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Shaw J, Zakhary B, Coimbra R, Moore L, Scalea T, Kundi R, Teeter W, Romagnoli A, Moore E, Sauaia A, Dennis B, Brenner M. Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial. Am Surg 2023; 89:4208-4217. [PMID: 37431165 DOI: 10.1177/00031348231177918] [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] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Tranexamic acid (TXA) use has been associated with thrombotic complications. OBJECTIVE We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA). PARTICIPANTS The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation. RESULTS 574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation. CONCLUSION Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.
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Affiliation(s)
| | - Bishoy Zakhary
- Riverside University Health System, Department of Surgery, 26520 Cactus Ave, Moreno Valley, CA 92555
| | - Raul Coimbra
- Riverside University Health System, Department of Surgery, 26520 Cactus Ave, Moreno Valley, CA 92555
| | - Laura Moore
- University of Texas Health Science Center at Houston (UTHealth), Department of Surgery, 6431 Fannin Street, Houston TX 77030
| | - Thomas Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - William Teeter
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Anna Romagnoli
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Ernest Moore
- University of Colorado Anschutz Medical Campus, Department of Surgery, 12631 East 17th Avenue, Aurora, CO 80045
| | - Angela Sauaia
- University of Colorado Anschutz Medical Campus, Department of Surgery, 12631 East 17th Avenue, Aurora, CO 80045
| | - Bradley Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery, 1161 21st,Avenue South, Medical Center North, D-5203, Nashville, TN 37232
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Rangasamy K, Neradi D, Gopinathan NR, Gandhi KA, Sodavarapu P. Efficacy of antifibrinolytics in reducing blood loss during hip reconstruction surgery in cerebral palsy children. A systematic review and meta-analysis. J Clin Orthop Trauma 2021; 20:101488. [PMID: 34277342 PMCID: PMC8267494 DOI: 10.1016/j.jcot.2021.101488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/23/2021] [Accepted: 06/27/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Cerebral palsy (CP) children undergoing hip reconstruction are more prone to blood loss during surgery due to poor nutritional status, antiepileptic medication intake, depletion of clotting factors, and the extent of surgery involved. We conducted this present review to analyze whether antifibrinolytics during hip surgery in CP children would reduce surgical blood loss and transfusion requirements. METHODS Three databases (PubMed, EMBASE, and Cochrane library) were searched independently for publications mentioning the use of antifibrinolytics during hip reconstruction surgery in CP children. The primary outcome was to compare the surgical blood loss with and without antifibrinolytics use. Secondary outcomes were transfusion requirements, drop in hemoglobin level, length of hospital stay, and complication rates. RESULTS All five studies (reporting 478 patients) published on this topic were found eligible based on inclusion criteria and were included for final analysis. Primary outcome: In three of the included studies, antifibrinolytics use resulted in a significant reduction in total blood loss with a mean difference (MD) of -151.05 mL (95% CI -272.30 to -29.80, p = 0.01). In the other two studies although statistically not significant, antifibrinolytics use reduces estimated blood loss (MD: 3.27, 95% CI -21.44 to 14.91, p = 0.72). Secondary outcomes: We observed that in the antifibrinolytics group, there was a reduction in total blood transfusion requirements (OD: 0.70, 95% CI 0.35 to 1.37, p = 0.29), and a drop in haemoglobin level (MD: 0.16, 95% CI -0.62 to 0.30, p = 0.49) but statistically not significant. No adverse effects related directly to antifibrinolytics were noticed in all five studies. CONCLUSION Only two out of five included studies favored the use of antifibrinolytics in CP children undergoing hip reconstruction. The evidence synthesized on this meta-analysis is also not sufficient enough to support its routine use in this cohort of children for hip reconstruction surgery. High-quality studies with adequate sample size to determine the effective and safe dosage, timing, and cost involved of different antifibrinolytics are the need of the hour. LEVEL OF EVIDENCE Ⅲ.
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Affiliation(s)
- Karthick Rangasamy
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Deepak Neradi
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nirmal Raj Gopinathan
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India,Corresponding author. Department of Orthopaedics, PGIMER, Chandigarh, India.
| | - Komal Anil Gandhi
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Praveen Sodavarapu
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Sumann G, Moens D, Brink B, Brodmann Maeder M, Greene M, Jacob M, Koirala P, Zafren K, Ayala M, Musi M, Oshiro K, Sheets A, Strapazzon G, Macias D, Paal P. Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel. Scand J Trauma Resusc Emerg Med 2020; 28:117. [PMID: 33317595 PMCID: PMC7737289 DOI: 10.1186/s13049-020-00790-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/10/2020] [Indexed: 12/11/2022] Open
Abstract
Background Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments. Objective To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments. Eligibility criteria All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms. Sources of evidence PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles. Charting methods Evidence was searched according to clinically relevant topics and PICO questions. Results Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland. Conclusions Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.
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Affiliation(s)
- G Sumann
- Austrian Society of Mountain and High Altitude Medicine, Emergency physician, Austrian Mountain and Helicopter Rescue, Altach, Austria
| | - D Moens
- Emergency Department Liège University Hospital, CMH HEMS Lead physician and medical director, Senior Lecturer at the University of Liège, Liège, Belgium
| | - B Brink
- Mountain Emergency Paramedic, AHEMS, Canadian Society of Mountain Medicine, Whistler Blackcomb Ski Patrol, Whistler, Canada
| | - M Brodmann Maeder
- Department of Emergency Medicine, University Hospital and University of Bern, Switzerland and Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy
| | - M Greene
- Medical Officer Mountain Rescue England and Wales, Wales, UK
| | - M Jacob
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Hospitallers Brothers Saint-Elisabeth-Hospital Straubing, Bavarian Mountain Rescue Service, Straubing, Germany
| | - P Koirala
- Adjunct Assistant Professor, Emergency Medicine, University of Maryland School of Medicine, Mountain Medicine Society of Nepal, Kathmandu, Nepal
| | - K Zafren
- ICAR MedCom, Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA, USA.,Alaska Native Medical Center, Anchorage, AK, USA
| | - M Ayala
- University Hospital Germans Trias i Pujol, Badalona, Spain
| | - M Musi
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - K Oshiro
- Department of Cardiovascular Medicine and Director of Mountain Medicine, Research, and Survey Division, Hokkaido Ohno Memorial Hospital, Sapporo, Japan
| | - A Sheets
- Emergency Department, Boulder Community Health, Boulder, CO, USA
| | - G Strapazzon
- Institute of Mountain Emergency Medicine, Eurac Research, Bolzano, Italy.,The Corpo Nazionale Soccorso Alpino e Speleologico, National Medical School (CNSAS SNaMed), Milan, Italy
| | - D Macias
- Department of Emergency Medicine, International Mountain Medicine Center, University of New Mexico, Albuquerque, NM, USA
| | - P Paal
- Department of Anaesthesiology and Intensive Care Medicine, St. John of God Hospital, Paracelsus Medical University, Salzburg, Austria.
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Ramkiran S, Kumar M, Krishnakumar L, Nair SG. Comparison of Blood-Conserving and Allogenic Transfusion-Sparing Effects of Antifibrinolytics in Scoliosis Correction Surgery. Anesth Essays Res 2020; 14:259-265. [PMID: 33487826 PMCID: PMC7819401 DOI: 10.4103/aer.aer_59_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/01/2020] [Indexed: 01/08/2023] Open
Abstract
Background: Intraoperative antifibrinolytic drug administration is a safe and effective method of reducing blood loss and allogenic transfusions in patients undergoing spine deformity correction. Aim: This study aimed to compare the effectiveness of two antifibrinolytic drugs tranexamic acid (TXA) and epsilon amino caproic acid (EACA) in reducing peri-operative blood loss and transfusion requirements against a placebo control in patients with idiopathic scoliosis undergoing correction surgery. Setting and Design: This is a prospective, randomized, double-blinded, controlled comparative study. Methodology: Patients in TXA group received 50 mg.kg−1 bolus and 10 mg.kg−1.h−1 infusion as against 100 mg.kg−1 and 10 mg.kg−1.h−1 infusion in EACA group. The placebo group had saline bolus and infusion. Parameters observed included baseline demographic and deformity data, duration of surgery, total peri-operative blood loss, and allogenic packed red cell transfusion requirements. Statistical Analysis: Mean and standard deviation were used to represent the quantitative continuous data, and percentage was used to represent categorical data. The Student's t-test and ANOVA were used to compare means between groups. Bonferroni's multiple comparison test was used to find out the association between categorical variables. Results: A total of 36 patients were enrolled with 12 patients in each group. Peri-operative blood loss was 50.1% lower in patients receiving TXA and 17.7% lower in patients receiving EACA compared with the placebo group. The volume of total packed red cell transfusion was 66.7% lower in patients receiving TXA and 45.6% lower in patients receiving EACA compared with placebo. Conclusion: TXA was more effective in reducing total peri-operative blood loss and allogenic transfusion requirement in idiopathic scoliosis correction surgery compared to EACA.
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Affiliation(s)
- Seshadri Ramkiran
- Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Vishakapatnam, Andhra Pradesh, India
| | - Mritunjay Kumar
- Department of Anaesthesiology Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Lakshmi Krishnakumar
- Department of Anesthesia and Critical Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
| | - Suresh G Nair
- Department of Anesthesiology and Critical Care, Aster Medcity, Kochi, Kerala, India
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Amer GF, Elawady MS, ElDerie A, Sanad M. Normothermia versus Hypothermia during Cardiopulmonary Bypass in Cases of Repair of Atrioventricular Septal Defect. Anesth Essays Res 2020; 14:112-118. [PMID: 32843803 PMCID: PMC7428111 DOI: 10.4103/aer.aer_123_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 11/04/2022] Open
Abstract
Background Cardiopulmonary bypass (CPB) used for cardiac surgery is now uniformly carried out under normothermic conditions in adult patients; however, the temperature applied in pediatric CPB vary significantly, ranging from deep hypothermia to normothermia due to the lack of a consistent approach to CPB temperature in pediatric cardiac surgery, which is related to a lack of supportive evidence. Organs protection aim to decrease metabolic requirement and provide energy and oxygen, hypothermia has reached these goals by arresting and cooling the heart, delivering oxygen, and modifying reperfusion. Recently, a large number of studies investigated effect of hypothermia to decrease the negative impact of hypothermia. It has been suggested that the degree of hypothermia affects the inflammatory responses triggered by CPB. However, the use of normothermia during CPB had been introduced and resulted in acceptable results. We hypothesized that the use of normothermia during corrective surgery of AV septal defects improves the outcome of the CPB. Objective The study aimed to compare the outcome of normothermic technique and mild hypothermic technique during (CPB) in pediatric cardiac patients undergoing repair of atrioventricular (AV) septal defect and their effect on tissue perfusion, serum lactate level, duration of patient intubation, and postoperative hospital stay. Patients and Methods Forty patients presented for repair of AV defect aged from 1 month to 36 months were divided randomly into two equal groups (20 patients in each): Group I (Normothermic group) of body temperature more than 35°C up to 37°C and Group II (mild Hypothermic group) body temperature between (32°C-35°C). Basal data include complete blood count, electrolytes, arterial blood gases (ABGs), coagulation profile, and liver function tests were collected. Hemodynamic variables, ABG, serum lactate, and activated clotting time (ACT) measured in different time intervals related to CPB. With the termination of CPB, aortic cross-clamping time (minutes), CPB time (minutes), spontaneous regaining of the heart function, need for inotropic administration, and/or vasopressor requirements to wean the heart from CPB were reported in all patients. Results This study showed statistically significant lower PH and HCO3 levels and significantly higher serum lactate levels in Group II (hypothermic) than Group I (normothermic) after weaning from CPB. Furthermore, ACT level was statistically significantly higher in Group II than Group I after weaning of CPB. During postoperative period, hypothermic group showed significantly higher liver enzymes than the normothermic group. The duration of inotropes administration and duration of intubation were significantly longer in Group II than Group I. Conclusion Normothermia during CPB showed better global tissue perfusion than hypothermia in elective surgeries for repair of AV defects in the form of less degree of lactic acidosis, less effect on coagulation system, shorter duration of inotropic support, shorter intubation period, and shorter stay in the intensive care unit.
