1
|
Newman KL, Johnson KM, Cornia PB, Wu P, Itani K, Ioannou GN. Perioperative Evaluation and Management of Patients With Cirrhosis: Risk Assessment, Surgical Outcomes, and Future Directions. Clin Gastroenterol Hepatol 2020; 18:2398-2414.e3. [PMID: 31376494 PMCID: PMC6994232 DOI: 10.1016/j.cgh.2019.07.051] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/18/2019] [Accepted: 07/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Patients with cirrhosis are at increased risk of perioperative morbidity and mortality. We provide a narrative review of the available data regarding perioperative morbidity and mortality, risk assessment, and management of patients with cirrhosis undergoing non-hepatic surgical procedures. METHODS We conducted a comprehensive review of the literature from 1998-2018 and identified 87 studies reporting perioperative outcomes in patients with cirrhosis. We extracted elements of study design and perioperative mortality by surgical procedure, Child-Turcotte-Pugh (CTP) class and Model for End-stage Liver Disease (MELD) score reported in these 87 studies to support our narrative review. RESULTS Overall, perioperative mortality is 2-10 times higher in patients with cirrhosis compared to patients without cirrhosis, depending on the severity of liver dysfunction. For elective procedures, patients with compensated cirrhosis (CTP class A, or MELD <10) have minimal increase in operative mortality. CTP class C patients (or MELD >15) are at high risk for mortality; liver transplantation or alternatives to surgery should be considered. Very little data exist to guide perioperative management of patients with cirrhosis, so most recommendations are based on case series and expert opinion. Existing risk calculators are inadequate. CONCLUSIONS Severity of liver dysfunction, medical comorbidities and the type and complexity of surgery, including whether it is elective versus emergent, are all determinants of perioperative mortality and morbidity in patients with cirrhosis. There are major limitations to the existing clinical research on risk assessment and perioperative management that warrant further investigation.
Collapse
Affiliation(s)
- Kira L Newman
- Internal Medicine Residency Program, University of Washington School of Medicine, Seattle, Washington.
| | - Kay M Johnson
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Paul B Cornia
- Hospital and Specialty Medicine Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Peter Wu
- Department of Surgery, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington
| | - Kamal Itani
- Boston VA Health Care System and Boston University, Boston, Massachusetts
| | - George N Ioannou
- Division of Gastroenterology, Department of Medicine, Veterans Affairs Puget Sound Health Care System and University of Washington School of Medicine, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| |
Collapse
|
2
|
Miyata S, Itakura A, Ueda Y, Usui A, Okita Y, Ohnishi Y, Katori N, Kushimoto S, Sasaki H, Shimizu H, Nishimura K, Nishiwaki K, Matsushita T, Ogawa S, Kino S, Kubo T, Saito N, Tanaka H, Tamura T, Nakai M, Fujii S, Maeda T, Maeda H, Makino S, Matsunaga S. TRANSFUSION GUIDELINES FOR PATIENTS WITH MASSIVE BLEEDING. ACTA ACUST UNITED AC 2019. [DOI: 10.3925/jjtc.65.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Shigeki Miyata
- Department of Clinical Laboratory Medicine, National Cerebral and Cardiovascular Center
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Yuichi Ueda
- Nara Prefectural Hospital Organization, Nara Prefecture General Medical Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Kobe University
| | - Yoshihiko Ohnishi
- Operation Room, Anesthesiology, National Cerebral and Cardiovascular Center
| | - Nobuyuki Katori
- Department of Anesthesiology, Keio University School of Medicine
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | | | | | - Satoru Ogawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine
| | | | | | - Nobuyuki Saito
- Shock and Trauma Center, Nippon Medical School Chiba Hokusoh Hospital
| | - Hiroshi Tanaka
- Department of Surgery, Division of Minimum Invasive Surgery, Kobe University
| | | | - Michikazu Nakai
