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Edgerton JR, Filardo G, Pollock BD, da Graca B, Ogola GO, DiMaio JM, Mack MJ. Risk of Transfusion in Isolated Coronary Artery Bypass Graft: Models Developed From The Society of Thoracic Surgeons Database. Ann Thorac Surg 2024:S0003-4975(24)00542-3. [PMID: 38972369 DOI: 10.1016/j.athoracsur.2024.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 06/06/2024] [Accepted: 06/10/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Perioperative blood transfusion is associated with adverse outcomes and higher costs after coronary artery bypass graft (CABG) surgery. We developed risk assessments for patients' probability of perioperative transfusion and the expected transfusion volume to improve clinical management and resource use. METHODS Among 1,266,545 consecutive (2008-2016) isolated CABG operations in The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 657,821 (51.9%) received perioperative transfusions of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate, and/or platelets. We developed "full" models to predict perioperative transfusion of any blood product, and of RBC, FFP, or platelets. Using least absolute shrinkage and selection operator model selection, we built a rapid risk score based on 5 variables (age, body surface area, sex, preoperative hematocrit, and use of intra-aortic balloon pump). RESULTS C statistics for the full model were 0.785, 0.815, 0.707, and 0.699 for any blood product, RBC, FFP, and platelets, respectively. C statistics for rapid risk assessments were 0.752, 0.785, 0.670, and 0.661 for any blood product, RBC, FFP, and platelets, respectively. The observed vs expected risk plots showed strong calibration for full models and risk assessment tools; absolute differences between observed and expected risks of transfusion were <10.8% in each percentile of expected risk. Risk assessment-predicted probabilities of transfusion were strongly and nonlinearly associated (P < .0001) with total units transfused. CONCLUSIONS These robust and well-calibrated risk assessment tools for perioperative transfusion in CABG can inform surgeons regarding patients' risks and the number of RBC, FFP, and platelets units they can expect to need. This can aid in optimizing outcomes and increasing efficient use of blood products.
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Affiliation(s)
- James R Edgerton
- Baylor Scott & White Health, Dallas, Texas; Division of Cardiothoracic Surgery, Washington University in St. Louis, Barnes Jewish Hospital, St Louis, Missouri.
| | - Giovanni Filardo
- Department of Statistical Sciences, Southern Methodist University, Dallas, Texas; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, Texas
| | - Benjamin D Pollock
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | | | | | - J Michael DiMaio
- Baylor Scott & White Research Institute, Dallas, Texas; The Heart Hospital Baylor Plano, Plano, Texas
| | - Michael J Mack
- Baylor Scott & White Research Institute, Dallas, Texas; The Heart Hospital Baylor Plano, Plano, Texas
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2
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Chen DX, Wang YS, Yan M, Du L, Li Q. A model based on electronic health records to predict transfusion events in on-pump cardiac surgery. iScience 2023; 26:107798. [PMID: 37744030 PMCID: PMC10514444 DOI: 10.1016/j.isci.2023.107798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Perioperative blood transfusion is costly and raises safety concerns. We developed and validated a model for predicting minor, moderate, or major transfusion given to patients during on-pump cardiac procedures based on two centers' database. Model performance incorporating 7 variables on the development set had an AUC of 0.803 [95% CI, 0.790-0.815] for minor transfusion; moderate transfusion, giving an AUC of 0.822 (95% CI, 0.803-0.841); and major transfusion, giving an AUC of 0.813 (95% CI, 0.759-0.866). Model performance on the validation set had an AUC of 0.739 (95% CI 0.714-0.765), 0.730 (95% CI 0.702-0.758), and 0.713 (95% CI 0.677-0.749), respectively. A model based entirely on readily available electronic health records can accurately predict intraoperative minor, moderate, or major transfusion and provide individualized transfusion risk profiles before surgery among those on-pump cardiac surgical patients, and may help guide patient management.
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Affiliation(s)
- Dong Xu Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
| | - Yi Shun Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, P.R.China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
- The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, No. 37 Wainan Guoxue Road, Chengdu, Sichuan 610041, P.R.China
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3
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Zuckerman J, Coburn N, Callum J, Mahar AL, Lin Y, Turgeon AF, McLeod R, Pearsall E, Martel G, Hallet J. Evaluating variation in perioperative red blood cell transfusion for patients undergoing elective gastrointestinal cancer surgery. Surgery 2023; 173:392-400. [PMID: 36336508 DOI: 10.1016/j.surg.2022.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/22/2022] [Accepted: 09/11/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients. METHODS We identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with R2 measures, variance partition coefficients, and median odds ratios. RESULTS Of 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30-1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23-1.42). We observed comparable effects across procedure-type subgroups. CONCLUSION Transfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.
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Affiliation(s)
- Jesse Zuckerman
- Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada
| | - Natalie Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada; Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada; Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Alyson L Mahar
- Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Canada; Department of Laboratory Medicine and Pathobiology, University of Toronto, Canada
| | - Alexis F Turgeon
- CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Québec City, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, Canada
| | - Robin McLeod
- Department of Surgery, University of Toronto, Canada
| | | | | | - Julie Hallet
- Division of General Surgery, Department of Surgery, University of Toronto, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada; Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada.
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4
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Levy JH, Faraoni D, Almond CS, Baumann-Kreuziger L, Bembea MM, Connors JM, Dalton HJ, Davies R, Dumont LJ, Griselli M, Karkouti K, Massicotte MP, Teruya J, Thiagarajan RR, Spinella PC, Steiner ME. Consensus Statement: Hemostasis Trial Outcomes in Cardiac Surgery and Mechanical Support. Ann Thorac Surg 2022; 113:1026-1035. [PMID: 34826386 DOI: 10.1016/j.athoracsur.2021.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes. METHODS A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support. RESULTS For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180. CONCLUSIONS The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.
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Affiliation(s)
- Jerrold H Levy
- Division Cardiothoracic Anesthesiology and Critical Care, Departments of Anesthesiology and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina.
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Almond
- Heart Failure Service, Cardiac Anticoagulation Service, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi J Dalton
- INOVA Heart and Vascular Institute; Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ryan Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Larry J Dumont
- Vitalant Research Institute, Denver, Colorado; Department of Pathology, University of Colorado Medical School, Denver, Colorado; Department of Pathology and Laboratory Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Patricia Massicotte
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Department of Pathology and Immunology, Pediatrics and Medicine, Texan Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Marie E Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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5
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Cholette JM, Muszynski JA, Ibla JC, Emani S, Steiner ME, Vogel AM, Parker RI, Nellis ME, Bembea MM. Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e25-e36. [PMID: 34989703 PMCID: PMC8769357 DOI: 10.1097/pcc.0000000000002856] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements. CONCLUSIONS Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.
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Affiliation(s)
- Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Robert I Parker
- Professor Emeritus, Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, SUNY at Stony Brook, Stony Brook, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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6
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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7
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Yoo DW, Lee HJ, Oh SH, Kim IS, Kim HH, Je HG, Kim D, Cho WH, Kim JS, Lee SY, Yeo HJ. Transfusion Requirements and Blood Bank Support in Heart and Lung Transplantation. Lab Med 2021; 52:74-79. [PMID: 32700736 DOI: 10.1093/labmed/lmaa044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Transplantations may require massive transfusion of blood products. Therefore, blood banks need to predict, prepare, and supply the required amount of blood products. METHODS We measured the volume of transfused blood components as red blood cells, fresh frozen plasma, platelets, and cryoprecipitate in 54 and 89 patients who received heart and lung transplantation, respectively, in our hospital between January 2012 and December 2019. RESULTS Platelets were the most frequently transfused blood component. Transfusion volumes during heart and lung transplantation surgeries differed: red blood cells, 7.83 units vs 14.84 units; fresh frozen plasma, 2.67 units vs 12.29 units; platelets, 13.13 units vs 23.63 units; and cryoprecipitate, 1.74 units vs 2.57 units; respectively. The average transfusion volume of transplants was different each year. CONCLUSION Periodic evaluation of transfusion requirements will facilitate the efficient management of blood products at the time of transplantation and help blood banks predict changes in blood requirements.