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Affiliation(s)
- Ghada F Amer
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - Mostafa S Elawady
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
| | - Ahmad ElDerie
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
| | - Mohammed Sanad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Mansoura University, Egypt
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Athavale A, Kulkarni H, Arslan CD, Hart P. Desmopressin and bleeding risk after percutaneous kidney biopsy. BMC Nephrol 2019; 20:413. [PMID: 31730448 PMCID: PMC6858772 DOI: 10.1186/s12882-019-1595-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/16/2019] [Indexed: 01/17/2023] Open
Abstract
Background Desmopressin is used to reduce bleeding after kidney biopsy but evidence supporting its use is weak, especially in patients with elevated creatinine. The present study was undertaken to evaluate efficacy of desmopressin in reducing bleeding after percutaneous kidney biopsy. Methods Retrospective cohort study. 269 of 322 patients undergoing percutaneous kidney biopsy between January 1, 2014 and January 31, 2018 were included. Patients had normal bleeding time, platelet count and coagulation profile. Primary outcome was defined as composite of hemoglobin drop ≥1 g/dL, hematoma on post biopsy ultrasound, gross hematuria, erythrocyte transfusion or angiography to stop bleeding. Association of desmopressin with outcomes was assessed using linear (for continuous variables) and logistic (for binary variables) regression models. Propensity score was used to minimize potential confounding. Results Desmopressin was administered to 100/269 (37.17%) patients. After propensity score adjustment patients who received desmopressin had increased odds of post biopsy bleeding [OR 3.88 (1.95–7.74), p < 0.001]. Creatinine at time of biopsy influenced bleeding risk; gender, emergent vs elective biopsy, obesity, AKI, diabetes, hypertension or bleeding time did not influence bleeding risk. Administration of desmopressin to patients with serum creatinine ≥1.8 mg/dL decreased bleeding risk [OR 2.11 (95% CI 0.87–5.11), p = 0.09] but increased bleeding risk when serum creatinine was < 1.8 mg/dL (OR 9.72 (95% CI 2.95–31.96), p < 0.001). Conclusion Desmopressin should not be used routinely prior to percutaneous kidney biopsy in patients at low risk for bleeding but should be reserved for patients who are at high risk for bleeding.
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Affiliation(s)
- Ambarish Athavale
- Division of Nephrology, Cook County Health, 1950 W. Polk Street, 5th Floor, Chicago, IL, 60605, USA.
| | | | - Cagil D Arslan
- Division of Nephrology, Cook County Health, 1950 W. Polk Street, 5th Floor, Chicago, IL, 60605, USA
| | - Peter Hart
- Division of Nephrology, Cook County Health, 1950 W. Polk Street, 5th Floor, Chicago, IL, 60605, USA
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Das SK, Reddy MM, Ray S. Hemostatic Agents in Critically Ill Patients. Indian J Crit Care Med 2019; 23:S226-S229. [PMID: 31656384 PMCID: PMC6785814 DOI: 10.5005/jp-journals-10071-23258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Das SK, Reddy MM, Ray S. Hemostatic Agents in Critically Ill Patients. Indian J Crit Care Med 2019;23(Suppl 3):S226–S229.
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Affiliation(s)
- Saurabh Kumar Das
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India
| | | | - Sumit Ray
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India
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Akbas E, Cebi Z, Cansiz E, Isler SC, Cakarer S. Does intravenous tranexamic acid reduce blood loss during surgically assisted rapid palatal expansion? J Istanb Univ Fac Dent 2017; 51:32-37. [PMID: 29114428 PMCID: PMC5624143 DOI: 10.17096/jiufd.94203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 02/21/2017] [Indexed: 11/15/2022] Open
Abstract
Purpose: The purpose of this study was to evaluate the efficacy of tranexamic acid (TXA) in reducing blood loss during surgically assisted
rapid palatal expansion (SARPE) procedure. Subjects and Methods: A total of 34 patients (12 male, 22 female) who had been treated surgically under general anesthesia with SARPE
including pterygoid disjunction for transverse maxillary deficiency (TMD) were included in this study. The study group (n=17) received intravenous (IV)
TXA 10 mg/kg as a preoperative bolus; the control group (n=17) received normal saline solution. Preoperative and postoperative haemoglobin and haematocrit
values, intraoperative blood loss, and any blood product transfusion were recorded. Results: Blood loss during SARPE was statistically significantly less in the study group than the control group (p=0.0001). Conclusion: Preoperative IV administration of TXA can effectively control blood loss during when SARPE with pterygoid disjunction is performed.
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Affiliation(s)
- Emine Akbas
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Zerrin Cebi
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Erol Cansiz
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Sabri Cemil Isler
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
| | - Sırmahan Cakarer
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Istanbul University Turkey
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Desborough MJ, Oakland K, Brierley C, Bennett S, Doree C, Trivella M, Hopewell S, Stanworth SJ, Estcourt LJ. Desmopressin use for minimising perioperative blood transfusion. Cochrane Database Syst Rev 2017; 7:CD001884. [PMID: 28691229 PMCID: PMC5546394 DOI: 10.1002/14651858.cd001884.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Blood transfusion is administered during many types of surgery, but its efficacy and safety are increasingly questioned. Evaluation of the efficacy of agents, such as desmopressin (DDAVP; 1-deamino-8-D-arginine-vasopressin), that may reduce perioperative blood loss is needed. OBJECTIVES To examine the evidence for the efficacy of DDAVP in reducing perioperative blood loss and the need for red cell transfusion in people who do not have inherited bleeding disorders. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (2017, issue 3) in the Cochrane Library, MEDLINE (from 1946), Embase (from 1974), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (from 1937), the Transfusion Evidence Library (from 1980), and ongoing trial databases (all searches to 3 April 2017). SELECTION CRITERIA We included randomised controlled trials comparing DDAVP to placebo or an active comparator (e.g. tranexamic acid, aprotinin) before, during, or immediately after surgery or after invasive procedures in adults or children. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. MAIN RESULTS We identified 65 completed trials (3874 participants) and four ongoing trials. Of the 65 completed trials, 39 focused on adult cardiac surgery, three on paediatric cardiac surgery, 12 on orthopaedic surgery, two on plastic surgery, and two on vascular surgery; seven studies were conducted in surgery for other conditions. These trials were conducted between 1986 and 2016, and 11 were funded by pharmaceutical companies or by a party with a commercial interest in the outcome of the trial.The GRADE quality of evidence was very low to moderate across all outcomes. No trial reported quality of life. DDAVP versus placebo or no treatmentTrial results showed considerable heterogeneity between surgical settings for total volume of red cells transfused (low-quality evidence) and for total blood loss (very low-quality evidence) due to large differences in baseline blood loss. Consequently, these outcomes were not pooled and were reported in subgroups.Compared with placebo, DDAVP may slightly decrease the total volume of red cells transfused in adult cardiac surgery (mean difference (MD) -0.52 units, 95% confidence interval (CI) -0.96 to -0.08 units; 14 trials, 957 participants), but may lead to little or no difference in orthopaedic surgery (MD -0.02, 95% CI -0.67 to 0.64 units; 6 trials, 303 participants), vascular surgery (MD 0.06, 95% CI -0.60 to 0.73 units; 2 trials, 135 participants), or hepatic surgery (MD -0.47, 95% CI -1.27 to 0.33 units; 1 trial, 59 participants).DDAVP probably leads to little or no difference in the total number of participants transfused with blood (risk ratio (RR) 0.96, 95% CI 0.86 to 1.06; 25 trials; 1806 participants) (moderate-quality evidence).Whether DDAVP decreases total blood loss in adult cardiac surgery (MD -135.24 mL, 95% CI -210.80 mL to -59.68 mL; 22 trials, 1358 participants), orthopaedic surgery (MD -285.76 mL, 95% CI -514.99 mL to -56.53 mL; 5 trials, 241 participants), or vascular surgery (MD -582.00 mL, 95% CI -1264.07 mL to 100.07 mL; 1 trial, 44 participants) is uncertain because the quality of evidence is very low.DDAVP probably leads to little or no difference in all-cause mortality (Peto odds ratio (pOR) 1.09, 95% CI 0.51 to 2.34; 22 trials, 1631 participants) or in thrombotic events (pOR 1.36, 95% CI, 0.85 to 2.16; 29 trials, 1984 participants) (both low-quality evidence). DDAVP versus placebo or no treatment for people with platelet dysfunctionCompared with placebo, DDAVP may lead to a reduction in the total volume of red cells transfused (MD -0.65 units, 95% CI -1.16 to -0.13 units; 6 trials, 388 participants) (low-quality evidence) and in total blood loss (MD -253.93 mL, 95% CI -408.01 mL to -99.85 mL; 7 trials, 422 participants) (low-quality evidence).DDAVP probably leads to little or no difference in the total number of participants receiving a red cell transfusion (RR 0.83, 95% CI 0.66 to 1.04; 5 trials, 258 participants) (moderate-quality evidence).Whether DDAVP leads to a difference in all-cause mortality (pOR 0.72, 95% CI 0.12 to 4.22; 7 trials; 422 participants) or in thrombotic events (pOR 1.58, 95% CI 0.60 to 4.17; 7 trials, 422 participants) is uncertain because the quality of evidence is very low. DDAVP versus tranexamic acidCompared with tranexamic acid, DDAVP may increase the volume of blood transfused (MD 0.6 units, 95% CI 0.09 to 1.11 units; 1 trial, 40 participants) and total blood loss (MD 142.81 mL, 95% CI 79.78 mL to 205.84 mL; 2 trials, 115 participants) (both low-quality evidence).Whether DDAVP increases or decreases the total number of participants transfused with blood is uncertain because the quality of evidence is very low (RR 2.42, 95% CI 1.04 to 5.64; 3 trials, 135 participants).No trial reported all-cause mortality.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 2.92, 95% CI 0.32 to 26.83; 2 trials, 115 participants). DDAVP versus aprotininCompared with aprotinin, DDAVP probably increases the total number of participants transfused with blood (RR 2.41, 95% CI 1.45 to 4.02; 1 trial, 99 participants) (moderate-quality evidence).No trials reported volume of blood transfused or total blood loss and the single trial that included mortality as an outcome reported no deaths.Whether DDAVP leads to a difference in thrombotic events is uncertain because the quality of evidence is very low (pOR 0.98, 95% CI 0.06 to 15.89; 2 trials, 152 participants). AUTHORS' CONCLUSIONS Most of the evidence derived by comparing DDAVP versus placebo was obtained in cardiac surgery, where DDAVP was administered after cardiopulmonary bypass. In adults undergoing cardiac surgery, the reduction in volume of red cells transfused and total blood loss was small and was unlikely to be clinically important. It is less clear whether DDAVP may be of benefit for children and for those undergoing non-cardiac surgery. A key area for researchers is examining the effects of DDAVP for people with platelet dysfunction. Few trials have compared DDAVP versus tranexamic acid or aprotinin; consequently, we are uncertain of the relative efficacy of these interventions.
