.99-0.98, p = 0.99) with very low certainty of the evidence. However, the use of fresh-frozen plasma (FFP) transfusion significantly increased in the first 24 h after admission with FC treatment (MD 2.61 Unit higher in the FC group, 95% CI 0.07-5.16, p = 0.04). The occurrence of thrombotic events did not significantly differ with FC treatment. CONCLUSIONS The present study indicates that the use of FC may result in a slight increase in in-hospital mortality. While FC did not appear to reduce the use of RBC transfusion, it likely increased the use of FFP transfusion and may result in a large increase in platelet concentrate transfusion. However, the results should be interpreted cautiously due to the unbalanced severity in the patient population, high heterogeneity, and risk of bias.
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Affiliation(s)
- Yuki Itagaki
- Department of Surgery, Kushiro City General Hospital, 1-12 Shunkodai, Kushiro, Hokkaido, 085-0822, Japan.
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan.
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Yuki Takahashi
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Faculty of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Osaka, Japan
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Carrier FM, Deshêtres A, Ferreira Guerra S, Rioux-Massé B, Zaouter C, Lee N, Amzallag É, Joosten A, Massicotte L, Chassé M. Preoperative Fibrinogen Level and Bleeding in Liver Transplantation for End-stage Liver Disease: A Cohort Study. Transplantation 2023; 107:693-702. [PMID: 36150121 DOI: 10.1097/tp.0000000000004333] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver transplantation is a high-risk surgery associated with important perioperative bleeding and transfusion needs. Uncertainties remain on the association between preoperative fibrinogen level and bleeding in this population. METHODS We conducted a cohort study that included all consecutive adult patients undergoing a liver transplantation for end-stage liver disease in 1 center. We analyzed the association between the preoperative fibrinogen level and bleeding-related outcomes. Our primary outcome was intraoperative blood loss, and our secondary outcomes were estimated perioperative blood loss, intraoperative and perioperative red blood cell transfusions, reinterventions for bleeding and 1-y graft and patient survival. We estimated linear regression models and marginal risk models adjusted for all important potential confounders. We used restricted cubic splines to explore potential nonlinear associations and reported dose-response curves. RESULTS We included 613 patients. We observed that a lower fibrinogen level was associated with a higher intraoperative blood loss, a higher estimated perioperative blood loss and a higher risk of intraoperative and perioperative red blood cell transfusions (nonlinear effects). Based on an exploratory analysis of the dose-response curves, these effects were observed below a threshold value of 3 g/L for these outcomes. We did not observe any association between preoperative fibrinogen level and reinterventions, 1-y graft survival or 1-y patient survival. CONCLUSIONS This study suggests that a lower fibrinogen level is associated with bleeding in liver transplantation. The present results may help improving the selection of patients for further studies on preoperative fibrinogen administration in liver transplant recipients with end-stage liver disease.
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Affiliation(s)
- François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Annie Deshêtres
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Steve Ferreira Guerra
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | - Benjamin Rioux-Massé
- Department of Medicine, Hematology Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
| | - Cédrick Zaouter
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Nick Lee
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Éva Amzallag
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Bicêtre and Paul Brousse Hospitals, Assistance Publique Hôpitaux de Paris, Villejuif, France
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Michaël Chassé
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
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Beverly A, Ong G, Kimber C, Sandercock J, Dorée C, Welton NJ, Wicks P, Estcourt LJ. Drugs to reduce bleeding and transfusion in major open vascular or endovascular surgery: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 2:CD013649. [PMID: 36800489 PMCID: PMC9936832 DOI: 10.1002/14651858.cd013649.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
BACKGROUND Vascular surgery may be followed by internal bleeding due to inadequate surgical haemostasis, abnormal clotting, or surgical complications. Bleeding ranges from minor, with no transfusion requirement, to massive, requiring multiple blood product transfusions. There are a number of drugs, given systemically or applied locally, which may reduce the need for blood transfusion. OBJECTIVES To assess the effectiveness and safety of anti-fibrinolytic and haemostatic drugs and agents in reducing bleeding and the need for blood transfusion in people undergoing major vascular surgery or vascular procedures with a risk of moderate or severe (> 500 mL) blood loss. SEARCH METHODS We searched: Cochrane Central Register of Controlled Trials; MEDLINE; Embase; CINAHL, and Transfusion Evidence Library. We also searched the WHO ICTRP and ClinicalTrials.gov trial registries for ongoing and unpublished trials. Searches used a combination of MeSH and free text terms from database inception to 31 March 2022, without restriction on language or publication status. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adults of drug treatments to reduce bleeding due to major vascular surgery or vascular procedures with a risk of moderate or severe blood loss, which used placebo, usual care or another drug regimen as control. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were units of red cells transfused and all-cause mortality. Our secondary outcomes included risk of receiving an allogeneic blood product, risk of reoperation or repeat procedure due to bleeding, risk of a thromboembolic event, risk of a serious adverse event and length of hospital stay. We used GRADE to assess certainty of evidence. MAIN RESULTS We included 22 RCTs with 3393 participants analysed, of which one RCT with 69 participants was reported only in abstract form, with no usable data. Seven RCTs evaluated systemic drug treatments (three aprotinin, two desmopressin, two tranexamic acid) and 15 RCTs evaluated topical drug treatments (drug-containing bioabsorbable dressings or glues), including fibrin, thrombin, collagen, gelatin, synthetic sealants and one investigational new agent. Most trials were conducted in high-income countries and the majority of the trials only included participants undergoing elective surgery. We also identified two ongoing RCTs. We were unable to perform the planned network meta-analysis due to the sparse reporting of outcomes relevant to this review. Systemic drug treatments We identified seven trials of three systemic drugs: aprotinin, desmopressin and tranexamic acid, all with placebo controls. The trials of aprotinin and desmopressin were small with very low-certainty evidence for all of our outcomes. Tranexamic acid versus placebo was the systemic drug comparison with the largest number of participants (2 trials; 1460 participants), both at low risk of bias. The largest of these included a total of 9535 individuals undergoing a number of different higher risk surgeries and reported limited information on the vascular subgroup (1399 participants). Neither trial reported the number of units of red cells transfused per participant up to 30 days. Three outcomes were associated with very low-certainty evidence due to the very wide confidence intervals (CIs) resulting from small study sizes and low number of events. These were: all-cause mortality up to 30 days; number of participants requiring an allogeneic blood transfusion up to 30 days; and risk of requiring a repeat procedure or operation due to bleeding. Tranexamic acid may have no effect on the risk of thromboembolic events up to 30 days (risk ratio (RR) 1.10, 95% CI 0.88 to 1.36; 1 trial, 1360 participants; low-certainty evidence due to imprecision). There is one large ongoing trial (8320 participants) comparing tranexamic acid versus placebo in people undergoing non-cardiac surgery who are at high risk of requiring a red cell transfusion. This aims to complete recruitment in April 2023. This trial has primary outcomes of proportion of participants transfused with red blood cells and incidence of venous thromboembolism (DVT or PE). Topical drug treatments Most trials of topical drug treatments were at high risk of bias due to their open-label design (compared with usual care, or liquids were compared with sponges). All of the trials were small, most were very small, and few reported clinically relevant outcomes in the postoperative period. Fibrin sealant versus usual care was the topical drug comparison with the largest number of participants (5 trials, 784 participants). The five trials that compared fibrin sealant with usual care were all at high risk of bias, due to the open-label trial design with no measures put in place to minimise reporting bias. All of the trials were funded by pharmaceutical companies. None of the five trials reported the number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. The other three outcomes were associated with very low-certainty evidence with wide confidence intervals due to small sample sizes and the low number of events, these were: all-cause mortality up to 30 days; risk of requiring a repeat procedure due to bleeding; and risk of thromboembolic disease up to 30 days. We identified one large trial (500 participants) comparing fibrin sealant versus usual care in participants undergoing abdominal aortic aneurysm repair, which has not yet started recruitment. This trial lists death due to arterial disease and reintervention rates as primary outcomes. AUTHORS' CONCLUSIONS Because of a lack of data, we are uncertain whether any systemic or topical treatments used to reduce bleeding due to major vascular surgery have an effect on: all-cause mortality up to 30 days; risk of requiring a repeat procedure or operation due to bleeding; number of red cells transfused per participant up to 30 days or the number of participants requiring an allogeneic blood transfusion up to 30 days. There may be no effect of tranexamic acid on the risk of thromboembolic events up to 30 days, this is important as there has been concern that this risk may be increased. Trials with sample size targets of thousands of participants and clinically relevant outcomes are needed, and we look forward to seeing the results of the ongoing trials in the future.