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Affiliation(s)
- Dong-Won Yoo
- Department of Laboratory Medicine and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyun-Ji Lee
- Department of Laboratory Medicine and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Seung-Hwan Oh
- Department of Laboratory Medicine and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - In Suk Kim
- Department of Laboratory Medicine and Biomedical Research Institute, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hyung-Hoi Kim
- Department of Laboratory Medicine, Pusan National University Hospital, Pusan, Korea
| | - Hyung Gon Je
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Dohyung Kim
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Woo Hyun Cho
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Soo Yong Lee
- Division of Cardiology, Department of Internal Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Hye Ju Yeo
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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8
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Elassal AA, Al-Ebrahim KE, Debis RS, Ragab ES, Faden MS, Fatani MA, Allam AR, Abdulla AH, Bukhary AM, Noaman NA, Eldib OS. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg 2021; 16:166. [PMID: 34099003 PMCID: PMC8183590 DOI: 10.1186/s13019-021-01545-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
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Affiliation(s)
- Ahmed Abdelrahman Elassal
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | | | - Ragab Shehata Debis
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ehab Sobhy Ragab
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | | | | | - Amr Ragab Allam
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Department of Cardiac Surgery, Naser Institute of Research and Treatment, Cairo, Egypt
| | - Ahmed Hasan Abdulla
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Alahrar Hospital, Zagazig, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Saber Eldib
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
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9
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Pearse BL, Keogh S, Rickard CM, Fung YL. Barriers and facilitators to implementing evidence based bleeding management in Australian Cardiac Surgery Units: a qualitative interview study analysed with the theoretical domains framework and COM-B model. BMC Health Serv Res 2021; 21:550. [PMID: 34090421 PMCID: PMC8178922 DOI: 10.1186/s12913-021-06269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background Bleeding during cardiac surgery is a common complication that often requires the transfusion of blood products. The combination of bleeding and blood product transfusion incrementally increases adverse outcomes including infection and mortality. Following bleeding management guideline recommendations could assist with minimising risk but adherence is not high, and the cause for lack of adherence is not well understood. This study aimed to identify barriers and facilitators to practicing and implementing evidenced-based intra-operative, bleeding management in Australian cardiac surgery units. Methods We used a qualitative descriptive design to conduct semi-structured interviews with Australian cardiac surgeons, anaesthetists and perfusionists. The Theoretical Domains Framework (TDF) was utilised to guide interviews and thematically analyse the data. Categorised data were then linked with the three key domains of the COM-B model (capability, opportunity, motivation - behaviour) to explore and understand behaviour. Results Seventeen interviews were completed. Nine of the 14 TDF domains emerged as significant. Analysis revealed key themes to improving capability included, standardisation, monitoring, auditing and feedback of data and cross discipline training. Opportunity for change was improved with interpersonal and interdepartmental collaboration through shared goals, and more efficient and supportive processes allowing clinicians to navigate unfamiliar business and financial models of health care. Results suggest as individuals, clinicians had the motivation to make change and healthcare organisations have an obligation and a responsibility to partner with clinicians to support change and improve goal directed best practice. Conclusion Using a theory-based approach it was possible to identify factors which may be positively or negatively influence clinicians ability to implement best practice bleeding management in Australian cardiac surgical units. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06269-8.
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Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia. .,Departments of Surgery, Anaesthesia and Critical Care, The Prince Charles Hospital, Sippy Downs, QLD, Australia. .,School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia.
| | - Samantha Keogh
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Yoke L Fung
- School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia
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10
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Hu Z, Wang Z, Chang J, Zhang M, Hu X, Ren Z, Li B, Hu R. Application of prosthesis eversion method for ascending aorta replacement guarantees better clinical outcomes of type A acute aortic dissection surgery. J Thorac Dis 2021; 13:533-540. [PMID: 33717526 PMCID: PMC7947529 DOI: 10.21037/jtd-20-2578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The advantages of prosthesis eversion method in patients diagnosed with Stanford type A acute aortic dissection (AAD) undergoing ascending aorta replacement (AAR) is unknown. This research is designed to explore it. Methods We retrospectively analyzed the data of a total of 283 patients diagnosed with type A aortic dissection that underwent surgery in Renmin Hospital of Wuhan University from March, 2006 to April, 2020. Eighty-eight patients underwent surgical repair with traditional continuous suture technique, and 195 patients received prosthesis eversion. Baseline data, intra-operative data and early-stage clinical results were collected and statistically analyzed. Results Baseline data were similar except for age, incidence of hyperlipidemia and taking ACEI/ARB drugs (P<0.05). Cardiopulmonary bypass time, cross-clamp time, circulation arrest time, hemostasis time and total operation time in the traditional method group were far longer than in the prothesis eversion group (P<0.01). The operative mortality was similar (P>0.01). Post-operatively, there was no statistically significant difference in the mean ventilation time, mortality, incidence of re-exploration, tracheostomy, paraplegia, long-term coma and stroke between the two groups (P>0.05). Patients in the traditional method group had a longer duration stay in ICU and hospital than patients in the prosthesis eversion group (P<0.05). Patients in the traditional method group received more red blood cells (RBC) (P<0.01), plasma (P<0.05), fibrinogen (P<0.01) and albumin (P<0.05) transfusions, and CoSeal™ surgical sealant (P<0.05) than patients in the prosthesis eversion group. Conclusions Our experience and statistical analysis showed prosthesis eversion method to have some advantage in reducing blood loss and improving clinical results compared with repair with continuous suture. This technique is both simple to learn and perform.
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Affiliation(s)
- Zhipeng Hu
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhiwei Wang
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jinxing Chang
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Min Zhang
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaoping Hu
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zongli Ren
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bowen Li
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Rui Hu
- Department of Cardiovascular Surgery, Renmin Hospital of Wuhan University, Wuhan, China
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11
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Scherner M, Weber C, Schmidt H, Kuhr K, Hamacher S, Sabashnikov A, Eghbalzadeh K, Mader N, Wahlers T, Wippermann J. Impact of urgent coronary artery bypass grafting on acute kidney injury : A matched cohort study. Med Klin Intensivmed Notfmed 2021; 117:152-158. [PMID: 33471151 DOI: 10.1007/s00063-020-00769-x] [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: 04/18/2020] [Revised: 09/26/2020] [Accepted: 10/21/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES There is limited knowledge regarding the specific interrelationships between urgent coronary artery bypass graft (U-CABG) surgery and postoperative acute kidney injury (AKI). We aimed to (1) analyze the impact of urgent CABG (U-CABG) on the incidence and severity of postoperative AKI, (2) estimate the influence of AKI after U‑CABG or elective CABG (E-CABG) on mortality and (3) identify risk factors for AKI depending on the urgency of operation. RESULTS U‑CABG patients showed a higher incidence of AKI (49.8% vs. E‑CABG: 39.7%; p = 0.026), especially for higher AKI stages 2 + 3. In-hospital mortality was higher in U‑CABG patients (12.6%) compared to E‑CABG patients (2.3%; p < 0.001). The impact of AKI on mortality did not differ, but showed a strong coherency between higher AKI stages (2 + 3) and mortality (stage 1: OR 2.409, 95% CI 1.017-5.706; p = 0.046 vs. stage 2 + 3: OR 5.577; 95% CI 2.033-15.3; p = 0.001). Univariate logistic regression analysis revealed that preoperative renal impairment, peripheral vascular disease and transfusion of more than two red blood cell concentrates were predictors for postoperative AKI in both groups. CONCLUSIONS U‑CABG is a risk factor for postoperative AKI and even "mild" AKI leads to a significantly higher mortality. Hence, the prevention of modifiable risk factors might reduce the incidence of postoperative AKI and thus improve outcome.