- Department of Statistics and Data Analysis, Dept of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center
| | - Satoshi Fujii
- Department of Laboratory Medicine, Asahikawa Medical University
| | - Takuma Maeda
- Division of Transfusion Medicine, National Cerebral and Cardiovascular Center
| | - Hiroo Maeda
- Transfusion Medicine and Cell Therapy, Saitama Medical Center/Saitama Medical University
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Faculty of Medicine, Juntendo University
| | - Shigetaka Matsunaga
- Department of Obstetrics and Gynecology, Saitama Medical Center/Saitama Medical University
| |
Collapse
|
3
|
Zhao LR, Willing A. Enhancing endogenous capacity to repair a stroke-damaged brain: An evolving field for stroke research. Prog Neurobiol 2018; 163-164:5-26. [PMID: 29476785 PMCID: PMC6075953 DOI: 10.1016/j.pneurobio.2018.01.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 01/11/2018] [Accepted: 01/30/2018] [Indexed: 02/07/2023]
Abstract
Stroke represents a severe medical condition that causes stroke survivors to suffer from long-term and even lifelong disability. Over the past several decades, a vast majority of stroke research targets neuroprotection in the acute phase, while little work has been done to enhance stroke recovery at the later stage. Through reviewing current understanding of brain plasticity, stroke pathology, and emerging preclinical and clinical restorative approaches, this review aims to provide new insights to advance the research field for stroke recovery. Lifelong brain plasticity offers the long-lasting possibility to repair a stroke-damaged brain. Stroke impairs the structural and functional integrity of entire brain networks; the restorative approaches containing multi-components have great potential to maximize stroke recovery by rebuilding and normalizing the stroke-disrupted entire brain networks and brain functioning. The restorative window for stroke recovery is much longer than previously thought. The optimal time for brain repair appears to be at later stage of stroke rather than the earlier stage. It is expected that these new insights will advance our understanding of stroke recovery and assist in developing the next generation of restorative approaches for enhancing brain repair after stroke.
Collapse
Affiliation(s)
- Li-Ru Zhao
- Department of Neurosurgery, State University of New York, Upstate Medical University, Syracuse, NY, 13210, USA.
| | - Alison Willing
- Center for Excellence in Aging and Brain Repair, Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, 33612, USA.
| |
Collapse
|
4
|
Muirhead B, Weiss ADH. Massive hemorrhage and transfusion in the operating room. Can J Anaesth 2017; 64:962-978. [DOI: 10.1007/s12630-017-0925-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/11/2017] [Accepted: 06/20/2017] [Indexed: 12/01/2022] Open
|
5
|
Patel PA, Fabbro M. CON: Factor Concentrates Should Not Have an Expanded Role in the Routine Management of the Bleeding Cardiac Surgical Patient. J Cardiothorac Vasc Anesth 2017; 32:565-569. [PMID: 28918979 DOI: 10.1053/j.jvca.2017.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.
| | - Michael Fabbro
- Department of Anesthesiology, University of Miami, Miller School of Medicine, Miami, FL
| |
Collapse
|
6
|
Bleeding Risk and Management in Interventional Procedures in Chronic Liver Disease. J Vasc Interv Radiol 2016; 27:1665-1674. [PMID: 27595469 DOI: 10.1016/j.jvir.2016.05.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 05/25/2016] [Accepted: 05/31/2016] [Indexed: 12/14/2022] Open
Abstract
The coagulopathy of liver disease is distinctly different from therapeutic anticoagulation in a patient. Despite stable elevated standard clot-based coagulation assays, nearly all patients with stable chronic liver disease (CLD) have normal or increased clotting. Common unfamiliarity with the limitations of these assays in CLD may lead to inappropriate and sometimes harmful interventions, including blood product transfusions before a procedure. Knowledge of the distinct hemostatic alterations in CLD can allow identification of the small subset of patients with clinically significant coagulopathy who can benefit from hematologic optimization before invasive procedures.