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Affiliation(s)
| | - Kathryn Oakland
- NHS Blood and TransplantHaematology/Transfusion MedicineOxfordUK
| | - Charlotte Brierley
- John Radcliffe HospitalDepartment of HaematologyHeadley WayOxfordUKOX3 9DU
| | - Sean Bennett
- University of OttawaDepartment of Surgery501 Smyth RoadOttawaOntarioCanadaK1M 1R4
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Simon J Stanworth
- Oxford University Hospitals NHS Foundation Trust and University of OxfordNational Institute for Health Research (NIHR) Oxford Biomedical Research CentreJohn Radcliffe Hospital, Headley WayHeadingtonOxfordUKOX3 9BQ
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineOxfordUK
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Mirmansoori A, Farzi F, Sedighinejad A, Imantalab V, mohammadzadeh A, Atrkar Roushan Z, Ghazanfar Tehran S, Nemati M, Dehghan A. The Effect of Desmopressin on the Amount of Bleeding in Patients Undergoing Coronary Artery Bypass Graft Surgery with a Cardiopulmonary Bypass Pump After Taking Anti-Platelet Medicine. Anesth Pain Med 2016; 6:e39226. [PMID: 27847701 PMCID: PMC5101425 DOI: 10.5812/aapm.39226] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/05/2016] [Accepted: 06/22/2016] [Indexed: 02/03/2023] Open
Abstract
Background Coronary artery bypass grafting (CABG) is a common surgical intervention at the end-stages of coronary artery occlusion disease. Despite the effectiveness of CABG, it may have particular complications, such as bleeding during and after surgery. So far, there have been many drugs used to reduce bleeding. Objectives This study aimed at investigating the effects of desmopressin on the amount of bleeding in patients undergoing CABG with a cardiopulmonary bypass pump (CPBP) who were taking anti-platelet medicine. Methods One hundred patients scheduled for elective CABG with a CPBP were included in a prospective, placebo-controlled, double-blinded clinical trial study. They were randomly divided into two groups. One group received desmopressin (40 μg) and the other group received a placebo (isotonic saline). Seven patients were excluded from the study, and 47 and 46 patients participated in the desmopressin and control groups, respectively. The methods of monitoring and the anesthetic techniques were similar in both groups, and all surgeries were performed by one surgeon. Variables including age, gender, pump time, aortic clamp time, duration of surgery, complications (e.g., nausea and vomiting, blood pressure changes), the necessity to receive blood products, and coagulation tests (prothrombin time, partial thromboplastin time, international normalized ratio, and bleeding time) were assessed. Data were statistically analyzed with SPSS software version 17. Results There was no significant difference between the groups regarding age, gender, pump time, clamp time, duration of surgery, complications, and the changes in hemoglobin and coagulation test measurements (P > 0.05). No significant difference was noted between the groups regarding the rate of bleeding after surgery (359.3 ± 266.2 in group D vs. 406.3 ± 341.6 in group P (control group); P = 0.208). However, the platelet changes after surgery in both groups were significantly different. The analysis revealed that the rate of thrombocytopenia after surgery was higher in the control group (P = 0.012). Conclusions Our study showed that desmopressin could not reduce the amount of blood loss after CABG. Also, desmopressin did not have a significant effect on coagulation status. Therefore, based on the results of our study, it seems that the use of this medication cannot be a helpful for patients with any indication for CABG.
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Affiliation(s)
- Ali Mirmansoori
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Farnoush Farzi
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Corresponding author: Farnoush Farzi, Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran. Tel: +98-9113311653, Fax: +98-1333369024, E-mail:
| | - Abbas Sedighinejad
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Vali Imantalab
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali mohammadzadeh
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | | | | - Maryam Nemati
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Afsaneh Dehghan
- Anesthesiology Research Center, Guilan University of Medical Sciences, Rasht, Iran
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11
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Sabzi F, Faraji R. Liver Function Tests Following Open Cardiac Surgery. J Cardiovasc Thorac Res 2015; 7:49-54. [PMID: 26191391 PMCID: PMC4492177 DOI: 10.15171/jcvtr.2015.11] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 01/25/2015] [Indexed: 12/13/2022] Open
Abstract
Introduction: The cardiopulmonary bypass may have multiple systemic effects on the body organs as liver. This prospective study was planned to explore further the incidence and significance of this change.
Methods: Two hundred patients with coronary artery bypass grafting (CABG), were randomly selected for the study. Total and indirect bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase were measured preoperatively and at 24, 48 and 72 hours, following coronary artery bypass grafting. Postoperative value of the liver function tests with respect to hypothermia or hypotension were compared by one way analysis of variance for repeated measure and compared with t test. Patient’s characteristics with bilirubin value (≤1.5 mg or >1.5 mg) were compared with t test.
Results: A significant increase of total bilirubin, aspartate aminotransferase, and alkaline phosphatase were noted in the third postoperative day. Significant relation was seen between hypotension and alkaline phosphatase, and aspartate aminotransferase change but hypothermia had not affected alanine aminotransferase, total bilirubin and indirect bilirubin change. Pump time, alanine aminotransferase in third postoperative day and direct bilirubin in first and second day of postoperative period had significant relation with pre and post-operative bilirubin change.
Conclusion: Transient but not permanent alterations of hepatic enzymes after coronary artery bypass grafting presumably attributed to the decreased hepatic flow, hypoxia, or pump-induced inflammation.
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Affiliation(s)
- Feridoun Sabzi
- Preventive Cardiovascular Research Center Kermanshah, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Reza Faraji
- Yazd Cardiovascular Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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12
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Madershahian N, Scherner M, Pfister R, Rudolph T, Deppe AC, Slottosch I, Kuhn E, Choi YH, Wahlers T. Prophylactic intraoperative tranexamic acid administration and postoperative blood loss after transapical aortic valve implantation. J Cardiothorac Surg 2015; 10:45. [PMID: 25888231 PMCID: PMC4393600 DOI: 10.1186/s13019-015-0246-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Accepted: 03/13/2015] [Indexed: 11/10/2022] Open
Abstract
Objectives Antifibrinolytics are widely used in cardiac surgery to save blood perioperatively. In the present study we evaluated the hemostatic effects of tranexamic acid (TXA) to decrease bleeding tendency and transfusion requirements in high-risk patients following transapical aortic valve implantation (TA-AVI). Methods A retrospective analysis was performed on aortic stenosis patients undergoing TA-AVI with or without intraoperative TXA administration to determine postoperative blood loss and transfusion requirements. From January 2009 to August 2010 in total 92 patients were treated without intraoperative TXA administration, from August 2010 to July 2011 54 patients received TXA intraoperatively. Results Early postoperative (24 h) blood loss was significantly lower in TXA-group than in non-TXA group (327 ± 274 mL vs. 481.1 ± 318.8 mL; p = 0.003). In the TXA group 53.7% of patients received allogeneic blood products during the hospital stay as compared to 72.8% in the non-TXA group (p = 0.242). TXA group required fewer transfusions (2.1 ± 1.9 vs. 2.9 ± 3.5 Units; p = 0.046) and had no increased incidence of thrombotic or neurological complications. There was no significant difference in the length of ICU, hospital stay, or 30-day mortality. Administration of tranexamic acid was found to be significantly associated with lower blood loss postoperatively (p = 0.002). Furthermore, there was a significant correlation between the postoperative blood loss (p = 0.036) and red blood cell transfusion (p = 0.001) with 30-day mortality. Conclusion Low dose prophylactic intraoperative administration of tranexamic acid appears to be effective in reducing postoperative bleeding and the need for allogeneic blood products following TA-AVI.
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Affiliation(s)
- Navid Madershahian
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
| | - Maximilian Scherner
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
| | - Roman Pfister
- Department of Internal Medicine III, Cologne University Heart Center, 50937, Cologne, Germany.
| | - Tanja Rudolph
- Department of Internal Medicine III, Cologne University Heart Center, 50937, Cologne, Germany.
| | - Antje C Deppe
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
| | - Ingo Slottosch
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Cologne University Heart Center, Kerpener Strasse 62, D-50937, Cologne, Germany.
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13
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Abstract
Background Tranexamic acid reduces haemorrhage through its antifibrinolytic effects. In a previous version of the present review, we found that tranexamic acid may reduce mortality. This review includes updated searches and new trials.Objectives To assess the effects of tranexamic acid versus no intervention, placebo or other antiulcer drugs for upper gastrointestinal bleeding.Search methods We updated the review by performing electronic database searches (Cochrane Central Register of Controlled Trials (CENTRAL),MEDLINE, EMBASE, Science Citation Index) and manual searches in July 2014.Selection criteriaRandomised controlled trials, irrespective of language or publication status.Data collection and analysis We used the standard methodological procedures of the The Cochrane Collaboration. All-cause mortality, bleeding and adverse events were the primary outcome measures. We performed fixed-effect and random-effects model meta-analyses and presented results as risk ratios (RRs) with 95% confidence intervals (CIs) and used I² as a measure of between-trial heterogeneity. We analysed tranexamic acid versus placebo or no intervention and tranexamic acid versus antiulcer drugs separately. To analyse sources of heterogeneity and robustness of the overall results, we performed subgroup, sensitivity and sequential analyses.Main results We included eight randomised controlled trials on tranexamic acid for upper gastrointestinal bleeding. Additionally, we identified one large ongoing pragmatic randomised controlled trial from which data are not yet available. Control groups were randomly assigned to placebo (seven trials) or no intervention (one trial). Two trials also included a control group randomly assigned to antiulcer drugs(lansoprazole or cimetidine). The included studies were published from 1973 to 2011. The number of participants randomly assigned ranged from 47 to 216 (median 204). All trials reported mortality. In total, 42 of 851 participants randomly assigned to tranexamic acid and 71 of 850 in the control group died (RR 0.60, 95% CI 0.42 to 0.87; P value 0.007; I² = 0%). The analysis was not confirmed when all participants in the intervention group with missing outcome data were included as treatment failures, or when the analysis was limited to trials with low risk of attrition bias. Rebleeding was diagnosed for 117 of 826 participants in the tranexamic acid group and for 146 of 825 participants in the control group (RR 0.80, 95% CI 0.64 to 1.00; P value 0.07; I² = 49%).We were able to evaluate the risk of serious adverse events on the basis of only four trials. Our analyses showed 'no evidence of a difference between tranexamic acid and control interventions regarding the risk of thromboembolic events.’ Tranexamic acid appeared to reduce the risk of surgery ina fixed-effect meta-analysis (RR 0.73, 95% CI 0.56 to 0.95), but this result was no longer statistically significant in a random-effects meta-analysis (RR 0.61, 95% CI 0.35 to 1.04; P value 0.07). No difference was apparent between tranexamic acid and placebo in the assessment of transfusion (RR 1.02, 95% CI 0.94 to 1.11; I² = 0%), and meta-analyses that compared tranexamic acid versus antiulcer drugs did not identify beneficial or detrimental effects of tranexamic acid for any of the outcomes assessed.Authors' conclusions This review found that tranexamic acid appears to have a beneficial effect on mortality, but a high dropout rate in some trials means that we cannot be sure of this until the findings of additional research are published. At the time of this update in 2014, one large study(8000 participants) is in progress, so this review will be much more informative in a few years. Further examination of tranexamic acid would require inclusion of high-quality randomised controlled trials. Timing of randomisation is essential to avoid attrition bias and to limit the number of withdrawals. Future trials may use a pragmatic design and should include all participants with suspected bleeding or with endoscopically verified bleeding, as well as a tranexamic placebo arm and co-administration of pump inhibitors and endoscopic therapy. Assessment of outcome measures in such studies should be clearly defined. Endoscopic examination with appropriate control of severe bleeding should be performed, as should endoscopic verification of clinically significant rebleeding. In addition, clinical measures of rebleeding should be included. Other important outcome measures include mortality (30-day or in-hospital), need for emergency surgery or blood transfusion and adverse events (major or minor).
