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Liu X, Liu M, Li S, Ren Y, Zheng M, Zeng M, Peng Y. Efficacy and safety of tranexamic acid on blood loss and seizures in patients undergoing meningioma resection: A systematic review and meta-analysis. PLoS One 2024; 19:e0308070. [PMID: 39231164 PMCID: PMC11373793 DOI: 10.1371/journal.pone.0308070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 07/16/2024] [Indexed: 09/06/2024] Open
Abstract
INTRODUCTION It is unclear how tranexamic acid (TXA) affects blood loss and seizures in meningioma resections. We performed a systematic review and meta-analysis and tried to evaluate the effectiveness and safety of TXA use for patients undergoing meningioma resections. METHODS Regards to this systematic review and meta-analysis (registered with CRD42023416693), we searched PubMed, Embase (Ovid), EBSCO, and Cochrane central library up to and including Oct 2023. Patients undergoing meningioma resections treated with TXA and placebo or no treatment were eligible for this study. This would allow delineation of the impact of TXA on blood loss, postoperative seizure, and other complication incidences. RESULTS Four prospective cohort studies with 781 patients (390 patients in the TXA group and 391 patients in the control group) were conducted via a systematic review and meta-analysis. The results suggested that the application of TXA for patients undergoing meningioma resections reduced mean blood loss of 252 mL with 95% confidence interval (CI) -469.26 to -34.67 (P = 0.02) and I2 of 94% but did not increase postoperative seizure (risk ratio: 1.08; 95%CI: 0.54 to 2.15; P = 0.84) and other complication rates. CONCLUSIONS This systematic review and meta-analysis suggests that the administration of TXA could reduce blood loss in patients undergoing intracerebral meningioma resection. REGISTRY INFORMATION The systematic review protocol has been registered at PROSPERO (Registration No. CRD42023416693) on April 23, 2023.
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Affiliation(s)
- Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Outcomes Research Consortium, Cleveland, Ohio, United States of America
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Maoyao Zheng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Outcomes Research Consortium, Cleveland, Ohio, United States of America
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Marous CL, Farhat OJ, Cefalu M, Rothschild MI, Alapati S, Wladis EJ. Effects of Preoperative Intravenous Versus Subcutaneous Tranexamic Acid on Postoperative Periorbital Ecchymosis and Edema Following Upper Eyelid Blepharoplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled, Comparative Study. Ophthalmic Plast Reconstr Surg 2024; 40:523-532. [PMID: 38687303 DOI: 10.1097/iop.0000000000002633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
PURPOSE To compare the effects of preoperative tranexamic acid (TXA) administered intravenously (IV) versus subcutaneously on postoperative ecchymosis and edema in patients undergoing bilateral upper eyelid blepharoplasty. METHODS A prospective, double-blinded, placebo-controlled study of patients undergoing bilateral upper eyelid blepharoplasty at a single-center. Eligible participants were randomized to preoperatively receive either (1) 1 g of TXA in 100 ml normal saline IV, (2) 50 µl/ml of TXA in local anesthesia, or (3) no TXA. Primary outcomes included ecchymosis and edema at postoperative day 1 (POD1) and 7 (POD7). Secondary outcomes included operative time, pain, time until resuming activities of daily living, patient satisfaction, and adverse events. RESULTS By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), ecchymosis scores were significantly lower on POD1 (1.31 vs. 1.56 vs. 2.09, p = 0.02) and on POD7 (0.51 vs. 0.66 vs. 0.98, p = 0.04) among those that received TXA. By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA), significant reductions in edema scores occurred in those that received TXA on POD1 (1.59 vs. 1.43 vs. 1.91, p = 0.005) and on POD7 (0.85 vs. 0.60 vs. 0.99, p = 0.04). By comparison (IV TXA vs. local subcutaneous TXA vs. no TXA) patients treated with intravenous and local subcutaneous TXA preoperatively were more likely to experience shorter operative times (10.8 vs. 11.8 vs. 12.9 minutes, p = 0.01), reduced time to resuming activities of daily livings (1.6 vs. 1.6 vs. 2.3 days, p < 0.0001), and higher satisfaction scores at POD1 (8.8 vs. 8.7 vs. 7.9, p = 0.0002). No adverse events occurred were reported. CONCLUSION In an analysis of 106 patients, preoperative TXA administered either IV or subcutaneously safely reduced postoperative ecchymosis and edema in patients undergoing upper eyelid blepharoplasty. While statistical superiority between intravenous versus local subcutaneous TXA treatment was not definitively identified, our results suggest clinical superiority with IV dosing.
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Affiliation(s)
- Charlotte L Marous
- Oculoplastic and Orbital Surgery, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | - Omar J Farhat
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | - Matthew Cefalu
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
| | | | | | - Edward J Wladis
- Ophthalmic Plastic Surgery, Department of Ophthalmology, Albany Medical College
- Department of Otolaryngology and Head and Neck Surgery, Albany Medical College, Albany, New York, U.S.A
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Dehne S, Riede C, Feisst M, Klotz R, Etheredge M, Hölle T, Merle U, Mehrabi A, Michalski CW, Büchler MW, Weigand MA, Larmann J. Tranexamic Acid Administration During Liver Transplantation Is Not Associated With Lower Blood Loss or With Reduced Utilization of Red Blood Cell Transfusion. Anesth Analg 2024; 139:598-608. [PMID: 38236761 DOI: 10.1213/ane.0000000000006804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
BACKGROUND Current clinical guidelines recommend antifibrinolytic treatment for liver transplantation to reduce blood loss and transfusion utilization. However, the clinical relevance of fibrinolysis during liver transplantation is questionable, a benefit of tranexamic acid (TXA) in this context is not supported by sufficient evidence, and adverse effects are also conceivable. Therefore, we tested the hypothesis that use of TXA is associated with reduced blood loss. METHODS We performed a retrospective cohort study on patients who underwent liver transplantation between 2004 and 2017 at Heidelberg University Hospital, Heidelberg, Germany. Univariable and multivariable linear regression analyses were used to determine the association between TXA administration and the primary end point intraoperative blood loss and the secondary end point intra- and postoperative red blood cell (RBC) transfusions. For further secondary outcome analyses, the time to the first occurrence of a composite end point of hepatic artery thrombosis, portal vein thrombosis, and thrombosis of the inferior vena cava were analyzed using a univariable and multivariable Cox proportional hazards model. RESULTS Data from 779 transplantations were included in the final analysis. The median intraoperative blood loss was 3000 mL (1600-5500 mL). Intraoperative TXA administration occurred in 262 patients (33.6%) with an average dose of 1.4 ± 0.7 g and was not associated with intraoperative blood loss (regression coefficient B, -0.020 [-0.051 to 0.012], P = .226) or any of the secondary end points (intraoperative RBC transfusion; regression coefficient B, 0.023 [-0.006 to 0.053], P = .116), postoperative RBC transfusion (regression coefficient B, 0.007 [-0.032 to 0.046], P = .717), and occurrence of thrombosis (hazard ratio [HR], 1.110 [0.903-1.365], P = .321). CONCLUSIONS Our data do not support the use of TXA during liver transplantation. Physicians should exercise caution and consider individual factors when deciding whether or not to administer TXA.
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Affiliation(s)
- Sarah Dehne
- From the Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Carlo Riede
- From the Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Manuel Feisst
- Heidelberg University, Medical Faculty Heidelberg, Institute of Medical Biometry, Heidelberg, Germany
| | - Rosa Klotz
- Heidelberg University, Medical Faculty Heidelberg, Departement of General, Visceral, and Transplantation Surgery, Heidelberg, Germany
| | - Melanie Etheredge
- From the Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Tobias Hölle
- From the Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Uta Merle
- Heidelberg University, Medical Faculty Heidelberg, Department of Internal Medicine IV (Gastroenterology, Infectious Diseases and Intoxications), Heidelberg, Germany
| | - Arianeb Mehrabi
- Heidelberg University, Medical Faculty Heidelberg, Departement of General, Visceral, and Transplantation Surgery, Heidelberg, Germany
| | - Christoph W Michalski
- Heidelberg University, Medical Faculty Heidelberg, Departement of General, Visceral, and Transplantation Surgery, Heidelberg, Germany
| | - Markus W Büchler
- Heidelberg University, Medical Faculty Heidelberg, Departement of General, Visceral, and Transplantation Surgery, Heidelberg, Germany
| | - Markus A Weigand
- From the Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
| | - Jan Larmann
- From the Heidelberg University, Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg, Germany
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Mergoum AM, Mergoum AS, Larson NJ, Dries DJ, Cook A, Blondeau B, Rogers FB. Tranexamic Acid Use in the Surgical Arena: A Narrative Review. J Surg Res 2024; 302:208-221. [PMID: 39106732 DOI: 10.1016/j.jss.2024.07.042] [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: 05/10/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION Tranexamic acid (TXA) is a potent antifibrinolytic drug that inhibits the activation of plasmin by plasminogen. While not a new medication, TXA has quickly gained traction across a variety of surgical subspecialties to prevent and treat bleeding. Knowledge on the use of this drug is essential for the modern surgeon to continue to provide excellent care to their patients. METHODS A comprehensive review of the PubMed database was conducted of articles published within the last 10 y (2014-2024) relating to TXA and its use in various surgical subspecialties. Seminal studies regarding the use of TXA older than 10 y were included from the author's archives. RESULTS Indications for TXA are not limited to trauma alone, and TXA is utilized across a variety of surgical subspecialties from neurosurgery to hepatic surgery to control hemorrhage. Overall, TXA is well tolerated with common dose-dependent adverse effects, including headache, nasal symptoms, dizziness, nausea, diarrhea, and fatigue. More severe adverse events are rare and easily mitigated by not exceeding a dose of 50 mg/kg. CONCLUSIONS The administration of TXA as an adjunct to treat trauma saves lives. The ability of TXA to induce seizures is dose dependent with identifiable risk factors, making this serious adverse effect predictable. As for the potential for TXA to cause thrombotic events, uncertainty remains. If this association is proven to be real, the risk will likely be small, since the use of TXA is still advantageous in most situations because of its efficacy for a more common concern, bleeding.
