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Liu X, Jiang H, Ren L, Cao L. Post-transfusion severe headache in a patient with thalassemia with superficial siderosis of the central nervous system: a case report and literature review. BMC Neurol 2024; 24:21. [PMID: 38184518 PMCID: PMC10770896 DOI: 10.1186/s12883-024-03526-1] [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: 10/03/2023] [Accepted: 01/01/2024] [Indexed: 01/08/2024] Open
Abstract
BACKGROUND Patients with severe thalassemia may experience adverse effects from transfusion such as fever, rash, and iron overload after long-term transfusion therapy. Severe headaches as a side effect of blood transfusion in patients with thalassemia are not commonly observed, especially when combined with superficial siderosis of the central nervous system, which is easily misdiagnosed and requires excessive examination and treatment. CASE PRESENTATION A 31-year-old woman was admitted with severe headache and vomiting over 3 days following blood transfusion. She was diagnosed with intermediate α-thalassemia at 2 years of age and had a history of irregular blood transfusions. Physical examination revealed horizontal nystagmus with no other abnormal neurological signs. Magnetic resonance (MR) imaging, MR venography, MR arteriography, and cerebrospinal fluid analysis were normal. However, susceptibility-weighted imaging showed abnormal signals in the bilateral and fourth ventricles. Initial antibiotics, antivirals, decompression of intracranial pressure, iron chelation, and symptomatic treatments were administered; subsequently, small intermittent blood transfusions were cautiously administered for severe anemia. The patient's headache was gradually relieved, and she was discharged on day 9. At the 5-month follow-up, the patient's headache recurred following another transfusion. CONCLUSIONS Severe post-transfusion headache in patients with thalassemia has not been fully recognized and is easily misdiagnosed, leading to excessive examination and treatment. Understanding the clinical features of transfusion-related headaches can help identify this complication, but the exact pathophysiological mechanism requires further research.
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Affiliation(s)
- Xudong Liu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Hongliang Jiang
- Department of Neurology, The Third People's Hospital of Yiyang City, Yiyang, China
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China.
- Department of Neurology, Shenzhen Second Peoples Hospital, Shenzhen, China.
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
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2
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Moore CC, Yu S, Aljure O. A comprehensive review of cerebral oximetry in cardiac surgery. J Card Surg 2022; 37:5418-5433. [PMID: 36423259 DOI: 10.1111/jocs.17232] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 09/03/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its noninvasive and user-friendly nature. Cerebral oximetry desaturations during cardiac surgery have been linked to an array of adverse clinical outcomes. However, the most effective intraoperative interventions to protect this vulnerable patient population have yet to be ascertained. AIM OF STUDY To provide a comprehensive summary of the intraoperative management for cerebral oximetry desaturations during cardiac surgery. The review highlights clinical outcomes from cerebral oximetry use to quantify the importance of identifying cerebral desaturations during cardiac surgery. The review then interrogates possible interventions for cerebral oximetry desaturations in an effort to determine which interventions are most efficacious and to enlighten possible areas for further research. METHODS A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses was performed through August 2021. RESULTS There is significant heterogeneity among patient populations for which cerebral oximetry monitoring has been studied in cardiac surgery. Further, the definition of a clinically significant cerebral desaturation and the assessment of neurocognitive outcomes varied substantially across studies. As a result, metanalysis is challenging and few conclusions can be drawn. Cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality to date. The evidence to support a particular intervention for an acute desaturation is equivocal. CONCLUSIONS Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.
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Affiliation(s)
- Christina C Moore
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
| | | | - Oscar Aljure
- Jackson Memorial Hospital/University of Miami Miller School of Medicine, Miami, Florida, USA
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3
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Wei S, Cao Y, Liu D, Zhang D. Cerebral infarction after cardiac surgery. IBRAIN 2022; 8:190-198. [PMID: 37786885 PMCID: PMC10528768 DOI: 10.1002/ibra.12046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/04/2022] [Accepted: 05/08/2022] [Indexed: 10/04/2023]
Abstract
Cerebral infarction, a common central nervous system complication after adult cardiac surgery, is one of the main factors leading to the poor prognosis of cardiac surgery patients besides cardiac insufficiency. However, there is currently no effective treatment for cerebral infarction. Therefore, early prevention and diagnosis of postoperative cerebral infarction are particularly important. There are many factors and mechanisms during and after cardiac surgery that play an important role in the occurrence of postoperative cerebral infarction, such as intraoperative embolism, systemic inflammatory response syndrome, atrial fibrillation, temperature regulation, blood pressure control, use of postoperative blood products, and so forth. The mechanism by which most risk factors act on the human body, leading to postoperative cerebral infarction, is not well understood, and further research is needed. Therefore, this paper aims to summarize and explain the relevant risk factors, mechanisms, clinical signs, imaging characteristics, and early diagnosis methods of cerebral infarction complications after cardiac surgery, and provides useful data for the establishment of related diagnosis and treatment standards.
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Affiliation(s)
- Shan Wei
- Department of Cardiovascular SurgeryAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Yi‐Ran Cao
- Department of Cardiovascular SurgeryAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Da‐Xing Liu
- Department of Cardiovascular SurgeryAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
| | - Deng‐Shen Zhang
- Department of Cardiovascular SurgeryAffiliated Hospital of Zunyi Medical UniversityZunyiGuizhouChina
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Maimaitiming M, Zhang C, Xie J, Zheng Z, Luo H, Ooi OC. Impact of restrictive red blood cell transfusion strategy on thrombosis-related events: A meta-analysis and systematic review. Vox Sang 2022; 117:887-899. [PMID: 35332942 DOI: 10.1111/vox.13274] [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: 09/22/2021] [Revised: 03/03/2022] [Accepted: 03/09/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES There is an ongoing controversy regarding the risks of restrictive and liberal red blood cell (RBC) transfusion strategies. This meta-analysis assessed whether transfusion at a lower threshold was superior to transfusion at a higher threshold, with regard to thrombosis-related events, that is, whether these outcomes can benefit from a restrictive transfusion strategy is debated. MATERIALS AND METHODS We searched PubMed, Cochrane Central Register of Controlled Trials and Scopus from inception up to 31 July 2021. We included randomized controlled trials (RCTs) in any clinical setting that evaluated the effects of restrictive versus liberal RBC transfusion in adults. We used random-effects models to calculate the risk ratios (RRs) and 95% confidence intervals (CIs) based on pooled data. RESULTS Thirty RCTs involving 17,334 participants were included. The pooled RR for thromboembolic events was 0.65 (95% CI 0.44-0.94; p = 0.020; I2 = 0.0%, very low-quality evidence), favouring the restrictive strategy. There were no significant differences in cerebrovascular accidents (RR = 0.83; 95% CI 0.64-1.09; p = 0.180; I2 = 0.0%, very low-quality evidence) or myocardial infarction (RR = 1.05; 95% CI 0.87-1.26; p = 0.620; I2 = 0.0%, low-quality evidence). Subgroup analyses showed that a restrictive (relative to liberal) strategy reduced (1) thromboembolic events in RCTs conducted in North America and (2) myocardial infarctions in the subgroup of RCTs where the restrictive transfusion threshold was 7 g/dl but not in the 8 g/dl subgroup (with a liberal transfusion threshold of 10 g/dl in both subgroups). CONCLUSIONS A restrictive (relative to liberal) transfusion strategy may be effective in reducing venous thrombosis but not arterial thrombosis.