Collapse
|
7
|
Martínez-Calle N, Hidalgo F, Alfonso A, Muñoz M, Hernández M, Lecumberri R, Páramo JA. Implementation of a management protocol for massive bleeding reduces mortality in non-trauma patients: Results from a single centre audit. Med Intensiva 2016; 40:550-559. [PMID: 27425576 DOI: 10.1016/j.medin.2016.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 04/15/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To audit the impact upon mortality of a massive bleeding management protocol (MBP) implemented in our center since 2007. DESIGN A retrospective, single-center study was carried out. Patients transfused after MBP implementation (2007-2012, Group 2) were compared with a historical cohort (2005-2006, Group 1). BACKGROUND Massive bleeding is associated to high mortality rates. Available MBPs are designed for trauma patients, whereas specific recommendations in the medical/surgical settings are scarce. PATIENTS After excluding patients who died shortly (<6h) after MBP activation (n=20), a total of 304 were included in the data analysis (68% males, 87% surgical). INTERVENTIONS Our MBP featured goal-directed transfusion with early use of adjuvant hemostatic medications. VARIABLES OF INTEREST Primary endpoints were 24-h and 30-day mortality. Fresh frozen plasma-to-red blood cells (FFP:RBC) and platelet-to-RBC (PLT:RBC) transfusion ratios, time to first FFP unit and the proactive MBP triggering rate were secondary endpoints. RESULTS After MBP implementation (Group 2; n=222), RBC use remained stable, whereas FFP and hemostatic agents increased, when compared with Group 1 (n=82). Increased FFP:RBC ratio (p=0.053) and earlier administration of FFP (p=0.001) were also observed, especially with proactive MBP triggering. Group 2 patients presented lower rates of 24-h (0.5% vs. 7.3%; p=0.002) and 30-day mortality (15.9% vs. 30.2%; p=0.018) - the greatest reduction corresponding to non-surgical patients. Logistic regression showed an independent protective effect of MBP implementation upon 30-day mortality (OR=0.3; 95% CI 0.15-0.61). CONCLUSIONS These data suggest that the implementation of a goal-directed MBP for prompt and aggressive management of non-trauma, massive bleeding patients is associated to reduced 24-h and 30-day mortality rates.
Collapse
Affiliation(s)
- N Martínez-Calle
- Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - F Hidalgo
- Department of Anaesthesia and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - A Alfonso
- Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - M Muñoz
- Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain
| | - M Hernández
- Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - R Lecumberri
- Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - J A Páramo
- Hematology Department, Clínica Universidad de Navarra, Pamplona, Spain.
| |
Collapse
|
8
|
Omar HR, Enten G, Karlnoski R, Ching YH, Mangar D, Camporesi EM. Recombinant Activated Factor VII Significantly Reduces Transfusion Requirements in Cardiothoracic Surgery. Drugs R D 2016; 15:187-94. [PMID: 25862216 PMCID: PMC4488183 DOI: 10.1007/s40268-015-0093-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The off-label use of recombinant activated factor VII (rFVIIa) for intractable bleeding is associated with a risk of thrombotic events. The objective of this study was to evaluate the incidence and predictors of rFVIIa-related thrombotic events and its efficacy in the reduction of transfusion requirements during various surgeries. Methods Ninety-two cases received rFVIIa for uncontrollable bleeding despite medical and surgical hemostasis. The incidence and risk factors of thrombotic events were analyzed. Blood products transfused in the 24 h before and after rFVIIa injection were calculated. Subgroup analysis was performed to see which types of surgeries benefited most from rFVIIa. Results The main indication for rFVIIa administration was uncontrollable bleeding during cardiothoracic surgery followed by coagulopathy due to liver failure followed by neurosurgical procedures. Requirements of blood products after rFVIIa decreased significantly by 45 % (p = 0.012), 52 % (p = 0.0001), and 75 % (p = 0.0001) for red blood cells, plasma, and cryoprecipitate, respectively. Subgroup analysis showed that cardiothoracic surgery was the sole group that benefited from rFVIIa with a reduction in transfusion of red blood cells (p = 0.013), plasma (p = 0.0001), and cryoprecipitate (p = 0.0001). Thrombotic events occurred in 9.8 % of the cases mostly on the arterial side (89 %) and have not contributed to mortality. Conclusion rFVIIa can significantly reduce transfusion requirements when given for intractable bleeding during cardiothoracic surgery at the expense of thrombotic events in approximately one tenth of the cases. Further prospective studies are necessary to study if this effect of rFVIIa is translated to a favorable outcome. Electronic supplementary material The online version of this article (doi:10.1007/s40268-015-0093-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Medical Center, 1410 N. Fourth Street, Clinton, IA, 52732, USA,