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Affiliation(s)
| | - Adel S Mergoum
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
| | - Alan Cook
- Department of Surgery, University of Texas at Tyler School of Medicine, Tyler, Texas
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, Minnesota
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Rabiee Rad M, Ghasempour Dabaghi G, Amani-Beni R. Efficacy of Epsilon Aminocaproic Acid Versus Placebo in Coronary Artery Bypass Graft: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2024; 26:161-174. [DOI: 10.1007/s11936-024-01039-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 07/23/2024]
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Aiza-Haddad I, Cisneros-Garza LE, Morales-Gutiérrez O, Malé-Velázquez R, Rizo-Robles MT, Alvarado-Reyes R, Barrientos-Quintanilla LA, Betancourt-Sánchez F, Cerda-Reyes E, Contreras-Omaña R, Dehesa-Violante MB, Flores-García NC, Gómez-Almaguer D, Higuera-de la Tijera MF, Lira-Pedrin MA, Lira-Vera JE, Manzano-Cortés H, Meléndez-Mena DE, Muñoz-Ramírez MR, Pérez-Hernández JL, Ramos-Gómez MV, Sánchez-Ávila JF. Guidelines for the management of coagulation disorders in patients with cirrhosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:144-162. [PMID: 38600006 DOI: 10.1016/j.rgmxen.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/07/2023] [Indexed: 04/12/2024]
Abstract
Coagulation management in the patient with cirrhosis has undergone a significant transformation since the beginning of this century, with the concept of a rebalancing between procoagulant and anticoagulant factors. The paradigm that patients with cirrhosis have a greater bleeding tendency has changed, as a result of this rebalancing. In addition, it has brought to light the presence of complications related to thrombotic events in this group of patients. These guidelines detail aspects related to pathophysiologic mechanisms that intervene in the maintenance of hemostasis in the patient with cirrhosis, the relevance of portal hypertension, mechanical factors for the development of bleeding, modifications in the hepatic synthesis of coagulation factors, and the changes in the reticuloendothelial system in acute hepatic decompensation and acute-on-chronic liver failure. They address new aspects related to the hemorrhagic complications in patients with cirrhosis, considering the risk for bleeding during diagnostic or therapeutic procedures, as well as the usefulness of different tools for diagnosing coagulation and recommendations on the pharmacologic treatment and blood-product transfusion in the context of hemorrhage. These guidelines also update the knowledge regarding hypercoagulability in the patient with cirrhosis, as well as the efficacy and safety of treatment with the different anticoagulation regimens. Lastly, they provide recommendations on coagulation management in the context of acute-on-chronic liver failure, acute liver decompensation, and specific aspects related to the patient undergoing liver transplantation.
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Affiliation(s)
- I Aiza-Haddad
- Clínica de Enfermedades Hepáticas, Hospital Ángeles Lomas, Mexico City, Mexico.
| | - L E Cisneros-Garza
- Departamento de Gastroenterología y Hepatología, Hospital Christus Muguerza Alta Especialidad, Monterrey, Mexico
| | - O Morales-Gutiérrez
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | | | - M T Rizo-Robles
- Departamento de Gastroenterología y Hepatología, Instituto Mexicano del Seguro Social Centro Médico Nacional «La Raza», Mexico City, Mexico
| | - R Alvarado-Reyes
- Departamento de Hepatología, Hospital San José Tec Salud, Monterrey, Mexico
| | | | | | - E Cerda-Reyes
- Servicio de Gastroenterología, Hospital Central Militar, Mexico City, Mexico
| | - R Contreras-Omaña
- Centro de Investigación en Enfermedades Hepáticas y Gastroenterología (CIEHG) Pachuca, Hidalgo, México
| | | | - N C Flores-García
- Escuela de Medicina y Ciencias de la Salud. Tecnológico de Monterrey, Monterrey Nuevo Leon, México
| | | | - M F Higuera-de la Tijera
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - M A Lira-Pedrin
- Departamento de Gastroenterología, Endoscopía Digestiva, Motilidad y Hepatología, Centro Médico Corporativo Galeana, Tijuana, México
| | - J E Lira-Vera
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | | | - D E Meléndez-Mena
- Hospital General de Especialidades «Maximino Ávila Camacho», IMSS, UMAE, Puebla, México
| | - M R Muñoz-Ramírez
- Departamento de Hepatología, Hospital San José Tec Salud, Monterrey, Mexico
| | - J L Pérez-Hernández
- Departamento de Gastroenterología y Hepatología, Hospital General de México «Dr. Eduardo Liceaga», Mexico City, Mexico
| | - M V Ramos-Gómez
- Departamento Hepatología, ISSSTE, Centro Médico Nacional «20 de noviembre», Ciudad de México, México
| | - J F Sánchez-Ávila
- Escuela de Medicina y Ciencias de la Salud. Tecnológico de Monterrey, Monterrey Nuevo Leon, México
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Vandyck KB, Rusin W, Mondal S, Tanaka KA. Coagulation management during liver transplantation: monitoring and decision making for hemostatic interventions. Curr Opin Organ Transplant 2023; 28:404-411. [PMID: 37728052 DOI: 10.1097/mot.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
PURPOSE OF REVIEW Rebalanced hemostasis describes the precarious balance of procoagulant and antithrombotic proteins in patients with severe liver failure. This review is aimed to discuss currently available coagulation monitoring tests and pertinent decision-making process for plasma coagulation factor replacements during liver transplantation (LT). RECENT FINDINGS Contemporary viscoelastic coagulation monitoring systems have demonstrated advantages over conventional coagulation tests in assessing the patient's coagulation status and tailoring hemostatic interventions. There is increasing interest in the use of prothrombin complex and fibrinogen concentrates, but it remains to be proven if purified factor concentrates are more efficacious and safer than allogeneic hemostatic components. Furthermore, the decision to use antifibrinolytic therapy necessitates careful considerations given the risks of venous thromboembolism in severe liver failure. SUMMARY Perioperative hemostatic management and thromboprophylaxis for LT patients is likely to be more precise and patient-specific through a better understanding and monitoring of rebalanced coagulation. Further research is needed to refine the application of these tools and develop more standardized protocols for coagulation management in LT.
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Affiliation(s)
- Kofi B Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Walter Rusin
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Samhati Mondal
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Hvas CL, Larsen JB. The Fibrinolytic System and Its Measurement: History, Current Uses and Future Directions for Diagnosis and Treatment. Int J Mol Sci 2023; 24:14179. [PMID: 37762481 PMCID: PMC10532028 DOI: 10.3390/ijms241814179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The fibrinolytic system is a key player in keeping the haemostatic balance, and changes in fibrinolytic capacity can lead to both bleeding-related and thrombosis-related disorders. Our knowledge of the fibrinolytic system has expanded immensely during the last 75 years. From the first successful use of thrombolysis in myocardial infarction in the 1960s, thrombolytic therapy is now widely implemented and has reformed treatment in vascular medicine, especially ischemic stroke, while antifibrinolytic agents are used routinely in the prevention and treatment of major bleeding worldwide. Despite this, this research field still holds unanswered questions. Accurate and timely laboratory diagnosis of disturbed fibrinolysis in the clinical setting remains a challenge. Furthermore, despite growing evidence that hypofibrinolysis plays a central role in, e.g., sepsis-related coagulopathy, coronary artery disease, and venous thromboembolism, there is currently no approved treatment of hypofibrinolysis in these settings. The present review provides an overview of the fibrinolytic system and history of its discovery; measurement methods; clinical relevance of the fibrinolytic system in diagnosis and treatment; and points to future directions for research.
