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Boxma RPJ, Garnier RP, Bulte CSE, Meesters MI. The effect of non-point-of-care haemostasis management protocol implementation in cardiac surgery: A systematic review. Transfus Med 2021; 31:328-338. [PMID: 34096120 PMCID: PMC8597010 DOI: 10.1111/tme.12790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/11/2021] [Accepted: 05/03/2021] [Indexed: 11/26/2022]
Abstract
Objectives This systematic review aims to outline the evidence on the implementation of a non‐point‐of‐care (non‐point‐of‐care [POC]) haemostasis management protocol compared to experience‐based practice in adult cardiac surgery. Background Management of coagulopathy in cardiac surgery is complex and remains highly variable among centres and physicians. Although various guidelines recommend the implementation of a transfusion protocol, the literature on this topic has never been systematically reviewed. Methods PubMed, Embase, Cochrane Library, and Web of Science were searched from January 2000 till May 2020. Results A total of seven studies (one randomised controlled trial [RCT], one prospective cohort study, and five retrospective studies) met the inclusion criteria. Among the six non‐randomised, controlled studies, the risk of bias was determined to be serious to critical, and the one RCT was determined to have a high risk of bias. Five studies showed a significant reduction in red blood cells, fresh frozen plasma, and/or platelet transfusion after the implementation of a structural non‐POC algorithm, ranging from 2% to 28%, 2% to 19.5%, and 7% to17%, respectively. One study found that fewer patients required transfusion of any blood component in the protocol group. Another study had reported a significantly increased transfusion rate of platelet concentrate in the haemostasis algorithm group. Conclusion Owing to the high heterogeneity and a substantial risk of bias of the included studies, no conclusion can be drawn on the additive value of the implementation of a cardiac‐surgery‐specific non‐POC transfusion and haemostasis management algorithm compared to experience‐based practice. To define the exact impact of a transfusion protocol on blood product transfusion, bleeding, and adverse events, well‐designed prospective clinical trials are required.
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Affiliation(s)
- Reinier P J Boxma
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU Medical Center, Amsterdam, The Netherlands
| | - Robert P Garnier
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU Medical Center, Amsterdam, The Netherlands
| | - Carolien S E Bulte
- Department of Anesthesiology, Amsterdam University Medical Center, Location VU Medical Center, Amsterdam, The Netherlands
| | - Michael I Meesters
- Department of Anesthesiology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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Moraes A, Giordani JN, Borges CT, Mariani PE, Costa LMD, Bridi LH, Santos ATLD, Kalil R. Transfusion of Blood Products in the Postoperative of Cardiac Surgery. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20190192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Clinical impact of rotational thromboelastometry in cardiac surgery. Transfus Clin Biol 2021; 28:276-282. [PMID: 33839299 DOI: 10.1016/j.tracli.2021.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 03/25/2021] [Accepted: 03/27/2021] [Indexed: 11/22/2022]
Abstract
Patients undergoing cardiac surgery are at high risk of postoperative bleeding, which is related to worse prognosis and survival. The use of ROTEM®, together with the implementation of a specific treatment algorithm, to reduce the risk of postoperative bleeding. An observational, comparative, cross-case study with historical controls. A total of 1772 consecutive patients admitted to intensive care unit after having undergone cardiac surgery, was divided into 3 groups: Group 1: Coagulation was only monitored by the classical coagulation test (control group). Group 2: Monitorization was done by ROTEM®, according to a protocol designed in our center. Group 3: VerifyNow® was added to ROTEM®, implementing a specific treatment algorithm. We observed a decreased of red blood cell transfusion (Group 1 55.5%, Group 2 52.7%, Group 3 46.6%, P<0.01). Postoperative results include a significant reduction in complications with a marked improvement in overall survival in the ROTEM® - guided groups. Conclusions: Monitoring of hemostasis by POCT'S (ROTEM® and VerifyNow®) in patients undergoing cardiac surgery and cardiac transplantation was associated with a decreased incidence of blood transfusion, postoperative clinical complications, and mortality.