| | | | | | | | | | | |
Collapse
|
9
|
Curnow J, Pasalic L, Favaloro EJ. Why Do Patients Bleed? Surg J (N Y) 2016; 2:e29-e43. [PMID: 28824979 PMCID: PMC5553458 DOI: 10.1055/s-0036-1579657] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 02/01/2016] [Indexed: 12/19/2022] Open
Abstract
Patients undergoing surgical procedures can bleed for a variety of reasons. Assuming that the surgical procedure has progressed well and that the surgeon can exclude surgical reasons for the unexpected bleeding, then the bleeding may be due to structural (anatomical) anomalies or disorders, recent drug intake, or disorders of hemostasis, which may be acquired or congenital. The current review aims to provide an overview of reasons that patients bleed in the perioperative setting, and it also provides guidance on how to screen for these conditions, through consideration of appropriate patient history and examination prior to surgical intervention, as well as guidance on investigating and managing the cause of unexpected bleeding.
Collapse
Affiliation(s)
- Jennifer Curnow
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia
| | - Leonardo Pasalic
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia.,Pathology West, NSW Health Pathology, Westmead, Australia
| | - Emmanuel J Favaloro
- Department of Clinical and Laboratory Hematology, Institute of Clinical Pathology and Medical Research and Westmead Hospital, Sydney Centres for Thrombosis and Hemostasis, Westmead, Australia.,Pathology West, NSW Health Pathology, Westmead, Australia
| |
Collapse
|
10
|
Bolliger D, Mauermann E, Tanaka KA. Thresholds for Perioperative Administration of Hemostatic Blood Components and Coagulation Factor Concentrates: An Unmet Medical Need. J Cardiothorac Vasc Anesth 2015; 29:768-76. [DOI: 10.1053/j.jvca.2015.02.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Indexed: 12/19/2022]
|
11
|
Bawazeer M, Ahmed N, Izadi H, McFarlan A, Nathens A, Pavenski K. Compliance with a massive transfusion protocol (MTP) impacts patient outcome. Injury 2015; 46:21-8. [PMID: 25452004 DOI: 10.1016/j.injury.2014.09.020] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/16/2014] [Accepted: 09/25/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND About 5% of civilian trauma requires massive transfusion. Protocolized resuscitation with blood products to achieve high plasma:RBC ratio has been advocated to improve survival. Our objectives were to measure compliance to our institutional MTP, to identify quality assurance activities that could improve protocol compliance and to determine if protocol compliance was related to patient outcome. METHODS The investigators determined 13 compliance criteria based upon our institutional protocol. We measured compliance in 72 consecutive MTP activations between January 2010 and September 2011 at a Level I trauma centre. Data elements were retrospectively retrieved from blood bank, trauma registry and clinical records. Patients were stratified into three groups based on compliance level, and mortality differences were compared. RESULTS Average compliance for the cohort (n=72) was 66%. The most common cause of non-compliance was failure to send a complete haemorrhage panel from the trauma bay (96%). Failure to monitoring blood work every 30min occurred in 89% of cases. Delay in activation and deactivation occurred in 50% and 50% respectively. Non-compliance to protocol-based administration of blood products happened in 47%. The cohort was stratified into three groups based on compliance, A: <60%, B: 60-80% and C: >80% (low, moderate and high compliance groups). There was no statistical significance with regard to median age, median ISS, ED SBP, ED GCS and AIS of the head/spine, chest and abdomen. The mortality rates in each group were 62%, 50% and 10% in the low, moderate and high compliance groups respectively. Mortality differences were compared using adjusted logistic regression. The OR for mortality between Groups A and B=1.1 [95% CI 0.258-4.687 (P=0.899)] while the OR for mortality between Groups C and B=0.02 [95% CI <0.001-0.855 (P=0.041)]. CONCLUSIONS Measures should be directed towards provider and system factors to improve compliance. In this study, there was an association between survival and higher level of compliance.