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Affiliation(s)
- Anair Beverly
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Giok Ong
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Josie Sandercock
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Carolyn Dorée
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Nicky J Welton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Peter Wicks
- Cardiac Anaesthesia and Intensive Care, University Hospital Southampton, Southampton, UK
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
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10
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Effect of fibrinogen replacement therapy on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery: a retrospective cohort study. J Anesth 2023; 37:119-129. [PMID: 36436075 DOI: 10.1007/s00540-022-03140-w] [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: 07/16/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to examine the effect of fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery. METHODS We retrospectively studied 439 consecutive patients who underwent thoracic aortic surgery with cardiopulmonary bypass between January 1st, 2010 and December 31st, 2019 and identified patients who received cryoprecipitate or fibrinogen concentrate (the fibrinogen replacement group) and those who did not (the control group). Multivariate analyses were performed to examine the associations of fibrinogen replacement therapy with perioperative major bleeding (i.e., excessive hemorrhage or blood transfusion), re-exploration for bleeding, and 1-year mortality. RESULTS There were 285 patients in the fibrinogen replacement group who received 2.2 ± 1.0 g of concentrated fibrinogen amount and 154 patients in the control group. The incidence of major bleeding in the fibrinogen replacement group was less than that in the control group in patients with fibrinogen level < 150 mg/dL during cardiopulmonary bypass (49.7% versus 74.6%, p = 0.0007, multivariate odds ratio; 0.33, 95% confidence intervals; 0.12-0.91, p = 0.03), but not in patients with fibrinogen level ≥ 150 mg/dL (25.0% versus 29.6%, p = 0.51). No significant difference was found in re-exploration for bleeding (1.0% versus 1.3%, p = 1.00) or 1-year mortality (10.4% versus 5.3%, multivariate Cox proportional-hazard ratio; 1.03, 95% confidence intervals; 0.82-1.31, p = 0.74) between the fibrinogen replacement group and the control group. CONCLUSIONS The results of this study indicate that 2-3 g of fibrinogen replacement reduces the incidence of major bleeding in patients with hypofibrinogenemia during cardiopulmonary bypass in thoracic aortic surgery.
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11
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Vlot EA, Hackeng CM, Aper SJ, Sonker U, Heijmen RH, van Dongen EP, Noordzij PG. Does Intraoperative Fibrinogen Affect Blood Loss or Transfusion Practice After Aortic Arch Surgery: A Prematurely Ended Randomized Trial. Clin Appl Thromb Hemost 2022; 28:10760296221144042. [PMID: 36476152 PMCID: PMC9742581 DOI: 10.1177/10760296221144042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular surgery is often complicated by significant bleeding due to perioperative coagulopathy. The effectiveness of treatment with fibrinogen concentrate to reduce the perioperative blood transfusion rate after thoracic aortic replacement surgery in prior studies has shown conflicting results. Therefore, we conducted a double-blind randomized controlled trial to investigate if a single dose of intraoperative fibrinogen administration reduced blood loss and allogeneic transfusion rate after elective surgery for thoracic arch aneurysm with deep hypothermic circulatory arrest. Twenty patients were randomized to fibrinogen concentrate (N = 10) or placebo (N = 10). The recruitment of study patients was prematurely ended due to a low inclusion rate. Perioperative transfusion, 5-minute bleeding mass after study medication and postoperative blood loss were not different between the groups with fibrinogen concentrate or placebo. Due to small volumes of postoperative blood loss and premature study termination, a beneficial effect of fibrinogen concentrate on the number of blood transfusions could not be established. However, treatment with fibrinogen efficiently restored fibrinogen levels and clot strength to preoperative values with a more effective preserved postoperative thrombin generation capacity. This result might serve as a pilot for further multicenter studies to assess the prospective significance of automated and standardized thrombin generation as a routine assay for monitoring perioperative coagulopathy and its impact on short- and long-term operative results.
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Affiliation(s)
- Eline A. Vlot
- Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands,Eline A. Vlot, Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, Netherlands.
| | - Christian M. Hackeng
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Stijn J.A. Aper
- Department of Clinical Chemistry, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Uday Sonker
- Department of Cardiac Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Robin H. Heijmen
- Department of Cardiac Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Eric P.A. van Dongen
- Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Peter G. Noordzij
- Department of Anesthesia, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, Netherlands
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12
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Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol 2022; 198:654-667. [PMID: 35687716 DOI: 10.1111/bjh.18275] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Simon J Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Kerry Dowling
- Transfusion Laboratory Manager, Southampton University Hospitals NHS Foundation Trust, Southampton, UK
| | - Nikki Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Heidi Doughty
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, UK
| | - Beverley J Hunt
- Department of Haematology, Guy's and St Thomas's Hospital, London, UK
| | - Laura Fraser
- Transfusion Practitioner, NHS Lanarkshire, University Hospital Wishaw, Wishaw, UK.,National Services Scotland/Scottish National Blood Transfusion, Edinburgh, UK
| | - Shruthi Narayan
- Medical director, Serious Hazards of Transfusion, Manchester, UK
| | - Juliet Smith
- Lead Transfusion Practitioner, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ian Sullivan
- Transfusion Laboratory Manager, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Laura Green
- Transfusion Medicine, NHS Blood and Transplant, London, UK.,Barts Health NHS Trust, London, UK.,Blizzard Institute, Queen Mary University of London, London, UK
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13
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Bartoszko J, Martinez-Perez S, Callum J, Karkouti K, Farouh ME, Scales DC, Heddle NM, Crowther M, Rao V, Hucke HP, Carroll J, Grewal D, Brar S, Brussières J, Grocott H, Harle C, Pavenski K, Rochon A, Saha T, Shepherd L, Syed S, Tran D, Wong D, Zeller M. Impact of cardiopulmonary bypass duration on efficacy of fibrinogen replacement with cryoprecipitate compared with fibrinogen concentrate: a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) randomised controlled trial. Br J Anaesth 2022; 129:294-307. [DOI: 10.1016/j.bja.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/16/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022] Open
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14
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Ise H, Oyama K, Kunioka S, Shirasaka T, Kanda H, Akhyari P, Kamiya H. Hypothermic circulatory arrest does not induce coagulopathy in vitro. J Artif Organs 2022; 25:314-322. [PMID: 35303203 DOI: 10.1007/s10047-022-01324-5] [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: 09/15/2021] [Accepted: 03/03/2022] [Indexed: 11/27/2022]
Abstract
Hypothermic circulatory arrest (HCA) is an essential procedure during aortic surgery to protect organs; however, hypothermia is believed to cause coagulopathy, which is a major fatal complication. This study aimed to clarify the impact of hypothermia on coagulation by eliminating clinical biases in vitro. In the hypothermic storage study, blood samples from five healthy volunteers were stored at 37 ℃ (group N) for 3 h or at 20 ℃ for 2 h, followed by 1 h of rewarming at 37 ℃ (group H). Thromboelastography was performed before and after 3 h of storage. In the mock circulation loop (MCL) study, blood samples were placed in the MCL and (a) maintained at 37 ℃ for 4 h (group N, n = 5), or (b) cooled to 20 ℃ to simulate HCA with a 0.1 L/min flow rate for 3 h and then rewarmed to 37 ℃ (group H, n = 5). The total MCL duration was 4 h, and the flow rate was maintained at 1 L/min, except during HCA. Blood samples collected 15 min after the beginning and end of MCL were subjected to standard laboratory tests and rotational thromboelastometry analyses. Hypothermia had no impact on coagulation in both the hypothermic storage and MCL studies. MCL significantly decreased the platelet counts and clot elasticity in the INTEM and EXTEM assays; however, there was no effect on fibrinogen contribution measured by FIBTEM. Hypothermia does not cause irreversible coagulopathy in vitro; however, MCL decreases coagulation due to the deterioration of platelets.
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Affiliation(s)
- Hayato Ise
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.,Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Kyohei Oyama
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Shingo Kunioka
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Hirotsugu Kanda
- Department of Anesthesiology and Critical Care Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Payam Akhyari
- Department of Cardiovascular Surgery, Heinrich Heine University, Düsseldorf, Germany
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
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15
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Abstract
Massive diffuse bleeding is still a problem in cardiovascular surgery. The first line treatment is platelet concentrate transfusion, although there is still insufficient information regarding efficacy, quantity, and timing. The objective of this prospective cohort study was to find out whether the amount of 4 apheresis platelet concentrates could reduce intraoperative bleeding and improve viscoelasticity and aggregometry.10 patients were enrolled intraoperatively because of life-threatening diffuse bleeding after cardiopulmonary bypass and received 4 apheresis platelet concentrates back-to-back. The units were given every 5 minutes. After every unit, thromboelastometry, performed by ROTEM®, and aggregometry, performed by Multiplate®, were done together with Hematocrit, Hemoglobin, and Platelet Count.Hematocrit and Hemoglobin showed a statistically significant decrease of 14%, whereas Platelet Count showed a statistically significant increase of 205%. MCE-EXTEM increased statistically significant: 46%. There was no statistically significant increase in both ADP and COL results.Even a series of 4 platelet concentrates did not comprehensively improve both essential components of an adequate hemostasis: viscoelasticity and aggregation. Just the transfusion of platelet concentrates alone did not build a sufficient strategy improving hemostasis and reducing bleeding. A positive effect of surgical packing on stopping the bleeding could be seen.