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Affiliation(s)
- Cathy Bennett
- Coventry UniversityCentre for Technology Enabled Health Research (CTEHR)Priory StreetCoventryUKCV1 5FB
| | - Sarah Louise Klingenberg
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Ebbe Langholz
- Gentofte University HospitalDepartment F, Gastroenterology SectionNiels Andersensvej 65HellerupDenmark2900
| | - Lise Lotte Gluud
- Copenhagen University Hospital HvidovreGastrounit, Medical DivisionKettegaards AlleHvidovreDenmark2650
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14
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Hébert PC, Fergusson DA, Hutton B, Mazer CD, Fremes S, Blajchman M, MacAdams C, Wells G, Robblee J, Bussières J, Teoh K. Regulatory decisions pertaining to aprotinin may be putting patients at risk. CMAJ 2014; 186:1379-86. [PMID: 25267766 DOI: 10.1503/cmaj.131582] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Paul C Hébert
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Dean A Fergusson
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont.
| | - Brian Hutton
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - C David Mazer
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Stephen Fremes
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Morris Blajchman
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Charles MacAdams
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - George Wells
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Jim Robblee
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Jean Bussières
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
| | - Kevin Teoh
- Centre de Recherche (Hébert), Centre Hospitalier de L'Université de Montréal, Montréal, Que.; Département de Médecine (Hébert), Université de Montréal, Montréal, Que.; Clinical Epidemiology Program (Fergusson), Ottawa Hospital Research Institute, Ottawa, Ont.; Department of Medicine (Fergusson, Hutton, Mazer), University of Ottawa, Ottawa, Ont.; Department of Anesthesia (Fremes), Keenan Center/Li Ka Shing Institute, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Sunnybrook Health Sciences Centre, Department of Surgery (Blajchman), Division of Cardiac and Vascular Surgery, University of Toronto, Toronto, Ont.; Department of Pathology and Molecular Medicine (MacAdams), McMaster University, Hamilton, Ont.; Libin Cardiovascular Institute (Wells), University of Calgary, Calgary, Alta.; University of Ottawa Heart Institute (Robblee), Ottawa, Ont.; Hôpital Laval (Bussières), Institut Universitaire de Cardiologie et Pneumologie de l'Université Laval, Laval, Que.; Hamilton Health Science Centre (Teoh), McMaster University, Hamilton, Ont
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Hutton B, Joseph L, Fergusson D, Mazer CD, Shapiro S, Tinmouth A. Risks of harms using antifibrinolytics in cardiac surgery: systematic review and network meta-analysis of randomised and observational studies. BMJ 2012; 345:e5798. [PMID: 22968722 PMCID: PMC3438881 DOI: 10.1136/bmj.e5798] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2012] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To estimate the relative risks of death, myocardial infarction, stroke, and renal failure or dysfunction between antifibrinolytics and no treatment following the suspension of aprotinin from the market in 2008 for safety reasons and its recent reintroduction in Europe and Canada. DESIGN Systematic review and network meta-analysis. DATA SOURCES A Cochrane review of antifibrinolytic treatments was chosen as the starting point for this systematic review. Medline, Embase, and the Cochrane register of trials were searched with no date restrictions for observational evidence. STUDY SELECTION Propensity matched or adjusted observational studies with two or more of the interventions of interest (aprotinin, tranexamic acid, epsilon-aminocaproic acid, and no treatment) that were carried out in patients undergoing cardiac surgery. DATA ANALYSIS Network meta-analysis was used to compare treatments, and odds ratios with 95% credible intervals were estimated. Meta-analyses were carried out for randomised controlled trials alone and for randomised controlled trials with observational studies. RESULTS 106 randomised controlled trials and 11 observational studies (43,270 patients) were included. Based on the results from analysis of randomised controlled trials, tranexamic acid was associated on average with a reduced risk of death compared with aprotinin (odds ratio 0.64, 95% credible interval 0.41 to 0.99). When observational data were incorporated, comparisons showed an increased risk of mortality with aprotinin on average relative to tranexamic acid (odds ratio 0.71, 95% credible interval 0.50 to 0.98) and epsilon-aminocaproic acid (0.60, 0.43 to 0.87), and an increased risk of renal failure or dysfunction on average relative to all comparators: odds ratio 0.66 (95% credible interval 0.45 to 0.88) compared with no treatment, 0.66 (0.48 to 0.91) versus tranexamic acid, and 0.65 (0.45 to 0.88) versus epsilon-aminocaproic acid. CONCLUSION Although meta-analyses of randomised controlled trials were largely inconclusive, inclusion of observational data suggest concerns remain about the safety of aprotinin. Tranexamic and epsilon-aminocaproic acid are effective alternatives that may be safer for patients.
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Affiliation(s)
- Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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16
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Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. BMJ 2012; 344:e3054. [PMID: 22611164 PMCID: PMC3356857 DOI: 10.1136/bmj.e3054] [Citation(s) in RCA: 575] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the effect of tranexamic acid on blood transfusion, thromboembolic events, and mortality in surgical patients. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane central register of controlled trials, Medline, and Embase, from inception to September 2011, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of relevant articles. STUDY SELECTION Randomised controlled trials comparing tranexamic acid with no tranexamic acid or placebo in surgical patients. Outcome measures of interest were the number of patients receiving a blood transfusion; the number of patients with a thromboembolic event (myocardial infarction, stroke, deep vein thrombosis, and pulmonary embolism); and the number of deaths. Trials were included irrespective of language or publication status. RESULTS 129 trials, totalling 10,488 patients, carried out between 1972 and 2011 were included. Tranexamic acid reduced the probability of receiving a blood transfusion by a third (risk ratio 0.62, 95% confidence interval 0.58 to 0.65; P<0.001). This effect remained when the analysis was restricted to trials using adequate allocation concealment (0.68, 0.62 to 0.74; P<0.001). The effect of tranexamic acid on myocardial infarction (0.68, 0.43 to 1.09; P = 0.11), stroke (1.14, 0.65 to 2.00; P = 0.65), deep vein thrombosis (0.86, 0.53 to 1.39; P = 0.54), and pulmonary embolism (0.61, 0.25 to 1.47; P=0.27) was uncertain. Fewer deaths occurred in the tranexamic acid group (0.61, 0.38 to 0.98; P = 0.04), although when the analysis was restricted to trials using adequate concealment there was considerable uncertainty (0.67, 0.33 to 1.34; P = 0.25). Cumulative meta-analysis showed that reliable evidence that tranexamic acid reduces the need for transfusion has been available for over 10 years. CONCLUSIONS Strong evidence that tranexamic acid reduces blood transfusion in surgery has been available for many years. Further trials on the effect of tranexamic acid on blood transfusion are unlikely to add useful new information. However, the effect of tranexamic acid on thromboembolic events and mortality remains uncertain. Surgical patients should be made aware of this evidence so that they can make an informed choice.
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Affiliation(s)
- Katharine Ker
- Clinical Trials Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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17
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Trethowan BA, Gilliland H, Popov AF, Varadarajan B, Phillips SA, McWhirter L, Ghent R. A case report and brief review of the literature on bilateral retinal infarction following cardiopulmonary bypass for coronary artery bypass grafting. J Cardiothorac Surg 2011; 6:154. [PMID: 22104114 PMCID: PMC3253690 DOI: 10.1186/1749-8090-6-154] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 11/21/2011] [Indexed: 11/18/2022] Open
Abstract
Postoperative visual loss is a devastating perioperative complication. The commonest aetiologies are anterior ischaemic optic neuropathy (AION), posterior ischaemic optic neuropathy (PION), and central retinal artery occlusion (CRAO). These appear to be related to certain types of operation, most commonly spinal and cardiac bypass procedures; with the rest divided between: major trauma causing excessive blood loss; head/neck and nasal or sinus surgery; major vascular procedures (aortic aneurysm repair, aorto-bifemoral bypass); general surgery; urology; gynaecology; liposuction; liver transplantation and duration of surgery. The non-surgical risk factors are multifactorial: advanced age, prolonged postoperative anaemia, positioning (supine v prone), alteration of venous drainage of the retina, hypertension, smoking, atherosclerosis, hyperlipidaemia, diabetes, hypercoagulability, hypotension, blood loss and large volume resuscitation. Other important cardiac causes are septic emboli from bacterial endocarditis and emboli caused by atrial myxomata. The majority of AION cases occur during CPB followed by head/neck surgery and prone spine surgery. CPB is used to allow coronary artery bypass grafting on a motionless heart. It has many side-effects and complications associated with its use and we report here a case of bilateral retinal infarction during routine coronary artery bypass grafting in a young male patient with multiple risk factors for developing this complication despite steps to minimise its occurrence.
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Affiliation(s)
- Brian A Trethowan
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
- Department of Cardiothoracic Transplantation & Mechanical Support, Royal Brompton & Harefield NHS Trust, Harefield, UB9 6JH, London, United Kingdom
| | - Helen Gilliland
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Aron F Popov
- Department of Cardiothoracic Transplantation & Mechanical Support, Royal Brompton & Harefield NHS Trust, Harefield, UB9 6JH, London, United Kingdom
| | - Barathi Varadarajan
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Sally-Anne Phillips
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
| | - Louise McWhirter
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
- Department of Critical Care, The Royal London Hospital, Whitechapel Road, E1 1BB, London, United Kingdom
| | - Robert Ghent
- Department of Anaesthesia, Royal Group of Hospitals and Dental Hospital Health and Social Services Trust, Grosvenor Road, Belfast, BT12 6BA, Northern Ireland
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18
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Petros S. [Management of bleeding disorders in intensive care medicine]. Med Klin Intensivmed Notfmed 2011; 106:177-82. [PMID: 22037560 DOI: 10.1007/s00063-011-0017-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 09/09/2011] [Indexed: 11/24/2022]
Abstract
Bleeding disorders are frequent in intensive care medicine, the most common form being acquired. Trauma, gastrointestinal bleeding, liver failure, hematologic malignancies, and adverse drug reactions play an important role. Moderate to severe hereditary bleeding disorders are usually known prior to the acute disease state, while mild hereditary forms may manifest for the first time in association with the acute stress condition. Generally, proper history taking and structured observation are decisive in order to conduct an appropriate diagnostic workup and initiate logical hemostatic management. One cannot always wait for laboratory results during continuous blood loss or conditions such as hypothermia and acidosis. In such cases, pathophysiological extrapolation of expected hemostatic disturbances is essential for timely hemostatic management.
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Affiliation(s)
- S Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig AöR, Liebigstrasse 20, Leipzig, Germany.
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Schloss B, Gulati P, Yu L, Abdel-Rasoul M, O'Brien W, Von Visger J, Awad H. Impact of aprotinin and renal function on mortality: a retrospective single center analysis. J Cardiothorac Surg 2011; 6:103. [PMID: 21878108 PMCID: PMC3178482 DOI: 10.1186/1749-8090-6-103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 08/30/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND An estimated up to 7% of high-risk cardiac surgery patients return to the operating room for bleeding. Aprotinin was used extensively as an antifibrinolytic agent in cardiac surgery patients for over 15 years and it showed efficacy in reducing bleeding. Aprotinin was removed from the market by the U.S. Food and Drug Administration after a large prospective, randomized clinical trial documented an increased mortality risk associated with the drug. Further debate arose when a meta-analysis of 211 randomized controlled trials showed no risk of renal failure or death associated with aprotinin. However, only patients with normal kidney function have been studied. METHODS In this study, we look at a single center clinical trial using patients with varying degrees of baseline kidney function to answer the question: Does aprotinin increase odds of death given varying levels of preoperative kidney dysfunction? RESULTS Based on our model, aprotinin use was associated with a 3.8-fold increase in odds of death one year later compared to no aprotinin use with p-value = 0.0018, regardless of level of preoperative kidney dysfunction after adjusting for other perioperative variables. CONCLUSIONS Lessons learned from our experience using aprotinin in the perioperative setting as an antifibrinolytic during open cardiac surgery should guide us in testing future antifibrinolytic drugs for not only efficacy of preventing bleeding, but for overall safety to the whole organism using long-term clinical outcome studies, including those with varying degree of baseline kidney function.
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Affiliation(s)
- Brian Schloss
- Department of Anesthesiology, The Ohio State University Medical Center, (410 West 10th Avenue), Columbus, (43210), USA
| | - Parul Gulati
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - Lianbo Yu
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, The Ohio State University Medical Center, (2012 Kenny Road), Columbus, (43210), USA
| | - William O'Brien
- Perfusion Services, The Ohio State University Medical Center, (452 W. 10th Avenue), Columbus, (43210), USA
| | - Jon Von Visger
- Department of Nephrology, The Ohio State University Medical Center, (395 West 12th Avenue), Columbus, 43210, USA
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Medical Center, (410 West 10th Avenue), Columbus, (43210), USA
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20
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:320-35. [PMID: 21627922 PMCID: PMC3136601 DOI: 10.2450/2011.0076-10] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Giancarlo Maria Liumbruno
- Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, San Giovanni Calibita Fatebenefratelli Hospital, Rome.