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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Whiting P, Al M, Westwood M, Ramos IC, Ryder S, Armstrong N, Misso K, Ross J, Severens J, Kleijnen J. Viscoelastic point-of-care testing to assist with the diagnosis, management and monitoring of haemostasis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2016. [PMID: 26215747 DOI: 10.3310/hta19580] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with substantive bleeding usually require transfusion and/or (re-)operation. Red blood cell (RBC) transfusion is independently associated with a greater risk of infection, morbidity, increased hospital stay and mortality. ROTEM (ROTEM® Delta, TEM International GmbH, Munich, Germany; www.rotem.de), TEG (TEG® 5000 analyser, Haemonetics Corporation, Niles, IL, USA; www.haemonetics.com) and Sonoclot (Sonoclot® coagulation and platelet function analyser, Sienco Inc., Arvada, CO) are point-of-care viscoelastic (VE) devices that use thromboelastometry to test for haemostasis in whole blood. They have a number of proposed advantages over standard laboratory tests (SLTs): they provide a result much quicker, are able to identify what part of the clotting process is disrupted, and provide information on clot formation over time and fibrinolysis. OBJECTIVES This assessment aimed to assess the clinical effectiveness and cost-effectiveness of VE devices to assist with the diagnosis, management and monitoring of haemostasis disorders during and after cardiac surgery, trauma-induced coagulopathy and post-partum haemorrhage (PPH). METHODS Sixteen databases were searched to December 2013: MEDLINE (OvidSP), MEDLINE In-Process and Other Non-Indexed Citations and Daily Update (OvidSP), EMBASE (OvidSP), BIOSIS Previews (Web of Knowledge), Science Citation Index (SCI) (Web of Science), Conference Proceedings Citation Index (CPCI-S) (Web of Science), Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Latin American and Caribbean Health Sciences Literature (LILACS), International Network of Agencies for Health Technology Assessment (INAHTA), National Institute for Health Research (NIHR) HTA programme, Aggressive Research Intelligence Facility (ARIF), Medion, and the International Prospective Register of Systematic Reviews (PROSPERO). Randomised controlled trials (RCTs) were assessed for quality using the Cochrane Risk of Bias tool. Prediction studies were assessed using QUADAS-2. For RCTs, summary relative risks (RRs) were estimated using random-effects models. Continuous data were summarised narratively. For prediction studies, the odds ratio (OR) was selected as the primary effect estimate. The health-economic analysis considered the costs and quality-adjusted life-years of ROTEM, TEG and Sonoclot compared with SLTs in cardiac surgery and trauma patients. A decision tree was used to take into account short-term complications and longer-term side effects from transfusion. The model assumed a 1-year time horizon. RESULTS Thirty-one studies (39 publications) were included in the clinical effectiveness review. Eleven RCTs (n=1089) assessed VE devices in patients undergoing cardiac surgery; six assessed thromboelastography (TEG) and five assessed ROTEM. There was a significant reduction in RBC transfusion [RR 0.88, 95% confidence interval (CI) 0.80 to 0.96; six studies], platelet transfusion (RR 0.72, 95% CI 0.58 to 0.89; six studies) and fresh frozen plasma to transfusion (RR 0.47, 95% CI 0.35 to 0.65; five studies) in VE testing groups compared with control. There were no significant differences between groups in terms of other blood products transfused. Continuous data on blood product use supported these findings. Clinical outcomes did not differ significantly between groups. There were no apparent differences between ROTEM or TEG; none of the RCTs evaluated Sonoclot. There were no data on the clinical effectiveness of VE devices in trauma patients or women with PPH. VE testing was cost-saving and more effective than SLTs. For the cardiac surgery model, the cost-saving was £43 for ROTEM, £79 for TEG and £132 for Sonoclot. For the trauma population, the cost-savings owing to VE testing were more substantial, amounting to per-patient savings of £688 for ROTEM compared with SLTs, £721 for TEG, and £818 for Sonoclot. This finding was entirely dependent on material costs, which are slightly higher for ROTEM. VE testing remained cost-saving following various scenario analyses. CONCLUSIONS VE testing is cost-saving and more effective than SLTs, in both patients undergoing cardiac surgery and trauma patients. However, there were no data on the clinical effectiveness of Sonoclot or of VE devices in trauma patients. STUDY REGISTRATION This study is registered as PROSPERO CRD42013005623. FUNDING The NIHR Health Technology Assessment programme.