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Affiliation(s)
- M Scherner
- Dept. of Cardiothoracic Surgery, University of Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany. .,Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany.
| | - C Weber
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - H Schmidt
- Departement of Cardiology, Klinikum Magdeburg, Magdeburg, Germany.,Faculty of Medicine, University of Halle, Halle, Germany
| | - K Kuhr
- Faculty of Medicine, University of Halle, Halle, Germany
| | - S Hamacher
- Faculty of Medicine, University of Halle, Halle, Germany
| | - A Sabashnikov
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - K Eghbalzadeh
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - N Mader
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - T Wahlers
- Department of Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - J Wippermann
- Dept. of Cardiothoracic Surgery, University of Magdeburg, Leipziger Straße 44, 39120, Magdeburg, Germany
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12
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Lin C, Fu Y, Huang S, Zhou S, Shen C. Rapid thrombelastography predicts perioperative massive blood transfusion in patients undergoing coronary artery bypass grafting: A retrospective study. Medicine (Baltimore) 2020; 99:e21833. [PMID: 32925720 PMCID: PMC7489729 DOI: 10.1097/md.0000000000021833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Massive blood transfusion (MBT) is a relatively common complication of cardiac surgery, which is independently associated with severe postoperative adverse events. However, the value of using rapid thrombotomography (r-TEG) to predict MBT in perioperative period of cardiac surgery has not been explored. This study aimed to identify the effect of r-TEG in predicting MBT for patients undergoing coronary artery bypass grafting (CABG).This retrospective study included consecutive patients first time undergoing CABG at the Zhongnan Hospital of Wuhan University between March 2015 and November 2017. All the patients had done r-TEG tests before surgery. The MBT was defined as receiving at least 4 units of red blood cells intra-operatively and 5 units postoperatively (1 unit red blood cells from 200 mL whole blood).Lower preoperative hemoglobin level (P = .001) and longer cardiopulmonary bypass time (P = .001) were the independent risk factors for MBT during surgery, and no components of the r-TEG predicted MBT during surgery. Meanwhile, longer activated clotting time (P < .001), less autologous blood transfusion (P = .001), and older age (P = .008) were the independent risk factors for MBT within 24 hours of surgery.Preoperative r-TEG activated clotting time can predict the increase of postoperative MBT in patients undergoing CABG. We recommend the careful monitoring of coagulation system with r-TEG, which allows rapid diagnosis of coagulation abnormalities even before the start of surgery.
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Affiliation(s)
- Chenyao Lin
- Department of Laboratory Mediciney, Ningbo Medical Treatment Center Lihuili Hospital, Ningbo
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Yourong Fu
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuang Huang
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Shuimei Zhou
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
| | - Changxin Shen
- Department of Blood Transfusion, ZhongNan Hospital of Wuhan University, Wuhan, China
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13
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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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14
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Meesters MI, von Heymann C. Optimizing Perioperative Blood and Coagulation Management During Cardiac Surgery. Anesthesiol Clin 2019; 37:713-728. [PMID: 31677687 DOI: 10.1016/j.anclin.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Bleeding and transfusion are common in cardiac surgery and associated with poorer outcome. Bleeding is frequently due to coagulopathy caused by the complex interaction between cardiopulmonary bypass, major surgical trauma, anticoagulation management, and perioperative factors. Patient blood management has emerged to improve outcome by the prediction, prevention, monitoring, and treatment of bleeding and transfusion. Each part of this chain has several individual modalities and when combined leads to result in a better outcome. This article reviews the hemostasis disturbances in cardiac surgery with cardiopulmonary bypass and gives an overview of the most important patient blood management strategies.
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Affiliation(s)
- Michael Isaäc Meesters
- Department of Anesthesiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, the Netherlands.
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee 49, Berlin 10249, Germany
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15
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Nwafor IA, Eze JC. Management of bleeding and blood transfusion in open cardiac surgery in a developing country: five-years institutional experience. Chirurgia (Bucur) 2019. [DOI: 10.23736/s0394-9508.18.04904-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Ho LTS, Lenihan M, McVey MJ, Karkouti K, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, Achen B, Brar S, Morrison D, Wong D, Bussières JS, Waal T, Harle C, Médicis É, McAdams C, Syed S, Tran D, Waters T. The association between platelet dysfunction and adverse outcomes in cardiac surgical patients. Anaesthesia 2019; 74:1130-1137. [PMID: 30932171 DOI: 10.1111/anae.14631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.
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Affiliation(s)
- L T S Ho
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M Lenihan
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M J McVey
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, ON, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.,Toronto General Research Institute and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, ON, Canada
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17
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Huang D, Chen C, Ming Y, Liu J, Zhou L, Zhang F, Yan M, Du L. Risk of massive blood product requirement in cardiac surgery: A large retrospective study from 2 heart centers. Medicine (Baltimore) 2019; 98:e14219. [PMID: 30702577 PMCID: PMC6380710 DOI: 10.1097/md.0000000000014219] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Cardiac surgery under cardiopulmonary bypass (CPB) accounts for most consumption of red blood cells (RBCs). Identifying risk factors for massive red blood cell transfusion (MRT) in cardiac surgery may help to reduce this consumption.We retrospectively analyzed 8238 patients who underwent valve surgery and/or coronary artery bypass grafting (CABG) under CPB at 2 major heart centers in China. Uni- and multivariate logistic regression was carried out to assess whether risk factors for MRT (defined as receiving at least 4 units RBCs) varied with type of cardiac surgery.A total of 1691 patients (21%) received at least 4 units RBCs (6.77 ± 4.78 units per person). This MRT group consumed 70% of the total units of allogeneic RBCs in the study. MRT incidence was 2-fold higher among patients undergoing CABG with or without valve surgery than among patients undergoing valve surgery alone. Multivariate logistic analysis identified the following MRT risk factors common to valve surgery alone, CABG alone, and their combination: female sex, older age, renal dysfunction, lower body mass index, lower preoperative hemoglobin, and longer CPB. Several independent MRT risk factors were also identified specific to valve surgery: active endocarditis, nonatrial fibrillation, smaller left atrium diameter, abnormal international normalized ratio, and repeat surgery.Different types of cardiac surgery share several, but not all, MRT risk factors. This study may help guide the prediction and management of patients at higher MRT risk.
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Affiliation(s)
- Dou Huang
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Changwei Chen
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jing Liu
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Li Zhou
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lei Du
- Department of Anesthesiology and Translational Center, West China Hospital, Sichuan University, Chengdu, Sichuan
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18
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Rubens FD. Life imitates art far more than art imitates life—Oscar Wilde, “The Decay of Lying”. J Thorac Cardiovasc Surg 2018; 156:64-65. [DOI: 10.1016/j.jtcvs.2018.03.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 03/15/2018] [Indexed: 11/25/2022]
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19
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Biancari F, Mariscalco G, Gherli R, Reichart D, Onorati F, Faggian G, Franzese I, Santarpino G, Fischlein T, Rubino AS, Maselli D, Nardella S, Salsano A, Nicolini F, Zanobini M, Saccocci M, Ruggieri VG, Bounader K, Perrotti A, Rosato S, D’Errigo P, D’Andrea V, De Feo M, Tauriainen T, Gatti G, Dalén M. Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting: results from the multicentre E-CABG registry. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 4:246-257. [DOI: 10.1093/ehjqcco/qcy027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 06/22/2018] [Indexed: 11/14/2022]