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21
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011; 2011:CD001886. [PMID: 21412876 PMCID: PMC4234031 DOI: 10.1002/14651858.cd001886.pub4] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery, and previous reviews have found them to be effective in reducing blood loss, the need for transfusion, and the need for re-operation due to continued or recurrent bleeding. In the last few years questions have been raised regarding the comparative performance of the drugs. The safety of the most popular agent, aprotinin, has been challenged, and it was withdrawn from world markets in May 2008 because of concerns that it increased the risk of cardiovascular complications and death. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood cell (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched: the Cochrane Injuries Group's Specialised Register (July 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (Ovid SP) 1950 to July 2010, EMBASE (Ovid SP) 1980 to July 2010. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. This version of the review includes a sensitivity analysis excluding trials authored by Prof. Joachim Boldt. MAIN RESULTS This review summarises data from 252 RCTs that recruited over 25,000 participants. Data from the head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of reducing perioperative blood loss, but the differences were small. Compared to control, aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.60 to 0.72). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.53 to 0.70) and was 0.81 (95% CI 0.67 to 0.99) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared more effective in reducing the need for RBC transfusion (RR 0.90; 95% CI 0.81 to 0.99).Aprotinin reduced the need for re-operation due to bleeding by a relative 54% (RR 0.46, 95% CI 0.34 to 0.62). This translates into an absolute risk reduction of 2% and a number needed-to-treat (NNT) of 50 (95% CI 33 to 100). A similar trend was seen with EACA (RR 0.32, 95% CI 0.11 to 0.99) but not TXA (RR 0.80, 95% CI 0.55 to 1.17). The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias.When compared with no treatment aprotinin did not increase the risk of myocardial infarction (RR 0.87, 95% CI 0.69 to 1.11), stroke (RR 0.82, 95% CI 0.44 to 1.52), renal dysfunction (RR 1.10, 95% CI 0.79 to 1.54) or overall mortality (RR 0.81, 95% CI 0.63 to 1.06). Similar trends were seen with the lysine analogues, but data were sparse. These data conflict with the results of recently published non-randomised studies, which found increased risk of cardiovascular complications and death with aprotinin. There are concerns about the adequacy of reporting of uncommon events in the small clinical trials included in this review.When aprotinin was compared directly with either, or both, of the two lysine analogues it resulted in a significant increase in the risk of death (RR 1.39, 95% CI 1.02, 1.89), and a non-significant increase in the risk of myocardial infarction (RR 1.11 95% CI 0.82, 1.50). Most of the data contributing to this added risk came from a single study - the BART trial (2008). AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the receipt of allogeneic red cell transfusion. Aprotinin appears to be slightly more effective than the lysine analogues in reducing blood loss and the receipt of blood transfusion. However, head to head comparisons show a lower risk of death with lysine analogues when compared with aprotinin. The lysine analogues are effective in reducing blood loss during and after surgery, and appear to be free of serious adverse effects.
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Affiliation(s)
- David A Henry
- Institute of Clinical Evaluative Sciences2075 Bayview AvenueG1 06TorontoOntarioCanadaM4N 3M5
| | - Paul A Carless
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - Annette J Moxey
- Faculty of Health, University of NewcastleResearch Centre for Gender, Health & AgeingLevel 2, David Maddison BuildingCnr King & Watt StreetsNewcastleNew South WalesAustralia2300
| | - Dianne O'Connell
- Cancer CouncilCancer Epidemiology Research UnitPO Box 572Kings CrossSydneyNSWAustralia1340
| | - Barrie J Stokes
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - Dean A Fergusson
- University of Ottawa Centre for Transfusion ResearchOttawa Health Research Institute501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Katharine Ker
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupRoom 135Keppel StreetLondonUKWC1E 7HT
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Carless PA, Rubens FD, Anthony DM, O’Connell D, Henry DA. Platelet-rich-plasmapheresis for minimising peri-operative allogeneic blood transfusion. Cochrane Database Syst Rev 2011:CD004172. [PMID: 21412885 PMCID: PMC4171963 DOI: 10.1002/14651858.cd004172.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have generated considerable enthusiasm for the use of technologies intended to reduce the use of allogeneic blood (blood from an unrelated donor). Platelet-rich plasmapheresis (PRP) offers an alternative approach to blood conservation. OBJECTIVES To examine the evidence for the efficacy of PRP in reducing peri-operative allogeneic red blood cell (RBC) transfusion, and the evidence for any effect on clinical outcomes such as mortality and re-operation rates. SEARCH STRATEGY We identified studies by searching MEDLINE (1950 to 2009), EMBASE (1980 to 2009), The Cochrane Library (Issue 1, 2009), the Internet (to March 2009) and the reference lists of published articles, reports, and reviews. SELECTION CRITERIA Controlled parallel group trials in which adult patients, scheduled for non-urgent surgery, were randomised to PRP, or to a control group which did not receive the intervention. DATA COLLECTION AND ANALYSIS Primary outcomes measured were: the number of patients exposed to allogeneic RBC transfusion, and the amount of RBC transfused. Other outcomes measured were: the number of patients exposed to allogeneic platelet transfusions, fresh frozen plasma, and cryoprecipitate, blood loss, re-operation for bleeding, post-operative complications (thrombosis), mortality, and length of hospital stay. Treatment effects were pooled using a random-effects model. Trial quality was assessed using criteria proposed by Schulz et al (Schulz 1995). MAIN RESULTS Twenty-two trials of PRP were identified that reported data for the number of patients exposed to allogeneic RBC transfusion. These trials evaluated a total of 1589 patients. The relative risk (RR) of exposure to allogeneic blood transfusion in those patients randomised to PRP was 0.73 (95%CI 0.59 to 0.90), equating to a relative risk reduction (RRR) of 27% and a risk difference (RD) of 19% (95%CI 10% to 29%). However, significant heterogeneity of treatment effect was observed (p < 0.00001; I² = 79%). When the four trials by Boldt are excluded, the RR is 0.76 (95% CI 0.62 to 0.93). On average, PRP did not significantly reduce the total volume of RBC transfused (weighted mean difference [WMD] -0.69, 95%CI -1.93 to 0.56 units). Trials provided inadequate data regarding the impact of PRP on morbidity, mortality, and hospital length of stay. Trials were generally small and of poor methodological quality. AUTHORS' CONCLUSIONS Although the results suggest that PRP is effective in reducing allogeneic RBC transfusion in adult patients undergoing elective surgery, there was considerable heterogeneity of treatment effects and the trials were of poor methodological quality. The available studies provided inadequate data for firm conclusions to be drawn regarding the impact of PRP on clinically important endpoints.
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Affiliation(s)
- Paul A Carless
- Discipline of Clinical Pharmacology, Faculty of Health, University of Newcastle, Newcastle, Australia
| | - Fraser D Rubens
- Department of Surgery, University of Ottawa Heart Institute, Ottawa, Canada
| | - Danielle M Anthony
- Discipline of Clinical Pharmacology, Faculty of Health, University of Newcastle, Newcastle, Australia
| | - Dianne O’Connell
- Cancer Epidemiology Research Unit, Cancer Council, Sydney, Australia
| | - David A Henry
- Institute of Clinical Evaluative Sciences, Toronto, Canada
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Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2011:CD001886. [PMID: 21249650 DOI: 10.1002/14651858.cd001886.pub3] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have led to the development of a range of interventions to minimise blood loss during major surgery. Anti-fibrinolytic drugs are widely used, particularly in cardiac surgery, and previous reviews have found them to be effective in reducing blood loss, the need for transfusion, and the need for re-operation due to continued or recurrent bleeding. In the last few years questions have been raised regarding the comparative performance of the drugs. The safety of the most popular agent, aprotinin, has been challenged, and it was withdrawn from world markets in May 2008 because of concerns that it increased the risk of cardiovascular complications and death. OBJECTIVES To assess the comparative effects of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon aminocaproic acid (EACA) on blood loss during surgery, the need for red blood cell (RBC) transfusion, and adverse events, particularly vascular occlusion, renal dysfunction, and death. SEARCH STRATEGY We searched: the Cochrane Injuries Group's Specialised Register (July 2010), Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 3), MEDLINE (Ovid SP) 1950 to July 2010, EMBASE (Ovid SP) 1980 to July 2010. References in identified trials and review articles were checked and trial authors were contacted to identify any additional studies. The searches were last updated in July 2010. SELECTION CRITERIA Randomised controlled trials (RCTs) of anti-fibrinolytic drugs in adults scheduled for non-urgent surgery. Eligible trials compared anti-fibrinolytic drugs with placebo (or no treatment), or with each other. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. MAIN RESULTS This review summarises data from 252 RCTs that recruited over 25,000 participants. Data from the head-to-head trials suggest an advantage of aprotinin over the lysine analogues TXA and EACA in terms of reducing perioperative blood loss, but the differences were small. Compared to control, aprotinin reduced the probability of requiring RBC transfusion by a relative 34% (relative risk [RR] 0.66, 95% confidence interval [CI] 0.60 to 0.72). The RR for RBC transfusion with TXA was 0.61 (95% CI 0.53 to 0.70) and was 0.81 (95% CI 0.67 to 0.99) with EACA. When the pooled estimates from the head-to-head trials of the two lysine analogues were combined and compared to aprotinin alone, aprotinin appeared more effective in reducing the need for RBC transfusion (RR 0.90; 95% CI 0.81 to 0.99).Aprotinin reduced the need for re-operation due to bleeding by a relative 54% (RR 0.46, 95% CI 0.34 to 0.62). This translates into an absolute risk reduction of 2% and a number needed-to-treat (NNT) of 50 (95% CI 33 to 100). A similar trend was seen with EACA (RR 0.32, 95% CI 0.11 to 0.99) but not TXA (RR 0.80, 95% CI 0.55 to 1.17). The blood transfusion data were heterogeneous and funnel plots indicate that trials of aprotinin and the lysine analogues may be subject to publication bias.When compared with no treatment aprotinin did not increase the risk of myocardial infarction (RR 0.87, 95% CI 0.69 to 1.11), stroke (RR 0.82, 95% CI 0.44 to 1.52), renal dysfunction (RR 1.10, 95% CI 0.79 to 1.54) or overall mortality (RR 0.81, 95% CI 0.63 to 1.06). Similar trends were seen with the lysine analogues, but data were sparse. These data conflict with the results of recently published non-randomised studies, which found increased risk of cardiovascular complications and death with aprotinin. There are concerns about the adequacy of reporting of uncommon events in the small clinical trials included in this review.When aprotinin was compared directly with either, or both, of the two lysine analogues it resulted in a significant increase in the risk of death (RR 1.39, 95% CI 1.02, 1.89), and a non-significant increase in the risk of myocardial infarction (RR 1.11 95% CI 0.82, 1.50). Most of the data contributing to this added risk came from a single study - the BART trial (2008). AUTHORS' CONCLUSIONS Anti-fibrinolytic drugs provide worthwhile reductions in blood loss and the receipt of allogeneic red cell transfusion. Aprotinin appears to be slightly more effective than the lysine analogues in reducing blood loss and the receipt of blood transfusion. However, head to head comparisons show a lower risk of death with lysine analogues when compared with aprotinin. The lysine analogues are effective in reducing blood loss during and after surgery, and appear to be free of serious adverse effects.
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Affiliation(s)
- David A Henry
- Institute of Clinical Evaluative Sciences, 2075 Bayview Avenue, G1 06, Toronto, Ontario, Canada, M4N 3M5
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. I. The pre-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:19-40. [PMID: 21235852 PMCID: PMC3021395 DOI: 10.2450/2010.0074-10] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Giancarlo Maria Liumbruno
- Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
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25
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Interstitial plasmin activity with epsilon aminocaproic acid: temporal and regional heterogeneity. Ann Thorac Surg 2010; 89:1538-45. [PMID: 20417774 DOI: 10.1016/j.athoracsur.2010.01.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 01/21/2010] [Accepted: 01/25/2010] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epsilon aminocaproic acid (EACA) is used in cardiac surgery to modulate plasmin activity (PLact). The present study developed a fluorogenic-microdialysis system to measure in vivo region specific temporal changes in PLact after EACA administration. METHODS Pigs (25 to 35 kg) received EACA (75 mg/kg, n = 7) or saline in which microdialysis probes were placed in the liver, myocardium, kidney, and quadricep muscle. The microdialysate contained a plasmin-specific fluorogenic peptide and fluorescence emission, which directly reflected PLact, determined at baseline, 30, 60, 90, and 120 minutes after EACA/vehicle infusion. RESULTS Epsilon aminocaproic acid caused significant decreases in liver and quadricep PLact at 60, 90, 120 minutes, and at 30, 60, and 120 minutes, respectively (p < 0.05). In contrast, EACA induced significant biphasic changes in heart and kidney PLact profiles with initial increases followed by decreases at 90 and 120 minutes (p < 0.05). The peak EACA interstitial concentrations for all compartments occurred at 30 minutes after infusion, and were fivefold higher in the renal compartment and fourfold higher in the myocardium, when compared with the liver or muscle (p < 0.05). CONCLUSIONS Using a large animal model and in vivo microdialysis measurements of plasmin activity, the unique findings from this study were twofold. First, EACA induced temporally distinct plasmin activity profiles within the plasma and interstitial compartments. Second, EACA caused region-specific changes in plasmin activity profiles. These temporal and regional heterogeneic effects of EACA may have important therapeutic considerations when managing fibrinolysis in the perioperative period.