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Affiliation(s)
- Christine Lodberg Hvas
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, 8200 Aarhus N, Denmark;
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
| | - Julie Brogaard Larsen
- Department of Clinical Medicine, Faculty of Health Sciences, Aarhus University, 8200 Aarhus N, Denmark
- Department of Clinical Biochemistry, Regional Hospital Horsens, 8700 Horsens, Denmark
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Yu H, Liu M, Zhang X, Ma T, Yang J, Wu Y, Wang J, Li M, Wang J, Zeng M, Zhang L, Jin H, Liu X, Li S, Peng Y. The effect of tranexamic acid on intraoperative blood loss in patients undergoing brain meningioma resections: Study protocol for a randomized controlled trial. PLoS One 2023; 18:e0290725. [PMID: 37651373 PMCID: PMC10470952 DOI: 10.1371/journal.pone.0290725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 06/18/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) has been proven to prevent thrombolysis and reduce bleeding and blood transfusion requirements in various surgical settings. However, the optimal dose of TXA that effectively reduce intraoperative bleeding and blood product infusion in patients undergoing neurosurgical resection of meningioma with a diameter ≥ 5 cm remains unclear. METHODS This is a single-center, randomized, double-blinded, paralleled-group controlled trial. Patients scheduled to receive elective tumor resection with meningioma diameter ≥ 5 cm will be randomly assigned the high-dose TXA group, the low-dose group, and the placebo. Patients in the high-dose TXA group will be administered with a loading dose of 20 mg/kg TXA followed by continuous infusion TXA at a rate of 5 mg/kg/h. In the low-dose group, patients will receive the same loading dose of TXA followed by a continuous infusion of normal saline. In the control group, patients will receive an identical volume of normal saline. The primary outcome is the estimated intraoperative blood loss calculated using the following formula: collected blood volume in the suction canister (mL)-the volume of flushing (mL) + the volume from the gauze tampon (mL). Secondary outcomes include calculated intraoperative blood loss, intraoperative coagulation function assessed using thromboelastogram (TEG), intraoperative cell salvage use, blood product infusion, and other safety outcomes. DISCUSSION Preclinical studies suggest that TXA could reduce intraoperative blood loss, yet the optimal dose was controversial. This study is one of the early studies to evaluate the impact of intraoperative different doses infusion of TXA on reducing blood loss in neurological meningioma patients. TRIAL REGISTRATION ClinicalTrials.gov, NCT05230381. Registered on February 8, 2022.
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Affiliation(s)
- Haojie Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Minying Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jingchao Yang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yaru Wu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Muhan Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Juan Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Min Zeng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liyong Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hailong Jin
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaoyuan Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Pérez-Calatayud AA, Hofmann A, Pérez-Ferrer A, Escorza-Molina C, Torres-Pérez B, Zaccarias-Ezzat JR, Sanchez-Cedillo A, Manuel Paez-Zayas V, Carrillo-Esper R, Görlinger K. Patient Blood Management in Liver Transplant—A Concise Review. Biomedicines 2023; 11:biomedicines11041093. [PMID: 37189710 DOI: 10.3390/biomedicines11041093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/07/2023] Open
Abstract
Transfusion of blood products in orthotopic liver transplantation (OLT) significantly increases post-transplant morbidity and mortality and is associated with reduced graft survival. Based on these results, an active effort to prevent and minimize blood transfusion is required. Patient blood management is a revolutionary approach defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood while promoting patient safety and empowerment. This approach is based on three pillars of treatment: (1) detecting and correcting anemia and thrombocytopenia, (2) minimizing iatrogenic blood loss, detecting, and correcting coagulopathy, and (3) harnessing and increasing anemia tolerance. This review emphasizes the importance of the three-pillar nine-field matrix of patient blood management to improve patient outcomes in liver transplant recipients.
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Affiliation(s)
| | - Axel Hofmann
- Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth 6907, WA, Australia
- Institute of Anesthesiology, University of Zurich and University Hospital Zurich, 8057 Zurich, Switzerland
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, 28700 San Sebastián de los Reyes, Spain
- Department of Anesthesiology, European University of Madrid, 28702 Madrid, Spain
| | - Carla Escorza-Molina
- Departmen of Anesthesiology, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Bettina Torres-Pérez
- Department of Anesthesiology, Pediatric Transplant, Centro Medico de Occidente, Instituto Mexicano del Seguro Social, Guadalajara 44329, Mexico
| | | | - Aczel Sanchez-Cedillo
- Transplant Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | - Victor Manuel Paez-Zayas
- Gastroenterology Department Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico
| | | | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45131 Essen, Germany
- TEM Innovations GmbH, 81829 Munich, Germany
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Carrier FM, Deshêtres A, Ferreira Guerra S, Rioux-Massé B, Zaouter C, Lee N, Amzallag É, Joosten A, Massicotte L, Chassé M. Preoperative Fibrinogen Level and Bleeding in Liver Transplantation for End-stage Liver Disease: A Cohort Study. Transplantation 2023; 107:693-702. [PMID: 36150121 DOI: 10.1097/tp.0000000000004333] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Liver transplantation is a high-risk surgery associated with important perioperative bleeding and transfusion needs. Uncertainties remain on the association between preoperative fibrinogen level and bleeding in this population. METHODS We conducted a cohort study that included all consecutive adult patients undergoing a liver transplantation for end-stage liver disease in 1 center. We analyzed the association between the preoperative fibrinogen level and bleeding-related outcomes. Our primary outcome was intraoperative blood loss, and our secondary outcomes were estimated perioperative blood loss, intraoperative and perioperative red blood cell transfusions, reinterventions for bleeding and 1-y graft and patient survival. We estimated linear regression models and marginal risk models adjusted for all important potential confounders. We used restricted cubic splines to explore potential nonlinear associations and reported dose-response curves. RESULTS We included 613 patients. We observed that a lower fibrinogen level was associated with a higher intraoperative blood loss, a higher estimated perioperative blood loss and a higher risk of intraoperative and perioperative red blood cell transfusions (nonlinear effects). Based on an exploratory analysis of the dose-response curves, these effects were observed below a threshold value of 3 g/L for these outcomes. We did not observe any association between preoperative fibrinogen level and reinterventions, 1-y graft survival or 1-y patient survival. CONCLUSIONS This study suggests that a lower fibrinogen level is associated with bleeding in liver transplantation. The present results may help improving the selection of patients for further studies on preoperative fibrinogen administration in liver transplant recipients with end-stage liver disease.
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Affiliation(s)
- François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Annie Deshêtres
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Steve Ferreira Guerra
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Canada
| | - Benjamin Rioux-Massé
- Department of Medicine, Hematology Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
| | - Cédrick Zaouter
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Nick Lee
- Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Éva Amzallag
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Alexandre Joosten
- Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Bicêtre and Paul Brousse Hospitals, Assistance Publique Hôpitaux de Paris, Villejuif, France
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Departement of Anesthesiology and Pain Medicine, Université de Montréal, Montréal, Canada
| | - Michaël Chassé
- Department of Medicine, Critical Care Division, Centre hospitalier de l'Université de Montréal, Montréal, Canada
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
- Department of Medicine, Université de Montréal, Montréal, Canada
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12
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Stewart E, Nydam TL, Hendrickse A, Pomposelli JJ, Pomfret EA, Moore HB. Viscoelastic Management of Coagulopathy during the Perioperative Period of Liver Transplantation. Semin Thromb Hemost 2023; 49:119-133. [PMID: 36318962 PMCID: PMC10366939 DOI: 10.1055/s-0042-1758058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Viscoelastic testing (VET) in liver transplantation (LT) has been used since its origin, in combination with standard laboratory testing (SLT). There are only a few, small, randomized controlled trials that demonstrated a reduction in transfusion rates using VET to guide coagulation management. Retrospective analyses contrasting VET to SLT have demonstrated mixed results, with a recent concern for overtreatment and the increase in postoperative thrombotic events. An oversight of many studies evaluating VET in LT is a single protocol that does not address the different phases of surgery, in addition to pre- and postoperative management. Furthermore, the coagulation spectrum of patients entering and exiting the operating room is diverse, as these patients can have varying anatomic and physiologic risk factors for thrombosis. A single transfusion strategy for all is short sighted. VET in combination with SLT creates the opportunity for personalized resuscitation in surgery which can address the many challenges in LT where patients are at a paradoxical risk for both life-threatening bleeding and clotting. With emerging data on the role of rebalanced coagulation in cirrhosis and hypercoagulability following LT, there are numerous potential roles in VET management of LT that have been unaddressed.
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Affiliation(s)
- Erin Stewart
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - Trevor L. Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Adrian Hendrickse
- Department of Anesthesia, University of Colorado School of Medicine, Aurora, Colorado
| | - James J. Pomposelli
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth A. Pomfret
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Hunter B. Moore
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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13
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La Mura V, Bitto N, Tripodi A. Rational hemostatic management in cirrhosis: from old paradigms to new clinical challenges. Expert Rev Hematol 2022; 15:1031-1044. [PMID: 36342412 DOI: 10.1080/17474086.2022.2144217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Patients with cirrhosis are at risk of both thrombotic and hemorrhagic events. Traditional hemostatic tests are inadequate to assess the complex and fragile balance of hemostasis in this setting, especially in advanced stages of disease such as decompensated cirrhosis or acute on chronic liver failure (ACLF). Furthermore, the indiscriminate use of pro-hemostatic agents for prophylaxis and treatment of bleeding episodes is still debated and often contraindicated. Alongside, splanchnic, and peripheral thrombotic events are frequent in this population and require management that involves a careful balance between risks and benefits of antithrombotic therapy. AREAS COVERED This review aims to address the state of the art on the clinical management of the hemostatic balance of cirrhosis in terms of established knowledge and future challenges. EXPERT OPINION The old paradigm of cirrhosis as a naturally anticoagulated condition has been challenged by more sophisticated global tests of hemostasis. Integrating this information in the clinical decision-making is still challenging for physicians and experts in hemostasis.