Collapse
Affiliation(s)
- M Bawazeer
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - N Ahmed
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - H Izadi
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - A McFarlan
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - A Nathens
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| | - K Pavenski
- Trauma Program and Transfusion Medicine, Departments of Surgery and Laboratory Medicine, St. Michael's Hospital, University of Toronto, Canada.
| |
Collapse
|
12
|
Murphy DA, Hockings LE, Andrews RK, Aubron C, Gardiner EE, Pellegrino VA, Davis AK. Extracorporeal membrane oxygenation-hemostatic complications. Transfus Med Rev 2014; 29:90-101. [PMID: 25595476 DOI: 10.1016/j.tmrv.2014.12.001] [Citation(s) in RCA: 252] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/19/2014] [Accepted: 12/03/2014] [Indexed: 12/17/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) support for cardiac and respiratory failure has increased in recent years. Improvements in ECMO oxygenator and pump technologies have aided this increase in utilization. Additionally, reports of successful outcomes in supporting patients with respiratory failure during the 2009 H1N1 pandemic and reports of ECMO during cardiopulmonary resuscitation have led to increased uptake of ECMO. Patients requiring ECMO are a heterogenous group of critically ill patients with cardiac and respiratory failure. Bleeding and thrombotic complications remain a leading cause of morbidity and mortality in patients on ECMO. In this review, we describe the mechanisms and management of hemostatic, thrombotic and hemolytic complications during ECMO support.
Collapse
Affiliation(s)
- Deirdre A Murphy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia.
| | - Lisen E Hockings
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
| | - Robert K Andrews
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Cecile Aubron
- ANZIC Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Vincent A Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
| | - Amanda K Davis
- Department of Haematology, Alfred Hospital Melbourne, Australia
| |
Collapse
|
13
|
Yampolsky N, Stofko D, Veznedaroglu E, Liebman K, Binning MJ. Recombinant factor VIIa use in patients presenting with intracranial hemorrhage. SPRINGERPLUS 2014; 3:471. [PMID: 25197623 PMCID: PMC4155054 DOI: 10.1186/2193-1801-3-471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 08/18/2014] [Indexed: 12/04/2022]
Abstract
Recombinant factor VIIa (rFVIIa) can be used for rapid INR normalization in life-threatening hemorrhage in anticoagulated patients. Dosing is unclear and may carry thromboembolic risks. We reviewed the use of rFVIIa at a comprehensive stroke and cerebrovascular center to evaluate dose effectiveness on INR reduction and thromboembolic complications experienced. The primary endpoint was to review the efficacy of rFVIIa in lowering INR. Secondary endpoints included doses used and adverse effects caused by rFVIIa administration. Forty-one percent of patients presented with a subdural hemorrhage. The mean INR prior to rFVIIa administration was 3.5 (0.9-15) and decreased to 1.13 (0.6-2). The mean dose of rFVIIa given was 73 mcg/kg (±24 mcg/kg). Two patients (3%) experienced a thromboembolic event. Recombinant factor VIIa appears to lower INR without significant thromboembolic complications.