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Carless PA, Henry DA, Moxey AJ, O'Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2010; 2010:CD001888. [PMID: 20393932 PMCID: PMC4163967 DOI: 10.1002/14651858.cd001888.pub4] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Concerns regarding the safety of transfused blood have prompted reconsideration of the use of allogeneic (from an unrelated donor) red blood cell (RBC) transfusion, and a range of techniques to minimise transfusion requirements. OBJECTIVES To examine the evidence for the efficacy of cell salvage in reducing allogeneic blood transfusion and the evidence for any effect on clinical outcomes. SEARCH STRATEGY We identified studies by searching CENTRAL (The Cochrane Library 2009, Issue 2), MEDLINE (1950 to June 2009), EMBASE (1980 to June 2009), the internet (to August 2009) and bibliographies of published articles. SELECTION CRITERIA Randomised controlled trials with a concurrent control group in which adult patients, scheduled for non-urgent surgery, were randomised to cell salvage (autotransfusion) or to a control group who did not receive the intervention. DATA COLLECTION AND ANALYSIS Data were independently extracted and the risk of bias assessed. Relative risks (RR) and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random-effects model. The primary outcomes were the number of patients exposed to allogeneic red cell transfusion and the amount of blood transfused. Other clinical outcomes are detailed in the review. MAIN RESULTS A total of 75 trials were included. Overall, the use of cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 38% (RR 0.62; 95% CI 0.55 to 0.70). The absolute reduction in risk (ARR) of receiving an allogeneic RBC transfusion was 21% (95% CI 15% to 26%). In orthopaedic procedures the RR of exposure to RBC transfusion was 0.46 (95% CI 0.37 to 0.57) compared to 0.77 (95% CI 0.69 to 0.86) for cardiac procedures. The use of cell salvage resulted in an average saving of 0.68 units of allogeneic RBC per patient (WMD -0.68; 95% CI -0.88 to -0.49). Cell salvage did not appear to impact adversely on clinical outcomes. AUTHORS' CONCLUSIONS The results suggest cell salvage is efficacious in reducing the need for allogeneic red cell transfusion in adult elective cardiac and orthopaedic surgery. The use of cell salvage did not appear to impact adversely on clinical outcomes. However, the methodological quality of trials was poor. As the trials were unblinded and lacked adequate concealment of treatment allocation, transfusion practices may have been influenced by knowledge of the patients' treatment status potentially biasing the results in favour of cell salvage.
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Affiliation(s)
- Paul A Carless
- Faculty of Health, University of NewcastleDiscipline of Clinical PharmacologyLevel 5, Clinical Sciences Building, Newcastle Mater HospitalEdith Street, WaratahNewcastleNew South WalesAustralia2298
| | - David A Henry
- Institute of Clinical Evaluative Sciences2075 Bayview AvenueG1 06TorontoOntarioCanadaM4N 3M5
| | - Annette J Moxey
- Faculty of Health, University of NewcastleResearch Centre for Gender, Health & AgeingLevel 2, David Maddison BuildingUniversity DriveCallaghanNew South WalesAustralia2308
| | - Dianne O'Connell
- Cancer CouncilCancer Epidemiology Research UnitPO Box 572Kings CrossSydneyNSWAustralia1340
| | - Tamara Brown
- University of TeessideSchool of Health & Social Care, Centre for Food, Physical Activity and ObesityCenturia BuildingTees ValleyMiddlesbroughUKTS1 3BA
| | - Dean A Fergusson
- University of Ottawa Centre for Transfusion ResearchOttawa Health Research Institute501 Smyth RoadOttawaOntarioCanadaK1H 8L6
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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Hunt BJ, Komadina R, Nardi G, Neugebauer E, Ozier Y, Riddez L, Schultz A, Stahel PF, Vincent JL, Spahn DR. Management of bleeding following major trauma: an updated European guideline. Crit Care 2010; 14:R52. [PMID: 20370902 PMCID: PMC2887168 DOI: 10.1186/cc8943] [Citation(s) in RCA: 468] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 03/23/2010] [Accepted: 04/06/2010] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes. METHODS The multidisciplinary Task Force for Advanced Bleeding Care in Trauma was formed in 2005 with the aim of developing a guideline for the management of bleeding following severe injury. This document presents an updated version of the guideline published by the group in 2007. Recommendations were formulated using a nominal group process, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence and based on a systematic review of published literature. RESULTS Key changes encompassed in this version of the guideline include new recommendations on coagulation support and monitoring and the appropriate use of local haemostatic measures, tourniquets, calcium and desmopressin in the bleeding trauma patient. The remaining recommendations have been reevaluated and graded based on literature published since the last edition of the guideline. Consideration was also given to changes in clinical practice that have taken place during this time period as a result of both new evidence and changes in the general availability of relevant agents and technologies. CONCLUSIONS This guideline provides an evidence-based multidisciplinary approach to the management of critically injured bleeding trauma patients.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Hospital Cologne Merheim, Ostmerheimerstrasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- Faculty of Medicine in Hradec Králové, Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, 50005 Hradec Králové, Czech Republic
| | - Timothy J Coats
- Accident and Emergency Department, University of Leicester, Infirmary Square, Leicester LE1 5WW, UK
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, University of Paris XI, Faculté de Médecine Paris-Sud, 63 rue Gabriel Péri, 94276 Le Kremlin-Bicêtre, France
| | - Enrique Fernández-Mondéjar
- Department of Emergency and Critical Care Medicine, University Hospital Virgen de las Nieves, ctra de Jaén s/n, 18013 Granada, Spain
| | - Beverley J Hunt
- Guy's & St Thomas' Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- Shock and Trauma Center, S. Camillo Hospital, I-00152 Rome, Italy
| | - Edmund Neugebauer
- Institute for Research in Operative Medicine (IFOM), Ostmerheimerstrasse 200, 51109 Cologne, Germany
| | - Yves Ozier
- Department of Anaesthesia and Intensive Care, Université Paris Descartes, AP-HP Hopital Cochin, Paris, France
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- Ludwig-Boltzmann-Institute for Experimental and Clinical Traumatology and Lorenz Boehler Trauma Center, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Philip F Stahel
- Department of Orthopaedic Surgery and Department of Neurosurgery, University of Colorado Denver School of Medicine, Denver Health Medical Center, 777 Bannock Street, Denver, CO 80204, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R Spahn
- Institute of Anesthesiology, University Hospital Zurich, 8091 Zurich, Switzerland
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Reust DL, Reeves ST, Abernathy JH, Dixon JA, Gaillard WF, Mukherjee R, Koval CN, Stroud RE, Spinale FG. Temporally and regionally disparate differences in plasmin activity by tranexamic acid. Anesth Analg 2010; 110:694-701. [PMID: 20185649 DOI: 10.1213/ane.0b013e3181c7eb27] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND A major complication associated with cardiac surgery is excessive and prolonged bleeding in the perioperative period. Improving coagulation by inhibiting fibrinolysis, primarily through inhibition of plasmin activity (PLact) with antifibrinolytics such as tranexamic acid (TXA), has been a pharmacological mainstay in cardiac surgical patients. Despite its almost ubiquitous use, the temporal and regional modulation of PLact profiles by TXA remains unexplored. Accordingly, we developed a fluorogenic-microdialysis system to measure in vivo dynamic changes in PLact after TXA administration in a large animal model. METHODS Pigs (25-35 kg) were randomly assigned to receive TXA (30 mg/kg, diluted into 50 mL normal saline; n = 9) or vehicle (50 mL normal saline; n = 7). Microdialysis probes were placed in the liver, myocardium, kidney, and quadriceps muscle compartments. The microdialysate infusion contained a validated plasmin-specific fluorogenic peptide. The fluorescence emission (standard fluorogenic units [SFU]) of the interstitial fluid collected from the microdialysis probes, which directly reflects PLact, was determined at steady-state baseline and 30, 60, 90, and 120 min after TXA/vehicle infusion. Plasma PLact was determined at the same time points using the same fluorogenic substrate approach. RESULTS TXA reduced plasma PLact at 30 min after infusion by >110 SFU compared with vehicle values (P < 0.05). Specifically, there was a decrease in liver PLact at 90 and 120 min after TXA infusion of >150 SFU (P < 0.05) and 175 SFU (P < 0.05), respectively. The decrease in liver PLact occurred 60 min after the maximal decrease in plasma PLact. In contrast, kidney, heart, and quadriceps PLact transiently increased followed by an overall decrease at 120 min. CONCLUSIONS Using a large animal model and in vivo microdialysis measurements of PLact, the unique findings from this study were 2-fold. First, TXA induced temporally distinct PLact profiles within the plasma and selected interstitial compartments. Second, TXA caused region-specific changes in PLact profiles. These temporal and regional differences in the effects of TXA may have important therapeutic considerations when managing fibrinolysis in the perioperative period.
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Affiliation(s)
- Daryl L Reust
- Department of Anesthesiology and Perioperative Medicine, Medical University of South Carolina, Charleston, SC 29403, USA
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Preoperative evaluation of patients with liver cirrhosis undergoing open heart surgery. Gen Thorac Cardiovasc Surg 2009; 57:293-7. [PMID: 19533274 DOI: 10.1007/s11748-008-0374-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Accepted: 11/19/2008] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Clinical outcomes after open heart surgery in patients with liver cirrhosis are not satisfactory. For evaluating hepatic function, the Child-Pugh classification has been widely used. It has been reported that open heart surgery can be performed safely in patients with mild liver cirrhosis. In this study, we examined the clinical outcomes after open heart surgery in patients with liver cirrhosis and evaluated the usefulness of the Child-Pugh classification. METHODS There were 12 liver cirrhosis patients who underwent open heart surgery between January 2002 and December 2006 at our institution. The severity of cirrhosis was graded according to the Child-Pugh classification. We reviewed clinical outcomes, such as postoperative mortality and morbidity, and tried to determine the risk factors. Finally, we assessed the usefulness of the Child-Pugh classification. RESULTS Six patients were classified as having Child class A, and the other six patients were classified as B. The overall mortality of group A was 50%, and that of group B was 17%. Postoperative major morbidities occurred in half of the patients of Child class A and in all of the patients of Child class B. Patients who experienced major morbidities had markedly lower levels of serum cholinesterase (106 +/- 46 vs. 199 +/- 72 IU/l; P = 0.02) and lower platelet level (7.5 +/- 2.9 vs. 11.9 +/- 3.6 x 104/microl; P = 0.04). CONCLUSION The mortality and morbidity rates were high even in the Child class A patients. The Child classification may be an insufficient method for evaluating hepatic function. We have to assess other factors, such as the serum cholinesterase level or the platelet count.
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Fraser IS, Porte RJ, Kouides PA, Lukes AS. A benefit-risk review of systemic haemostatic agents: part 1: in major surgery. Drug Saf 2008; 31:217-30. [PMID: 18302446 DOI: 10.2165/00002018-200831030-00003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Systemic haemostatic agents play an important role in the management of blood loss during major surgery where significant blood loss is likely and their use has increased in recent times as a consequence of demand for blood products outstripping supply and the risks associated with transfusions. Their main application is as prophylaxis to reduce bleeding in major surgery, including cardiac and orthopaedic surgery and orthotopic liver transplantation. Aprotinin has been the predominant agent used in this setting; of the other antifibrinolytic agents that have been studied, tranexamic acid is the most effective and epsilon-aminocaproic acid may also have a role. Eptacog alfa (recombinant factor VIIa) has also shown promise. Tranexamic acid, epsilon-aminocaproic acid and eptacog alfa are generally well tolerated; however, when considering the methods to reduce or prevent blood loss intra- and postoperatively, the benefits of these agents need to be weighed against the risk of adverse events. Recently, concerns have been raised about the safety of aprotinin after an association between increased renal dysfunction and mortality was shown in retrospective observational studies and an increase in all-cause mortality with aprotinin relative to tranexamic acid or epsilon-aminocaproic acid was seen after a pre-planned periodic analysis of the large BART (Blood conservation using Antifibrinolytics in a Randomized Trial) study. The latter finding resulted in the trial being halted, and aprotinin has subsequently been withdrawn from the market pending detailed analysis of efficacy and safety results from the study. Part 1 of this benefit-risk review examines the efficacy and adverse effect profiles of systemic haemostatic agents commonly used in surgery, and provides individual benefit-risk profiles that may assist clinicians in selecting appropriate pharmacological therapy in this setting.