Affiliation(s)
- Fausto Biancari
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
- Department of Surgery, University of Turku, Hämeentie 11, PO Box, Turku, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Kajaanintie 50, Oulu, Finland
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield, Hospital, Groby Road, Leicester, Leicestershire, UK
| | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo, -Forlanini Hospital, Circonvallazione Gianicolense, 87, Rome, Italy
| | - Daniel Reichart
- Hamburg University Heart Center, Martinistraße 52, Hamburg, Germany
| | - Francesco Onorati
- Department of Cardiovascular Surgery, Division of Cardiovascular Surgery, Verona University Hospital, P. Le Stefani 1, Verona, Italy
| | - Giuseppe Faggian
- Department of Cardiovascular Surgery, Division of Cardiovascular Surgery, Verona University Hospital, P. Le Stefani 1, Verona, Italy
| | - Ilaria Franzese
- Department of Cardiovascular Surgery, Division of Cardiovascular Surgery, Verona University Hospital, P. Le Stefani 1, Verona, Italy
| | - Giuseppe Santarpino
- Department of Cardiovascular Surgery, Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany and Città di Lecce Hospital GVM Care&Research, Strada Provinciale per Arnesano km 4, Lecce LE, Italy
| | - Theodor Fischlein
- Department of Cardiovascular Surgery, Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany and Città di Lecce Hospital GVM Care&Research, Strada Provinciale per Arnesano km 4, Lecce LE, Italy
| | - Antonino S Rubino
- Department of Cardiovascular Surgery, Centro Clinico-Diagnostico “G.B. Morgagni”, Centro Cuore, Via della Resistenza, 31, Pedara CT, Italy
| | - Daniele Maselli
- Department of Cardiovascular Surgery, St. Anna Hospital, Catanzaro, Viale Papa Pio X, 111, Catanzaro, Italy
| | - Saverio Nardella
- Department of Cardiovascular Surgery, St. Anna Hospital, Catanzaro, Viale Papa Pio X, 111, Catanzaro, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Largo Rosanna Benzi, 10, Genova GE, Italy
| | - Francesco Nicolini
- Division of Cardiac Surgery, University of Parma, Via Gramsci 14 – Parma, Italy
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico – Fondazione Monzino IRCCS, University of Milan, Via Carlo Parea, 4, Milan MI, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico – Fondazione Monzino IRCCS, University of Milan, Via Carlo Parea, 4, Milan MI, Italy
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Rue du Général Koenig, Reims, France
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, 2 Rue Henri le Guilloux, Rennes, France
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, 3 Boulevard Alexandre Fleming, Besançon, France
| | - Stefano Rosato
- National Center of Global Health, Istituto Superiore di Sanità, Via Giano della Bella 34, Rome RM, Italy
| | - Paola D’Errigo
- National Center of Global Health, Istituto Superiore di Sanità, Via Giano della Bella 34, Rome RM, Italy
| | - Vito D’Andrea
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Marisa De Feo
- Department of Cardiovascular Diseases, University of Campania “Luigi Vanvitelli”, Piazza Luigi Miraglia, 2, Naples, Italy
| | - Tuomas Tauriainen
- Department of Surgery, Oulu University Hospital and University of Oulu, Kajaanintie 50, Oulu, Finland
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, via Farneto 3, Trieste, Italy
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Karolinska Universitetssjukhuset, Karolinska vägen, Solna, Sweden
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20
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Karkouti K, Callum J, Rao V, Heddle N, Farkouh ME, Crowther MA, Scales DC. Protocol for a phase III, non-inferiority, randomised comparison of a new fibrinogen concentrate versus cryoprecipitate for treating acquired hypofibrinogenaemia in bleeding cardiac surgical patients: the FIBRES trial. BMJ Open 2018; 8:e020741. [PMID: 29678987 PMCID: PMC5914770 DOI: 10.1136/bmjopen-2017-020741] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Coagulopathic bleeding is a serious complication of cardiac surgery to which an important contributor is acquired hypofibrinogenaemia (plasma fibrinogen <1.5-2.0 g/L). The standard intervention for acquired hypofibrinogenaemia is cryoprecipitate, but purified fibrinogen concentrates are also available. There is little comparative data between the two therapies and randomised trials are needed. METHODS AND ANALYSIS FIBrinogen REplenishment in Surgery (FIBRES) is a multicentre, randomised (1:1), active-control, single-blinded, phase III trial in adult cardiac surgical patients experiencing clinically significant bleeding related to acquired hypofibrinogenaemia. The primary objective is to demonstrate that fibrinogen concentrate (Octafibrin/Fibryga; Octapharma) is non-inferior to cryoprecipitate. All patients for whom fibrinogen supplementation is ordered by the clinical team within 24 hours of cardiopulmonary bypass will receive 4 g of fibrinogen concentrate or 10 units of cryoprecipitate (dose-equivalent to 4 g), based on random allocation and deferred consent. The primary outcome is total red cell, platelet and plasma transfusions administered within 24 hours of bypass. Secondary outcomes include major bleeding, fibrinogen levels and adverse events within 28 days. Enrolment of 1200 patients will provide >90% power to demonstrate non-inferiority. One preplanned interim analysis will include 600 patients. The pragmatic design and treatment algorithm align with standard practice, aiding adherence and generalisability. ETHICS AND DISSEMINATION The study is approved by the local research ethics board and will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. Patient consent prior to treatment is waived, as per criteria in the Tri-Council Policy Statement. Results will be published in the scientific/medical literature, and at international congresses. Non-inferiority of purified fibrinogen concentrate would support its use in acquired hypofibrinogenaemia. The results are likely to improve care for cardiac surgical patients experiencing significant bleeding, an understudied yet high-risk population. TRIAL REGISTRATION NUMBER NCT03037424; Pre-results.
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Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Peter Munk Cardiac Centre and Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Heddle
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark A Crowther
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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21
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Meesters MI, Burtman D, van de Ven PM, Boer C. Prediction of Postoperative Blood Loss Using Thromboelastometry in Adult Cardiac Surgery: Cohort Study and Systematic Review. J Cardiothorac Vasc Anesth 2018; 32:141-150. [DOI: 10.1053/j.jvca.2017.08.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Indexed: 12/22/2022]
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22
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Biancari F, Kinnunen EM, Kiviniemi T, Tauriainen T, Anttila V, Airaksinen JKE, Brascia D, Vasques F. Meta-analysis of the Sources of Bleeding after Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 32:1618-1624. [PMID: 29338997 DOI: 10.1053/j.jvca.2017.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to pool data on the proportion and prognostic impact of sources of bleeding in patients requiring re-exploration after adult cardiac surgery. DESIGN Systematic review of the literature and meta-analysis. SETTING Multistitutional study. MEASUREMENTS AND MAIN RESULTS A literature review was performed to identify studies published since 1990 evaluating the outcome after reoperation for bleeding or tamponade after adult cardiac surgery. Eighteen studies including 5,1497 patients fulfilled the selection criteria. Reoperation for bleeding/tamponade was performed in 2,455 patients (4.6%; 95% confidence interval [CI] 3.9%-5.2%, I2 92%). These had a significantly higher risk of in-hospital/30-day mortality compared with patients not reoperated for bleeding (pooled rates: 9.3% v 2.3%; risk ratio 3.30; 95% CI 2.52-4.32; I2 47%; 8 studies; 25,463 patients). Surgical sites of bleeding were identified in 65.7% of cases (95% CI 58.3%-73.2%; I2 94%), cardiac site bleeding in 40.9% of cases (95% CI 29.7%-52.0%; I2 94%), and mediastinal/sternum site bleeding in 27.0% of cases (95% CI 16.8%-37.3%; I2 94%). The main sites of bleeding were the body of the graft (20.2%), the sternum (17.0%), vascular sutures (12.5%), the internal mammary artery harvest site (13.0%), and anastomoses (9.9%). In metaregression, surgical site bleeding was associated with a lower risk of in-hospital/30-day mortality compared with diffuse bleeding (p = 0.003). CONCLUSIONS Surgical site bleeding is identified in two-thirds of patients undergoing re-exploration after adult cardiac surgery. Meticulous surgical technique and systematic intraoperative checking of potential surgical sites of bleeding at the time of the original cardiac surgery may reduce the risk of such a severe complication.