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Affiliation(s)
- Vincenzo La Mura
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Niccolò Bitto
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli studi di Milano, Milan, Italy
| | - Armando Tripodi
- Fondazione I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milan, Italy
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14
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The management of peri-operative anaemia in patients undergoing major abdominal surgery in Australia and New Zealand: a prospective cohort study. Med J Aust 2022; 217:487-493. [PMID: 36134647 PMCID: PMC9825983 DOI: 10.5694/mja2.51725] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To assess the prevalence and management of anaemia in patients undergoing major abdominal surgery, and the influence of guideline adherence on patient outcomes. DESIGN Prospective observational cohort study. SETTING 56 hospitals in Australia and New Zealand. PARTICIPANTS People aged 18 years or more who underwent major abdominal surgery during two 2-week periods in July 2021. MAIN OUTCOME MEASURES Proportions of patients managed according to Australian National Blood Authority patient blood management guidelines. SECONDARY OUTCOMES anaemia prevalence, post-operative complications, length of hospital stay, re-admission within 30 days of discharge. RESULTS Data were available for 2730 eligible patients (mean age, 56.7 years; SD, 17.3 years), including 1558 women (57.1%). Haemoglobin levels prior to surgery were documented for 2461 of 2727 patients (90.2%), 689 of whom had anaemia (28.0%). Pre-operative anaemia assessment and management were associated with lower likelihood of intra-operative (adjusted odds ratio [aOR], 0.33; 95% CI, 0.19-0.57) and post-operative blood transfusion (aOR, 0.36; 95% CI, 0.25-0.53), and of post-operative complications (aOR, 0.79; 95% CI, 0.63-0.99). Tranexamic acid was administered during 128 of 2728 procedures (4.7%); a restrictive transfusion strategy was followed for 96 of the 167 patients who received post-operative blood transfusions (58%). Post-operative anaemia was identified in 1227 of 2069 patients (59.3%) in whom haemoglobin was assessed prior to discharge. The proportion of people re-admitted to hospital within 30 days was larger for patients with anaemia at discharge (169 of 1207 patients followed up, 14.0% v 61 of 825, 7.4%). Haemoglobin assessments were recorded by 30 days after discharge for only 288 patients with post-operative anaemia (24.3%). CONCLUSIONS The management of peri-operative anaemia differs between hospitals in Australia and New Zealand, with consequences for patient outcomes. Patients are often discharged after surgery with anaemia, which is therefore a potential therapeutic target. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12621001517864 (retrospective).
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15
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Pillai AA, Kriss M, Al‐Adra DP, Chadha RM, Cushing MM, Farsad K, Fortune BE, Hess AS, Lewandowski R, Nadim MK, Nydam T, Sharma P, Karvellas CJ, Intagliata N. Coagulopathy and hemostasis management in patients undergoing liver transplantation: Defining a dynamic spectrum across phases of care. Liver Transpl 2022; 28:1651-1663. [PMID: 35253365 PMCID: PMC9790275 DOI: 10.1002/lt.26451] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 01/10/2023]
Abstract
Patients with acute and chronic liver disease present with a wide range of disease states and severity that may require liver transplantation (LT). Physiologic alterations occur that are dynamic throughout all phases of perioperative care, creating complex management scenarios that necessitate multidisciplinary clinical care. Specifically, alterations in hemostasis in liver disease can be pronounced and evolve with disease progression over time. Recent studies and society guidance address this emerging paradigm and offer recommendations to assist with hemostatic management in patients with liver disease. However, patients undergoing LT are unique and diverse, often with unstable disease that requires specialized approaches. Our aim is to provide a focused review of hemostatic management of the LT patient, distinguish unique aspects of the three main phases of care (before LT, perioperative, and after LT), and identify knowledge gaps and critical areas of future research.
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Affiliation(s)
- Anjana A. Pillai
- Department of MedicineUniversity of Chicago MedicineChicagoIllinoisUSA
| | - Michael Kriss
- Department of Internal MedicineUniversity of ColoradoAuroraColoradoUSA
| | - David P. Al‐Adra
- Department of SurgerySchool of Medicine and Public HealthUniversity of WisconsinMadisonWisconsinUSA
| | - Ryan M. Chadha
- Department of Anesthesiology and Perioperative MedicineMayo ClinicJacksonvilleFloridaUSA
| | - Melissa M. Cushing
- Department of Pathology and Laboratory MedicineWeill Cornell MedicineNew YorkNew YorkUSA
| | - Khashayar Farsad
- Department of Interventional RadiologyOregon Health & Science UniversityPortlandOregonUSA
| | | | - Aaron S. Hess
- Department of AnesthesiologyUniversity of WisconsinMadisonWisconsinUSA,Department of Pathology & Laboratory MedicineUniversity of WisconsinMadisonWisconsinUSA
| | | | - Mitra K. Nadim
- Department of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Trevor Nydam
- Department of SurgeryUniversity of ColoradoAuroraColoradoUSA
| | - Pratima Sharma
- Department of MedicineUniversity of MichiganAnn ArborMichiganUSA
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16
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Alam MS, Barh A, Kundu D. A randomized control trial on the role of tranexamic acid in preventing intraoperative bleeding during external dacryocystorhinostomy. Indian J Ophthalmol 2022; 70:3634-3637. [PMID: 36190062 PMCID: PMC9789862 DOI: 10.4103/ijo.ijo_925_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose To evaluate the role of tranexamic acid in controlling intra-operative and immediate post-operative bleeding during external dacryocystorhinostomy. Methods This was a double-blinded randomized placebo-controlled trial. All patients diagnosed with primary acquired nasolacrimal duct obstruction presenting between June 2018 to December 2019 were included in the study. All patients in the study group received a single dose of 1 gm tranexamic acid injection intravenously 30 minutes before the surgery, whereas the patients from group B (placebo) received normal saline. The effect of the injection was measured in terms of duration of the surgery, surgical field grading, amount of total blood loss during the surgery, and the need for postoperative nasal packing. Results A total of 96 patients were included, of whom 45 were males and 51 were females. The study group (Group A) included 51 patients (27 males and 24 females) and the control group (Group B) included 45 patients (18 males and 27 females). There were no statistically significant differences between the two groups in terms of the duration of surgery (48.43 ± 20.01 minutes vs. 53.38 ± 19.8 minutes, P = 0.228), view of the surgical field (P = 0.084), the amount of intraoperative blood loss (88.63 ± 69.34 mL vs. 88.89 ± 51.93 mL, P = 0.984) and requirement of postoperative nasal packing (54.9% vs 62.2%, P = 0.471). Conclusion There seems to be little to justify the role of preoperative intravenous tranexamic acid injection in controlling intra-operative and immediate postoperative bleeding during external dacryocystorhinostomy.
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Affiliation(s)
- Md Shahid Alam
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata (A Unit of Medical Research Foundation, Chennai, India), West Bengal, India,Correspondence to: Dr. Md Shahid Alam, Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata, (A Unit of Medical Research Foundation, Chennai, India), West Bengal, India. E-mail:
| | - Atanu Barh
- Department of Oculoplasty, ASG Group of Hospitals, Kolkata, West Bengal, India
| | - Debi Kundu
- Orbit, Oculoplasty, Reconstructive and Aesthetic Services, Aditya Birla Sankara Nethralaya, Kolkata (A Unit of Medical Research Foundation, Chennai, India), West Bengal, India
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17
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Prophylactic tranexamic acid in patients with hematologic malignancy: a placebo-controlled, randomized clinical trial. Blood 2022; 140:1254-1262. [PMID: 35667085 PMCID: PMC9479029 DOI: 10.1182/blood.2022016308] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/20/2022] [Indexed: 11/26/2022] Open
Abstract
Evidence of the effectiveness of prophylactic use of tranexamic acid (TXA) in thrombocytopenia is lacking. To determine whether TXA safely reduces bleeding incidence in patients undergoing treatment for hematologic malignancies, a randomized, double-blind clinical trial was conducted from June 2016 through June 2020. Of 3120 screened adults, 356 patients were eligible and enrolled, and 337 patients (mean age, 53.9; 141 [41.8%] women), randomized to 1300 mg TXA orally or 1000 mg TXA through IV (n = 168) vs placebo (n = 169) thrice daily for maximum 30 days. Three hundred thirty patients were activated when their platelet counts fell below 30 000 per µL; 279 (83%) had complete outcome ascertainment. World Health Organization (WHO) grade ≥2 bleeding was observed in the 30 days following activation in 50.3% (73/145) and 54.2% (78/144) of patients in the TXA and placebo groups, with an adjusted odds ratio of 0.83 (95% confidence interval [CI], 0.50-1.34; P = .44). There was no statistically significant difference in the mean number of platelet transfusions (mean difference, 0.1; 95% CI, -1.9 to 2.0), mean days alive without grade ≥2 bleeding (mean difference, 0.8; 95% CI, -0.4 to 2.0), thrombotic events (6/163 [3.7%] TXA, 9/163 [5.5%] placebo), or deaths due to serious bleeding. Most common adverse events were: diarrhea (116/164 [70.7%] TXA and 114/163 [69.9%] placebo); febrile neutropenia (111/164 [67.7%] TXA, 105/163 [64.4%] placebo); fatigue (106/164 [64.6%] TXA, 109/163 [66.9%] placebo); and nausea (104/164 [63.4%] TXA, 97/163 [59.5%] placebo). Among patients with hematologic malignancy undergoing chemotherapy or hematopoietic stem cell transplantation, prophylactic treatment with TXA compared with placebo did not significantly reduce the risk of WHO grade ≥2 bleeding.