Collapse
Affiliation(s)
- Natalie Yampolsky
- Department of Pharmacy, Capital Health Regional Medical Center, 750 Brunswick Ave, Trenton, NJ 08534 USA
| | - Douglas Stofko
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| | - Erol Veznedaroglu
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| | - Kenneth Liebman
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| | - Mandy J Binning
- Department of Neurosurgery, Capital Institute for Neurosciences, Trenton, NJ USA
| |
Collapse
|
14
|
Off-Label Use of Recombinant Human Factor VIIa. Ann Thorac Surg 2014; 98:393-5. [DOI: 10.1016/j.athoracsur.2014.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Revised: 06/02/2014] [Accepted: 06/03/2014] [Indexed: 11/23/2022]
|
15
|
Off-label use of recombinant activated factor VII in surgical and non-surgical patients at 16 Canadian hospitals from 2007 to 2010 (Canadian Registry Report). Can J Anaesth 2014; 61:727-35. [DOI: 10.1007/s12630-014-0184-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/15/2014] [Indexed: 01/21/2023] Open
|
16
|
Baumann Kreuziger LM, Morton CT, Subramanian AT, Anderson CP, Dries DJ. Not only in trauma patients: hospital-wide implementation of a massive transfusion protocol. Transfus Med 2014; 24:162-8. [PMID: 24372790 PMCID: PMC4043857 DOI: 10.1111/tme.12096] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 09/16/2013] [Accepted: 11/26/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To review outcomes of massive transfusion protocol (MTP) activation and determine the impact of MTP implementation on blood bank use. BACKGROUND MTP has been established to rapidly provide plasma and packed red blood cells in ratios approaching 1 : 1. Due to availability, MTP has been utilised in non-traumatic haemorrhage despite evidence of benefit in this population. Our hospital-wide implementation of MTP was reviewed for propriety, outcomes and effect on blood bank resources. METHODS Retrospective cohort study of patients receiving transfusion after MTP activation from October 2009 to 2011. Underlying medical conditions and baseline medication use were determined. In-hospital and 24-h mortality were compared with evaluation for confounding by Acute Physiology And Chronic Health Evaluation (APACHE) score and duration of MTP activation. Blood product use before and after MTP implementation was reviewed. RESULTS MTP activation occurred in 62 trauma and 63 non-trauma patients. Non-trauma patients were older, had more underlying medical conditions and higher APACHE scores compared with trauma patients; 24-h mortality was higher in trauma compared with non-trauma patients (27·4 vs 11·1%, P = 0·02). There was no significant difference of in-hospital mortality. Transfusion ratio did not differ between trauma and non-trauma patients and was not associated with mortality even when MTP activation duration and APACHE score were considered. Hospital-wide blood product use did not change with MTP implementation. CONCLUSIONS MTP may be successfully used in trauma and non-trauma settings without significantly impacting overall blood product utilisation. Inclusion of non-trauma patients into prospective studies of resuscitation with blood products is warranted to ensure benefit in these patients.
Collapse
Affiliation(s)
| | - Colleen T. Morton
- University of Minnesota, Regions Hospital, Department of Hematology, Oncology and Transplant
| | | | | | - David J. Dries
- University of Minnesota, Regions Hospital, Department of Surgery
| |
Collapse
|
17
|
Liver Transplantation without Perioperative Transfusions Single-Center Experience Showing Better Early Outcome and Shorter Hospital Stay. J Transplant 2013; 2013:649209. [PMID: 24455193 PMCID: PMC3876589 DOI: 10.1155/2013/649209] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 11/17/2013] [Indexed: 12/14/2022] Open
Abstract
Background. Significant amounts of red blood cells (RBCs) transfusions are associated with poor outcome after liver transplantation (LT). We report our series of LT without perioperative RBC (P-RBC) transfusions to evaluate its influence on early and long-term outcomes following LT. Methods. A consecutive series of LT between 2006 and 2011 was analyzed. P-RBC transfusion was defined as one or more RBC units administrated during or ≤48 hours after LT. We divided the cohort in “No-Transfusion” and “Yes-Transfusion.” Preoperative status, graft quality, and intra- and postoperative variables were compared to assess P-RBC transfusion risk factors and postoperative outcome. Results. LT was performed in 127 patients (“No-Transfusion” = 39 versus “Yes-Transfusion” = 88). While median MELD was significantly higher in Yes-Transfusion (11 versus 21; P = 0.0001) group, platelet count, prothrombin time, and hemoglobin were significantly lower. On multivariate analysis, the unique independent risk factor associated with P-RBC transfusions was preoperative hemoglobin (P < 0.001). Incidence of postoperative bacterial infections (10 versus 27%; P = 0.03), median ICU (2 versus 3 days; P = 0.03), and hospital stay (7.5 versus 9 days; P = 0.01) were negatively influenced by P-RBC transfusions. However, 30-day mortality (10 versus 15%) and one- (86 versus 70%) and 3-year (77 versus 66%) survival were equivalent in both groups. Conclusions. Recipient MELD score was not a predictive factor for P-RBC transfusion. Patients requiring P-RBC transfusions had worse postoperative outcome. Therefore, maximum efforts must be focused on improving hemoglobin levels during waiting list time to prevent using P-RBC in LT recipients.