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Affiliation(s)
- Mairehaba Maimaitiming
- School of Management, University of Science and Technology of China, Hefei, Anhui, China
| | - Chenxiao Zhang
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Jingui Xie
- School of Management, Technical University of Munich, Heilbronn, Germany.,Munich Data Science Institute, Technical University of Munich, Munich, Germany
| | - Zhichao Zheng
- Lee Kong Chian School of Business, Singapore Management University, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
| | - Oon Cheong Ooi
- Department of Cardiac, Thoracic and Vascular Surgery, National University Hospital, Singapore
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5
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Spadaccio C, Nenna A, Candura D, Rose D, Moscarelli M, Al-Attar N, Sutherland F. Total arterial coronary artery bypass grafting in patients with preoperative anemia. J Card Surg 2022; 37:1528-1536. [PMID: 35324020 DOI: 10.1111/jocs.16425] [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: 01/29/2022] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Blood transfusions after coronary artery bypass grafting (CABG) has been associated to adverse outcomes, especially in anemic patients. However, little is known about the influence of the modality of revascularization. Total arterial revascularization (TAR) was shown to reduce postoperative transfusion when compared to saphenous vein-based (SV)-CABG (LIMA plus one/more SV grafts). We, therefore, aimed to investigate the impact of TAR-CABG versus SV-CABG on blood products use and perioperative outcomes in patients with preoperative anemia, normally at higher risk for postoperative transfusions. METHODS From a cohort of 936 patients with mild preoperative anemia undergoing primary elective on-pump CABG, 166 matched pairs of patients undergoing either TAR- or SV-CABG were obtained. Anemia was defined as hemoglobin level <13 g/dl for men and <12 g/dl for women. The primary endpoint was the evaluation of red packed cells (RPC) use over the entire hospital stay. RESULTS TAR patients showed significantly reduced RPC usage compared with SV (mean difference 0.45 units). TAR patients had a reduced intubation time (mean difference 7.6 h) and were discharged 1.24 days earlier than SV patients. Pneumonia and acute kidney injury were doubled among SV patients. Adjusted regression showed that TAR technique is a predictor of reduced RPC unit use regardless of age and EuroSCORE II (odds ratio: 0.63, p < .01). CONCLUSION Patients with preoperative anemia might benefit from TAR regardless of age or calculated operative risk. TAR-CABG was associated to reduced postoperative use of blood products and postoperative length of stay in comparison with SV-CABG in this subset of patients.
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Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK.,Cardiac Surgery Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio Nenna
- Cardiac Surgery Department, Università Campus Bio-Medico di Roma, Rome, Italy
| | - Dario Candura
- Cardiac Surgery Department, Leiden University Medical Centrum, Leiden, The Netherlands
| | - David Rose
- Cardiac Surgery Department, Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool, UK
| | - Marco Moscarelli
- Cardiothoracic and Vascular Department, Maria Cecilia Hospital (GVM), Cotignola, Ravenna, Italy
| | - Nawwar Al-Attar
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK
| | - Fraser Sutherland
- Cardiothoracic Surgery Department, Golden Jubilee National Hospital, Glasgow, UK
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6
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Nuttall GA, Smith MM, Smith BB, Christensen JM, Santrach PJ, Schaff HV. A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients. Ann Thorac Cardiovasc Surg 2021; 28:204-213. [PMID: 34937821 PMCID: PMC9209891 DOI: 10.5761/atcs.oa.21-00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy. Materials and Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements. Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups. Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paula J Santrach
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Red blood cell transfusion induces abnormal HIF-1α response to cytokine storm after adult cardiac surgery. Sci Rep 2021; 11:22230. [PMID: 34782683 PMCID: PMC8592994 DOI: 10.1038/s41598-021-01695-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
Patients undergoing cardiac surgery develop a marked postoperative systemic inflammatory response. Blood transfusion may contribute to disruption of homeostasis in these patients. We sought to evaluate the impact of blood transfusion on serum interleukin-6 (IL-6), hypoxia induced factor-1 alpha (HIF-1α) levels as well as adverse outcomes in patients undergoing adult cardiac surgery. We prospectively enrolled 282 patients undergoing adult cardiac surgery. Serum IL-6 and HIF-1α levels were measured preoperatively and on the first postoperative day. Packed red blood cells were transfused in 26.3% of patients (mean 2.93 ± 3.05 units) by the time of postoperative sampling. Postoperative IL-6 levels increased over 30-fold and were similar in both groups (p = 0.115), whilst HIF-1α levels (0.377 pg/mL vs. 0.784 pg/mL, p = 0.002) decreased significantly in patients who received red blood cell transfusion. Moreover, greater decrease in HIF-1α levels predicted worse in-hospital and 3mo adverse outcome. Red blood cell transfusion was associated with higher risk of major adverse outcomes (stroke, pneumonia, all-cause mortality) during the index hospitalization. Red blood cell transfusion induces blunting of postoperative HIF-1 α response and is associated with higher risk of adverse thrombotic and pulmonary adverse events after cardiac surgery.
Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03444259.