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18
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Montalvá E, Rodríguez-Perálvarez M, Blasi A, Bonanad S, Gavín O, Hierro L, Lladó L, Llop E, Pozo-Laderas JC, Colmenero J. Consensus Statement on Hemostatic Management, Anticoagulation, and Antiplatelet Therapy in Liver Transplantation. Transplantation 2022; 106:1123-1131. [PMID: 34999660 PMCID: PMC9128618 DOI: 10.1097/tp.0000000000004014] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Anticoagulation and antiplatelet therapies are increasingly used in liver transplant (LT) candidates and recipients due to cardiovascular comorbidities, portal vein thrombosis, or to manage posttransplant complications. The implementation of the new direct-acting oral anticoagulants and the recently developed antiplatelet drugs is a great challenge for transplant teams worldwide, as their activity must be monitored and their complications managed, in the absence of robust scientific evidence. In this changing and clinically heterogeneous scenario, the Spanish Society of Liver Transplantation and the Spanish Society of Thrombosis and Haemostasis aimed to achieve consensus regarding the indications, drugs, dosing, and timing of anticoagulation and antiplatelet therapies initiated from the inclusion of the patient on the waiting list to post-LT surveillance. A multidisciplinary group of experts composed by transplant hepatologists, surgeons, hematologists, transplant-specialized anesthesiologists, and intensivists performed a comprehensive review of the literature and identified 21 clinically relevant questions using the patient-intervention-comparison-outcome format. A preliminary list of recommendations was drafted and further validated using a modified Delphi approach by a panel of 24 transplant delegates, each representing a LT institution in Spain. The present consensus statement contains the key recommendations together with the core supporting scientific evidence, which will provide guidance for improved and more homogeneous clinical decision making.
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Affiliation(s)
- Eva Montalvá
- Department of HPB Surgery and Transplantation, La Fe University Hospital and University of Valencia, Instituto de Investigación Sanitaria de La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Manuel Rodríguez-Perálvarez
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, University of Córdoba, Córdoba, Spain
| | - Annabel Blasi
- Department of Anesthesiology, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
| | - Santiago Bonanad
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Olga Gavín
- Departamento de Hematología y Hemoterapia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Loreto Hierro
- Department of Liver Transplantation, Hospital Universitario La Paz, Madrid, Spain
| | - Laura Lladó
- Liver Transplant Unit, Department of Surgery, Bellvitge University Hospital, IDIBELL, University of Barcelona, Barcelona, Spain
| | - Elba Llop
- Department of Hepatology and Liver Transplantation, Reina Sofía University Hospital, IMIBIC, University of Córdoba, Córdoba, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Puerta de Hierro-Segovia Arana (IDIPHISA), Madrid, Spain
| | | | - Jordi Colmenero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Department of Hepatology and Liver Transplantation, Hospital Clínic de Barcelona, IDIBAPS, CIBERehd, Barcelona, Spain
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19
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EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76:1151-1184. [PMID: 35300861 DOI: 10.1016/j.jhep.2021.09.003] [Citation(s) in RCA: 122] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 12/11/2022]
Abstract
The prevention and management of bleeding and thrombosis in patients with cirrhosis poses several difficult clinical questions. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics, including current views on haemostasis in liver disease, controversy regarding the need to correct thrombocytopenia and abnormalities in the coagulation system in patients undergoing invasive procedures, and the need for thromboprophylaxis in hospitalised patients with haemostatic abnormalities. Multiple recommendations in this document are based on interventions that the panel feels are not useful, even though widely applied in clinical practice.
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20
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Carrier FM, Ferreira Guerra S, Coulombe J, Amzallag É, Massicotte L, Chassé M, Trottier H. Intraoperative phlebotomies and bleeding in liver transplantation: a historical cohort study and causal analysis. Can J Anaesth 2022; 69:438-447. [PMID: 35112303 DOI: 10.1007/s12630-022-02197-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/31/2021] [Accepted: 11/03/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Liver transplantation is associated with major bleeding and red blood cell (RBC) transfusions. No well-designed causal analysis on interventions used to reduce transfusions, such as an intraoperative phlebotomy, has been conducted in this population. METHODS We conducted a historical cohort study among liver transplantations performed from July 2008 to January 2021 in a Canadian centre. The exposure was intraoperative phlebotomy. The outcomes were blood loss, perioperative RBC transfusions (intraoperative and up to 48 hr after surgery), intraoperative RBC transfusions, and one-year survival. We estimated marginal multiplicative factors (MFs), risk differences (RDs), and hazard ratios by inverse probability of treatment weighting both among treated patients and the whole population. Estimates are reported with 95% confidence intervals (CIs). RESULTS We included 679 patients undergoing liver transplantations of which 365 (54%) received an intraoperative phlebotomy. A phlebotomy did not reduce bleeding, transfusion risks, or mortality when estimated among the treated but reduced bleeding and transfusion risks when estimated among the whole population (MF, 0.85; 95% CI, 0.72 to 0.99; perioperative RD, -15.2%; 95% CI, -26.1 to -0.8; intraoperative RD, -14.7%; 95% CI, -23.2 to -2.8). In a subgroup analysis on 584 patients with end-stage liver disease, slightly larger effects were observed on both transfusion risks when estimated among the whole population while beneficial effects were observed on the intraoperative transfusion risk when estimated among the treated population. CONCLUSION The use of intraoperative phlebotomy was not consistently associated with better outcomes in all targets of inference but may improve outcomes among the whole population. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT04826666); registered 1 April 2021.
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Affiliation(s)
- François Martin Carrier
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montréal, QC, Canada. .,Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada. .,Critical Care Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.
| | - Steve Ferreira Guerra
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
| | - Janie Coulombe
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, QC, Canada
| | - Éva Amzallag
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montréal, QC, Canada
| | - Luc Massicotte
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Michaël Chassé
- Carrefour de l'innovation et santé des populations, Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), 900, rue St-Denis, porte S03-434, Montréal, QC, Canada.,Critical Care Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Helen Trottier
- Department of Social and Preventive Medicine, Université de Montréal, Sainte-Justine University Hospital Center, Montréal, QC, Canada
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21
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Nguyen G, Lejeune M, Crichi B, Frere C. Hemostasis testing in patients with liver dysfunction: Advantages and caveats. World J Gastroenterol 2021; 27:7285-7298. [PMID: 34876789 PMCID: PMC8611202 DOI: 10.3748/wjg.v27.i42.7285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/08/2021] [Accepted: 10/20/2021] [Indexed: 02/06/2023] Open
Abstract
Due to concomitant changes in pro- and anti-coagulant mechanisms, patients with liver dysfunction have a “rebalanced hemostasis”, which can easily be tipped toward either a hypo- or a hypercoagulable phenotype. Clinicians are often faced with the question whether patients with chronic liver disease undergoing invasive procedures or surgery and those having active bleeding require correction of the hemostasis abnormalities. Conventional coagulation screening tests, such as the prothrombin time/international normalized ratio and the activated partial thromboplastin time have been demonstrated to have numerous limitations in these patients and do not predict the risk of bleeding prior to high-risk procedures. The introduction of global coagulation assays, such as viscoelastic testing (VET), has been an important step forward in the assessment of the overall hemostasis profile. A growing body of evidence now suggests that the use of VET might be of significant clinical utility to prevent unnecessary infusion of blood products and to improve outcomes in numerous settings. The present review discusses the advantages and caveats of both conventional and global coagulation assays to assess the risk of bleeding in patients with chronic liver disease as well as the current role of transfusion and hemostatic agents to prevent or manage bleeding.