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Affiliation(s)
| | - Maiwenn Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Isaac Corro Ramos
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | | | - Kate Misso
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Johan Severens
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Jos Kleijnen
- School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, the Netherlands
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Greilich PE, Edson E, Rutland L, Jessen ME, Key NS, Levy JH, Faraday N, Steiner ME. Protocol Adherence When Managing Massive Bleeding Following Complex Cardiac Surgery: A Study Design Pilot. J Cardiothorac Vasc Anesth 2015; 29:303-10. [DOI: 10.1053/j.jvca.2014.08.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Indexed: 12/31/2022]
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dos Santos AA, Sousa AG, Piotto RF, Pedroso JCM. Mortality risk is dose-dependent on the number of packed red blood cell transfused after coronary artery bypass graft. Braz J Cardiovasc Surg 2014; 28:509-17. [PMID: 24598957 PMCID: PMC4389431 DOI: 10.5935/1678-9741.20130083] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 11/04/2013] [Indexed: 11/20/2022] Open
Abstract
Introduction Transfusions of one or more packed red blood cells is a widely strategy used in
cardiac surgery, even after several evidences of increased morbidity and
mortality. The world's blood shortage is also already evident. Objective To assess whether the risk of mortality is dose-de>pendent on the number of
packed red blood cells transfused after coronary artery bypass graft. Methods Between June 2009 and July 2010, were analyzed 3010 patients: transfused and
non-transfused. Transfused patients were divided into six groups according to the
number of packed red blood cells received: one, two, three, four, five, six or
more units, then we assess the mortality risk in each group after a year of
coronary artery bypass graft. To calculate the odds ratio was used the
multivariate logistic regression model. Results The increasing number of allogeneic packed red blood cells transfused results in
an increasing risk of mortality, highlighting a dose-dependent relation. The odds
ratio values increase with the increased number of packed red blood cells
transfused. The death's gross odds ratio was 1.42 (P=0.165), 1.94
(P=0.005), 4.17; 4.22, 8.70, 33.33
(P<0.001) and the adjusted death's odds ratio was 1.22
(P=0.43), 1.52 (P=0.08); 2.85; 2.86; 4.91 and
17.61 (P<0.001), as they received one, two, three, four, five,
six or more packed red blood cells, respectively. Conclusion The mortality risk is directly proportional to the number of packed red blood
cells transfused in coronary artery bypass graft. The greater the amount of
allogeneic blood transfused the greater the risk of mortality. The current
transfusion practice needs to be reevaluated.
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Affiliation(s)
- Antônio Alceu dos Santos
- Hospital Real e Benemérita Associação Portuguesa
de Beneficência de São Paulo, São Paulo, SP, Brazil
- Associação Médica Brasileira (AMB), São
Paulo, SP, Brazil
- Sociedade Brasileira de Cardiologia (SBC), São Paulo, SP,
Brazil
- Correspondence address: Antônio Alceu dos Santos, Rua 13 de
Maio, 1838 - apto. 93 - Paraíso - São Paulo, SP Brazil - Zip code:
01327-002. E-mail:
| | - Alexandre Gonçalves Sousa
- Hospital Real e Benemérita Associação Portuguesa
de Beneficência de São Paulo, São Paulo, SP, Brazil
| | - Raquel Ferrari Piotto
- Hospital Real e Benemérita Associação Portuguesa
de Beneficência de São Paulo, São Paulo, SP, Brazil
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Doussau A, Perez P, Puntous M, Calderon J, Jeanne M, Germain C, Rozec B, Rondeau V, Chêne G, Ouattara A, Janvier G. Fresh-frozen plasma transfusion did not reduce 30-day mortality in patients undergoing cardiopulmonary bypass cardiac surgery with excessive bleeding: the PLASMACARD multicenter cohort study. Transfusion 2013; 54:1114-24. [PMID: 24117772 DOI: 10.1111/trf.12422] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 07/03/2013] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND During on-pump cardiac surgery, hemorrhagic complications occur frequently. Fresh-frozen plasma (FFP) is widely transfused to provide coagulation factors. Yet, no randomized clinical trial has demonstrated its benefits on mortality. We assessed the relationship between therapeutic transfusion of FFP and 30-day mortality in cardiac surgery patients suffering from excessive bleeding in a prospective cohort study. STUDY DESIGN AND METHODS Adult patients who underwent on-pump cardiac surgery and experienced excessive bleeding during the 48-hour perioperative period were recruited from 15 French centers between February 2004 and January 2006. Patients who received a preventive FFP transfusion were excluded. The association between FFP transfusion and all cause 30-day mortality was estimated using a Cox proportional hazards model, adjusted for confounding. A propensity score (PS) sensitivity analysis was also performed. RESULTS Among 967 patients included in this study, 58.1% received FFP. The median dose was 11.3 mL/kg (interquartile range, 7.6-19.5). The cumulative 30-day mortality rate was 11.3% (95% confidence interval [CI], 9.5-13.5). FFP transfusion was associated with a higher 30-day mortality (hazard ratio [HR], 3.2; 95% CI, 1.7-6.1) in univariate analysis; however, after adjusting for prognostic factors, there was no longer any association (HR, 1.5; 95% CI, 0.8-3.0, p = 0.20). The results of the PS analysis were consistent with the adjusted analysis. CONCLUSION Among on-pump cardiac surgery patients experiencing excessive perioperative bleeding, there is no evidence of a beneficial impact of FFP transfusion on mortality.