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Affiliation(s)
- Fausto Biancari
- Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland; Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
| | | | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Vesa Anttila
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Debora Brascia
- Department of Surgery, University of Turku, Turku, Finland
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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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24
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Bartoszko J, Karkouti K. Can predicting transfusion in cardiac surgery help patients? Br J Anaesth 2017; 119:350-352. [DOI: 10.1093/bja/aex216] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Affiliation(s)
- Paul M Ness
- Transfusion Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA.,Pathology, Medicine and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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26
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Orlov D, McCluskey SA, Callum J, Rao V, Moreno J, Karkouti K. Utilization and Effectiveness of Desmopressin Acetate After Cardiac Surgery Supplemented With Point-of-Care Hemostatic Testing: A Propensity-Score–Matched Analysis. J Cardiothorac Vasc Anesth 2017; 31:883-895. [DOI: 10.1053/j.jvca.2016.11.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Indexed: 01/09/2023]
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Habib AM. Comparison of low- and high-dose recombinant activated factor VII for postcardiac surgical bleeding. Indian J Crit Care Med 2016; 20:497-503. [PMID: 27688624 PMCID: PMC5027741 DOI: 10.4103/0972-5229.190365] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Aim of the Study: A retrospective observational study to compare safety and efficacy of high and low doses of recombinant activated factor VIIa (rFVIIa) in severe postcardiac surgical bleeding. Patients and Methods: From 2004 to 2014, all patients who received rFVIIa for bleeding after cardiac surgery were included and arranged in two groups; Group 1: Low dose (40–50 mcg/kg) (n = 98) and Group 2: High dose (90–120 mcg/kg) (n = 156). Results: There was no significant difference in demographic and surgical characteristics of both groups on admission to Cardiac Surgical Intensive Care Unit (CSICU). There was no significant difference between the two groups regarding the reduction in chest tube bleeding in the first 6 h or the transfusion requirement in the 24 h after admission to CSICU. A total of 15 patients (5.9%) had thromboembolic adverse events. (Seven (7.1%) patients in Group 1 compared to 8 (5.1%) patients in Group 2, P = 0.58). There were no significant differences in all-cause mortality at 30 days (2% in Group 1 vs. 3.2% in Group 2, P = 0.6) and at hospital discharge between the two study groups (6.1% in Group 1 vs. 8.3% in Group 2, P = 0.5), respectively. There was no significant difference between the two groups regarding the need for re-exploration, days on mechanical ventilation, CSICU, or hospital stay. Conclusion: In this report, Low-dose rFVIIa showed equivalent efficacy and safety to high-dose rFVIIa. Further prospective randomized studies are needed to confirm these findings.
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Affiliation(s)
- Aly Makram Habib
- Department of Intensive Care, Adult Cardiac Intensive Care Unit, Prince Sultan Cardiac Centre, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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Karkouti K, Callum J, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC. Point-of-Care Hemostatic Testing in Cardiac Surgery: A Stepped-Wedge Clustered Randomized Controlled Trial. Circulation 2016; 134:1152-1162. [PMID: 27654344 DOI: 10.1161/circulationaha.116.023956] [Citation(s) in RCA: 190] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/02/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiac surgery is frequently complicated by coagulopathic bleeding that is difficult to optimally manage using standard hemostatic testing. We hypothesized that point-of-care hemostatic testing within the context of an integrated transfusion algorithm would improve the management of coagulopathy in cardiac surgery and thereby reduce blood transfusions. METHODS We conducted a pragmatic multicenter stepped-wedge cluster randomized controlled trial of a point-of-care-based transfusion algorithm in consecutive patients undergoing cardiac surgery with cardiopulmonary bypass at 12 hospitals from October 6, 2014, to May 1, 2015. Following a 1-month data collection at all participating hospitals, a transfusion algorithm incorporating point-of-care hemostatic testing was sequentially implemented at 2 hospitals at a time in 1-month intervals, with the implementation order randomly assigned. No other aspects of care were modified. The primary outcome was red blood cell transfusion from surgery to postoperative day 7. Other outcomes included transfusion of other blood products, major bleeding, and major complications. The analysis adjusted for secular time trends, within-hospital clustering, and patient-level risk factors. All outcomes and analyses were prespecified before study initiation. RESULTS Among the 7402 patients studied, 3555 underwent surgery during the control phase and 3847 during the intervention phase. Overall, 3329 (45.0%) received red blood cells, 1863 (25.2%) received platelets, 1645 (22.2%) received plasma, and 394 (5.3%) received cryoprecipitate. Major bleeding occurred in 1773 (24.1%) patients, and major complications occurred in 740 (10.2%) patients. The trial intervention reduced rates of red blood cell transfusion (adjusted relative risk, 0.91; 95% confidence interval, 0.85-0.98; P=0.02; number needed to treat, 24.7), platelet transfusion (relative risk, 0.77; 95% confidence interval, 0.68-0.87; P<0.001; number needed to treat, 16.7), and major bleeding (relative risk, 0.83; 95% confidence interval, 0.72-0.94; P=0.004; number needed to treat, 22.6), but had no effect on other blood product transfusions or major complications. CONCLUSIONS Implementation of point-of-care hemostatic testing within the context of an integrated transfusion algorithm reduces red blood cell transfusions, platelet transfusions, and major bleeding following cardiac surgery. Our findings support the broader adoption of point-of-care hemostatic testing into clinical practice. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02200419.
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Affiliation(s)
- Keyvan Karkouti
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.).
| | - Jeannie Callum
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Duminda N Wijeysundera
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Vivek Rao
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Mark Crowther
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Hilary P Grocott
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Ruxandra Pinto
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
| | - Damon C Scales
- From Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, Canada (K.K.); Department of Laboratory Medicine and Pathobiology, Sunnybrook Health Sciences Centre, University of Toronto, Canada (J.C.); Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Canada (D.N.W.); Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital, University Health Network, University of Toronto, Canada (V.R.); Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada (M.C.); Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada (H.P.G.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (R.P.); Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care, University of Toronto, Canada (D.C.S.); and the Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (K.K., D.N.W., V.R.)
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Colson PH, Gaudard P, Fellahi JL, Bertet H, Faucanie M, Amour J, Blanloeil Y, Lanquetot H, Ouattara A, Picot MC. Active Bleeding after Cardiac Surgery: A Prospective Observational Multicenter Study. PLoS One 2016; 11:e0162396. [PMID: 27588817 PMCID: PMC5010224 DOI: 10.1371/journal.pone.0162396] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/22/2016] [Indexed: 11/18/2022] Open
Abstract
MAIN OBJECTIVES To estimate the incidence of active bleeding after cardiac surgery (AB) based on a definition directly related on blood flow from chest drainage; to describe the AB characteristics and its management; to identify factors of postoperative complications. METHODS AB was defined as a blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or in case of reoperation for hemostasis during the first 12 postoperative hours. The definition was applied in a prospective longitudinal observational study involving 29 French centers; all adult patients undergoing cardiac surgery with cardiopulmonary bypass were included over a 3-month period. Perioperative data (including blood product administration) were collected. To study possible variation in clinical practice among centers, patients were classified into two groups according to the AB incidence of the center compared to the overall incidence: "Low incidence" if incidence is lower and "High incidence" if incidence is equal or greater than overall incidence. Logistic regression analysis was used to identify risk factors of postoperative complications. RESULTS Among 4,904 patients, 129 experienced AB (2.6%), among them 52 reoperation. Postoperative bleeding loss was 1,000 [820;1,375] ml and 1,680 [1,280;2,300] ml at 6 and 24 hours respectively. Incidence of AB varied between centers (0 to 16%) but was independent of in-centre cardiac surgical experience. Comparisons between groups according to AB incidence showed differences in postoperative management. Body surface area, preoperative creatinine, emergency surgery, postoperative acidosis and red blood cell transfusion were risk factors of postoperative complication. CONCLUSIONS A blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or early reoperation for hemostasis seems a relevant definition of AB. This definition, independent of transfusion, adjusted to body weight, may assess real time bleeding occurring early after surgery.