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Affiliation(s)
- Lisa Blath
- Department for Anesthesiology and Intensive Care Medicine, Franziskus Hospital Bielefeld, Bielefeld, Germany
| | - Jörg Martens
- Institute for Transfusion Medicine and Transplant Engineering, Hannover Medical School, Hannover, Germany
| | - Niels Rahe-Meyer
- Department for Anesthesiology and Intensive Care Medicine, Franziskus Hospital Bielefeld, Bielefeld, Germany.,Department for Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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16
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Levy JH, Faraoni D, Almond CS, Baumann-Kreuziger L, Bembea MM, Connors JM, Dalton HJ, Davies R, Dumont LJ, Griselli M, Karkouti K, Massicotte MP, Teruya J, Thiagarajan RR, Spinella PC, Steiner ME. Consensus Statement: Hemostasis Trial Outcomes in Cardiac Surgery and Mechanical Support. Ann Thorac Surg 2022; 113:1026-1035. [PMID: 34826386 DOI: 10.1016/j.athoracsur.2021.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes. METHODS A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support. RESULTS For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180. CONCLUSIONS The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.
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Affiliation(s)
- Jerrold H Levy
- Division Cardiothoracic Anesthesiology and Critical Care, Departments of Anesthesiology and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina.
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Almond
- Heart Failure Service, Cardiac Anticoagulation Service, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi J Dalton
- INOVA Heart and Vascular Institute; Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ryan Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Larry J Dumont
- Vitalant Research Institute, Denver, Colorado; Department of Pathology, University of Colorado Medical School, Denver, Colorado; Department of Pathology and Laboratory Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Patricia Massicotte
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Department of Pathology and Immunology, Pediatrics and Medicine, Texan Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Marie E Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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17
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A Randomized Pilot Trial Assessing the Role of Human Fibrinogen Concentrate in Decreasing Cryoprecipitate Use and Blood Loss in Infants Undergoing Cardiopulmonary Bypass. Pediatr Cardiol 2022; 43:1444-1454. [PMID: 35305111 PMCID: PMC9489575 DOI: 10.1007/s00246-022-02866-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/03/2022] [Indexed: 10/30/2022]
Abstract
The objective of this study was to determine whether treatment with human fibrinogen concentrate decreases the need for component blood therapy and blood loss in neonate and infant patients undergoing cardiopulmonary bypass. Pediatric patients (N = 30) undergoing elective cardiac surgery were randomized to receive human fibrinogen concentrate or placebo following cardiopulmonary bypass termination. The primary endpoint was the amount of cryoprecipitate administered. Secondary endpoints included estimated blood loss during the 24 h post-surgery; perioperative blood product transfusion; effects of fibrinogen infusion on global hemostasis, measured by laboratory testing and rotational thromboelastometry; and adverse events. No clinically significant differences were identified in baseline characteristics between groups. A significantly lower volume of cryoprecipitate was administered to the treatment group during the perioperative period [median (interquartile range) 0.0 (0.0-0.0) cc/kg vs 12.0 (8.2-14.3) cc/kg; P < 0.0001] versus placebo. No difference was observed between treatment groups in blood loss, laboratory coagulation tests, use of other blood components, or incidence of adverse events. FIBTEM amplitude of maximum clot firmness values was significantly higher among patients treated with human fibrinogen concentrate versus placebo (P ≤ 0.0001). No significant differences were observed in post-drug HEPTEM, INTEM, and EXTEM results. Human fibrinogen concentrate (70 mg/kg) administered after the termination of cardiopulmonary bypass reduced the need for transfusion with cryoprecipitate in a neonate and infant patient population.ClinicalTrials.gov identifier: NCT02822599.
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18
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Vlaar APJ, Dionne JC, de Bruin S, Wijnberge M, Raasveld SJ, van Baarle FEHP, Antonelli M, Aubron C, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Müller MCA, Lance M, Nielsen ND, Schöchl H, Hunt BJ, Cecconi M, Oczkowski S. Transfusion strategies in bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med 2021; 47:1368-1392. [PMID: 34677620 PMCID: PMC8532090 DOI: 10.1007/s00134-021-06531-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/04/2021] [Indexed: 12/19/2022]
Abstract
PURPOSE To develop evidence-based clinical practice recommendations regarding transfusion practices and transfusion in bleeding critically ill adults. METHODS A taskforce involving 15 international experts and 2 methodologists used the GRADE approach to guideline development. The taskforce addressed three main topics: transfusion support in massively and non-massively bleeding critically ill patients (transfusion ratios, blood products, and point of care testing) and the use of tranexamic acid. The panel developed and answered structured guideline questions using population, intervention, comparison, and outcomes (PICO) format. RESULTS The taskforce generated 26 clinical practice recommendations (2 strong recommendations, 13 conditional recommendations, 11 no recommendation), and identified 10 PICOs with insufficient evidence to make a recommendation. CONCLUSIONS This clinical practice guideline provides evidence-based recommendations for the management of massively and non-massively bleeding critically ill adult patients and identifies areas where further research is needed.
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Affiliation(s)
- Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, He Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Division of Gastroenterology, McMaster University, Hamilton, ON, Canada
| | - Sanne de Bruin
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marije Wijnberge
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - S Jorinde Raasveld
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Frank E H P van Baarle
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anaesthesiology e Rianimazione Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cecile Aubron
- Department of Intensive Care Medicine, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud (HUPS), Le Kremlin-Bicêtre, France
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- OLVG Hospital, Amsterdam, The Netherlands
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Kepler University, Linz, Austria
| | - Gavin J Murphy
- NIHR Leicester Biomedical Research Centre-Cardiovascular, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Riccardo Abbasciano
- NIHR Leicester Biomedical Research Centre-Cardiovascular, Department of Cardiovascular Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Marcella C A Müller
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marcus Lance
- Department of Anesthesiology, Intensive Care and Perioperative Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Nathan D Nielsen
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guys & St Thomas' NHS Foundation Trust, London, UK
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Centre-IRCCS, Rozzano, MI, Italy
- Humanitas University, via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- The Guidelines in Intensive Care Development and Evaluation (GUIDE) Group, He Research Institute St. Joseph's Healthcare Hamilton, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
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19
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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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20
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [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: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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21
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Rahe-Meyer N, Levy JH, Ueda Y, Schmidt DS, Gill R. Viscoelastic testing to assess the effects of rapid fibrinogen concentrate administration after cardiopulmonary bypass: insights from the REPLACE study. Blood Coagul Fibrinolysis 2021; 32:359-365. [PMID: 33973891 DOI: 10.1097/mbc.0000000000001046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Haemorrhage during and following surgery results in increased morbidity and mortality. Low plasma fibrinogen levels have been associated with increased blood loss and transfusion requirements. Fibrinogen supplementation has been shown to reduce bleeding in coagulopathic patients. This post hoc study evaluated fibrinogen repletion and pharmacokinetic data from the REPLACE study. One hundred and fifty-two adult patients undergoing elective aortic surgery requiring cardiopulmonary bypass (CPB) with defined bleeding of 60-250 g at first 5 min bleeding mass were included in the phase III trial. Patients were randomized to receive either fibrinogen concentrate (FCH) or placebo following CPB removal. Plasma fibrinogen levels and viscoelastic testing parameters (ROTEM-based FIBTEM and EXTEM assays) were measured before, during, and after study treatment administration. A mean dose of 6.3 g FCH was administered in the FCH group, with a median infusion duration of 2 min. Immediately following completion of FCH administration, a rapid increase in plasma fibrinogen levels to near baseline (median change from baseline -0.10 g/l) was seen in the FCH group but not in the placebo group (median change from baseline -1.29 g/l). FCH administration also caused an immediate increase in FIBTEM maximum clot firmness (MCF) to 23 mm and improvements in EXTEM coagulation time and clot formation time by the end of infusion. There was a strong correlation between the plasma fibrinogen level and FIBTEM MCF. Treatment with high doses of FCH with a rapid infusion time resulted in immediate recovery to baseline levels of plasma fibrinogen and viscoelastic testing parameters.