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8
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Subramaniam K, Kumar A, Hernandez S, Nouraie SM. Effect of Blood Product Transfusion on Perioperative Outcomes After Heart Transplantation. J Cardiothorac Vasc Anesth 2020; 35:1067-1072. [PMID: 33168431 DOI: 10.1053/j.jvca.2020.10.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/13/2020] [Accepted: 10/14/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE(S) The objective of this study was to identify transfusion-related in-hospital outcomes in orthotopic heart transplantation (OHT) recipients. DESIGN Retrospective chart review. SETTING Tertiary care hospital. PARTICIPANTS Adult OHT recipients undergoing transplantation between January 2010 and December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary composite outcome was occurrence of any of the following events during admission for OHT: (1) graft dysfunction requiring mechanical circulatory support (MCS); (2) respiratory failure requiring tracheostomy; (3) renal failure requiring hemodialysis; (4) 30-day mortality; (5) complication requiring readmission to intensive care unit; (6) sepsis; and (7) stroke. The authors evaluated these outcomes in relation to all blood component transfusions received intraoperatively and in the first 24 hours postoperatively. The study included 197 patients and the primary composite outcome was present in 72 (36.6%). After adjusting for propensity score, red blood cell (RBC) transfusion was associated with composite outcomes (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.05-1.31, p = 0.004), postoperative MCS use (OR 1.36, 95% CI 1.18-1.58, p < 0.001), acute renal failure requiring hemodialysis (OR 1.21, 5% CI 1.06-1.38, p = 0.004), and 30-day mortality (OR 1.29, 95% CI 1.05-1.59, p = 0.02). Fresh frozen plasma was associated with composite outcome (OR 1.07, 95% CI [1.003-1.15], p = 0.042) and renal failure (OR 1.08, 95% CI 1.08 [1.002-1.17], p = 0.04). CONCLUSIONS Intra- and postoperative transfusions (first 24 hours) of RBC and FFP were associated with adverse postoperative composite outcomes in patients undergoing OHT.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Akshay Kumar
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Seyed Mehdi Nouraie
- Department of Pulmonary Allergy and Critical Care, University of Pittsburgh, Pittsburgh, PA
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Schlachtenberger G, Deppe AC, Gerfer S, Choi YH, Zeriouh M, Liakopoulos O, Wahlers TCW. Major Bleeding after Surgical Revascularization with Dual Antiplatelet Therapy. Thorac Cardiovasc Surg 2020; 68:714-722. [PMID: 32593177 DOI: 10.1055/s-0040-1710508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Patients with acute coronary syndrome are treated with dual antiplatelet therapy containing acetylsalicylic acid (ASA) and P2Y12 antagonists. In case of urgent coronary artery bypass grafting this might be associated with increasing risks of bleeding complications. METHODS Data from 1200 consecutive urgent operations between 2010 and 2018 were obtained from our institutional patient database. For this study off-pump surgery was excluded. The primary composite end point major bleeding consisted of at least one end point: transfusion ≥ 5 packed red blood cells within 24 hours, rethoracotomy due to bleeding, chest tube output >2000 mL within 24 hours. Demographic data, peri-, and postoperative variables and outcomes were compared between patients treated with mono antiplatelet therapy, ASA + clopidogrel (ASA-C) +ticagrelor (ASA-T) or +prasugrel (ASA-P) < 72 hours before surgery. Furthermore, we compared patients with dual antiplatelet therapy with ASA monotherapy. RESULTS From 1,086 patients, 475 (44%) received dual antiplatelet therapy. Three-hundred seventy-two received ASA-C (77.7%), 72 ASA-T (15%), and 31 ASA-P (6.5%). Major bleeding (44 vs. 23%, p < 0.0001) was more frequently in patients receiving dual therapy with higher rates of massive drainage loss within 24 hours (23 vs. 11%, p < 0.0001) of mass transfusion (34 vs. 16%, p < 0.0001) and rethoracotomy (10 vs. 5%, p = 0.002) when compared with ASA. In this analysis, ASA-T and ASA-P were not associated with higher bleeding complications compared with ASA-C. CONCLUSION Dual antiplatelet therapy is associated with higher rates of major bleeding. Further studies should examine the difference in the prevalence of major bleeding complications in the different dual antiplatelet therapy regimes in patients requiring urgent surgery.
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Affiliation(s)
- Georg Schlachtenberger
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Antje Christin Deppe
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Stephen Gerfer
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Yeong-Hoon Choi
- Department of Cardiac Surgery, Kerckhoff Vascular Centre Bad Nauheim, Bad Nauheim, Hessen, Germany
| | - Mohamed Zeriouh
- Department of Cardiac Surgery, Kerckhoff Vascular Centre Bad Nauheim, Bad Nauheim, Hessen, Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
| | - Thorsten C W Wahlers
- Department of Cardiothoracic Surgery, Klinikum der Universitat zu Koln Klinik und Poliklinik fur Herz- und Thoraxchirurgie, Köln, Nordrhein-Westfalen, Germany
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10
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Neurological complications after cardiac surgery: anesthetic considerations based on outcome evidence. Curr Opin Anaesthesiol 2020; 32:563-567. [PMID: 31145196 PMCID: PMC6735528 DOI: 10.1097/aco.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neurological complications after cardiac surgery remain prevalent. This review aims to discuss the modifiable and outcome-relevant risk factors based on an up-to-date literature review, with a focus on interventions that may improve outcomes.
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11
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van Hezel ME, van Manen L, Boshuizen M, Straat M, De Cuyper IM, Beuger B, Nieuwland R, Tanck MWT, de Korte D, Zwaginga JJ, van Bruggen R, Juffermans NP. The effect of red blood cell transfusion on platelet function in critically ill patients. Thromb Res 2019; 184:115-121. [PMID: 31731068 DOI: 10.1016/j.thromres.2019.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/11/2019] [Accepted: 10/31/2019] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Red blood cell (RBC) transfusion is associated with an increased risk of pro-thrombotic events, but the underlying mechanism is poorly understood. We hypothesized that RBC transfusion modulates platelet activity in critically ill patients with and without sepsis. METHODS In a prospective cohort study, 37 critically ill patients receiving a single RBC unit to correct for anemia were sampled prior to and 1 h after transfusion. Platelet exposure of P-selectin, CD63 and binding of PAC-1 as well as formation of platelet-leukocyte complexes were measured by flow cytometry. The ability of plasma from critically ill patients to induce ex vivo platelet aggregation was assessed by flow cytometry after incubation with platelets from a healthy donor. RESULTS RBC transfusion neither triggered the expression of platelet activation markers nor the formation of platelet-leukocyte complexes. Plasma from critically ill patients induced more spontaneous platelet aggregation prior to RBC transfusion compared to healthy controls, which was further augmented following RBC transfusion. Also collagen-induced platelet aggregation was already increased prior to RBC transfusion compared to healthy controls, and this response was unaffected by RBC transfusion. In contrast, ristocetin-induced platelet agglutination was decreased when compared to controls, suggesting impaired vWF-dependent platelet agglutination, even in the presence of high vWF levels. Following RBC transfusion, ristocetin-induced platelet agglutination further decreased. There were no differences between septic and non-septic recipients in all assays. CONCLUSION Ex vivo platelet aggregation is disturbed in the critically ill. Transfusion of a RBC unit may further increase the spontaneous platelet aggregatory response.