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Affiliation(s)
- Ian S Fraser
- Department of Obstetrics and Gynaecology, University of Sydney, Sydney, New South Wales, Australia.
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Fergusson DA, Hébert PC, Mazer CD, Fremes S, MacAdams C, Murkin JM, Teoh K, Duke PC, Arellano R, Blajchman MA, Bussières JS, Côté D, Karski J, Martineau R, Robblee JA, Rodger M, Wells G, Clinch J, Pretorius R. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008; 358:2319-31. [PMID: 18480196 DOI: 10.1056/nejmoa0802395] [Citation(s) in RCA: 693] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding and to reduce exposure to blood products. We sought to determine whether aprotinin was superior to either tranexamic acid or aminocaproic acid in decreasing massive postoperative bleeding and other clinically important consequences. METHODS In this multicenter, blinded trial, we randomly assigned 2331 high-risk cardiac surgical patients to one of three groups: 781 received aprotinin, 770 received tranexamic acid, and 780 received aminocaproic acid. The primary outcome was massive postoperative bleeding. Secondary outcomes included death from any cause at 30 days. RESULTS The trial was terminated early because of a higher rate of death in patients receiving aprotinin. A total of 74 patients (9.5%) in the aprotinin group had massive bleeding, as compared with 93 (12.1%) in the tranexamic acid group and 94 (12.1%) in the aminocaproic acid group (relative risk in the aprotinin group for both comparisons, 0.79; 95% confidence interval [CI], 0.59 to 1.05). At 30 days, the rate of death from any cause was 6.0% in the aprotinin group, as compared with 3.9% in the tranexamic acid group (relative risk, 1.55; 95% CI, 0.99 to 2.42) and 4.0% in the aminocaproic acid group (relative risk, 1.52; 95% CI, 0.98 to 2.36). The relative risk of death in the aprotinin group, as compared with that in both groups receiving lysine analogues, was 1.53 (95% CI, 1.06 to 2.22). CONCLUSIONS Despite the possibility of a modest reduction in the risk of massive bleeding, the strong and consistent negative mortality trend associated with aprotinin, as compared with the lysine analogues, precludes its use in high-risk cardiac surgery. (Current Controlled Trials number, ISRCTN15166455 [controlled-trials.com].).
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Napolitano LM. Transfusion Therapy. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Kristeller JL, Roslund BP, Stahl RF. Benefits and Risks of Aprotinin Use During Cardiac Surgery. Pharmacotherapy 2008; 28:112-24. [PMID: 18154481 DOI: 10.1592/phco.28.1.112] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Judith L Kristeller
- Department of Pharmacy Practice, Wilkes University, Wilkes-Barre, Pennsylvania 18766, USA
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Hemostasis and Coagulation. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Affiliation(s)
- Angus McEwan
- Great Ormond Street Hospital for Children, London, UK.
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Abstract
Goals of hemorrhage management involve promoting coagulation and reducing fibrinolysis to enhance clot formation and stability, and minimizing hemorrhagic expansion to reduce the likelihood of adverse outcomes. The optimal hemostatic regimen to obtain these goals will differ according to the clinical scenario. Two hypothetical cases of patients with hemorrhage are presented that are typical of those encountered by clinical pharmacists who practice in centers that treat trauma or surgical patients or patients in need of emergency or critical care because of serious bleeding. To maximize therapy, the clinician must be aware of how best to clinically apply hemostatic agents, their comparative benefits and disadvantages, and the optimal methods for monitoring their effectiveness and toxicities.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, School of Pharmacy, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80262, USA.
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Sperzel M, Huetter J. Evaluation of aprotinin and tranexamic acid in different in vitro and in vivo models of fibrinolysis, coagulation and thrombus formation. J Thromb Haemost 2007; 5:2113-8. [PMID: 17666018 DOI: 10.1111/j.1538-7836.2007.02717.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The serine protease inhibitor aprotinin and plasminogen inhibitor tranexamic acid are used in coronary artery bypass graft (CABG) surgery to reduce bleeding. Clinicians may consider these agents as readily substitutable regarding their pharmacological profiles. OBJECTIVE These agents were evaluated in assays of hemostasis to elucidate their underlying mechanism(s) of action. METHODS In human plasma, effects on both clot fibrinolysis and coagulation were spectrophotometrically quantified in vitro. Rat-tail bleeding and arteriovenous shunt thrombus formation models were conducted in vivo. RESULTS Fibrinolysis was inhibited by aprotinin (IC(50), 0.16 +/- 0.02 micromol L(-1)) and tranexamic acid (IC(50), 24.1 +/-1.1 micromol L(-1)). In vivo, aprotinin dose-dependently reduced rat-tail bleeding time (minimal effective dose, 3 mg kg(-1) bolus plus 6 mg kg(-1 )h(-1) infusion); tranexamic acid reduced bleeding time (minimal effective dose, 100 mg kg(-1) h(-1)). In vitro, coagulation time was doubled by aprotinin at 3.2 +/- 0.2 micromol L(-1), while tranexamic acid showed no effect at concentrations up to 3 mmol L(-1). Aprotinin inhibited thrombus formation in vivo in a dose-dependent manner (minimal effective dose, 3 mg kg(-1) bolus plus 6 mg kg(-1) h(-1) infusion). Conversely, tranexamic acid dose-dependently increased thrombus formation and thrombus weight (minimal effective dose, 100 mg kg(-1 )h(-1) infusion). CONCLUSIONS These data show that aprotinin and tranexamic acid have differential effects on hemostasis and are not necessarily substitutable with respect to mechanism of action. Although both agents have been shown to reduce bleeding in patients undergoing CABG, their divergent effects on thrombus formation observed in vitro and in vivo should be critically evaluated clinically.
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Affiliation(s)
- M Sperzel
- Product Related Research, Bayer Healthcare AG, Wuppertal, Germany.
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Abstract
Hospital pharmacists are often consulted for their knowledge about coagulation and therapeutic interventions for the management of critical bleeding. Many pharmacotherapies are available for this purpose, both systemic and topical, and others are in development. These agents and their mechanisms of action are reviewed, and perspectives are provided regarding their use in various clinical settings. Also provided are associated precautions to promote safe use. Current controversies surrounding pharmacotherapeutic agents used to control serious bleeding (e.g., in various types of surgery, trauma, obstetrics, and intracranial hemorrhage) are also discussed.
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Affiliation(s)
- Stacy Voils
- School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Hospitals, Richmond, Virginia 23298, USA.
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Arnold DM. The science of systematic reviews. Transfusion 2007; 47:1347-9. [PMID: 17655576 DOI: 10.1111/j.1537-2995.2007.01324.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Donald M Arnold
- Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada.
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Affiliation(s)
- Pier Mannuccio Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and the Department of Medicine and Medical Specialties, University of Milan, Milan.
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Heier HE, Bugge W, Hjelmeland K, Søreide E, Sørlie D, Håheim LL. Transfusion vs. alternative treatment modalities in acute bleeding: a systematic review. Acta Anaesthesiol Scand 2006; 50:920-31. [PMID: 16923085 DOI: 10.1111/j.1399-6576.2006.01089.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND METHODS The practice of transfusion varies a great deal between countries and hospitals. Therefore, a systematic literature review was performed to evaluate the evidence underlying practice of transfusion and alternative treatment modalities in acute bleeding. After a stepwise evaluation, 79 out of 2438 abstracts were approved as the evidence base. RESULTS Albumin for volume therapy is not better than artificial colloids or crystalloids and may be detrimental in trauma patients. No outcome difference has been proved between artificial colloids and crystalloids. Use of hypertonic solutions remains controversial, as do the concepts of delayed and hypotensive resuscitation. Healthy individuals tolerate acute, normovolaemic anaemia at 5 g haemoglobin/dl, but pre-operative haemoglobin < 6 g/dl gives increased mortality from surgical interventions. Keeping haemoglobin higher than 8-9 g/dl has not been associated with any positive effect on mortality or morbidity, even in patients with cardiovascular disease. The changes induced in erythrocytes by storage may be clinically insignificant. No alternative to erythrocyte transfusion was established. Evidence underlying the practice of thrombocyte and plasma transfusion is scarce. Available evidence on recombinant coagulation factor VIIa is insufficient to define its future role in acute bleedings. Antifibrinolytic drugs in general seem to reduce the need for transfusion. CONCLUSIONS Intravenous volume replacement and transfusion policies seem largely based on local tradition and expert opinions. As a result of the difficulties in performing controlled studies in patients with acute bleeding and the large number of patients needed to prove effects, other scientific evidence should be sought to better define best practice in this important field.
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Affiliation(s)
- H E Heier
- Department of Immunology and Transfusion Medicine, Ullevaal University Hospital, University of Oslo, Oslo, Norway.
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Vuylsteke A, Saravanan P, Gerrard C, Cafferty F. The impact of administration of tranexamic acid in reducing the use of red blood cells and other blood products in cardiac surgery. BMC Anesthesiol 2006; 6:9. [PMID: 16942621 PMCID: PMC1569373 DOI: 10.1186/1471-2253-6-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 08/30/2006] [Indexed: 11/18/2022] Open
Abstract
Background To study the effect of administration of tranexamic acid on the use of blood and blood products, return to theatre for post-operative bleeding and the length of intensive care stay after primary cardiac surgery, data for 4191 patients, of all priorities, who underwent primary cardiac operation during the period between 30/10/00 and 21/09/04 were analysed. Methods Retrospective analysis of data collected prospectively during the study period. The main outcome measures were whether or not patients were transfused with red blood cells, fresh frozen plasma or any blood product, the proportion of patients returned to theatre for investigation for post-operative bleeding and length of stay in the intensive care unit. We performed univariate analysis to identify the factors influencing the outcome measures and multivariate analysis to identify the effect of administration of tranexamic acid on the outcome measures. Results Administration of tranexamic acid was an independent factor affecting the transfusion of red blood cells, fresh frozen plasma or any blood product. It was also an independent factor influencing the rate of return to theatre for exploration of bleeding. The odds of receiving a transfusion or returning to theatre for bleeding were significantly lower in patients receiving tranexamic acid. The administration of tranexamic acid also significantly decreased blood loss. We did not find any association between the administration of tranexamic acid and the length of intensive care stay. Conclusion Based on the analysis of 4191 patients who underwent a primary cardiac operation, administration of tranexamic acid decreased the number of patients exposed to a transfusion or returned to theatre for bleeding in our institute.