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Affiliation(s)
- Pascal H. Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, Montpellier University, Montpellier, France
- Institut de Génomique Fonctionnelle, Endocrinology Department, CNRS UMR 5203, INSERM U1191, University of Montpellier, 34094, Montpellier, France
- * E-mail:
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, Montpellier University, Montpellier, France
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, 34295, Montpellier, cedex 5, France
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, Louis Pradel Academic Hospital, Lyon Bron, France
| | - Héléna Bertet
- Clinical Research and Epidemiology Unit, Academic Hospital, Montpellier, France
- Clinical Investigation Center, Academic Hospital, Montpellier, France
| | - Marie Faucanie
- Clinical Research and Epidemiology Unit, Academic Hospital, Montpellier, France
| | - Julien Amour
- Department of Anaesthesiology and Critical Care Medicine, Sorbonne University UPMC Univ Paris 06, UMR INSERM 1166 and Post-Genomic Platform, IHU ICAN, Paris, France
| | - Yvonnick Blanloeil
- Department of Anaesthesiology and Critical Care Medicine, Laënnec Academic Hôpital, Nantes, France
| | - Hervé Lanquetot
- Department of Anaesthesiology and Critical Care Medicine, Academic Hospital, Poitiers, France
| | - Alexandre Ouattara
- Department of Anaesthesiology and Critical Care Medicine II, Academic Hospital, Bordeaux-Pessac, France
| | - Marie Christine Picot
- Clinical Research and Epidemiology Unit, Academic Hospital, Montpellier, France
- Clinical Investigation Center, Academic Hospital, Montpellier, France
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Willems A, Datoussaid D, Tucci M, Sanchez Torres C, De Villé A, Fils JF, Van der Linden P. Impact of On-Bypass Red Blood Cell Transfusion on Severe Postoperative Morbidity or Mortality in Children. Anesth Analg 2016; 123:420-9. [DOI: 10.1213/ane.0000000000001425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ellis J, Valencia O, Crerar-Gilbert A, Phillips S, Meeran H, Sharma V. Point-of-care platelet function testing to predict blood loss after coronary artery bypass grafting surgery: a prospective observational pilot study. Perfusion 2016; 31:676-682. [DOI: 10.1177/0267659116656774] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: With an increase in the number of patients who are on antiplatelet medications until the day of surgery, we undertook a prospective observational study to assess the ability of thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate to detect platelet dysfunction and predict blood loss following coronary artery bypass grafting (CABG) surgery. Methods: Platelet function was evaluated pre- and post-cardiopulmonary bypass via thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate in 52 patients undergoing coronary artery bypass grafting surgery. The median chest tube drainage of all patients in the study was ascertained to stratify patients into two groups: patients with and those without evidence of excessive blood loss after cardiac surgery. Results: Although all modalities could detect a decrease in platelet function following cardiopulmonary bypass, univariate and multivariate regression analysis identified preoperative arachidonic acid and adenosine diphosphate testing via multiplate as independent predictors of bleeding after cardiac surgery. Receiver operating curves on these multiplate parameters showed an area under the curve of 0.68 (p=0.03) and 0.66 (p=0.01) for arachidonic acid and adenosine diphosphate assays, respectively. Conclusion: This pilot study shows that preoperative multiplate testing may be a better predictor of platelet dysfunction and the resultant blood loss following cardiac surgery.
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Affiliation(s)
- James Ellis
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | | | | | - Simon Phillips
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | - Hanif Meeran
- Department of Anaesthesia, St George’s Hospital, London, UK
| | - Vivek Sharma
- Department of Anaesthesia, St George’s Hospital, London, UK
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Kim TS, Lee JH, An H, Na CY. Transfusion Risk and Clinical Knowledge (TRACK) Score and Cardiac Surgery in Patients Refusing Transfusion. J Cardiothorac Vasc Anesth 2016; 30:373-8. [DOI: 10.1053/j.jvca.2015.11.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Indexed: 11/11/2022]
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Tan Z, Zhou L, Qin Z, Luo M, Chen H, Xiong J, Li J, Liu T, Du L, Zhou J. Low-Dose Sevoflurane May Reduce Blood Loss and Need for Blood Products After Cardiac Surgery: A Prospective, Randomized Pilot Study. Medicine (Baltimore) 2016; 95:e3424. [PMID: 27124028 PMCID: PMC4998691 DOI: 10.1097/md.0000000000003424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patients undergoing cardiac surgery often experience abnormal bleeding, due primarily to cardiopulmonary bypass (CPB)-induced activation of platelets. Sevoflurane may inhibit platelet activation, raising the possibility that administering it during CPB may reduce blood loss.Patients between 18 and 65 years old who were scheduled for cardiac surgery under CPB at our hospital were prospectively enrolled and randomized to receive intravenous anesthetics alone (control group, n = 77) or together with sevoflurane (0.5-1.0 vol/%) from an oxygenator (sevoflurane group, n = 76). The primary outcome was postoperative blood loss, the secondary outcome was postoperative need for blood products.Volume of blood loss was 48% lower in the sevoflurane group than the control group at 4 hours after surgery, and 33% lower at 12 hours after surgery. Significantly fewer patients in the sevoflurane group lost >700 mL blood within 24 hours (9 of 76 vs 28 of 77, P < 0.001). As a result, the sevoflurane group received significantly smaller volumes of packed red blood cells (1.25 ± 2.36 vs 2.23 ± 3.75 units, P = 0.011) and fresh frozen plasma (97 ± 237 vs 236 ± 344 mL, P = 0.004). Thus the sevoflurane group was at significantly lower risk of requiring complex blood products after surgery (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.17-0.68, P = 0.002).Sevoflurane inhalation from an oxygenator during CPB may reduce blood loss and need for blood products after cardiac surgery.
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Affiliation(s)
- Zhaoxia Tan
- From the Department of Anesthesiology and Translational Neuroscience Center, West China Hospital (ZT, LZ, ZQ, ML, JX, JL, TL, LD); and Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China (HC, JZ)
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Cheng ESW, Hallet J, Hanna SS, Law CH, Coburn NG, Tarshis J, Lin Y, Karanicolas PJ. Is central venous pressure still relevant in the contemporary era of liver resection? J Surg Res 2016; 200:139-46. [DOI: 10.1016/j.jss.2015.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 07/29/2015] [Accepted: 08/06/2015] [Indexed: 01/24/2023]
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Goudie R, Sterne J, Verheyden V, Bhabra M, Ranucci M, Murphy G. Risk scores to facilitate preoperative prediction of transfusion and large volume blood transfusion associated with adult cardiac surgery †. Br J Anaesth 2015; 114:757-66. [DOI: 10.1093/bja/aeu483] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2014] [Indexed: 11/12/2022] Open
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Evaluation of a novel transfusion algorithm employing point-of-care coagulation assays in cardiac surgery: a retrospective cohort study with interrupted time-series analysis. Anesthesiology 2015; 122:560-70. [PMID: 25485470 DOI: 10.1097/aln.0000000000000556] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cardiac surgery requiring the use of cardiopulmonary bypass is frequently complicated by coagulopathic bleeding that, largely due to the shortcomings of conventional coagulation tests, is difficult to manage. This study evaluated a novel transfusion algorithm that uses point-of-care coagulation testing. METHODS Consecutive patients who underwent cardiac surgery with bypass at one hospital before (January 1, 2012 to January 6, 2013) and after (January 7, 2013 to December 13, 2013) institution of an algorithm that used the results of point-of-care testing (ROTEM; Tem International GmBH, Munich, Germany; Plateletworks; Helena Laboratories, Beaumont, TX) during bypass to guide management of coagulopathy were included. Pre- and postalgorithm outcomes were compared using interrupted time-series analysis to control for secular time trends and other confounders. RESULTS Pre- and postalgorithm groups included 1,311 and 1,170 patients, respectively. Transfusion rates for all blood products (except for cryoprecipitate, which did not change) were decreased after algorithm institution. After controlling for secular pre- and postalgorithm time trends and potential confounders, the posttransfusion odds ratios (95% CIs) for erythrocytes, platelets, and plasma were 0.50 (0.32 to 0.77), 0.22 (0.13 to 0.37), and 0.20 (0.12 to 0.34), respectively. There were no indications that the algorithm worsened any of the measured processes of care or outcomes. CONCLUSIONS Institution of a transfusion algorithm based on point-of-care testing was associated with reduced transfusions. This suggests that the algorithm could improve the management of the many patients who develop coagulopathic bleeding after cardiac surgery. The generalizability of the findings needs to be confirmed.