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Affiliation(s)
| | - Jerrold H Levy
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuichi Ueda
- Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | - Ravi Gill
- University Hospital of Southampton, Southampton, UK
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22
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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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23
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Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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24
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Monaco F, Barucco G, Licheri M, Mattioli C, Ortalda A, Lombardi G, Pallanch O, De Luca M, Chiesa R, Melissano G, Zangrillo A. Trigger and Target for Fibrinogen Supplementation Using Thromboelastometry (ROTEM) in Patients Undergoing Open Thoraco-Abdominal Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg 2021; 61:799-808. [PMID: 33773905 DOI: 10.1016/j.ejvs.2021.02.046] [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: 05/21/2020] [Revised: 02/02/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To determine the relationship between the value of fibrinogen assessed by the FIBTEM clot amplitude at 10 minutes (A10 FIBTEM) measured on admission to the intensive care unit (ICU) and the amount of drainage output at 24 hours, to investigate whether the A10 FIBTEM predicts severe bleeding (SB), and to define A10 FIBTEM thresholds to prevent (trigger) and treat (target) severe bleeding by fibrinogen supplementation. METHODS In a single centre, retrospective observational study, 166 patients underwent elective open thoraco-abdominal aortic aneurysm (TAAA) repair between March 2016 and January 2019. Exclusion criteria were emergency, congenital, or acquired coagulopathy, or administration of P2Y12 inhibitor antiplatelet agents in the five days before surgery. All patients were managed intra-operatively and post-operatively according to a rotational thromboelastometry driven transfusion protocol. The principal endpoint was a composite outcome, which included bleeding, large volume transfusion, and re-operation. RESULTS FIBTEM clot amplitude after 10 minutes measured on ICU admission and post-operative bleeding at 24 hours showed an inverse linear relationship (R2 = .03; p = .026). Performance of A10 FIBTEM in predicting SB evaluated by Receiving Operating Curve analysis showed an area under the curve of 0.63 (95% CI 0.56 - 0.70; p = .026) with a best cutoff of 9 mm. An A10 FIBTEM of 3 mm was the cutoff associated with a positive predictive value of 50%, while an A10 FIBTEM of 9 mm showed a negative predictive value of 92%. On multivariable analysis, an A10 FIBTEM ≤ 3 mm remained independently associated with SB. CONCLUSION The present investigation shows for the first time in a population undergoing open TAAA repair that an A10 FIBTEM ≤ 3mm on ICU admission is associated with post-operative severe bleeding. Trigger and target values for fibrinogen supplementation, based on A10 FIBTEM, have been provided. The transferability and reliability of these cutoff values require further study.
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Affiliation(s)
- Fabrizio Monaco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gaia Barucco
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Margherita Licheri
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Mattioli
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Ortalda
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Gaetano Lombardi
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ottavia Pallanch
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Monica De Luca
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Roberto Chiesa
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Germano Melissano
- Department of Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
| | - Alberto Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; University Vita-Salute San Raffaele, Milan, Italy
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25
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Itagaki Y, Hayakawa M, Takahashi Y, Yamakawa K. Emergency administration of fibrinogen concentrate for hemorrhage: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e25099. [PMID: 33725904 PMCID: PMC7969309 DOI: 10.1097/md.0000000000025099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION The occurrence of massive hemorrhages in various emergency situations increases the need for blood transfusions and the risk of mortality. Use of fibrinogen concentrate (FC) may increase plasma fibrinogen levels more rapidly than the use of fresh-frozen product or cryoprecipitate. However, thus far, the efficacy of FC in significantly improving the risk of mortality and significantly reducing transfusion requirements has not been effectively demonstrated in several systematic reviews and meta-analyses. METHODS AND ANALYSIS We will conduct a systematic review and meta-analysis of FC for hemorrhages in emergency situations. We will include controlled trials, but will exclude randomized controlled trials in elective surgeries. We will include patients with hemorrhages in emergency situations. Intervention will be emergency supplementation of FC. The control group will be administered with ordinal transfusion or placebo. The primary outcome of the study is in-hospital mortality.We will search in electronic databases such as MEDLINE (PubMed), Web of Science, and the Cochrane Central Register of Controlled Trials. Two reviewers will independently screen the title and abstract, retrieve the full text of the selected articles, and extract the essential data. We will apply uniform criteria for evaluating the risk of bias associated with individual randomized controlled trial based on the Cochrane risk of bias tool. Values of the risk ratio will be expressed as a point estimate with 95% confidence intervals (CIs). Data of continuous variables will be expressed as the mean difference along with their 95% CIs and P values. We will assess the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION This systematic review will provide physicians with updated information on the efficacy and safety of using FC for hemorrhage in emergency settings. Approval from the ethics board and patient consent were not required in our study.This study protocol has been funded through a protocol registry. The registry number is UMIN000041598.
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Affiliation(s)
- Yuki Itagaki
- Emergency and Critical Care Centre, Sapporo City General Hospital
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido
| | - Yuki Takahashi
- Emergency and Critical Care Centre, Sapporo City General Hospital
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College, Osaka, Japan
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26
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Winearls J, Wullschleger M, Wake E, McQuilten Z, Reade M, Hurn C, Ryan G, Trout M, Walsham J, Holley A, George S, Dyer W, McCullough J, Keijzers G, Fraser J, Presneill J, Campbell D. Fibrinogen Early In Severe Trauma studY (FEISTY): results from an Australian multicentre randomised controlled pilot trial. CRIT CARE RESUSC 2021; 23:32-46. [PMID: 38046391 PMCID: PMC10692540 DOI: 10.51893/2021.1.oa3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Haemorrhage is a major cause of death in severe trauma. Fibrinogen plays a critical role in maintaining haemostasis in traumatic haemorrhage, and early replacement using fibrinogen concentrate (FC) or cryoprecipitate (Cryo) is recommended by several international trauma guidelines. Limited evidence supports one product over the other, with widespread geographic and institutional variation in practice. Two previous trials have investigated the feasibility of rapid FC administration in severely injured trauma patients, with conflicting results. Objective: To compare the time to fibrinogen replacement using FC or Cryo in severely injured trauma patients with major haemorrhage and hypofibrinogenaemia. Design, setting, patients and interventions: A multicentre controlled pilot trial in which adult trauma patients with haemorrhage were randomly assigned (1:1) to receive FC or Cryo for fibrinogen replacement, guided by FIBTEM A5 (functional fibrinogen assessment at 5 minutes after clot formation, using rotational thromboelastometry). Main outcome measures: The primary outcome was time to commencement of fibrinogen replacement. Secondary outcomes included effects of the intervention on plasma fibrinogen levels and clinical outcomes including transfusion requirements and mortality. Results: Of the 100 randomly assigned patients, 62 were hypofibrinogenaemic and received the intervention (n = 37) or Cryo (n = 25). Median (interquartile range [IQR]) time to delivery of FC was 29 min (23-40 min) compared with 60 min (40-80 min) for Cryo (P = 0.0001). All 62 patients were hypofibrinogenaemic before receiving FC or Cryo (FC: median FIBTEM A5, 8 mm [IQR, 7-9 mm]; Cryo: median FIBTEM A5, 9 mm [IQR, 5-10 mm]). In the FC arm patients received a median of 3 g FC (IQR, 2-4 g), and in the Cryo arm patients received a median of 8 units of Cryo (IQR, 8-14 units). Restoration of fibrinogen levels was achieved in both arms after the intervention. Blood product transfusion, fluid resuscitation and thromboembolic complications were similar in both arms. Overall mortality was 15.3%, with more deaths in the FC arm. Conclusion: Fibrinogen replacement in severely injured trauma patients with major haemorrhage and hypofibrinogenaemia was achieved substantially faster using FC compared with Cryo. Fibrinogen levels increased appropriately using either product. The optimal method for replacing fibrinogen in traumatic haemorrhage is controversial. Our results will inform the design of a larger trial powered to assess patient-centred outcomes.