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Affiliation(s)
- Adélaïde Doussau
- Pole de Sante Publique et CIC-EC7, Unité de Soutien Méthodologique à la Recherche Clinique et Épidémiologique, CHU de Bordeaux, Bordeaux, France; CIC-EC7 et Centre INSERM U897-Epidemiologie-Biostatistique, INSERM, Bordeaux, France; ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, Université Bordeaux, Bordeaux, France
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Preoperative identification of patients with increased risk for perioperative bleeding. Curr Opin Anaesthesiol 2013; 26:82-90. [DOI: 10.1097/aco.0b013e32835b9a23] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Intraoperative Transfusion of Small Amounts of Blood Heralds Worse Postoperative Outcome in Patients Having Noncardiac Thoracic Operations. Ann Thorac Surg 2011; 91:1674-80; discussion 1680. [DOI: 10.1016/j.athoracsur.2011.01.025] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 01/05/2011] [Accepted: 01/10/2011] [Indexed: 11/20/2022]
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Wasowicz M, McCluskey SA, Wijeysundera DN, Yau TM, Meinri M, Beattie WS, Karkouti K. The Incremental Value of Thrombelastography for Prediction of Excessive Blood Loss After Cardiac Surgery. Anesth Analg 2010; 111:331-8. [DOI: 10.1213/ane.0b013e3181e456c1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Willis CD, Cameron PA, Phillips LE. Clinical guidelines and off-license recombinant activated factor VII: content, use, and association with patient outcomes. J Thromb Haemost 2009; 7:2016-22. [PMID: 19804534 DOI: 10.1111/j.1538-7836.2009.03632.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) is increasingly being used off-license for treating critical bleeding. Guidelines may therefore be useful for improving processes and outcomes. Little is known regarding guidelines for off-license rFVIIa or their association with patient outcomes. OBJECTIVES To investigate the availability of hospital guidelines for off-license rFVIIa use and the association between these guidelines and mortality. METHODS Data were extracted from the Haemostasis Registry, which collects all cases of off-license rFVIIa use in participating institutions in Australia and New Zealand. Contributing hospitals were requested to supply a copy of the institutional guideline relating to off-license rFVIIa administration. The characteristics of patients treated in accordance with all elements of the guidelines were compared with those of patients for who one or more guideline elements had been violated. The relationship between guideline-directed treatment and 28-day mortality was investigated using stepwise logistic regression. RESULTS Two thousand five hundred and fifty-one patients in 75 hospitals were available for analysis. Of these hospitals, 58 provided a guideline for analysis. Patients complying with all guideline elements (n = 530) did not differ from patients receiving care that violated guidelines (n = 1035) regarding age, size of dose, or gender. Guideline-directed treatment was not found to have an association with 28-day mortality following logistic regression. CONCLUSIONS Few patients are treated in accordance with the criteria of rFVIIa guidelines, despite their availability in the majority of hospitals. Moreover, 28-day mortality does not appear to be associated with the use of guidelines in this patient group. Refinement of guidelines relating to the off-license use of rFVIIa is therefore required.