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Affiliation(s)
- Maike E van Hezel
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands
| | - Lisa van Manen
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands
| | - Margit Boshuizen
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands; Department of Intensive Care Medicine, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands
| | - Marleen Straat
- Department of Intensive Care Medicine, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands
| | - Iris M De Cuyper
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands
| | - Boukje Beuger
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands
| | - Rienk Nieuwland
- Laboratory of Experimental Clinical Chemistry, and Vesicle Observation Centre, Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics (KEBB), Academic Medical Center of the University of Amsterdam, Amsterdam, the Netherlands
| | - Dirk de Korte
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands; Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, the Netherlands
| | - Jaap Jan Zwaginga
- Department of Immunohematology and Bloodtransfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research, Amsterdam, the Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, the Netherlands.
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12
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Grothusen C, Cremer J. Chirurgische Revaskularisation im akuten Myokardinfarkt. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-019-0319-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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Tian WZ, Er JX, Liu L, Chen QL, Han JG. Effects of Autologous Platelet Rich Plasma on Intraoperative Transfusion and Short-Term Outcomes in Total Arch Replacement (Sun's Procedure): A Prospective, Randomized Trial. J Cardiothorac Vasc Anesth 2019; 33:2163-2169. [PMID: 31060939 DOI: 10.1053/j.jvca.2019.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To observe the effect of collecting and retransfusing autologous platelet rich plasma (aPRP) on the amount of allogeneic blood usage in total arch replacement (Sun's surgery) and the outcomes 30 days after surgery. DESIGN A prospective, randomized trial. SETTING A tertiary university hospital specialized in cardiovascular diseases. PARTICIPANTS The study comprised 120 patients undergoing Sun's surgery for Stanford type A acute aortic dissection. INTERVENTIONS aPRP was harvested before incision and was re-transfused after heparin neutralization for patients in the treatment group. MEASUREMENTS AND MAIN RESULTS There was no significant difference in preoperative demographic data between the 2 study groups. Intraoperative transfusions of erythrocyte (p = 0.009), plasma (p = 0.017), cryoprecipitate (p = 0.002), and platelets (p < 0.001) in the treatment group were reduced significantly. In addition, less blood loss was observed in the treatment group (p = 0.002). The durations of postoperative mechanical ventilation (p = 0.029) and hospitalization (p = 0.002) of the treatment group were significantly shorter. There were no statistically significant differences in the length of intensive care unit stay, the incidence of complications, and mortality 30 days after surgery. CONCLUSION In total arch replacement (Sun's surgery), collecting and retransfusing aPRP reduced intraoperative transfusions of erythrocyte, plasma, and cryoprecipitate and decreased the duration of postoperative mechanical ventilation and hospitalization. This technique had no significant effect on the incidence of complications and mortality 30 days postoperatively.
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Affiliation(s)
- Wen-Zhi Tian
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin Cardiovascular Diseases Institute, Tianjin, China
| | - Jian-Xu Er
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin Cardiovascular Diseases Institute, Tianjin, China
| | - Liang Liu
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin Cardiovascular Diseases Institute, Tianjin, China
| | - Qing-Liang Chen
- Department of Cardio-Vascular Surgery, Tianjin Chest Hospital, Tianjin Cardiovascular Diseases Institute, Tianjin, China
| | - Jian-GeHan Han
- Department of Anesthesiology, Tianjin Chest Hospital, Tianjin Cardiovascular Diseases Institute, Tianjin, China.
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14
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Roman M, Biancari F, Ahmed AB, Agarwal S, Hadjinikolaou L, Al-Sarraf A, Tsang G, Oo AY, Field M, Santini F, Mariscalco G. Prothrombin Complex Concentrate in Cardiac Surgery: A Systematic Review and Meta-Analysis. Ann Thorac Surg 2018; 107:1275-1283. [PMID: 30458156 DOI: 10.1016/j.athoracsur.2018.10.013] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/28/2018] [Accepted: 10/01/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Prothrombin complex concentrate (PCC) has recently emerged as an effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. This systematic review and meta-analysis evaluated the safety and efficacy of PCC administration as first-line treatment for coagulopathy after adult cardiac surgery. METHODS PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared with patients receiving FFP. RESULTS A total of 861 adult patients from four studies were retrieved. No randomized studies were identified. Pooled odds ratios (ORs) showed that the PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR, 2.22; 95% confidence interval [CI], 1.45 to 3.40) and units of RBC received (OR, 1.34; 95% CI, 0.78 to 1.90). No differences were observed between the groups for reexploration for bleeding (OR, 1.09; 95% CI, 0.66 to 1.82), chest drain output at 24 hours (OR, 66.36; 95% CI, -82.40 to 216.11), hospital mortality (OR, 0.94; 95% CI, 0.59 to 1.49), stroke (OR, 0.80; 95% CI, 0.41 to 1.56), and occurrence of acute kidney injury (OR, 0.80; 95% CI, 0.58 to 1.12). A trend toward increased risk of renal replacement therapy was observed in the PCC group (OR, 0.41; 95% CI, 0.16 to 1.02). CONCLUSIONS In patients with significant bleeding after cardiac surgery, PCC administration seems to be more effective than FFP in reducing perioperative blood transfusions. No additional risks of thromboembolic events or other adverse reactions were observed. Randomized controlled trials are needed to establish the safety of PCC in cardiac surgery definitively.
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Affiliation(s)
- Marius Roman
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland
| | - Aamer B Ahmed
- Department of Anesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Seema Agarwal
- Department of Anesthesia, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Leon Hadjinikolaou
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ali Al-Sarraf
- Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Geoff Tsang
- Cardiac Surgery Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Aung Y Oo
- Department of Cardiac Surgery, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Francesco Santini
- Department of Integrated Surgical and Diagnostic Sciences, Division of Cardiac Surgery, University of Genoa, Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, United Kingdom; Cardiac Surgery Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom.