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Affiliation(s)
- James Winearls
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- St Andrews War Memorial Hospital Brisbane, QLD, Australia
| | | | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Zoe McQuilten
- Transfusion Research Unit, Monash University, Melbourne, VIC, Australia
- Monash Health, Melbourne, VIC, Australia
| | - Michael Reade
- Military Medicine and Surgery, Joint Health Command, Australian Defence Force
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Catherine Hurn
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Glenn Ryan
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Melita Trout
- Townsville Hospital, Townsville, QLD, Australia
- Faculty of Medicine, James Cook University, Townsville, QLD, Australia
| | - James Walsham
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Anthony Holley
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Shane George
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Emergency Department and Children’s Critical Care Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
- Paediatric Critical Care Research Group, Child Health Research Centre, University of Queensland, Brisbane, QLD, Australia
| | | | - James McCullough
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Gerben Keijzers
- Intensive Care Unit, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medical Sciences, Griffith University, Gold Coast, QLD, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
| | - John Fraser
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Critical Care Research Group, Prince Charles Hospital, Brisbane, QLD, Australia
| | - Jeffrey Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Don Campbell
- Trauma Service, Gold Coast University Hospital, Gold Coast, QLD, Australia
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27
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Green L, Roberts N, Cooper J, Agarwal S, Brunskill SJ, Chang I, Gill R, Johnston A, Klein AA, Platton S, Rossi A, Sepehripour A, Stanworth S, Monk V, O'Brien B. Prothrombin complex concentrate vs. fresh frozen plasma in adult patients undergoing heart surgery - a pilot randomised controlled trial (PROPHESY trial). Anaesthesia 2020; 76:892-901. [PMID: 33285008 PMCID: PMC8246985 DOI: 10.1111/anae.15327] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 12/11/2022]
Abstract
There is equipoise regarding the use of prothrombin complex concentrate vs. fresh frozen plasma in bleeding patients undergoing cardiac surgery. We performed a pilot randomised controlled trial to determine the recruitment rate for a large trial, comparing the impact of prothrombin complex concentrate vs. fresh frozen plasma on haemostasis (1 h and 24 h post-intervention), and assessing safety. Adult patients who developed bleeding within 24 h of cardiac surgery that required coagulation factor replacement were randomly allocated to receive prothrombin complex concentrate (15 IU.kg-1 based on factor IX) or fresh frozen plasma (15 ml.kg-1 ). If bleeding continued after the first administration of prothrombin complex concentrate or fresh frozen plasma administration, standard care was administered. From February 2019 to October 2019, 180 patients were screened, of which 134 (74.4% (95%CI 67-81%)) consented, 59 bled excessively and 50 were randomly allocated; 25 in each arm, recruitment rate 35% (95%CI 27-44%). There were 23 trial protocol deviations, 137 adverse events (75 prothrombin complex concentrate vs. 62 fresh frozen plasma) and 18 serious adverse events (5 prothrombin complex concentrate vs. 13 fresh frozen plasma). There was no increase in thromboembolic events with prothrombin complex concentrate. No patient withdrew from the study, four were lost to follow-up and two died. At 1 h after administration of the intervention there was a significant increase in fibrinogen, Factor V, Factor XII, Factor XIII, α2 -antiplasmin and antithrombin levels in the fresh frozen plasma arm, while Factor II and Factor X were significantly higher in the prothrombin complex concentrate group. At 24 h, there were no significant differences in clotting factor levels. We conclude that recruitment to a larger study is feasible. Haemostatic tests have provided useful insight into the haemostatic changes following prothrombin complex concentrate or fresh frozen plasma administration. A definitive trial is needed to ascertain the benefits and safety for each.
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Affiliation(s)
- L Green
- Blizard Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK.,Department of Haematology, Barts Health NHS Trust, London, UK.,Department of Cardiac Surgery, Barts Health NHS Trust, London, UK
| | - N Roberts
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - J Cooper
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester, UK
| | - S Agarwal
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - S J Brunskill
- Department of Anaesthesia, University Hospital Southampton, Southampton, UK
| | - I Chang
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester, UK
| | - R Gill
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - A Johnston
- Department of Anaesthesia, Royal Papworth Hospital, Cambridge, UK
| | - A A Klein
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - S Platton
- Department of Cardiac Surgery, Barts Health NHS Trust, London, UK
| | - A Rossi
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - A Sepehripour
- William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK
| | - S Stanworth
- Department of Anaesthesia, Barts Health NHS Trust, London, UK.,NHS Blood and Transplant, Oxford, UK
| | - V Monk
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester, UK
| | - B O'Brien
- Department of Anaesthesia, Barts Health NHS Trust, London, UK.,Outcomes Research Consortium, Cleveland Clinic, OH, USA
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28
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Radawski CA, Hammad TA, Colilla S, Coplan P, Hornbuckle K, Freeman E, Smith MY, Sobel RE, Bahri P, Arias AE, Bennett D. The utility of real-world evidence for benefit-risk assessment, communication, and evaluation of pharmaceuticals: Case studies. Pharmacoepidemiol Drug Saf 2020; 29:1532-1539. [PMID: 33146901 DOI: 10.1002/pds.5167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 09/28/2020] [Accepted: 10/31/2020] [Indexed: 12/28/2022]
Abstract
PURPOSE In recent years, novel types of real-world evidence (RWE) have played a role in various decision-making processes relating to medicinal products, including regulatory approval, patient access, health technology assessment, safety monitoring, clinical use, and post-approval lifecycle management. We therefore reviewed the potential utility of RWE in the cycle of medicinal product benefit-risk (BR) assessment, communication/risk minimization and evaluation ("BRACE"). METHODS A convenience sample of illustrative studies was drawn from the published literature and examined. Specifically, we examined the purpose for using RWE, the type of RWE used, its novelty and how it might be integrated with other data and activities of the BRACE cycle, and how it contributed to regulatory decision-making. RESULTS Eight studies were selected with each illustrating a different activity in the BRACE cycle ranging from BR assessment in the preapproval setting, post-approval assessment of safety or effectiveness, communicating BR information to patients and healthcare professionals, and evaluating the effectiveness of risk minimization initiatives to support a positive BR balance. CONCLUSIONS RWE has an important role in informing regulatory decision-making regarding the BR management of medicines. With increasing digitalization, facilitating data collection and stakeholder engagement in health, this role is only expected to expand in the future. To reach the full potential of RWE, both regulators and sponsors will need to be familiar with a range of existing and emerging methods for generating and analyzing such evidence appropriately and achieve convergence regarding how different types of RWE can best be used to inform BR management and decision-making.
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Affiliation(s)
| | - Tarek A Hammad
- Sanofi Genzyme, Global Pharmacovigilance, Cambridge, Massachusetts, USA
| | - Susan Colilla
- Teva Pharmaceuticals, RWE & Epidemiology, Global Health Economics and Outcomes Research, West Chester, Pennsylvania, USA
| | - Paul Coplan
- Johnson & Johnson, Epidemiology, New Brunswick, New Jersey, USA.,Perelman School of Medicine, Adjunct, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kenneth Hornbuckle
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana, USA
| | - Emily Freeman
- Lundbeck Pharmaceuticals LLC, Global R&D, Patient Insights, Deerfield, Illinois, USA
| | - Meredith Y Smith
- Amgen, Inc., Global Patient Safety & Pediatrics, Thousand Oaks, California, USA.,Department of Regulatory and Quality Sciences, School of Pharmacy, University of Southern California, Los Angeles, California, USA
| | - Rachel E Sobel
- United Biosource Corporation (UBC)/Senior Consulting Group, Epidemiology, Blue Bell, Pennsylvania, USA
| | - Priya Bahri
- European Medicine Agency (EMA), Quality and Safety of Medicines, Pharmacovigilance, Amsterdam, Netherlands
| | - Ariel E Arias
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada.,Biologics and Genetic Therapies Directorate, Health Canada, Ottawa, Canada
| | - Dimitri Bennett
- Perelman School of Medicine, Adjunct, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Takeda Pharmaceutical Company Limited, Epidemiology Department, Cambridge, Massachusetts, USA
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Bolliger D, Tanaka KA. More Is Not Always Better: Effects of Cell Salvage in Cardiac Surgery on Postoperative Fibrinogen Concentrations. J Cardiothorac Vasc Anesth 2020; 34:2383-2385. [DOI: 10.1053/j.jvca.2020.03.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 12/25/2022]
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Son K, Yamada T, Tarao K, Kitamura Y, Okazaki J, Sato Y, Isono S. Effects of Cardiac Surgery and Salvaged Blood Transfusion on Coagulation Function Assessed by Thromboelastometry. J Cardiothorac Vasc Anesth 2020; 34:2375-2382. [DOI: 10.1053/j.jvca.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/01/2020] [Accepted: 02/05/2020] [Indexed: 12/13/2022]
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Bärnthaler T, Mahla E, Toth GG, Schuligoi R, Prüller F, Buschmann E, Heinemann A. Supplemental Fibrinogen Restores Platelet Inhibitor-Induced Reduction in Thrombus Formation without Altering Platelet Function: An In Vitro Study. Thromb Haemost 2020; 120:1548-1556. [PMID: 32772348 DOI: 10.1055/s-0040-1715445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND For patients treated with dual antiplatelet therapy, standardized drug-specific 3-to-7 day cessation is recommended prior to major surgery to reach sufficient platelet function recovery. Here we investigated the hypothesis that supplemental fibrinogen might mitigate the inhibitory effects of antiplatelet therapy. METHODS AND RESULTS To this end blood from healthy donors was treated in vitro with platelet inhibitors, and in vitro thrombus formation and platelet activation were assessed. Ticagrelor, acetylsalicylic acid, the combination of both, and tirofiban all markedly attenuated the formation of adherent thrombi, when whole blood was perfused through collagen-coated microchannels at physiological shear rates. Addition of fibrinogen restored in vitro thrombus formation in the presence of antiplatelet drugs and heparin. However, platelet activation, as investigated in assays of P-selectin expression and calcium flux, was not altered by fibrinogen supplementation. Most importantly, fibrinogen was able to restore in vitro thrombogenesis in patients on maintenance dual antiplatelet therapy after percutaneous coronary intervention. CONCLUSION Thus, our in vitro data support the notion that supplementation of fibrinogen influences the perioperative hemostasis in patients undergoing surgery during antiplatelet therapy by promoting thrombogenesis without significantly interfering with platelet activation.