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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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Karkouti K, Grocott HP, Hall R, Jessen ME, Kruger C, Lerner AB, MacAdams C, Mazer CD, de Medicis É, Myles P, Ralley F, Rheault MR, Rochon A, Slaughter MS, Sternlicht A, Syed S, Waters T. Interrelationship of preoperative anemia, intraoperative anemia, and red blood cell transfusion as potentially modifiable risk factors for acute kidney injury in cardiac surgery: a historical multicentre cohort study. Can J Anaesth 2014; 62:377-84. [DOI: 10.1007/s12630-014-0302-y] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 12/09/2014] [Indexed: 11/29/2022] Open
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Patterson JA, Roberts CL, Isbister JP, Irving DO, Nicholl MC, Morris JM, Ford JB. What factors contribute to hospital variation in obstetric transfusion rates? Vox Sang 2014; 108:37-45. [PMID: 25092527 PMCID: PMC4302973 DOI: 10.1111/vox.12186] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 07/09/2014] [Accepted: 07/11/2014] [Indexed: 11/28/2022]
Abstract
Background and Objectives To explore variation in red blood cell transfusion rates between hospitals, and the extent to which this can be explained. A secondary objective was to assess whether hospital transfusion rates are associated with maternal morbidity. Materials and Methods Linked hospital discharge and birth data were used to identify births (n = 279 145) in hospitals with at least 10 deliveries per annum between 2008 and 2010 in New South Wales, Australia. To investigate transfusion rates, a series of random-effects multilevel logistic regression models were fitted, progressively adjusting for maternal, obstetric and hospital factors. Correlations between hospital transfusion and maternal, neonatal morbidity and readmission rates were assessed. Results Overall, the transfusion rate was 1·4% (hospital range 0·6–2·9) across 89 hospitals. Adjusting for maternal casemix reduced the variation between hospitals by 26%. Adjustment for obstetric interventions further reduced variation by 8% and a further 39% after adjustment for hospital type (range 1·1–2·0%). At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0·59, P = 0·01), but not with low Apgar scores (0·39, P = 0·08), or readmission rates (0·18, P = 0·29). Conclusion Both casemix and practice differences contributed to the variation in transfusion rates between hospitals. The relationship between outcomes and transfusion rates was variable; however, low transfusion rates were not associated with worse outcomes.
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Affiliation(s)
- J A Patterson
- Clinical and Population Perinatal Health, Kolling Institute, University of Sydney, Sydney, NSW, Australia
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Jalali A, Ghiasi M, Aghaei A, Khaleghparast S, Ghanbari B, Bakhshandeh H. Can plasma fibrinogen levels predict bleeding after coronary artery bypass grafting? Res Cardiovasc Med 2014; 3:e19521. [PMID: 25478546 PMCID: PMC4253797 DOI: 10.5812/cardiovascmed.19521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/17/2014] [Accepted: 06/07/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Fibrinogen is the main biomarker for bleeding. To prevent excessive postoperative bleeding, it would be useful to identify high-risk patients before coronary artery bypass grafting (CABG). OBJECTIVES In order to predicating bleeding after CABG, we sought to determine whether preoperative fibrinogen concentration was associated with the amount of bleeding following CABG. PATIENTS AND METHODS A total of 144 patients (mean age = 61.50 ± 9.42 years; 65.7% men), undergoing elective and isolated CABG, were included in this case-series study. The same anesthesia technique and medicines were selected for all the patients. In the ICU, the patients were assessed in terms of bleeding at 12 and 24 hours post-operation, amount of contingent blood products received, and relevant tests. Statistical tests were subsequently conducted to analyze the correlation between preoperative fibrinogen concentration and the amount of post-CABG bleeding. RESULTS The mean ± standard deviation of bleeding at 12 and 24 hours post-operation was 285.37 ± 280.27 and 499.31 ± 355.57 mL, respectively. The results showed that postoperative bleeding was associated with different factors whereas pre-anesthesia fibrinogen was not correlated with bleeding at 12 (P = 0.856) and 24 hours (P = 0.936) post-operation. There were correlations between the extra-corporal circulation time and bleeding at 12 hours post-operation (ρ = 0.231, P = 0.007) and bleeding at 24 hours post-operation (ρ = 0.218, P = 0.013). CONCLUSIONS Preoperative assessment of plasma fibrinogen levels failed to predict post-CABG bleeding.
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Affiliation(s)
- Alireza Jalali
- Department of Cardiac Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Mohammadsaeid Ghiasi
- Department of Cardiac Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Aghdas Aghaei
- Department of Anesthesiology, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Shiva Khaleghparast
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Behrooz Ghanbari
- Mental Health Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Hooman Bakhshandeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
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Dyke C, Aronson S, Dietrich W, Hofmann A, Karkouti K, Levi M, Murphy GJ, Sellke FW, Shore-Lesserson L, von Heymann C, Ranucci M. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg 2014; 147:1458-1463.e1. [DOI: 10.1016/j.jtcvs.2013.10.070] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 09/24/2013] [Accepted: 10/28/2013] [Indexed: 10/25/2022]
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Dixon B, Reid D, Collins M, Newcomb AE, Rosalion A, Yap CH, Santamaria JD, Campbell DJ. The operating surgeon is an independent predictor of chest tube drainage following cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28:242-6. [PMID: 24439890 DOI: 10.1053/j.jvca.2013.09.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Bleeding into the chest is a major cause of blood transfusion and adverse outcomes following cardiac surgery. The authors investigated predictors of bleeding following cardiac surgery to identify potentially correctable factors. DESIGN Data were retrieved from the medical records of patients undergoing cardiac surgery over the period of 2002 to 2008. Multivariate analysis was used to identify the independent predictors of chest tube drainage. SETTING Tertiary hospital. PARTICIPANTS Two thousand five hundred seventy-five patients. INTERVENTIONS Cardiac surgery. RESULTS The individual operating surgeon was independently associated with the extent of chest tube drainage. Other independent factors included internal mammary artery grafting, cardiopulmonary bypass time, urgency of surgery, tricuspid valve surgery, redo surgery, left ventricular impairment, male gender, lower body mass index and higher preoperative hemoglobin levels. Both a history of diabetes and administration of aprotinin were associated with reduced levels of chest tube drainage. CONCLUSIONS The individual operating surgeon was an independent predictor of the extent of chest tube drainage. Attention to surgeon-specific factors offers the possibility of reduced bleeding, fewer transfusions, and improved patient outcomes.
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Affiliation(s)
- Barry Dixon
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia.
| | - David Reid
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Marnie Collins
- Department of Statistics, Peter MacCallum Hospital, Melbourne, Australia
| | - Andrew E Newcomb
- Department of Cardiothoracic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Alexander Rosalion
- Department of Cardiothoracic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Cheng-Hon Yap
- Department of Cardiothoracic Surgery, Geelong Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - John D Santamaria
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Duncan J Campbell
- St. Vincent's Institute of Medical Research, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia
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Transfusion practice varies widely in cardiac surgery: Results from a national registry. J Thorac Cardiovasc Surg 2013; 147:1684-1690.e1. [PMID: 24332109 DOI: 10.1016/j.jtcvs.2013.10.051] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 10/06/2013] [Accepted: 10/29/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Evidence is accumulating of adverse outcomes associated with transfusion of blood components. If there are differences in perioperative transfusion rates in cardiac surgery, and what hospital factors may contribute, requires further investigation. METHODS Analysis of 42,743 adult patients who underwent 43,482 procedures from 2005 to 2011 at 25 Australian hospitals, according to the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database. Multiple logistic regression examined associations of patient and hospital characteristics with transfusion of ≥1 red blood cell (RBC) unit; platelet (PLT), fresh frozen plasma (FFP), and cryoprecipitate (CRYO) doses; and ≥5 RBC units, from surgery until hospital discharge. RESULTS Procedures included 24,222 (55%) isolated coronary artery bypass grafts, 7299 (17%) isolated valve, 4714 (11%) coronary artery bypass graft and valve, and 7247 (17%) other procedures. After adjustment for various patient and procedure characteristics, transfusion rates varied across hospitals for ≥1 RBC unit from 22% to 67%, ≥5 RBC units from 5% to 25%, ≥1 PLT dose from 11% to 39%, ≥1 FFP dose from 11% to 48% and ≥1 CRYO dose from 1% to 20%. Hospital characteristics, including state or territory, private versus public, and teaching versus nonteaching, were not associated with variation in transfusion rates. CONCLUSIONS Variation in transfusion of all components and large volume RBC was identified, even after adjustment for patient and procedural factors known to influence transfusion, and this was not explained by hospital characteristics.