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Affiliation(s)
- Alain Vuylsteke
- Department of Anaesthesia, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, CB3 8RE, UK
| | - Palanikumar Saravanan
- Department of Anaesthesia, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, CB3 8RE, UK
| | - Caroline Gerrard
- Department of Anaesthesia, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, CB3 8RE, UK
| | - Fay Cafferty
- Research and Development Department, Papworth Hospital NHS Foundation Trust, Papworth Everard, Cambridgeshire, CB3 8RE, UK
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Durand M, Chavanon O, Tessier Y, Meyer C, Casez M, Bach V, Maitrasse B, Girardet P. Effect of aprotinin on postoperative blood loss in off-pump coronary artery bypass surgery. J Card Surg 2006; 21:17-21. [PMID: 16426342 DOI: 10.1111/j.1540-8191.2006.00162.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Off-pump coronary artery bypass (OPCAB) enables a reduction in postoperative complications, particularly bleeding and transfusion. Nevertheless, a significant percentage of patients still needs transfusion. The effect of antifibrinolytic therapy on postoperative bleeding as part of OPCAB is still not widely described. The purpose of this study was to investigate the potential benefit of aprotinin in OPCAB. METHODS We conducted a retrospective comparative study with a historical control group. Consecutive patients undergoing off-pump coronary bypass were divided in two groups: 40 patients were operated without any antifibinolytic drug (group C); 40 patients received aprotinin (group A) during surgery. Patients in group A received a bolus of 2 x 10(6) KIU during 30 minutes, followed by a continuous infusion of 0.5 x 10(6) KIU per hour until the end of surgery. The same protocol was used during the whole study period. RESULTS Preoperative data of the two groups did not differ except for the number of grafts performed, which was higher in group A. Prothrombin time and activated clotting time increased in both groups after surgery. The use of packed red blood cells or fresh frozen plasma was not significantly different between both groups. Postoperative blood loss was significantly reduced in the aprotinin group (540 mL +/- 320 vs. 770 mL +/- 390, p = 0.006). No increase in postoperative troponin values was found in group A. CONCLUSIONS Aprotinin significantly reduced postoperative blood loss without reducing the transfusion rate. Aprotinin was not associated with any increase in postoperative complications.
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Affiliation(s)
- M Durand
- Department of Anesthesia, Grenoble University Hospital, Grenoble, France.
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Lewis CE, Hiratzka LF, Woods SE, Hendy MP, Engel AM. Autologous blood transfusion in elective cardiac valve operations. J Card Surg 2006; 20:513-8. [PMID: 16309401 DOI: 10.1111/j.1540-8191.2005.00137.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM OF STUDY The aim of this study was to detect any outcome differences between patients who donated autologous blood versus nondonors undergoing nonemergent cardiac valve surgery. Of further interest was whether autologous donors required less allogeneic blood products overall than patients who did not donate. METHODS We conducted a nested case-control study in which data were collected prospectively on 225 variables. Cases underwent nonemergent, cardiac valve surgery and donated autologous blood products (n = 40). Controls also had nonemergent, cardiac valve surgery but did not donate autologous blood products (n = 120). Cases were matched to controls 1:3 on age (+/-3 years), gender, and New York Heart Association Functional Classification. We controlled for 12 potential confounding variables and examined 17 outcomes of interest. To generate the unadjusted risks of each outcome, chi-square and t-tests were performed comparing cases and controls to each outcome of interest. Then logistic regression analysis investigated the adjusted risk between cases and controls and for the outcomes of interest, each controlling for the potential confounding variables. RESULTS There were no significant differences between the cases and controls for 11 of the 12 possible confounding variables. Controls had significantly more chronic obstructive pulmonary disorder. There were no significant differences between cases and controls for 13 of the 17 outcomes of interest. Autologous blood donors received more total packed red blood cells (PRBCs) (p = 0.0373) and more total fresh frozen plasma than controls (p = 0.0002). Fewer autologous blood donors required allogeneic packed red blood cell transfusion (p = 0.0134), and the total length of stay was shorter for autologous donors (p = 0.0782). CONCLUSION Four of the 17 outcomes of interest were different for patients who donated autologous blood versus those who did not. Our experience demonstrated that elective cardiac valve surgery can safely reduce (by 18.3%) the need for allogeneic PRBCs by utilizing preoperative autologous blood donation.
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Affiliation(s)
- Chad E Lewis
- Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio 45220, USA
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Blanchette CM, Wang PF, Joshi AV, Asmussen M, Saunders W, Kruse P. Cost and utilization of blood transfusion associated with spinal surgeries in the United States. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2006; 16:353-63. [PMID: 16463198 PMCID: PMC2200697 DOI: 10.1007/s00586-006-0066-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2005] [Revised: 12/07/2005] [Accepted: 01/01/2006] [Indexed: 11/27/2022]
Abstract
The purpose of this study was to examine factors associated with the utilization and cost of blood transfusion during and post-spinal fusion surgery. A retrospective, observational study of 42,029 inpatients undergoing spinal fusion surgery in United States hospitals participating in the Perspective( Comparative Database for inpatient use was conducted. Descriptive analysis, logistic regression, and ordinary least squares (OLS) regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion (ABT). Hospitalization costs were $18,690 (SD=14,159) per patient, erythropoietin costs were $85.25 (SD=3,691.66) per patient, and topical sealant costs were $414.34 (SD=1,020.06) per patient. Sub-analysis of ABT restricted to users revealed ABT costs ranged from $312.24 (SD=543.35) per patient with whole blood to $2,520 (SD=3,033.49) per patient with fresh frozen plasma. Patients that received hypotensive anesthesia (OR,1.61; 95% CI, 1.47-1.77), a volume expander (OR,1.95; 95% CI, 1.75-2.18), autologous blood (OR, 2.04; 95% CI, 1.71-2.42), or an erythropoietic agent (OR=1.64; 95% CI, 1.27-2.12) had a higher risk of ABT. Patients that received cell salvage had a lower risk of transfusion (OR=0.40; 95% CI, 0.32-0.50). Most blood avoidance techniques have low utilization or do not reduce the burden of transfusion associated with spinal fusion.
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Affiliation(s)
| | - Peter F. Wang
- Premier Inc., Pharmaceutical Research Services, Charlotte, NC USA
| | | | | | - William Saunders
- Premier Inc., Pharmaceutical Research Services, Charlotte, NC USA
| | - Peter Kruse
- Novo Nordisk Inc., BioPharmaceuticals, Princeton, NJ USA
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Kuitunen A, Hiippala S, Vahtera E, Rasi V, Salmenperä M. The effects of aprotinin and tranexamic acid on thrombin generation and fibrinolytic response after cardiac surgery. Acta Anaesthesiol Scand 2005; 49:1272-9. [PMID: 16146463 DOI: 10.1111/j.1399-6576.2005.00809.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thrombin formation during cardiac surgery could result in disordered hemostasis and thrombosis. The aim of the study was to examine the effects of aprotinin and tranexamic acid on thrombin generation and fibrinolytic activity in patients undergoing cardiac surgery. METHODS Data were collected prospectively from 60 patients undergoing coronary artery bypass grafting using cardiopulmonary bypass (CPB). In a randomized sequence, 20 patients received aprotinin, 20 patients received tranexamic acid, and in 20 patients placebo was used. RESULTS Significant thrombin activity was found in all the studied patients. Thrombin generation was less in the aprotinin group than in the tranexamic acid and the placebo group (thrombin/anti-thrombin III complexes 33.7 +/- 3.6, 53.6 +/- 7.0 and 44.2 +/- 5.3 microg/l 2 h after CPB and F1 + 2 fragment 1.50 +/- 0.10, 2.37 +/- 0.37 and 2.04 +/- 0.20 nmol/l 6 h after surgery, respectively). The inhibition of fibrinolysis was significant with both anti-fibrinolytic drugs (D-dimers 0.427 +/- 0.032, 0.394 +/- 0.039 and 2.808 +/- 0.037 mg/l 2 h after CPB, respectively). The generation of d-dimers was inhibited until 16 h after CPB in the aprotinin group. The plasminogen activation was significantly less in the aprotinin group (plasmin/anti-plasmin complexes 0.884 +/- 0.095, 2.764 +/- 0.254 and 1.574 +/- 0.185 mg/l 2 h after CPB, respectively). CONCLUSION Thrombin formation is inevitable in coronary artery bypass surgery when CPB is used. The suppression of fibrinolytic activity, either with aprotinin or with tranexamic acid interferes with the hemostatic balance as evaluated by biochemical markers. Further investigations are needed to define the role of hemostatic activation in ischemic complications associated with cardiac surgery.
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Affiliation(s)
- A Kuitunen
- Department of Anesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Ma M, Eckert K, Ralley F, Chin-Yee I. A retrospective study evaluating single-unit red blood cell transfusions in reducing allogeneic blood exposure. Transfus Med 2005; 15:307-12. [PMID: 16101808 DOI: 10.1111/j.0958-7578.2005.00592.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although guidelines recommend the use of single-unit red blood cell (RBC) transfusions to minimize allogeneic blood exposure, clinical practice remains dominated by two-unit transfusions. This study assesses the potential impact of a single-unit transfusion policy on reducing RBC utilization. We performed a retrospective analysis of adult patients admitted to a tertiary care hospital who received one or two RBC units. In subjects transfused two units, the effect of one unit was estimated by dividing the change in haemoglobin by 2. The proportion of patients reaching a haemoglobin threshold of 70, 75, 80, 85 and 90 g L(-1) with a single RBC unit was estimated. Of 302 included patients, only 65 received a one-unit transfusion. Based on thresholds of > or = 90, > or = 80 and > or = 70 g L(-1), a single-unit transfusion would be sufficient in 42.0% (RRR = 0.54), 79.6% (RRR = 0.23) and 98.0% (RRR = 0.02) of cases, respectively. This corresponds to 0.21, 0.57 and 0.82 mean RBC units saved per patient. In the orthopaedic subpopulation, the mean RBC units saved are 0.53, 0.88 and 1.00 for the same haemoglobin targets. Adopting a policy of transfusing RBC in single-unit aliquots could significantly improve RBC utilization and decrease patient exposure to allogeneic blood.
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Affiliation(s)
- M Ma
- University of Western Ontario, London, Ontario, Canada
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Carless PA, Moxey AJ, Stokes BJ, Henry DA. Are antifibrinolytic drugs equivalent in reducing blood loss and transfusion in cardiac surgery? A meta-analysis of randomized head-to-head trials. BMC Cardiovasc Disord 2005; 5:19. [PMID: 15992412 PMCID: PMC1185524 DOI: 10.1186/1471-2261-5-19] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2004] [Accepted: 07/04/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aprotinin has been shown to be effective in reducing peri-operative blood loss and the need for re-operation due to continued bleeding in cardiac surgery. The lysine analogues tranexamic acid (TXA) and epsilon aminocaproic acid (EACA) are cheaper, but it is not known if they are as effective as aprotinin. METHODS Studies were identified by searching electronic databases and bibliographies of published articles. Data from head-to-head trials were pooled using a conventional (Cochrane) meta-analytic approach and a Bayesian approach which estimated the posterior probability of TXA and EACA being equivalent to aprotinin; we used as a non-inferiority boundary a 20% increase in the rates of transfusion or re-operation because of bleeding. RESULTS Peri-operative blood loss was significantly greater with TXA and EACA than with aprotinin: weighted mean differences were 106 mls (95% CI 37 to 227 mls) and 185 mls (95% CI 134 to 235 mls) respectively. The pooled relative risks (RR) of receiving an allogeneic red blood cell (RBC) transfusion with TXA and EACA, compared with aprotinin, were 1.08 (95% CI 0.88 to 1.32) and 1.14 (95% CI 0.84 to 1.55) respectively. The equivalent Bayesian posterior mean relative risks were 1.15 (95% Bayesian Credible Interval [BCI] 0.90 to 1.68) and 1.21 (95% BCI 0.79 to 1.82) respectively. For transfusion, using a 20% non-inferiority boundary, the posterior probabilities of TXA and EACA being non-inferior to aprotinin were 0.82 and 0.76 respectively. For re-operation the Cochrane RR for TXA vs. aprotinin was 0.98 (95% CI 0.51 to 1.88), compared with a posterior mean Bayesian RR of 0.63 (95% BCI 0.16 to 1.46). The posterior probability of TXA being non-inferior to aprotinin was 0.92, but this was sensitive to the inclusion of one small trial. CONCLUSION The available data are conflicting regarding the equivalence of lysine analogues and aprotinin in reducing peri-operative bleeding, transfusion and the need for re-operation. Decisions are sensitive to the choice of clinical outcome and non-inferiority boundary. The data are an uncertain basis for replacing aprotinin with the cheaper lysine analogues in clinical practice. Progress has been hampered by small trials and failure to study clinically relevant outcomes.
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Affiliation(s)
- Paul A Carless
- Discipline of Clinical Pharmacology, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, New South Wales, Australia
| | - Annette J Moxey
- Discipline of Clinical Pharmacology, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, New South Wales, Australia
| | - Barrie J Stokes
- Discipline of Clinical Pharmacology, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, New South Wales, Australia
| | - David A Henry
- Discipline of Clinical Pharmacology, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, New South Wales, Australia
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