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Affiliation(s)
- Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Division of Anaesthesiology for Cardiovascular and Thoracic Surgery and Intensive Care Medicine, Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Gabor G Toth
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rufina Schuligoi
- Otto Loewi Research Center, Division of Pharmacology Medical University of Graz, Graz, Austria
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Eva Buschmann
- Division of Cardiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology Medical University of Graz, Graz, Austria
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Ng KT, Yap JLL, Kwok PE. The effect of fibrinogen concentrate on postoperative blood loss: A systematic review and meta-analysis of randomized controlled trials. J Clin Anesth 2020; 63:109782. [DOI: 10.1016/j.jclinane.2020.109782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 02/01/2020] [Accepted: 03/07/2020] [Indexed: 12/29/2022]
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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Hypothermic circulatory arrest induced coagulopathy: rotational thromboelastometry analysis. Gen Thorac Cardiovasc Surg 2020; 68:754-761. [PMID: 32507998 PMCID: PMC7378042 DOI: 10.1007/s11748-020-01399-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 06/02/2020] [Indexed: 01/08/2023]
Abstract
Objectives Hypothermic circulatory arrest (HCA) has been considered to cause coagulopathy during cardiac surgery. However, coagulopathy associated with HCA has not been understood clearly in details. The objective of this study is to analyze the details of coagulopathy related to HCA in cardiac surgery by using rotational thromboelastometry (ROTEM). Methods We retrospectively analyzed 38 patients who underwent elective cardiac surgery (HCA group = 12, non-HCA group = 26) in our hospital. Blood samples were collected before and after cardiopulmonary bypass (CPB). Standard laboratory tests (SLTs) and ROTEM were performed. We performed four ROTEM assays (EXTEM, INTEM, HEPTEM and FIBTEM) and analyzed the following ROTEM parameters: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF) and maximum clot elasticity (MCE). The amount of perioperative bleeding, intraoperative transfusion and perioperative data were compared between the HCA and non-HCA group. Results Operation time and hemostatic time were significantly longer in the HCA group, whereas CPB time had no difference between the groups. The amount of perioperative bleeding and intraoperative transfusion were much higher in the HCA group. SLTs showed no difference between the groups both after anesthesia induction and after protamine reversal. In ROTEM analysis, MCE contributed by platelet was reduced in the HCA group, whereas MCE contributed by fibrinogen had no difference. Conclusion Our study confirmed that the amount of perioperative bleeding and intraoperative transfusion were significantly higher in the HCA group. ROTEM analysis would indicate that clot firmness contributed by platelet component is reduced by HCA in cardiac surgery.
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Chen W, Shen J, Zhang Y, Hu A, Liang J, Ma L, Yu X, Huang Y. A randomised controlled trial of fibrinogen concentrate during scoliosis surgery. Anaesthesia 2020; 75:1476-1481. [PMID: 32500569 DOI: 10.1111/anae.15124] [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] [Accepted: 05/06/2020] [Indexed: 01/28/2023]
Abstract
Bleeding and blood transfusion are common after scoliosis surgery. Fibrinogen is essential for blood clot formation and depletes quickly during haemorrhage. We randomly allocated 102 children 12-18 years old having surgery for idiopathic scoliosis, 51 to intra-operative fibrinogen concentrate 30 mg.kg-1 (maximum 2 g) and 51 to saline placebo. Fibrinogen reduced peri-operative blood loss by a median (95%CI) volume of 155 (5-320) ml, from a median (IQR [range]) of 1035 (818-1420 [400-3030]) ml to 885 (755-1155 [270-2645]) ml, p = 0.04. Seven and four children received allogeneic red blood cell transfusion after fibrinogen and placebo, respectively, p = 0.34. There were no side-effects.
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Affiliation(s)
- W Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - J Shen
- Department of Orthopedics Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Y Zhang
- Medical Research Center, Peking Union Medical College Hospital, Beijing, China
| | - A Hu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - J Liang
- Department of Orthopedics Surgery, Peking Union Medical College Hospital, Beijing, China
| | - L Ma
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - X Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Y Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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Kwapisz MM, Kent B, DiQuinzio C, LeGare J, Garnett S, Swyer W, Whynot S, Mingo H, Scheffler M. The prophylactic use of fibrinogen concentrate in high-risk cardiac surgery. Acta Anaesthesiol Scand 2020; 64:602-612. [PMID: 31889306 DOI: 10.1111/aas.13540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Perioperative blood loss is a major contributor to morbidity and mortality in cardiac surgery. Plasma fibrinogen levels play an essential role in hemostasis and deplete quickly during hemorrhage. The objective of this study was to determine whether prophylactic fibrinogen concentrate administration lowers overall blood product transfusion requirements in high-risk cardiac surgery in patients with low fibrinogen plasma levels. METHODS The study was performed in a prospective, randomized, and double-blinded design. The investigation included 62 patients undergoing elective, high-risk cardiac surgery. After weaning from cardiopulmonary bypass and reversal of heparin patients received either fibrinogen concentrate or placebo. The primary outcome variable was overall blood product usage 24 hours after intervention. RESULTS The fibrinogen group received numerically fewer total units of blood products than the placebo group, but the difference was not statistically or clinically significant (for groups n = 27; n = 29 and 19 vs 37 units, respectively, P = .908). The overall transfusion rate in both groups was significantly lower than the institutional average suggested (fibrinogen group 26%, placebo group 28%). The fibrinogen group showed significantly higher fibrinogen levels (2.38 vs 1.83 g/L (end of surgery), P < .001; 3.33 vs 2.68 g/L (12 hours after intervention), P = .003) and improved viscoelastic coagulation parameters (FIBTEM MCF, 27 vs 23 mm, P = .022). CONCLUSION This randomized, controlled trial demonstrates that point-of-care guided and prophylactic treatment with fibrinogen concentrate does not reduce transfusion of blood products in a setting of unexpectedly low transfusion rate as tested in this cohort, but may improve coagulation parameters in the setting of high-risk cardiac surgery.
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Affiliation(s)
- Myron M. Kwapisz
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Blaine Kent
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Claudio DiQuinzio
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Jean‐François LeGare
- Department of Surgery Division of Cardiac Surgery New Brunswick Heart Centre Saint John NB Canada
| | - Shirley Garnett
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Willi Swyer
- Department of Surgery, Perfusion Services Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Sara Whynot
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Heather Mingo
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Matthias Scheffler
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
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37
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Grottke O, Callum J, Cushing MM, Haas T. The use of coagulation factor concentrates for perioperative bleeding management - a global perspective. Transfusion 2020; 60:663-666. [PMID: 32154943 DOI: 10.1111/trf.15749] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine and Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
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38
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Downey LA, Andrews J, Hedlin H, Kamra K, McKenzie ED, Hanley FL, Williams GD, Guzzetta NA. Fibrinogen Concentrate as an Alternative to Cryoprecipitate in a Postcardiopulmonary Transfusion Algorithm in Infants Undergoing Cardiac Surgery. Anesth Analg 2020; 130:740-751. [DOI: 10.1213/ane.0000000000004384] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Roy A, Stanford S, Nunn S, Alves S, Sargant N, Rangarajan S, Smith EA, Bell J, Dayal S, Cecil T, Tzivanakis A, Kruzhkova I, Solomon C, Knaub S, Moran B, Mohamed F. Efficacy of fibrinogen concentrate in major abdominal surgery - A prospective, randomized, controlled study in cytoreductive surgery for pseudomyxoma peritonei. J Thromb Haemost 2020; 18:352-363. [PMID: 31654548 PMCID: PMC7027898 DOI: 10.1111/jth.14665] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy for pseudomyxoma peritonei (PMP) is associated with excessive bleeding and acquired fibrinogen deficiency. Maintaining plasma fibrinogen may support hemostasis. OBJECTIVES To compare hemostatic efficacy and safety of human fibrinogen concentrate (HFC) vs cryoprecipitate as fibrinogen sources for bleeding patients with acquired fibrinogen deficiency undergoing PMP CRS. METHODS FORMA-05 was an off-label single-center, prospective, randomized, controlled phase 2 study. Patients undergoing PMP surgery with predicted intraoperative blood loss ≥2 L received human fibrinogen concentrate (HFC; 4 g) or cryoprecipitate (two pools of 5 units, containing approximately 4.0-4.6 g fibrinogen), repeated as needed. The primary endpoint was a composite of intraoperative and postoperative efficacy, graded using objective 4-point scales and adjudicated by an independent committee. RESULTS One hundred percent of patients receiving HFC (95% confidence interval: 83.9-100.0, n = 21) or cryoprecipitate (84.6-100.0, n = 22) achieved hemostatic success. HFC demonstrated noninferior efficacy (P = .0095; post hoc) and arrived in the operating room 46 minutes faster. There were significantly greater mean increases with HFC vs cryoprecipitate in plasma fibrinogen (0.78 vs 0.35 g/L; P < .0001) and FIBTEM A20 (3.33 vs 0.93 mm; P = .003). Factor XIII, factor VIII, and von Willebrand factor activity were maintained throughout surgery. Only red blood cells were transfused intraoperatively (median units: HFC group, 1.0; cryoprecipitate group, 0.5). Thromboembolic events were detected with cryoprecipitate only. Safety was otherwise comparable between groups. CONCLUSIONS Human fibrinogen concentrate was hemostatically efficacious in patients undergoing major abdominal PMP surgery, with a favorable safety profile. These results are relevant to other surgical settings where bleeding and acquired fibrinogen deficiency occur.