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Affiliation(s)
- Guillaume Nguyen
- Department of Hematology, Trousseau Hospital, Assistance Publique Hôpitaux de Paris, Paris 75012, France
| | - Manon Lejeune
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris 75013, France
| | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris 75010, France
| | - Corinne Frere
- Department of Hematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris 75013, France
- Inserm UMRS_1166, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris 75013, France
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22
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Lisman T, Adelmeijer J, Huskens D, Meijers JCM. Aprotinin Inhibits Thrombin Generation by Inhibition of the Intrinsic Pathway, but is not a Direct Thrombin Inhibitor. TH OPEN 2021; 5:e363-e375. [PMID: 34485811 PMCID: PMC8407936 DOI: 10.1055/s-0041-1735154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/29/2021] [Indexed: 12/01/2022] Open
Abstract
Background
Aprotinin is a broad-acting serine protease inhibitor that has been clinically used to prevent blood loss during major surgical procedures including cardiac surgery and liver transplantation. The prohemostatic properties of aprotinin likely are related to its antifibrinolytic effects, but other mechanisms including preservation of platelet function have been proposed.
Aim
Here we assessed effects of aprotinin on various hemostatic pathways in vitro, and compared effects to tranexamic acid(TXA), which is an antifibrinolytic but not a serine protease inhibitor.
Methods
We used plasma-based clot lysis assays, clotting assays in whole blood, plasma, and using purified proteins, and platelet activation assays to which aprotinin or TXA were added in pharmacological concentrations.
Results
Aprotinin and TXA dose-dependently inhibited fibrinolysis in plasma. Aprotinin inhibited clot formation and thrombin generation initiated via the intrinsic pathway, but had no effect on reactions initiated by tissue factor. However, in the presence of thrombomodulin, aprotinin enhanced thrombin generation in reactions started by tissue factor. TXA had no effect on coagulation. Aprotinin did not inhibit thrombin, only weakly inhibited the TF-VIIa complex and had no effect on platelet activation and aggregation by various agonists including thrombin. Aprotinin and TXA inhibited plasmin-induced platelet activation.
Conclusion
Pharmacologically relevant concentrations of aprotinin inhibit coagulation initiated via the intrinsic pathway. The antifibrinolytic activity of aprotinin likely explains the prohemostatic effects of aprotinin during surgical procedures. The anticoagulant properties may be beneficial during surgical procedures in which pathological activation of the intrinsic pathway, for example by extracorporeal circuits, occurs.
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Affiliation(s)
- Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelle Adelmeijer
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dana Huskens
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Synapse Research Institute, Maastricht, The Netherlands
| | - Joost C M Meijers
- Department of Molecular Hematology, Sanquin Research, Amsterdam, The Netherlands.,Department of Experimental Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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23
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Perioperative Viscoelastic Assay Use for Monitoring Coagulation Among US Liver Transplantation Centers. Transplant Proc 2021; 53:2312-2317. [PMID: 34454730 DOI: 10.1016/j.transproceed.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/12/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Viscoelastic assay has been used in liver transplantation since 1985 and shown to be beneficial in detecting coagulopathy and to guide transfusion. The objective of this study was to review and evaluate the current uses of viscoelastic assay among US liver transplantation programs. METHODS Anesthesia program directors at all 137 liver transplantation centers in the United States were contacted via email and asked to complete a 21-item survey. The primary outcome measure was the percentage of viscoelastic assay used in the perioperative management of liver transplantation. Secondary outcome measures were institutional demographics, physician training level, and device demographics. RESULTS Sixty-one of 137 (46%) centers responded. Liver transplantations were performed in the university setting at 48 of the 61 centers (77%), with a modal value of 11 to 50 liver transplantations a year and 74% in adult patients only. Most of the institutions (n = 57, 92%) had access to either rotational thromboelastometry or thrombelastography during liver transplantation. Most centers (n = 54; 87%) also used viscoelastic monitoring routinely (>60% of the time), including 42 (67.7%) that always used viscoelastic assay intraoperatively during liver transplantation. Thirty-five centers (59%) used it preoperatively, and 51 (84%) used it postoperatively. Most viscoelastic assay users (68%) learned how to use it through self-education and 10.5% learned during their fellowship or from a superuser or colleagues. CONCLUSION Currently, viscoelastic monitoring is widely available and routinely used in most US liver transplantation centers regardless of university or private practice setting, but training in it is limited. Only 21.1% of respondents reported that they received any type of official training in viscoelastic assay interpretation.
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24
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Ockerman A, Vanassche T, Garip M, Vandenbriele C, Engelen MM, Martens J, Politis C, Jacobs R, Verhamme P. Tranexamic acid for the prevention and treatment of bleeding in surgery, trauma and bleeding disorders: a narrative review. Thromb J 2021; 19:54. [PMID: 34380507 PMCID: PMC8356407 DOI: 10.1186/s12959-021-00303-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We review the evidence for tranexamic acid (TXA) for the treatment and prevention of bleeding caused by surgery, trauma and bleeding disorders. We highlight therapeutic areas where evidence is lacking and discuss safety issues, particularly the concern regarding thrombotic complications. METHODS An electronic search was performed in PubMed and the Cochrane Library to identify clinical trials, safety reports and review articles. FINDINGS TXA reduces bleeding in patients with menorrhagia, and in patients undergoing caesarian section, myomectomy, hysterectomy, orthopedic surgery, cardiac surgery, orthognathic surgery, rhinoplasty, and prostate surgery. For dental extractions in patients with bleeding disorders or taking antithrombotic drugs, as well as in cases of idiopathic epistaxis, tonsillectomy, liver transplantation and resection, nephrolithotomy, skin cancer surgery, burn wounds and skin grafting, there is moderate evidence that TXA is effective for reducing bleeding. TXA was not effective in reducing bleeding in traumatic brain injury and upper and lower gastrointestinal bleeding. TXA reduces mortality in patients suffering from trauma and postpartum hemorrhage. For many of these indications, there is no consensus about the optimal TXA dose. With certain dosages and with certain indications TXA can cause harm, such as an increased risk of seizures after high TXA doses with brain injury and cardiac surgery, and an increased mortality after delayed administration of TXA for trauma events or postpartum hemorrhage. Whereas most trials did not signal an increased risk for thrombotic events, some trials reported an increased rate of thrombotic complications with the use of TXA for gastro-intestinal bleeding and trauma. CONCLUSIONS TXA has well-documented beneficial effects in many clinical indications. Identifying these indications and the optimal dose and timing to minimize risk of seizures or thromboembolic events is work in progress.
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Affiliation(s)
- Anna Ockerman
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium.
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium.
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Melisa Garip
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Jeroen Martens
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Reinhilde Jacobs
- Department of Imaging and Pathology, KU Leuven, OMFS-IMPATH Research Group, Leuven, Belgium
- Department of Oral & Maxillofacial Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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25
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Thrombocytopenia and Hemostatic Changes in Acute and Chronic Liver Disease: Pathophysiology, Clinical and Laboratory Features, and Management. J Clin Med 2021; 10:jcm10071530. [PMID: 33917431 PMCID: PMC8038677 DOI: 10.3390/jcm10071530] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Thrombocytopenia, defined as a platelet count <150,000/μL, is the most common complication of advanced liver disease or cirrhosis with an incidence of up to 75%. A decrease in platelet count can be the first presenting sign and tends to be proportionally related to the severity of hepatic failure. The pathophysiology of thrombocytopenia in liver disease is multifactorial, including (i) splenomegaly and subsequently increased splenic sequestration of circulating platelets, (ii) reduced hepatic synthesis of thrombopoietin with missing stimulation both of megakaryocytopoiesis and thrombocytopoiesis, resulting in diminished platelet production and release from the bone marrow, and (iii) increased platelet destruction or consumption. Among these pathologies, the decrease in thrombopoietin synthesis has been identified as a central mechanism. Two newly licensed oral thrombopoietin mimetics/receptor agonists, avatrombopag and lusutrombopag, are now available for targeted treatment of thrombocytopenia in patients with advanced liver disease, who are undergoing invasive procedures. This review summarizes recent advances in the understanding of defective but at low level rebalanced hemostasis in stable cirrhosis, discusses clinical consequences and persistent controversial issues related to the inherent bleeding risk, and is focused on a risk-adapted management of thrombocytopenia in patients with chronic liver disease, including a restrictive transfusion regimen.
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26
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Abstract
Patients with liver disease acquire complex changes in their hemostatic system. Historically, these patients were considered to have a bleeding tendency related, in part, to a hyperfibrinolytic state. However, studies using more modern fibrinolysis tests have questioned the presence of a hyperfibrinolytic state in patients with liver disease and its association with bleeding risk. It may be that the sickest patients with liver disease do have fibrinolytic abnormalities. However, the debate on the fibrinolytic state of patients with (decompensated) cirrhosis or critically ill liver disease is complicated by the fact that hypo- and hyperfibrinolysis have been poorly defined. This could, in part, be explained by the lack of reliable tests that assess a patient's fibrinolytic status. Moreover, large clinical studies on the relationship between bleeding and fibrinolysis in patients with liver disease are scarce. Here, we provide an overview of the current knowledge on fibrinolysis in various types of liver diseases and possible implications as a target for therapeutic strategies in liver disease. As antifibrinolytic therapy has been shown to be safe and effective during liver transplantation, it could potentially be of use in patients with (either laboratory-established or suspected) hyperfibrinolysis-related bleeding.