Collapse
|
18
|
Gris JC. [Off-label use of rhuFVIIa: Allegro ma non tropo]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2013; 32:650-652. [PMID: 24071486 DOI: 10.1016/j.annfar.2013.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- J-C Gris
- Consultations et laboratoire d'hématologie, centre hospitalier universitaire de Nîmes, groupe hospitalo-universitaire Caremeau, place du Professeur-Robert-Debré, 30029 Nîmes cedex 9, France.
| |
Collapse
|
19
|
Roberts DJ. The year's end. Transfus Med 2012; 22:369-71. [PMID: 23171299 DOI: 10.1111/tme.12003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
20
|
Dzik WH, Blajchman MA, Fergusson D, Hameed M, Henry B, Kirkpatrick AW, Korogyi T, Logsetty S, Skeate RC, Stanworth S, MacAdams C, Muirhead B. Clinical review: Canadian National Advisory Committee on Blood and Blood Products--Massive transfusion consensus conference 2011: report of the panel. Crit Care 2011; 15:242. [PMID: 22188866 PMCID: PMC3388668 DOI: 10.1186/cc10498] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.
Collapse
Affiliation(s)
- Walter H Dzik
- Blood Transfusion Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Morris A Blajchman
- Canadian Blood Services, Southern Ontario Region, Departments of Pathology and Medicine, McMaster University Medical Centre, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5
- NHLBI TMH Clinical Trials Network, Bethesda, MD, USA
| | - Dean Fergusson
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Clinical Epidemiology Program, Faculty of Medicine, University of Ottawa, 6th Floor Critical Care Wing, Office W6119, 501 Smyth Road, Box 201, Ottawa, Ontario, Canada K1H 8L6
| | - Morad Hameed
- General Surgery Residency Program, Department of Surgery and Critical Care Medicine, University of British Columbia, Trauma Services, Vancouver General Hospital, 855 W 12 Avenue, Vancouver, British Columbia, Canada V5Z 1M9
| | - Blair Henry
- Sunnybrook Health Sciences Centre, Joint Centre for Bioethics, Department of Family and Community Medicine, University of Toronto, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room H2-39, Toronto, Ontario, Canada M4N 3M5
| | - Andrew W Kirkpatrick
- Department of Critical Care Medicine and Surgery, University of Calgary, Regional Trauma Services, Foothills Medical Centre, 1403 29 St NW, Calgary, Alberta, Canada T2N 2T9
| | - Teresa Korogyi
- Emergency Department, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5
| | - Sarvesh Logsetty
- Manitoba Firefighters' Burn Unit, University of Manitoba, GC401A, 820 Sherbrook Avenue, Winnipeg, Manitoba, Canada R3A1R9
| | - Robert C Skeate
- Canadian Blood Services Central Ontario Region, Department of Laboratory Medicine and Pathobiology, University of Toronto, 67 College Street, Toronto, Ontario, Canada M5G 2M1
| | - Simon Stanworth
- Department of Haematology, John Radcliffe Hospital, University of Oxford, UK
| | - Charles MacAdams
- Perioperative Blood Conservation Program Calgary Zone, Department of Anesthesia, Foothills Medical Centre, 1403 29th Street NW, Calgary, Alberta, Canada T2N 2T9
| | - Brian Muirhead
- Transfusion Practices Committee, Blood Conservation Servcies, Winnipeg Regional Health Authority, Department of Anesthesiology, University of Manitoba, 347 Cambridge Street, Winnipeg, Manitoba, Canada R3M 3E8
| |
Collapse
|