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Affiliation(s)
- Ashok Roy
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | - Sean Nunn
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sue Alves
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Nigel Sargant
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Savita Rangarajan
- University Hospital Southampton NHS Foundation TrustUK
- KJ Somaiya AyurviharMumbaiIndia
| | | | - John Bell
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Sanjeev Dayal
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | - Tom Cecil
- Basingstoke and North Hampshire HospitalBasingstokeUK
| | | | | | | | | | - Brendan Moran
- Basingstoke and North Hampshire HospitalBasingstokeUK
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40
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Pearse BL, Keogh S, Rickard CM, Faulke DJ, Smith I, Wall D, McDonald C, Fung YL. Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model. J Multidiscip Healthc 2020; 13:27-41. [PMID: 32021232 PMCID: PMC6970603 DOI: 10.2147/jmdh.s232888] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/11/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose Excessive bleeding is an acknowledged consequence of cardiac surgery, occurring in up to 10% of adult patients. This clinically important complication leads to poorer patient outcomes. Clinical practice guidelines are available to support best practice however variability in bleeding management practice and related adverse outcomes still exist. This study had two objectives: 1) to gain insight into current bleeding management practice for adult cardiac surgery in Australia and how that compared to guidelines and literature; and 2) to understand perceived difficulties clinicians face implementing improvements in bleeding management. Methods A national cross-sectional questionnaire survey was utilized. Perspectives were sought from cardiac surgeons, cardiac anesthesiologists and perfusionists. Thirty-nine closed-ended questions focused on routine bleeding management practices to address pre and intra-operative care. One open-ended question was asked; “What would assist you to improve bleeding management with cardiac surgery patients?” Quantitative data were analysed with SPSS. Qualitative data were categorized into the domains of the Theoretical Domains Framework; the domains were then mapped to the COM-B model. Results Survey responses from 159 Anesthesiologists, 39 cardiac surgeons and 86 perfusionists were included (response rate 37%). Four of the recommendations queried in this survey were reported as routinely adhered to < 50% of the time, 9 queried recommendations were adhered to 51–75% of the time and 4 recommendations were routinely followed >76% of the time. Conclusion There is a wide variation in peri-operative bleeding management practice among cardiac anaesthesiologists, surgeons and perfusionists in Australian cardiac surgery units. Conceptualizing factors believed necessary to improve practice with the TDF and COM-B model found that bleeding management could be improved with a standardized approach including; point of care diagnostic assays, a bleeding management algorithm, access to concentrated coagulation factors, cardiac surgery specific bleeding management education, multidisciplinary team agreement and support, and an overarching national approach.
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Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia.,Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Samantha Keogh
- School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Daniel J Faulke
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Ian Smith
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Douglas Wall
- Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Yoke L Fung
- School of Health and Sports Sciences, University of Sunshine Coast, Sunshine Coast, QLD, Australia
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Green L, Roberts N, Cooper J, Field J, Gill R, Klein A, Agarwal S, Stanworth S, Johnston A, Monk V, O’Brien B. A pragmatic pilot phase II randomised controlled trial of prothrombin complex concentrates (PCC) versus fresh frozen plasma (FFP) in adult patients who are undergoing heart surgery (PROPHESY). Trials 2019; 20:684. [PMID: 31815658 PMCID: PMC6902595 DOI: 10.1186/s13063-019-3759-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/26/2019] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Fresh frozen plasma (FFP) is the accepted standard treatment for clotting factor replacement in bleeding patients during or immediately after cardiac surgery. In the United Kingdom prothrombin complex concentrate (PCC) is not licensed in this setting, although it is being used in Europe because it has a higher concentration of clotting factor levels, and it can be administered rapidly and in small volume, resulting in less volume overload during cardiac surgery. METHODS PROPHESY is a pragmatic, single-centre, open-label, randomised, controlled pilot trial that will assess whether it is feasible to perform a large trial in the future that will compare PCC versus FFP in patients who are bleeding (not on warfarin) and who require blood transfusion. Over a 15-month period, 50 patients will be randomised to PCC versus FFP if they develop active bleeding within 24 h of cardiac surgery and for whom the clinician has decided to administer FFP for treatment of bleeding. Standard laboratory and point-of-care assessments will be performed as per routine practice, and additional research blood samples will be taken at three time points to assess haemostasis. Subjects will be assessed daily up to hospital discharge or 30 days or death (whichever occurs first) and will be seen in follow-up for 90 days after surgery to assess for thromboembolic complications and hospital re-admission since discharge. Quality-of-life assessment will be performed pre-surgery and at 90 days post-surgery. We will also perform qualitative research with clinical experts and patients to explore the understanding of and experience with the interventions, as well as adherence to study procedures and protocol. DISCUSSION There have been no randomised controlled trials that have compared the safety and efficacy of FFP versus PCC in cardiac surgery patients who are bleeding. This pilot study will assess if individual components of a large trial are deliverable to assess the safety and efficacy of the two blood products in the future. TRIAL REGISTRATION EudraCT, 2018-003041-41; ClinicalTrials.gov, NCT03715348. Registered on 29 July 2018.
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Affiliation(s)
- Laura Green
- 0000 0001 2171 1133grid.4868.2Blizard Institute, Queen Mary University of London, NHS Blood and Transplant and Barts Health NHS Trust, 4 Newark Street, Whitechapel, London, E1 2AT UK
| | - Neil Roberts
- 0000 0000 9244 0345grid.416353.6St Bartholomew’s Hospital, West Smithfield, London, EC1A 7BE UK
| | - Jackie Cooper
- 0000 0001 2171 1133grid.4868.2Barts Cardiovascular Clinical Trials Unit (CVCTU), William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Jane Field
- 0000 0001 2171 1133grid.4868.2Barts Cardiovascular Clinical Trials Unit (CVCTU), William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Ravi Gill
- 0000000103590315grid.123047.3Southampton General Hospital, Tremona Road, Southampton, SO16 6YD UK
| | - Andrew Klein
- Papworth Hospitals NHS Foundation Trust, Papworth Everard, Cambridge, CB23 3RE UK
| | - Seema Agarwal
- 0000 0004 0641 2823grid.419319.7Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
| | - Simon Stanworth
- 0000 0001 0440 1440grid.410556.3Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9BQ UK
| | - Atholl Johnston
- 0000 0001 2171 1133grid.4868.2William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Vivienne Monk
- 0000 0001 2171 1133grid.4868.2Barts Cardiovascular Clinical Trials Unit (CVCTU), William Harvey Research Institute, Heart Centre, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ UK
| | - Ben O’Brien
- 0000 0000 9244 0345grid.416353.6St Bartholomew’s Hospital, West Smithfield, London, EC1A 7BE UK
- 0000 0001 0675 4725grid.239578.2Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH USA
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Curry N, Foley C, Wong H, Mora A, Curnow E, Zarankaite A, Hodge R, Hopkins V, Deary A, Ray J, Moss P, Reed MJ, Kellett S, Davenport R, Stanworth S. The application of a haemorrhage assessment tool in evaluating control of bleeding in a pilot trauma haemorrhage trial. Transfus Med 2019; 29:454-459. [PMID: 31680331 DOI: 10.1111/tme.12644] [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: 05/01/2019] [Revised: 08/22/2019] [Accepted: 10/06/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine whether it was feasible to use a haemorrhage assessment tool (HAT) within a trauma trial and whether the data obtained could differentiate patients who had achieved haemostasis. BACKGROUND Major haemorrhage is one of the leading causes of death worldwide, affecting 40% of trauma patients. Clinical trials evaluating haemostatic interventions often use transfusion outcomes as a primary endpoint. Transfusion is highly dependent on local practice, limiting its reliability as a robust, transferable endpoint. METHODS A five-point HAT questionnaire was applied to participants enrolled into the EFIT-1 trial. This RCT evaluated the feasibility of administering a 6 g fibrinogen concentrate to patients with severe trauma haemorrhage. RESULTS Of participants, 98% completed a HAT; 75% participants had 'achieved haemostasis' at the time of tool completion, as determined by clinical acumen alone. HAT scores were able to differentiate which participants required transfusion after 3 h. Of participants, 56% were transfused red blood cells when they scored 0-2, compared to 17% with HAT scores between 3 and 5. CONCLUSION This study has confirmed the feasibility of using a HAT during the emergency care of patients suffering trauma haemorrhage, and future studies should be conducted to determine its value as an endpoint in haemostasis studies.