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Affiliation(s)
- Fien A von Meijenfeldt
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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27
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Stubbs J, Klompas A, Thalji L. Transfusion Therapy in Specific Clinical Situations. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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28
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Sussman MS, Urrechaga EM, Cioci AC, Iyengar RS, Herrington TJ, Ryon EL, Namias N, Galbut DL, Salerno TA, Proctor KG. Do all cardiac surgery patients benefit from antifibrinolytic therapy? J Card Surg 2021; 36:1450-1457. [PMID: 33586229 DOI: 10.1111/jocs.15406] [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: 08/26/2020] [Revised: 12/03/2020] [Accepted: 12/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In trauma patients, the recognition of fibrinolysis phenotypes has led to a re-evaluation of the risks and benefits of antifibrinolytic therapy (AF). Many cardiac patients also receive AF, but the distribution of fibrinolytic phenotypes in that population is unknown. The purpose of this hypothesis-generating study was to fill that gap. METHODS Seventy-eight cardiac surgery patients were retrospectively reviewed. Phenotypes were defined as hypofibrinolytic (LY30 <0.8%), physiologic (0.8%-3.0%), and hyperfibrinolytic (>3%) based on thromboelastogram. RESULTS The population was 65 ± 10-years old, 74% male, average body mass index of 29 ± 5 kg/m2 . Fibrinolytic phenotypes were distributed as physiologic = 45% (35 of 78), hypo = 32% (25 of 78), and hyper = 23% (18 of 78). There was no obvious effect of age, gender, race, or ethnicity on this distribution; 47% received AF. For AF versus no AF, the time with chest tube was longer (4 [1] vs. 3 [1] days, p = .037), and all-cause morbidity was more prevalent (51% vs. 25%, p = .017). However, when these two groups were further stratified by phenotypes, there were within-group differences in the percentage of patients with congestive heart failure (p = .022), valve disease (p = .024), on-pump surgery (p < .0001), estimated blood loss during surgery (p = .015), transfusion requirement (p = .015), and chest tube output (p = .008), which highlight other factors along with AF that might have affected all-cause morbidity. CONCLUSION This is the first description of the prevalence of three different fibrinolytic phenotypes and their potential influence on cardiac surgery patients. The use of AF was associated with increased morbidity, but because of the small sample size and treatment allocation bias, additional confirmatory studies are necessary. We hope these present findings open the dialog on whether it is safe to administer AFs to cardiac surgery patients who are normo- or hypofibrinolytic.
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Affiliation(s)
- Matthew S Sussman
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Eva M Urrechaga
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Alessia C Cioci
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Rahul S Iyengar
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tyler J Herrington
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Emily L Ryon
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Nicholas Namias
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - David L Galbut
- Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Tomas A Salerno
- University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,Division of Cardiothoracic Surgery, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
| | - Kenneth G Proctor
- Divisions of Trauma, Surgical Critical Care, and Burns, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA.,University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Florida, USA
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29
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Montroy J, Hutton B, Fergusson DA, Tinmouth A, Lavallée LT, Cagiannos I, Morash C, Flaman A, Breau RH. Lysine analogue use during cancer surgery: a survey from a Canadian tertiary care centre. Curr Oncol 2020; 27:e560-e568. [PMID: 33380871 PMCID: PMC7755431 DOI: 10.3747/co.27.6613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background When used during surgery, antifibrinolytic hemostatic agents such as lysine analogues are effective at reducing blood loss and the need for transfusions. Despite proven efficacy, use of hemostatic agents remains low during some surgeries. Our objective was to explore surgeon opinions about, and use of lysine analogues in, oncologic surgeries at a large tertiary care academic institution. Methods We administered a survey to surgeons who perform high-transfusion-risk oncologic surgeries at a large academic hospital in Ottawa, Ontario. Design and distribution of the survey followed a modified Dillman method. To ensure that the survey questionnaire was relevant, clear, and concise, we performed informant interviews, cognitive interviews, and pilot-testing. The final survey consisted of 19 questions divided into 3 sections: respondent demographics, use of hemostatic agents, and potential clinical trial opinions. Results Of 28 surgeons, 24 (86%) participated. When asked to indicate the frequency of lysine analogue use, "never" accounted for 46% of the responses, and "rarely" (<10% of the time) accounted for 23% of the responses. Reasons for never using included "unfamiliar with benefits" and "prefer alternatives." Fifteen surgeons (63%) felt that a trial was needed to demonstrate the efficacy and safety of lysine analogues in their cancer field. Conclusions Our survey found that lysine analogues are infrequently used during oncologic surgeries at our institution. Many surgeons are unfamiliar with the benefits and side effects of lysine analogues and, alternatively, use topical hemostatic agents. Our results demonstrate that future trials exploring the efficacy and safety of lysine analogues in oncologic surgery are needed.
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Affiliation(s)
- J Montroy
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - B Hutton
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - D A Fergusson
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
- University of Ottawa, School of Epidemiology and Public Health, The Ottawa Hospital, Ottawa, ON
| | - A Tinmouth
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - L T Lavallée
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
- University of Ottawa, School of Epidemiology and Public Health, The Ottawa Hospital, Ottawa, ON
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
| | - I Cagiannos
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
| | - C Morash
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
| | - A Flaman
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
| | - R H Breau
- Clinical Epidemiology Program, Centre for Practice Changing Research, The Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON
- University of Ottawa, School of Epidemiology and Public Health, The Ottawa Hospital, Ottawa, ON
- Division of Urology, Department of Surgery, The Ottawa Hospital, Ottawa, ON
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30
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Risk Factors and Outcomes of Intracardiac Thrombosis During Orthotopic Liver Transplantation. Transplant Proc 2020; 53:250-254. [PMID: 33246584 DOI: 10.1016/j.transproceed.2020.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/20/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Intracardiac thrombosis incidence during orthotopic liver transplantation is estimated at 0.36% to 6.2% with mortality up to 68%. We aimed to evaluate risk factors and outcomes related to intracardiac thrombosis during orthotopic liver transplantation. MATERIALS AND METHODS A comprehensive retrospective data review of 388 patients who underwent orthotopic liver transplantation at an urban transplant center from January 2013 to October 2016 was obtained. RESULTS Six patients were found to have documented intracardiac thrombosis; 4 cases were recognized during the reperfusion stage and 1 during pre-anhepatic stage. All allografts were procured from decreased donors with a median donor age of 44 years (interquartile range, 35.25-49.75) and the cause of death was listed as cerebrovascular accident in 5 donors. Preoperative demographic, clinical, laboratory, and historical risk factors did not differ in patients with thrombosis. None had a prior history of trans-jugular intrahepatic portosystemic shunt or gastrointestinal bleeding. Three patients had renal injury, but no intraoperative hemodialysis was performed. Transesophageal echocardiographic findings included elevated pulmonary artery pressure (1/6), right ventricular strain (1/6), and pulmonary artery thrombus (1/6). Three patients died intraoperatively. Tissue plasminogen activator alone was given to 1 patient who did not survive, intravenous heparin only to 1 patient with resolution, and a combination of both was used in 2 patients with clot resolution achieved. CONCLUSION Cardiac thrombosis should be considered in patients having hemodynamic compromise during liver transplantation. Transesophageal echocardiography is a useful diagnostic tool. Intracardiac thrombosis treatment remains challenging; however, using both thrombolytics and heparin could achieve better results.
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31
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Effects of Intraoperative Fluid Balance During Liver Transplantation on Postoperative Acute Kidney Injury: An Observational Cohort Study. Transplantation 2020; 104:1419-1428. [PMID: 31644490 DOI: 10.1097/tp.0000000000002998] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Liver transplant recipients suffer many postoperative complications. Few studies evaluated the effects of fluid management on these complications. We conducted an observational cohort study to evaluate the association between intraoperative fluid balance and postoperative acute kidney injury (AKI) and other postoperative complications. METHODS We included consecutive adult liver transplant recipients who had their surgery between July 2008 and December 2017. Our exposure was intraoperative fluid balance, and our primary outcome was the grade of AKI at 48 hours after surgery. Our secondary outcomes were the grade of AKI at 7 days, the need for postoperative renal replacement therapy, postoperative red blood cell transfusions, time to first extubation, time to discharge from the intensive care unit (ICU), and 1-year survival. Every analysis was adjusted for potential confounders. RESULTS We included 532 transplantations in 492 patients. We observed no effect of fluid balance on either 48-hour AKI, 7-day AKI, or on the need for postoperative renal replacement therapy after adjustments for confounders. A higher fluid balance increased the time to ICU discharge, and increased the risk of dying (hazard ratio = 1.21 [1.04,1.40]). CONCLUSIONS We observed no association between intraoperative fluid balance and postoperative AKI. Fluid balance was associated with longer time to ICU discharge and lower survival. This study provides insight that might inform the design of a clinical trial on fluid management strategies in this population.