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15
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Peters AL, Vlaar APJ, van Bruggen R, de Korte D, Meijers JCM, Nieuwland R, Juffermans NP. Transfusion of autologous extracellular vesicles from stored red blood cells does not affect coagulation in a model of human endotoxemia. Transfusion 2018; 58:1486-1493. [PMID: 29577324 DOI: 10.1111/trf.14607] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/15/2018] [Accepted: 01/19/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Red blood cell (RBC) transfusion has been related to thromboembolic events. Microvesicles in the RBC product may support coagulation because they have procoagulant effects in vitro. We investigated whether transfusion of RBCs containing extracellular vesicles promotes coagulation in human recipients. As transfusion is mostly administered to ill patients, we used a model of endotoxemia. STUDY DESIGN AND METHODS Eighteen healthy volunteers were randomized to receive either saline or fresh (2 days stored) or stored autologous (35 days stored) RBC transfusion (Dutch Trial Register: NTR4455). Two hours after infusion of lipopolysaccharide (LPS, from Escherichia coli, 2 ng/kg body weight), subjects received either saline or fresh or stored RBCs. Blood was sampled every 2 hours up to 8 hours after LPS infusion. Vesicles were measured with a flow cytometer (A50-Micro, Apogee Flow Systems). RESULTS LPS resulted in increased thrombin generation compared to baseline. During storage, the total number of extracellular vesicles increased from 1.4 × 108 /mL (interquartile range [IQR], 8.3 × 107 -1.9 × 108 /mL) in the fresh product to 1.7 × 1010 /mL (IQR, 7.9 × 109 -2.3 × 1010 /mL; p < 0.01) in the stored product (p < 0.001). Vesicles appeared to be mostly RBC derived. CONCLUSION After transfusion, extracellular vesicles from stored RBC products, but not from fresh products, could be detected in the circulation of healthy volunteers. However, infusion of stored RBC extracellular vesicles did not augment thrombin generation compared to endotoxemic controls. Also, levels of d-dimer and thrombin-antithrombin complex were unaffected. In conclusion, transfusion of autologous RBCs containing high levels of extracellular vesicles does not enhance coagulation in human volunteers with endotoxemia.
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Affiliation(s)
- Anna L Peters
- Laboratory of Experimental Intensive Care and Anesthesia, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam, The Netherlands
| | - Alexander P J Vlaar
- Laboratory of Experimental Intensive Care and Anesthesia, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands
| | - Dirk de Korte
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Department of Product and Process Development, Sanquin Blood Bank, Amsterdam, The Netherlands
| | - Joost C M Meijers
- Department of Experimental Vascular Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Department of Plasma Proteins, Sanquin Research, Amsterdam, The Netherlands
| | - Rienk Nieuwland
- Laboratory for Experimental Clinical Chemistry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicole P Juffermans
- Laboratory of Experimental Intensive Care and Anesthesia, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam, The Netherlands
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16
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A model-based cost-effectiveness analysis of Patient Blood Management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018. [PMID: 29517965 DOI: 10.2450/2018.0213-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patient blood management (PBM) is a multidisciplinary concept focused on the management of anaemia, minimisation of iatrogenic blood loss and rational use of allogeneic blood products. The aims of this study were: (i) to analyse post-operative outcome in patients with liberal vs restrictive exposure to allogeneic blood products and (ii) to evaluate the cost-effectiveness of PBM in patients undergoing surgery. MATERIALS AND METHODS A systematic literature review and meta-analysis were performed to compare post-operative complications in predominantly non-transfused patients (restrictive transfusion group) and patients who received one to three units of red blood cells (liberal transfusion group). Outcome measures included sepsis with/without pneumonia, acute renal failure, acute myocardial infarction and acute stroke. In a second step, a health economic model was developed to calculate cost-effectiveness of PBM (PBM-arm vs control-arm) for simulated cohorts of 10,000 cardiac and non-cardiac surgical patients based on the results of the meta-analysis and costs. RESULTS Out of 478 search results, 22 studies were analysed in the meta-analysis. The pooled relative risk of any complication in the restrictive transfusion group was 0.43 for non-cardiac and 0.34 for cardiac surgical patients. In the simulation model, PBM was related to reduced complications (1,768 vs 1,245) and complication-related deaths (411 vs 304) compared to standard care. PBM-related costs of therapy exceeded costs of the control arm by € 150 per patient. However, total costs, including hospitalisation, were higher in the control-arm for both non-cardiac (€ 2,885.11) and cardiac surgery patients (€ 1,760.69). The incremental cost-effectiveness ratio including hospitalisation showed savings of € 30,458 (non-cardiac and cardiac surgery patients) for preventing one complication and € 128,023 (non-cardiac and cardiac surgery patients) for prevention of one complication-related death in the PBM-arm. DISCUSSION Our results indicate that PBM may be associated with fewer adverse clinical outcomes compared to control management and may, thereby, be cost-effective.
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17
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Craver C, Belk KW, Myers GJ. Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis. Perfusion 2017; 33:44-52. [PMID: 28816101 PMCID: PMC5734379 DOI: 10.1177/0267659117723698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Historically, perioperative hemoglobin monitoring has relied on calculated saturation, using blood gas devices that measure plasma hematocrit (Hct). Co-oximetry, which measures total hemoglobin (tHb), yields a more comprehensive assessment of hemodilution. The purpose of this study was to examine the association of tHb measurement by co-oximetry and Hct, using conductivity with red blood cell (RBC) transfusion, length of stay (LOS) and inpatient costs in patients having major cardiac surgery. Methods: A retrospective study was conducted on patients who underwent coronary artery bypass graft (CABG) and/or valve replacement (VR) procedures from January 2014 to June 2016, using MedAssets discharge data. The patient population was sub-divided by the measurement modality (tHb and Hct), using detailed billing records and Current Procedural Terminology coding. Cost was calculated using hospital-specific cost-to-charge ratios. Multivariable logistic regression was performed to identify significant drivers of RBC transfusion and resource utilization. Results: The study population included 18,169 cardiovascular surgery patients. Hct-monitored patients accounted for 66% of the population and were more likely to have dual CABG and VR procedures (10.4% vs 8.9%, p=0.0069). After controlling for patient and hospital characteristics, as well as patient comorbidities, Hct-monitored patients had significantly higher RBC transfusion risk (OR=1.26, CI 1.15-1.38, p<0.0001), longer LOS (IRR=1.08, p<0.0001) and higher costs (IRR=1.15, p<0.0001) than tHb-monitored patients. RBC transfusions were a significant driver of LOS (IRR=1.25, p<0.0001) and cost (IRR=1.22, p<0.0001). Conclusions: tHb monitoring during cardiovascular surgery could offer a significant reduction in RBC transfusion, length of stay and hospital cost compared to Hct monitoring.