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Affiliation(s)
- N Curry
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK
| | - C Foley
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - H Wong
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - A Mora
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - E Curnow
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - A Zarankaite
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - R Hodge
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - V Hopkins
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - A Deary
- NHS Blood and Transplant Clinical Trials Unit, NHS Blood and Transplant, Cambridge and Bristol, UK
| | - J Ray
- Department of Emergency Medicine, John Radcliffe Hospital, Oxford, UK
| | - P Moss
- Department of Emergency Medicine, St. George's Hospital, London, UK
| | - M J Reed
- Emergency Medicine Research Group Edinburgh (EMERGE), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - S Kellett
- Department of Anaesthetics, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - S Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR BRC Blood Theme, Oxford University, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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43
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Raphael J, Mazer CD, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Patel N, Welsby I, Greilich PE, Harvey R, Ranucci M, Heller LB, Boer C, Wilkey A, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Wilkey B, Gaitan B, Hill SS, Kwak J, Klick J, Bollen BA, Shore-Lesserson L, Abernathy J, Schwann N, Lau WT. Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2019; 33:2887-2899. [DOI: 10.1053/j.jvca.2019.04.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 01/28/2023]
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44
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Reducing Blood Transfusion in Aortic Surgery: A Novel Approach. Ann Thorac Surg 2019; 108:1369-1375. [DOI: 10.1016/j.athoracsur.2019.04.127] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 03/21/2019] [Accepted: 04/24/2019] [Indexed: 11/20/2022]
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45
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Raphael J, Mazer CD, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Patel N, Welsby I, Greilich PE, Harvey R, Ranucci M, Heller LB, Boer C, Wilkey A, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Wilkey B, Gaitan B, Hill SS, Kwak J, Klick J, Bollen BA, Shore-Lesserson L, Abernathy J, Schwann N, Lau WT. Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients. Anesth Analg 2019; 129:1209-1221. [PMID: 31613811 DOI: 10.1213/ane.0000000000004355] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.
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Affiliation(s)
- Jacob Raphael
- From the University of Virginia Health System, Charlottesville, Virginia
| | - C David Mazer
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Renata Ferreira
- University of Washington Medical Center, Seattle, Washington
| | | | - Nichlesh Patel
- University of California San Francisco, San Francisco, California
| | - Ian Welsby
- Duke University Hospital, Durham, North Carolina
| | | | - Reed Harvey
- UCLA Medical Center, Los Angeles, California
| | - Marco Ranucci
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Christa Boer
- VU University Medical Center, Amsterdam, the Netherlands
| | - Andrew Wilkey
- Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | | | | | - Prakash A Patel
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Jenny Kwak
- Loyola University Medical Center, Maywood, Illinois
| | - John Klick
- Case Western University Medical Center, Cleveland, Ohio
| | | | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra/Northwell, Northshore University Hospital, Manhasset, New York
| | | | - Nanette Schwann
- Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Tampa, Florida
- AAA Anesthesia Associates, PhyMed Healthcare Group, Allentown, Pennsylvania
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46
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Erdoes G, Koster A, Meesters MI, Ortmann E, Bolliger D, Baryshnikova E, Ahmed A, Lance MD, Ravn HB, Ranucci M, Heymann C, Agarwal S. The role of fibrinogen and fibrinogen concentrate in cardiac surgery: an international consensus statement from the Haemostasis and Transfusion Scientific Subcommittee of the European Association of Cardiothoracic Anaesthesiology. Anaesthesia 2019; 74:1589-1600. [DOI: 10.1111/anae.14842] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2019] [Indexed: 12/23/2022]
Affiliation(s)
- G. Erdoes
- Department of Anaesthesiology and Pain Medicine Inselspital, Bern University Hospital University of Bern Switzerland
| | - A. Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW Ruhr‐University Bochum Bad Oeynhausen Germany
| | - M. I. Meesters
- Department of Anaesthesiology University Medical Centre Utrecht The Netherlands
| | - E. Ortmann
- Department of Anaesthesia Kerckhoff Heart and Lung Centre Bad Nauheim Germany
| | - D. Bolliger
- Department of Anaesthesia Surgical Intensive Care Prehospital Emergency Medicine, and Pain Therapy University Hospital Basel Switzerland
| | - E. Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - A. Ahmed
- Department of Anaesthesia University Hospitals of Leicester NHS Trust LeicesterUK
| | - M. D. Lance
- Hamad Medical Corporation, HMC Anaesthesiology ICU and Peri‐operative Medicine Doha Qatar
| | - H. B. Ravn
- Department of Cardiothoracic Anaesthesiology Copenhagen University Hospital Copenhagen Denmark
| | - M. Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit IRCCS Policlinico San Donato Milan Italy
| | - C. Heymann
- Department of Anaesthesia Intensive Care Medicine, Emergency Medicine and Pain Therapy Vivantes Klinikum im Friedrichshain Berlin Germany
| | - S. Agarwal
- Department of Anaesthesia Manchester University Hospitals Manchester UK
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47
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Adelmann D, Koch S, Menger J, Opfermann P, Jaksch P, Hoetzenecker K, Kurz M, Mouhieddine M, Steinlechner B. Risk factors for early bleeding complications after lung transplantation – a retrospective cohort study. Transpl Int 2019; 32:1313-1321. [DOI: 10.1111/tri.13491] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/19/2019] [Accepted: 08/07/2019] [Indexed: 12/30/2022]
Affiliation(s)
- Dieter Adelmann
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine Department of Anesthesia, Intensive Care Medicine and Pain Medicine Medical University of Vienna Wien Austria
- Department of Anesthesia and Perioperative Care University of California San Francisco CA USA
| | - Stefan Koch
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine Department of Anesthesia, Intensive Care Medicine and Pain Medicine Medical University of Vienna Wien Austria
| | - Johannes Menger
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine Department of Anesthesia, Intensive Care Medicine and Pain Medicine Medical University of Vienna Wien Austria
| | - Philipp Opfermann
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine Department of Anesthesia, Intensive Care Medicine and Pain Medicine Medical University of Vienna Wien Austria
| | - Peter Jaksch
- Division of Thoracic Surgery Department of Surgery Medical University of Vienna Wien Austria
| | - Konrad Hoetzenecker
- Division of Thoracic Surgery Department of Surgery Medical University of Vienna Wien Austria
| | - Martin Kurz
- Department of Blood Group Serology and Transfusion Medicine Medical University of Vienna Wien Austria
| | - Mohammed Mouhieddine
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine Department of Anesthesia, Intensive Care Medicine and Pain Medicine Medical University of Vienna Wien Austria
| | - Barbara Steinlechner
- Division of Cardiac Thoracic Vascular Anesthesia and Intensive Care Medicine Department of Anesthesia, Intensive Care Medicine and Pain Medicine Medical University of Vienna Wien Austria
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48
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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49
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Peng HT, Nascimento B, Tien H, Callum J, Rizoli S, Rhind SG, Beckett A. A comparative study of viscoelastic hemostatic assays and conventional coagulation tests in trauma patients receiving fibrinogen concentrate. Clin Chim Acta 2019; 495:253-262. [DOI: 10.1016/j.cca.2019.04.066] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/27/2019] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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50
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Terwindt L, Karlas A, Eberl S, Wijnberge M, Driessen A, Veelo D, Geerts B, Hollmann M, Vlaar A. Patient blood management in the cardiac surgical setting: An updated overview. Transfus Apher Sci 2019; 58:397-407. [DOI: 10.1016/j.transci.2019.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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