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Hinton JV, Xing Z, Fletcher CM, Perry LA, Karamesinis A, Shi J, Ramson DM, Penny-Dimri JC, Liu Z, Coulson TG, Smith JA, Segal R, Bellomo R. Cryoprecipitate Transfusion After Cardiac Surgery. Heart Lung Circ 2023; 32:414-423. [PMID: 36528546 DOI: 10.1016/j.hlc.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The association of cryoprecipitate transfusion with patient outcomes after cardiac surgery is unclear. We aimed to investigate the predictors of, and outcomes associated with, postoperative cryoprecipitate transfusion in cardiac surgery patients. METHODS We used the Medical Information Mart for Intensive Care III and IV databases. We included adults undergoing cardiac surgery, and propensity score matched cryoprecipitate-treated patients to controls. Using the matched cohort, we investigated the association of cryoprecipitate use with clinical outcomes. The primary outcome was in-hospital mortality. Secondary outcomes were infection, acute kidney injury, intensive care unit length of stay, hospital length of stay, and chest tube output at 2-hour intervals. RESULTS Of 12,043 eligible patients, 283 (2.35%) patients received cryoprecipitate. The median dose was 5.83 units (IQR 4.17-7.24) given at a median first transfusion time of 1.75 hours (IQR 0.73-4.46) after intensive care unit admission. After propensity scoring, we matched 195 cryoprecipitate recipients to 743 controls. Postoperative cryoprecipitate transfusion was not significantly associated with in-hospital mortality (odds ratio [OR] 1.10; 99% confidence interval [CI] 0.43-2.84; p=0.791), infection (OR 0.77; 99% CI 0.45-1.34; p=0.220), acute kidney injury (OR 1.03; 99% CI 0.65-1.62; p=0.876) or cumulative chest tube output (adjusted mean difference 8 hrs post transfusion, 11 mL; 99% CI -104 to 125; p=0.804). CONCLUSIONS Although cryoprecipitate was typically given to sicker patients with more bleeding, its administration was not associated with worse outcomes. Large, multicentred studies are warranted to further elucidate cryoprecipitate's safety profile and patterns of use in cardiac surgery.
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Affiliation(s)
- Jake V Hinton
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia.
| | - Zhongyue Xing
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Calvin M Fletcher
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Vic, Australia
| | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Alexandra Karamesinis
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Jenny Shi
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Dhruvesh M Ramson
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia
| | - Zhengyang Liu
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Tim G Coulson
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, Vic, Australia; Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Vic, Australia; Department of Cardiothoracic Surgery, Monash Health, Melbourne, Vic, Australia
| | - Reny Segal
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Vic, Australia; Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Vic, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Vic, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Vic, Australia
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Effect of fibrinogen replacement therapy on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery: a retrospective cohort study. J Anesth 2023; 37:119-129. [PMID: 36436075 DOI: 10.1007/s00540-022-03140-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 11/14/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE This study aimed to examine the effect of fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery. METHODS We retrospectively studied 439 consecutive patients who underwent thoracic aortic surgery with cardiopulmonary bypass between January 1st, 2010 and December 31st, 2019 and identified patients who received cryoprecipitate or fibrinogen concentrate (the fibrinogen replacement group) and those who did not (the control group). Multivariate analyses were performed to examine the associations of fibrinogen replacement therapy with perioperative major bleeding (i.e., excessive hemorrhage or blood transfusion), re-exploration for bleeding, and 1-year mortality. RESULTS There were 285 patients in the fibrinogen replacement group who received 2.2 ± 1.0 g of concentrated fibrinogen amount and 154 patients in the control group. The incidence of major bleeding in the fibrinogen replacement group was less than that in the control group in patients with fibrinogen level < 150 mg/dL during cardiopulmonary bypass (49.7% versus 74.6%, p = 0.0007, multivariate odds ratio; 0.33, 95% confidence intervals; 0.12-0.91, p = 0.03), but not in patients with fibrinogen level ≥ 150 mg/dL (25.0% versus 29.6%, p = 0.51). No significant difference was found in re-exploration for bleeding (1.0% versus 1.3%, p = 1.00) or 1-year mortality (10.4% versus 5.3%, multivariate Cox proportional-hazard ratio; 1.03, 95% confidence intervals; 0.82-1.31, p = 0.74) between the fibrinogen replacement group and the control group. CONCLUSIONS The results of this study indicate that 2-3 g of fibrinogen replacement reduces the incidence of major bleeding in patients with hypofibrinogenemia during cardiopulmonary bypass in thoracic aortic surgery.
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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Leal-Noval SR, Fernández Pacheco J, Casado Méndez M, Cuenca-Apolo D, Múñoz-Gómez M. Current perspective on fibrinogen concentrate in critical bleeding. Expert Rev Clin Pharmacol 2020; 13:761-778. [PMID: 32479129 DOI: 10.1080/17512433.2020.1776608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION . Massive hemorrhage continues to be a treatable cause of death. Its management varies from prefixed ratio-driven administration of blood components to goal-directed therapy based on point-of-care testing and administration of coagulation factor concentrates. AREAS COVERED . We review the current role of fibrinogen concentrate (FC) for the management of massive hemorrhage, either administered without coagulation testing in life-threatening hemorrhage, or within an algorithm based on viscoelastic hemostatic assays and plasma fibrinogen level. We identified relevant guidelines, meta-analyzes, randomized controlled trials, and observational studies that included indications, dosage, and adverse effects of FC, especially thromboembolic events. EXPERT OPINION . Moderate- to high-grade evidence supports the use of FC for the treatment of severe hemorrhage in trauma and cardiac surgery; a lower grade of evidence is available for its use in postpartum hemorrhage and end-stage liver disease. Pre-emptive FC administration in non-bleeding patients is not recommended. FC should be administered early, in a goal-directed manner, guided by early amplitude of clot firmness parameters (A5- or A10-FIBTEM) or hypofibrinogenemia. Further investigation is required into the early use of FC, as well as its potential advantages over cryoprecipitate, and whether or not its administration at high doses leads to a greater risk of adverse events.
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Affiliation(s)
- Santiago R Leal-Noval
- Neuro Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Jose Fernández Pacheco
- Pharmacy and Statistics and Design, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Casado Méndez
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Diego Cuenca-Apolo
- Critical Care Department, University Hospital "Virgen Del Rocío" and Institute of Biomedicine "IBIS" , 41013, Seville, Spain
| | - Manuel Múñoz-Gómez
- Department of Surgical Specialties, Biochemistry and Immunology, University of Málaga , 29071, Málaga, Spain
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