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Affiliation(s)
- C D Willis
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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N-acetylcysteine is associated with increased blood loss and blood product utilization during cardiac surgery. Crit Care Med 2009; 37:1929-34. [PMID: 19384218 DOI: 10.1097/ccm.0b013e31819ffed4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE When used to prevent perioperative inflammation and ischemia-reperfusion injury, N-acetylcysteine may inadvertently impair hemostasis. We, therefore, performed a post hoc analysis of a recent randomized controlled trial in cardiac surgery to determine whether N-acetylcysteine was associated with increased blood loss and blood product transfusion. DESIGN Blinded (patients, caregivers, outcome assessors) placebo-controlled parallel group randomized trial (www.ClinicalTrials.gov ID NCT00188630). SETTING Tertiary care hospital in Toronto, Ontario, Canada (September 2003 to October 2005). PATIENTS A total of 177 patients with preexisting moderate renal insufficiency (estimated glomerular filtration rate <or=60 mL/min) and undergoing cardiac surgery. INTERVENTIONS Eighty-nine patients were randomized to receive intravenous N-acetylcysteine (100 mg/kg bolus; 20 mg.kg.hr infusion until 4 hours after cardiopulmonary bypass), and 88 were randomized to receive placebo. MEASUREMENTS AND MAIN RESULTS We used laboratory markers (hemoglobin, platelets, coagulation), chest-tube blood loss, and blood product transfusion to evaluate hemostasis. Compared with placebo, patients who received N-acetylcysteine arm experienced a mean 24-hour chest-tube blood loss that was 261 mL higher (95% confidence interval [CI] 93-488 mL, p = 0.008), and were transfused 1.6 more units of red blood cells (95% CI 0.4-3.1 units, p = 0.02) during hospitalization. The risk of receiving >or=5 units of red blood cells within 24 hours of surgery was significantly higher with N-acetylcysteine (relative risk 1.85, 95% CI 1.06-3.21, p = 0.03; adjusted relative risk 2.09, 95% CI 1.24-3.83, p = 0.005). CONCLUSIONS In patients who have preexisting moderate renal insufficiency and are undergoing cardiac surgery, N-acetylcysteine was associated with important effects on blood loss and blood product transfusion. Clinicians and researchers should, therefore, consider the potential for impaired hemostasis when using N-acetylcysteine in the perioperative setting. Further research is needed to elucidate mechanisms by which N-acetylcysteine may impair hemostasis, and the risk-benefit profile of N-acetylcysteine for perioperative organ protection.
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Snyder-Ramos SA, Mhnle P, Weng YS, Bttiger BW, Kulier A, Levin J, Mangano DT. The ongoing variability in blood transfusion practices in cardiac surgery. Transfusion 2008; 48:1284-99. [DOI: 10.1111/j.1537-2995.2008.01666.x] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Görlinger K, Jambor C, Hanke AA, Dirkmann D, Adamzik M, Hartmann M, Rahe-Meyer N. Perioperative Coagulation Management and Control of Platelet Transfusion by Point-of-Care Platelet Function Analysis. Transfus Med Hemother 2007. [DOI: 10.1159/000109642] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Karkouti K, Wijeysundera DN, Beattie WS, Callum JL, Cheng D, Dupuis JY, Kent B, Mazer D, Rubens FD, Sawchuk C, Yau TM. Variability and predictability of large-volume red blood cell transfusion in cardiac surgery: a multicenter study. Transfusion 2007; 47:2081-8. [DOI: 10.1111/j.1537-2995.2007.01432.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Karkouti K, Beattie WS, Crowther MA, Callum JL, Chun R, Fremes SE, Lemieux J, McAlister VC, Muirhead BD, Murkin JM, Nathan HJ, Wong BI, Yau TM, Yeo EL, Hall RI. The role of recombinant factor VIIa in on-pump cardiac surgery: Proceedings of the Canadian Consensus Conference. Can J Anaesth 2007; 54:573-82. [PMID: 17602044 DOI: 10.1007/bf03022322] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Recombinant activated factor VII (rFVIIa) is currently not approved by Health Canada or the Food and Drug Administration for treating excessive blood loss in nonhemophiliac patients undergoing on-pump cardiac surgery, but is increasingly being used "off-label" for this indication. A Canadian Consensus Conference was convened to generate recommendations for rFVIIa use in on-pump cardiac surgery. METHODS The panel undertook a literature review of the use of rFVIIa in both cardiac and non-cardiac surgery. Appropriateness, timing, and dosage considerations were addressed for three cardiac surgery indications: prophylactic, routine, and rescue uses. Recommendations were based on evidence from the literature and derived by consensus following recognized grading procedures. RESULTS The panel recommended against prophylactic or routine use of rFVIIa, as there is no evidence at this time that the benefits of rFVIIa outweigh its potential risks compared with standard hemostatic therapies. On the other hand, the panel made a weak recommendation (grade 2C) for the use of rFVIIa (one to two doses of 35-70 microg.kg(-1)) as rescue therapy for blood loss that is refractory to standard hemostatic therapies, despite the lack of randomized controlled trial data for this indication. CONCLUSIONS In cardiac surgery, the risks and benefits of rFVIIa are unclear, but current evidence suggests that its benefits may outweigh its risks for rescue therapy in selected patients. Methodologically rigorous studies are needed to clarify its riskbenefit profile in cardiac surgery patients.
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Affiliation(s)
- Keyvan Karkouti
- University Health Network, Toronto General Hospital, Department of Anesthesia, Toronto, Ontario, Canada.
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