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Affiliation(s)
- Christopher Craver
- 1 Vizient Inc., Health Data analytics, Irving, TX, USA.,2 University of North Carolina-Charlotte, College of Health and Human Services, Charlotte, NC, USA
| | - Kathy W Belk
- 1 Vizient Inc., Health Data analytics, Irving, TX, USA
| | - Gerard J Myers
- 3 Eastern Perfusion International, Dartmouth, Nova Scotia, Canada
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18
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Kinnunen EM, Zanobini M, Onorati F, Brascia D, Mariscalco G, Franzese I, Ruggieri VG, Bounader K, Perrotti A, Musumeci F, Santarpino G, Maselli D, Nardella S, Gulbins H, Gherli R, Rubino AS, Mignosa C, De Feo M, Gatti G, Santini F, Salsano A, Dalén M, Saccocci M, Reichart D, Faggian G, Gherli T, Nicolini F, Biancari F. The impact of minor blood transfusion on the outcome after coronary artery bypass grafting. J Crit Care 2017; 40:207-212. [PMID: 28445858 DOI: 10.1016/j.jcrc.2017.04.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 02/28/2017] [Accepted: 04/14/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE To investigate the impact of minor perioperative bleeding requiring transfusion of 1-2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). METHODS Sixteen cardiac surgical centers contributed to the prospective European CABG registry (E-CABG). 1014 patients receiving 1-2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs. RESULTS In 827 propensity score matched pairs, transfusion of 1-2 RBC units did not affect the risk of in-hospital/30-day death (p=0.523) or stroke (p=0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p=0.008), sternal wound infection (p=0.001), postoperative use of antibiotics (p=0.001), prolonged use of inotropes (p<0.0001), use of intra-aortic balloon pump (p=0.012), length of intensive care unit stay (p<0.0001) and length of in-hospital stay (p<0.0001). Matched paired analysis excluding pre- and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in-hospital/30-day death. CONCLUSION Minor perioperative bleeding and subsequent transfusion of 1-2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low-volume RBC transfusion may improve the outcome after CABG.
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Affiliation(s)
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Debora Brascia
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Ilaria Franzese
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Francesco Musumeci
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Saverio Nardella
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | | | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | | | - Marisa De Feo
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | | | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiothoracic Surgery and Anesthesiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | | | - Giuseppe Faggian
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Tiziano Gherli
- Division of Cardiac Surgery, University of Parma, Parma, Italy
| | | | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
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19
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Boettcher W, Sinzobahamvya N, Miera O, Redlin M, Dehmel F, Cho MY, Murin P, Berger F, Photiadis J. Routine Application of Bloodless Priming in Neonatal Cardiopulmonary Bypass: A 3-Year Experience. Pediatr Cardiol 2017; 38:807-812. [PMID: 28197644 DOI: 10.1007/s00246-017-1585-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 02/02/2017] [Indexed: 10/20/2022]
Abstract
A restrictive transfusion strategy led us to routinely try to conduct donor-blood free open-heart surgery even in neonates. The cardio-pulmonary bypass (CPB) circuit was minimized by priming volumina at 73 ml for the smallest patients with body weight up to 2.5 kg and 85-95 ml for those with body weight of more than 2.5 kg, and by positioning the console as close as possible to operation table. Measures were applied to save blood during the procedure. Transfusion threshold of 8 g/dl hemoglobin was retained. Effort was made to avoid transfusion while on CPB or to postpone transfusion towards CPB end. From 2013 to 2015, 149 consecutive neonates underwent 150 open-heart procedures without blood in priming volume. Weight was lower than 2.5 kg in five instances. The most frequent operations were arterial switch operation (n = 54) and Norwood procedure (n = 17). Transfusion-free operation was achieved in 44 procedures. The great majority (42/44 = 95%) involved biventricular repair and included 50% (27/54) of arterial switch operations. 106 patients were transfused: 63 mostly towards CPB end, and 43 after coming off bypass. Transfusion-free procedures were associated with postoperative lower lactate concentration (p = 0.0013) and shorter duration of mechanical ventilation (p = 0.0009). Seven patients were discharged from hospital without getting any transfusion of blood or blood products. In conclusion, routine application of bloodless priming in neonatal cardiopulmonary bypass is safe and beneficial. It results into a good number (29%= 44/150) of transfusion-free operations. Postponing transfusion towards CPB end favors an overall restrictive transfusion strategy for all patients.
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Affiliation(s)
- Wolfgang Boettcher
- Department of Pediatric Cardiac Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Nicodème Sinzobahamvya
- Department of Pediatric Cardiac Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Oliver Miera
- Department of Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Matthias Redlin
- Department of Anesthesiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Frank Dehmel
- Department of Pediatric Cardiac Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Mi-Young Cho
- Department of Pediatric Cardiac Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Peter Murin
- Department of Pediatric Cardiac Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Berger
- Department of Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Joachim Photiadis
- Department of Pediatric Cardiac Surgery, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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20
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Impact of transfusion on stroke after cardiovascular interventions: Meta-analysis of comparative studies. J Crit Care 2017; 38:157-163. [DOI: 10.1016/j.jcrc.2016.11.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 10/30/2016] [Accepted: 11/02/2016] [Indexed: 01/28/2023]
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21
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Kinnunen E, De Feo M, Reichart D, Tauriainen T, Gatti G, Onorati F, Maschietto L, Bancone C, Fiorentino F, Chocron S, Bounader K, Dalén M, Svenarud P, Faggian G, Franzese I, Santarpino G, Fischlein T, Maselli D, Dominici C, Nardella S, Gherli R, Musumeci F, Rubino AS, Mignosa C, Mariscalco G, Serraino FG, Santini F, Salsano A, Nicolini F, Gherli T, Zanobini M, Saccocci M, Ruggieri VG, Philippe Verhoye J, Perrotti A, Biancari F. Incidence and prognostic impact of bleeding and transfusion after coronary surgery in low‐risk patients. Transfusion 2016; 57:178-186. [DOI: 10.1111/trf.13885] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/29/2016] [Accepted: 08/10/2016] [Indexed: 01/01/2023]
Affiliation(s)