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Point of Care Testing in Cardiac Surgery: Diagnostic Modalities to Assess Coagulation and Platelet Function. Drug Dev Res 2013. [DOI: 10.1002/ddr.21099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sandoughdaran S, Sarzaeem MR, Bagheri J, Jebelli M, Mandegar MH. Predictors of blood transfusion in patients undergoing coronary artery bypass grafting surgery. Int Cardiovasc Res J 2013; 7:25-8. [PMID: 24757615 PMCID: PMC3987423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 02/23/2013] [Accepted: 03/02/2013] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The aim of this retrospective study is to identify intraoperative patient's characteristics predicting the need for blood transfusion during CABG in our local cardiac surgical service. METHODS This study included 1835 consecutive patients, 1311 males and 524 females with mean age 58.8±9.9 years, undergoing coronary artery bypass grafting. Risk factors detected by univariate study were entered in a multivariate logistic regression model of the relationship between preoperative variables and blood transfusion. RESULTS Blood transfusion was used in 435 patients (29.9%). Univariate analysis identified hemoglobin, smoking, hypertension, sex, diabetes, BMI and use of cardiopulmonary bypass (CPB) as significant predictors. Multivariate analysis revealed hemoglobin (OR: 0.8; CI: 0.74-0.86; P<0.001), CPB use (OR: 12.2; CI: 8.2-18.1; P<0.001) and female gender (OR: 2.29; CI:1.72-3.04; P<0.001) as independent risk factors for blood transfusion. CONCLUSIONS The predictors of RBC transfusion after isolated CABG were performing CPB, preoperative hemoglobin and female gender. These factors can be used as a clinical tool to preserve blood bank resources without increasing patient's risk.
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Affiliation(s)
- Saleh Sandoughdaran
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mahmood Reza Sarzaeem
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran,Corresponding author: Mahmood Reza Sarzaeem, Cardiac Surgery and Transplantation Research Center, Dr. Shariati Hospital, North Karegar Ave.,Tehran, IR Iran PO: 1411713137. Tel: +98-9125268001, Fax: +9821-44453449, E-mail:
| | - Jamshid Bagheri
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Jebelli
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Hossein Mandegar
- Cardiac Surgery and Transplantation Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
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Tung A. Critical care of the cardiac patient. Anesthesiol Clin 2013; 31:421-32. [PMID: 23711651 DOI: 10.1016/j.anclin.2012.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
As the spectrum of cardiac surgeries has grown, the diversity and complexity of postoperative cardiac surgical care has also increased. This article examines 4 areas in critical care where clinical practice is evolving rapidly. Among these are management of mechanical ventilation, thresholds for blood transfusion, strategies for hemodynamic monitoring, and processes for central line insertion. Also reviewed are current approaches to common dilemmas in postoperative cardiac care: diagnosis of tamponade, and the diagnosis and management of low cardiac output states in patients with a ventricular assist device.
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Affiliation(s)
- Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC4028, Chicago, IL 60637, USA.
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Cevenini G, Barbini E, Massai MR, Barbini P. A naïve Bayes classifier for planning transfusion requirements in heart surgery. J Eval Clin Pract 2013; 19:25-9. [PMID: 21883719 DOI: 10.1111/j.1365-2753.2011.01762.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Transfusion of allogeneic blood products is a key issue in cardiac surgery. Although blood conservation and standard transfusion guidelines have been published by different medical groups, actual transfusion practices after cardiac surgery vary widely among institutions. Models can be a useful support for decision making and may reduce the total cost of care. The objective of this study was to propose and evaluate a procedure to develop a simple locally customized decision-support system. METHODS We analysed 3182 consecutive patients undergoing cardiac surgery at the University Hospital of Siena, Italy. Univariate statistical tests were performed to identify a set of preoperative and intraoperative variables as likely independent features for planning transfusion quantities. These features were utilized to design a naïve Bayes classifier. Model performance was evaluated using the leave-one-out cross-validation approach. All computations were done using spss and matlab code. RESULTS The overall correct classification percentage was not particularly high if several classes of patients were to be identified. Model performance improved appreciably when the patient sample was divided into two classes (transfused and non-transfused patients). In this case the naïve Bayes model correctly classified about three quarters of patients with 71.2% sensitivity and 78.4% specificity, thus providing useful information for recognizing patients with transfusion requirements in the specific scenario considered. CONCLUSIONS Although the classifier is customized to a particular setting and cannot be generalized to other scenarios, the simplicity of its development and the results obtained make it a promising approach for designing a simple model for different heart surgery centres needing a customized decision-support system for planning transfusion requirements in intensive care unit.
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Affiliation(s)
- Gabriele Cevenini
- Department of Surgery and Bioengineering, University of Siena, Siena, Italy
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Apelseth TO, Molnar L, Arnold E, Heddle NM. Benchmarking: Applications to Transfusion Medicine. Transfus Med Rev 2012; 26:321-32. [DOI: 10.1016/j.tmrv.2011.12.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Weitzel NS, Weitzel LB, Epperson LE, Karimpour-Ford A, Tran ZV, Seres T. Platelet mapping as part of modified thromboelastography (TEG®) in patients undergoing cardiac surgery and cardiopulmonary bypass. Anaesthesia 2012; 67:1158-65. [PMID: 22809250 DOI: 10.1111/j.1365-2044.2012.07231.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The platelet-mapping assay of the thromboelastograph was used to measure platelet aggregation and to examine the effect of cardiopulmonary bypass on multiple platelet receptors and the role of altered receptor activity in postoperative bleeding. The percentage platelet aggregation for collagen, adenosine diphosphate and arachidonic acid was measured in 40 patients divided post-hoc into high- or low-bleeding groups depending on postoperative 24-h chest tube output. Platelet aggregation was lower after cardiopulmonary bypass compared to before it using collagen (mean (SD) 45 (25) vs 19 (12)%, p<0.001), adenosine diphosphate (76 (23) vs 35 (24)%, p<0.001), and arachidonic acid (61 (33) vs 31 (35)%, p<0.001). Only platelet aggregation as measured using collagen pre- and post-cardiopulmonary bypass was significantly less in the high- compared to the low-bleeding group. This finding was significantly correlated with the 24-h chest tube drainage, and it predicted postoperative bleeding with a sensitivity of 83% and a specificity of 68%. Therefore, platelet aggregation is reduced following cardiopulmonary bypass, and this may play a role in predicting postoperative blood loss.
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Affiliation(s)
- N S Weitzel
- Department of Anesthesiology, University of Colorado, Denver, CO, USA.
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Drug, Devices, Technologies, and Techniques for Blood Management in Minimally Invasive and Conventional Cardiothoracic Surgery a Consensus Statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 7:229-41. [DOI: 10.1097/imi.0b013e3182747699] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective The objectives of this consensus conference were to evaluate the evidence for the efficacy and safety of perioperative drugs, technologies, and techniques in reducing allogeneic blood transfusion for adults undergoing cardiac surgery and to develop evidence-based recommendations for comprehensive perioperative blood management in cardiac surgery, with emphasis on minimally invasive cardiac surgery. Methods The consensus panel short-listed the potential topics for review from a comprehensive list of potential drugs, devices, technologies, and techniques. The process of short-listing was based on the need to prioritize and focus on the areas of highest importance to surgeons, anesthesiologists, perfusionists, hematologists, and allied health care involved in the management of patients who undergo cardiac surgery whether through the conventional or minimally invasive approach. MEDLINE, Cochrane Library, and Embase databases were searched from their date of inception to May 2011, and supplemental hand searches were also performed. Detailed methodology and search strategies are outlined in each of the subsequently published systematic reviews. In general, all relevant synonyms for drugs (antifibrinolytic, aprotinin, ∊-aminocaproic acid, tranexamic acid [TA], desmopressin, anticoagulants, heparin, antiplatelets, anti-Xa agents, adenosine diphosphate inhibitors, acetylsalicylic acid [ASA], factor VIIa [FVIIa]), technologies (cell salvage, miniaturized cardiopulmonary bypass (CPB) circuits, biocompatible circuits, ultrafiltration), and techniques (transfusion thresholds, minimally invasive cardiac or aortic surgery) were searched and combined with terms for blood, red blood cells, fresh-frozen plasma, platelets, transfusion, and allogeneic exposure. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of each recommendation. Results and Recommendations Database search identified more than 6900 articles, with 4423 full-text randomized controlled trials assessed for eligibility, and the final 125 systematic reviews and meta-analyses were used in the consensus conference. The results of the consensus conference, including the evidence-based statements and the recommendations, are outlined in the text, with references given for the relevant evidence that formed the basis for the statements and recommendations.
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