| | - Marisa De Feo
- Division of Cardiac Surgery, Department of Cardiothoracic SciencesSecond University of NaplesNaples Italy
| | | | | | - Giuseppe Gatti
- Division of Cardiac SurgeryOspedali RiunitiTrieste Italy
| | - Francesco Onorati
- Division of Cardiovascular SurgeryVerona University HospitalVerona Italy
| | | | - Ciro Bancone
- Division of Cardiac Surgery, Department of Cardiothoracic SciencesSecond University of NaplesNaples Italy
| | - Francesca Fiorentino
- Division of Cardiac Surgery, Department of Cardiothoracic SciencesSecond University of NaplesNaples Italy
| | - Sidney Chocron
- Department of Thoracic and Cardio‐Vascular SurgeryUniversity Hospital Jean MinjozBesançon France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular SurgeryPontchaillou University HospitalRennes France
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiothoracic Surgery and AnesthesiologyKarolinska Institutet, Karolinska University HospitalStockholm Sweden
| | - Peter Svenarud
- Department of Molecular Medicine and Surgery, Department of Cardiothoracic Surgery and AnesthesiologyKarolinska Institutet, Karolinska University HospitalStockholm Sweden
| | - Giuseppe Faggian
- Division of Cardiovascular SurgeryVerona University HospitalVerona Italy
| | - Ilaria Franzese
- Division of Cardiovascular SurgeryVerona University HospitalVerona Italy
| | | | - Theodor Fischlein
- Cardiovascular Center, Paracelsus Medical UniversityNuremberg Germany
| | - Daniele Maselli
- Department of Cardiac SurgerySt. Anna HospitalCatanzaro Italy
| | | | | | - Riccardo Gherli
- Department of Cardiovascular SciencesCardiac Surgery Unit, S. Camillo‐Forlanini HospitalRome Italy
| | - Francesco Musumeci
- Department of Cardiovascular SciencesCardiac Surgery Unit, S. Camillo‐Forlanini HospitalRome Italy
| | | | | | - Giovanni Mariscalco
- Department of Cardiovascular SciencesClinical Sciences Wing, University of Leicester, Glenfield HospitalLeicester UK
| | - Filiberto G. Serraino
- Department of Cardiovascular SciencesClinical Sciences Wing, University of Leicester, Glenfield HospitalLeicester UK
| | | | | | | | - Tiziano Gherli
- Division of Cardiac SurgeryUniversity of ParmaParma Italy
| | - Marco Zanobini
- Department of Cardiac SurgeryCentro Cardiologico–Fondazione Monzino IRCCS, University of MilanMilan Italy
| | - Matteo Saccocci
- Department of Cardiac SurgeryCentro Cardiologico–Fondazione Monzino IRCCS, University of MilanMilan Italy
| | - Vito G. Ruggieri
- Division of Cardiothoracic and Vascular SurgeryPontchaillou University HospitalRennes France
| | - Jean Philippe Verhoye
- Division of Cardiothoracic and Vascular SurgeryPontchaillou University HospitalRennes France
| | - Andrea Perrotti
- Department of Thoracic and Cardio‐Vascular SurgeryUniversity Hospital Jean MinjozBesançon France
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22
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Biancari F, Tauriainen T, Perrotti A, Dalén M, Faggian G, Franzese I, Chocron S, Ruggieri VG, Bounader K, Gulbins H, Reichart D, Svenarud P, Santarpino G, Fischlein T, Puski T, Maselli D, Dominici C, Nardella S, Mariscalco G, Gherli R, Musumeci F, Rubino AS, Mignosa C, De Feo M, Bancone C, Gatti G, Maschietto L, Santini F, Salsano A, Nicolini F, Gherli T, Zanobini M, Saccocci M, D'Errigo P, Kinnunen EM, Onorati F. Bleeding, transfusion and the risk of stroke after coronary surgery: A prospective cohort study of 2357 patients. Int J Surg 2016; 32:50-7. [DOI: 10.1016/j.ijsu.2016.06.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/10/2016] [Accepted: 06/15/2016] [Indexed: 01/16/2023]
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23
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Nguyen TT, Donahue BS. Sex matching and red cell safety. J Thorac Cardiovasc Surg 2016; 152:233-4. [PMID: 27130299 DOI: 10.1016/j.jtcvs.2016.03.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 03/24/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Thanh T Nguyen
- Division of Pediatric Anesthesia, Department of Anesthesiology, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tenn
| | - Brian S Donahue
- Division of Pediatric Anesthesia, Department of Anesthesiology, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tenn.
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Scarpino M, Olivo G, Quilghini P, Lanzo G, Moretti M, Carrai R, Fontanari P, Amantini A, Grippo A. Cortical Blindness After Cardiac Surgery: Just an Ischemic Mechanism? J Cardiothorac Vasc Anesth 2016; 30:1053-6. [PMID: 26746795 DOI: 10.1053/j.jvca.2015.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Maenia Scarpino
- IRCCS Don Carlo Gnocchi, Florence, Italy; Neuromuscular Department
| | | | | | | | - Marco Moretti
- Neuroradiology Service Department, AOU Careggi, Florence, Italy
| | - Riccardo Carrai
- IRCCS Don Carlo Gnocchi, Florence, Italy; Neuromuscular Department
| | | | - Aldo Amantini
- IRCCS Don Carlo Gnocchi, Florence, Italy; Neuromuscular Department
| | - Antonello Grippo
- IRCCS Don Carlo Gnocchi, Florence, Italy; Neuromuscular Department.
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Cappabianca G, Mariscalco G, Biancari F, Maselli D, Papesso F, Cottini M, Crosta S, Banescu S, Ahmed AB, Beghi C. Safety and efficacy of prothrombin complex concentrate as first-line treatment in bleeding after cardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:5. [PMID: 26738468 PMCID: PMC4702344 DOI: 10.1186/s13054-015-1172-6] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/13/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Bleeding after cardiac surgery requiring surgical reexploration and blood component transfusion is associated with increased morbidity and mortality. Although prothrombin complex concentrate (PCC) has been used satisfactorily in bleeding disorders, studies on its efficacy and safety after cardiopulmonary bypass are limited. METHODS Between January 2005 and December 2013, 3454 consecutive cardiac surgery patients were included in an observational study aimed at investigating the efficacy and safety of PCC as first-line coagulopathy treatment as a replacement for fresh frozen plasma (FFP). Starting in January 2012, PCC was introduced as solely first-line treatment for bleeding following cardiac surgery. RESULTS After one-to-one propensity score-matched analysis, 225 pairs of patients receiving PCC (median dose 1500 IU) and FFP (median dose 2 U) were included. The use of PCC was associated with significantly decreased 24-h post-operative blood loss (836 ± 1226 vs. 935 ± 583 ml, p < 0.0001). Propensity score-adjusted multivariate analysis showed that PCC was associated with significantly lower risk of red blood cell (RBC) transfusions (odds ratio [OR] 0.50; 95% confidence interval [CI] 0.31-0.80), decreased amount of RBC units (β unstandardised coefficient -1.42, 95% CI -2.06 to -0.77) and decreased risk of transfusion of more than 2 RBC units (OR 0.53, 95% CI 0.38-0.73). Patients receiving PCC had an increased risk of post-operative acute kidney injury (AKI) (OR 1.44, 95% CI 1.02-2.05) and renal replacement therapy (OR 3.35, 95% CI 1.13-9.90). Hospital mortality was unaffected by PCC (OR 1.51, 95% CI 0.84-2.72). CONCLUSIONS In the cardiac surgery setting, the use of PCC compared with FFP was associated with decreased post-operative blood loss and RBC transfusion requirements. However, PCC administration may be associated with a higher risk of post-operative AKI.
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Affiliation(s)
- Giangiuseppe Cappabianca
- Department of Surgical and Morphological Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria, Varese, Italy.
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, Glenfield Hospital, University of Leicester, Groby Road, Leicester, LE39QP, UK.
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland.
| | - Daniele Maselli
- Department of Cardiovascular Surgery, Cardiac Surgery Unit, S.Anna Hospital Catanzaro, Catanzaro, Italy.
| | - Francesca Papesso
- Department of Surgical and Morphological Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria, Varese, Italy.
| | - Marzia Cottini
- Department of Surgical and Morphological Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria, Varese, Italy.
| | - Sandro Crosta
- Cardiac Intensive Care Unit, Varese University Hospital, University of Insubria, Varese, Italy.
| | - Simona Banescu
- Cardiac Intensive Care Unit, Varese University Hospital, University of Insubria, Varese, Italy.
| | - Aamer B Ahmed
- Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, UK.
| | - Cesare Beghi
- Department of Surgical and Morphological Sciences, Cardiac Surgery Unit, Varese University Hospital, University of Insubria, Varese, Italy.
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Assessing the Rates, Predictors, and Complications of Blood Transfusion Volume in Posterior Arthrodesis for Adolescent Idiopathic Scoliosis. Spine (Phila Pa 1976) 2015; 40:1422-30. [PMID: 26076438 DOI: 10.1097/brs.0000000000001019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To determine predictors of and 30-day complications associated with blood transfusion volume after posterior spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA Posterior arthrodesis is a common procedure performed for AIS, and patients frequently require perioperative blood transfusions. Few studies, however, have examined the rates and potential complications associated with blood transfusion volume. METHODS Patients undergoing posterior arthrodesis for AIS were selected from the National Surgical Quality Improvement Program pediatric database from 2012 to 2013. Patients were stratified on the basis of blood transfusion volume and patient demographics and comorbidities, operative characteristics, and 30-day complications were recorded. Multivariate analyses were performed to determine predictors of transfusion as well as the effect of transfusion volume on 30-day complication rates. RESULTS A total of 1691 patients were included. Male sex (P = 0.010), esophageal or gastrointestinal disease (P = 0.016), cardiac risk factors (P = 0.037), preoperative inotrope requirement (P = 0.031), total operative time of 300 minutes or more (P < 0.001), and posterior arthrodesis of 13 or more vertebral segments (P < 0.001) were independent risk factors for requiring blood transfusion. Total transfusion volume of 20 mL/kg or more was the minimum volume independently associated with increased rates of total complications (P = 0.018), with a complication rate of 5.9%. CONCLUSION We present the first large, comprehensive analysis of complications related to blood transfusion events and transfusion volume on short-term postoperative complications after posterior arthrodesis for AIS. Although transfusion in general is not associated with 30-day adverse events, a volume of 20 mL/kg was associated with higher complication rates. LEVEL OF EVIDENCE 4.
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Kinnunen EM, Juvonen T, Biancari F. Use of Blood Products and Diseased Ascending Aorta Are Determinants of Stroke After Off-Pump Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2015; 29:1180-6. [PMID: 26022913 DOI: 10.1053/j.jvca.2015.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine the effect of blood products on the occurrence of stroke after coronary artery surgery. DESIGN Institutional retrospective analysis. SETTING University hospital. PARTICIPANTS One thousand three hundred fourteen patients undergoing coronary artery surgery. INTERVENTIONS Off-pump coronary artery bypass grafting (OPCAB). Epiaortic ultrasound was performed in all patients. MEASUREMENTS AND MAIN RESULTS Complete pre-, intra- and postoperative data including the number of transfused blood products as well as the timing, type, and course of stroke were available in all patients. Postoperative stroke occurred in 23 patients (1.8%). Logistic regression identified transfusion of platelets (3.6% v 1.1%, p = 0.003, OR 3.34, 95%CI 1.46-7.67) and diseased ascending aorta (3.0% v 1.2%, p = 0.022, OR 2.64, 95% CI 1.15-6.06) as independent predictors of stroke. When these variables were adjusted for CHA2DS2VASc (p = 0.005, OR 1.44, 95% CI 1.12-1.86), only transfusion of platelets (p = 0.012, OR 2.91, 95% CI 1.26-6.70) was associated with stroke. Neither nadir hematocrit on the day of surgery nor nadir hematocrit during the perioperative period was an independent predictor of stroke. Chi-squared automatic interaction detection analysis identified solvent/detergent-treated plasma (Octaplas; Octapharma AG, Lachen, Switzerland) units >2 and platelet units >4 along with diseased ascending aorta as independent predictors of stroke. The stroke rate was 8.9% in patients receiving >2 units of Octaplas and having a diseased ascending aorta. In patients receiving ≤2 units of Octaplas, the stroke rate was as high as 3.8% in patients receiving >4 units of platelets. CONCLUSIONS The results of this study indicated that atherosclerosis of the ascending aorta as well as transfusion of platelets and/or Octaplas were independent predictors of stroke after OPCAB.
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Affiliation(s)
| | - Tatu Juvonen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
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Bockeria LA, Kupryashov AA. eComment. Allogeneic red blood cell transfusion: at the turn of sacred and scientific eras. Interact Cardiovasc Thorac Surg 2015; 20:171. [PMID: 25605821 DOI: 10.1093/icvts/ivu419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Leo A Bockeria
- Bakoulev Scientific Centre for Cardiovascular Surgery, Moscow, Russia
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