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Association between intraoperative rotational thromboelastometry or conventional coagulation tests and bleeding in liver transplantation: an observational exploratory study. Anaesth Crit Care Pain Med 2020; 39:765-770. [PMID: 33011332 DOI: 10.1016/j.accpm.2020.07.018] [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: 12/28/2019] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Liver transplantation is associated with major blood loss and transfusions. Our objective was to evaluate the association between coagulation results (rotational thromboelastometry (ROTEM) and conventional coagulation tests) and intraoperative bleeding or perioperative red blood cell (RBC) transfusions in liver transplantation. METHODS We measured ROTEM values and conventional coagulation tests at the beginning of surgery, after graft reperfusion and at the end of surgery. We did bivariate correlation and multivariable regression analyses to explore the association between test results and either intraoperative bleeding or perioperative RBC transfusions. RESULTS We enrolled 75 consecutive patients. Median [Q1-Q3] intraoperative blood loss was 1400 mL [675-2300] and 59% of patients did not receive any RBC transfusion either intraoperatively or postoperatively. In multivariable analyses, FIBTEM maximal clot firmness (MCF) measured at the beginning of surgery was associated with lower intraoperative blood loss (ß = -106 mL for each mm; 95% CI, -203 to -9 mL). Both a higher haemoglobin concentration (multiplicative factor = 0.89 for each g/L; 95% CI, 0.84 to 0.95) and FIBTEM MCF measured at the end of surgery (multiplicative factor = 0.68 for each mm; 95% CI, 0.48 to 0.95) were associated with fewer postoperative RBC transfusions. CONCLUSION FIBTEM MCF was strongly associated with intraoperative blood loss and postoperative transfusions while other coagulation results were not. This study might inform future clinical trials on ROTEM-based interventions in liver transplantation. STUDY REGISTRATION Clinical Trials.gov: NCT02356068.
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33
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Lange NW, Salerno DM, Berger K, Cushing MM, Brown RS. Management of Hepatic Coagulopathy in Bleeding and Nonbleeding Patients: An Evidence-Based Review. J Intensive Care Med 2020; 36:524-541. [PMID: 32079443 DOI: 10.1177/0885066620903027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with varying degrees of hepatic dysfunction often present with presumed bleeding diathesis based on interpretation of routine measures of coagulation (prothrombin time [PT], international normalized ratio [INR], and activated partial thromboplastin time). However, standard markers of coagulation do not reflect the actual bleeding risk in this population and may lead to inappropriate administration of hemostatic agents and blood products. The concept of "rebalanced hemostasis" explains both the risk of bleeding and clotting seen in patients with liver dysfunction. The role of pharmacologic agents and blood products for prevention of bleeding during high-risk procedures and treatment of clinically significant bleeding remains unclear. Viscoelastic measurements of the clotting cascade provide information about platelets, fibrinogen/fibrin polymerization, coagulation factors, and fibrinolysis that might better represent hemostasis in vivo and may better inform management strategies. Due to the paucity of available data, firm recommendations for the use of blood products and pharmacologic agents in patients with hepatic coagulopathies are lacking, and thus, these products should not be routinely administered. Traditional laboratory tests such as PT/INR should not be the sole determinant of potential interventions. Rather, clinicians should assess factors such as the severity of bleed or bleeding risk of the procedure, the patient's risk of thromboembolism, and the strength of available evidence for specific agents and blood products to guide decision-making.
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Affiliation(s)
- Nicholas W Lange
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - David M Salerno
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, 25065NewYork-Presbyterian Hospital, New York, NY, USA
| | - Melissa M Cushing
- Department of Pathology and Laboratory Medicine, 159947Weill Cornell Medicine, New York, NY, USA
- Department of Anesthesiology, 159947Weill Cornell Medicine, New York, NY, USA
| | - Robert S Brown
- Division of Gastroenterology, Department of Medicine, 159947Weill Cornell Medicine, New York, NY, USA
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34
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An Y, Bai Z, Xu X, Guo X, Romeiro FG, Philips CA, Li Y, Wu Y, Qi X. No Benefit of Hemostatic Drugs on Acute Upper Gastrointestinal Bleeding in Cirrhosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:4097170. [PMID: 32685481 PMCID: PMC7336197 DOI: 10.1155/2020/4097170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/25/2020] [Accepted: 06/01/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Acute upper gastrointestinal bleeding (AUGIB) is one of the most life-threatening emergency conditions. Hemostatic drugs are often prescribed to control AUGIB in clinical practice but have not been recommended by major guidelines and consensus. The aim of this study was to investigate the therapeutic effect of hemostatic drugs on AUGIB in cirrhosis. METHODS All cirrhotic patients with AUGIB who were admitted to our hospital from January 2010 to June 2014 were retrospectively included. Patients were divided into hemostatic drugs and no hemostatic drug groups. A 1 : 1 propensity score matching (PSM) analysis was performed by adjusting age, gender, etiology of liver disease, Child-Pugh score, MELD score, hematemesis, red blood cell transfusion, vasoactive drugs, antibiotics, proton pump inhibitors, and endoscopic variceal therapy. Primary outcomes included 5-day rebleeding and in-hospital mortality. RESULTS Overall, 982 cirrhotic patients with AUGIB were included (870 in hemostatic drugs group and 112 in no hemostatic drug group). In overall analyses, hemostatic drugs group had a significantly higher 5-day rebleeding rate (18.10% versus 5.40%, P = 0.001) than no hemostatic drug group; in-hospital mortality was not significantly different between them (7.10% versus 4.50%, P = 0.293). In PSM analyses, 172 patients were included (86 patients in each group). Hemostatic drugs group still had a significantly higher 5-day rebleeding rate (15.10% versus 5.80%, P = 0.046); in-hospital mortality remained not significantly different (7.00% versus 3.50%, P = 0.304) between them. Statistical results remained in PSM analyses according to the type of hemostatic drugs. CONCLUSIONS The use of hemostatic drugs did not improve the in-hospital outcomes of cirrhotic patients with AUGIB.
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Affiliation(s)
- Yang An
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Zhaohui Bai
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Xiangbo Xu
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 2Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, China
| | - Xiaozhong Guo
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
| | - Fernando Gomes Romeiro
- 3Department of Internal Medicine, Botucatu Medical School, UNESP-Univ Estadual Paulista. Av. Prof. Mário Rubens Guimarães Montenegro, s/n Distrito de Rubião Jr, Botucatu, Brazil
| | - Cyriac Abby Philips
- 4The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi, 682028 Kerala, India
| | - Yingying Li
- 5Department of Gastroenterology, The First People's Hospital of Huainan, Huainan 232007, China
| | - Yanyan Wu
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
- 6Postgraduate College, Jinzhou Medical University, Jinzhou 121001, China
| | - Xingshun Qi
- 1Department of Gastroenterology, General Hospital of Northern Theater Command (formerly General Hospital of Shenyang Military Area), Shenyang 110840, China
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Liver Transplantation. THE CRITICALLY ILL CIRRHOTIC PATIENT 2020. [PMCID: PMC7122092 DOI: 10.1007/978-3-030-24490-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The field of liver transplantation has changed since the MELD scoring system became the most widely used donor allocation tool. Due to the MELD-based allocation system, sicker patients with higher MELD scores are being transplanted. Persistent organ donor shortages remain a challenging issue, and as a result, the wait-list mortality is a persistent problem for most of the regions. This chapter focuses on deceased donor and live donor liver transplantation in patients with complications of portal hypertension. Special attention will also be placed on donor-recipient matching, perioperative management of transplant patients, and the impact of hepatic hemodynamics on transplantation.
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Effect of low dose naloxone on the immune system function of a patient undergoing video-assisted thoracoscopic resection of lung cancer with sufentanil controlled analgesia - a randomized controlled trial. BMC Anesthesiol 2019; 19:236. [PMID: 31856760 PMCID: PMC6923917 DOI: 10.1186/s12871-019-0912-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023] Open
Abstract
Background Perioperative immune function plays an important role in the prognosis of patients. Several studies have indicated that low-dose opioid receptor blockers can improve immune function. Methods Sixty-nine patients undergoing video-assisted thoracoscopic resection of the lung cancer were randomly assigned to either the naloxone group (n = 35) or the non-naloxone group (n = 34) for postoperative analgesia during the first 48 h after the operation. Both groups received sufentanil and palonosetron via postoperative analgesia pump, while 0.05 μg·kg− 1·h− 1 naloxone was added in naloxone group. The primary outcomes were the level of opioid growth factor (OGF) and immune function assessed by natural killer cells and CD4+/CD8+ T-cell ratio. Second outcomes were assessed by the intensity of postoperative pain, postoperative rescue analgesia dose, postoperative nausea and vomiting (PONV). Results The level of OGF in the naloxone group increased significantly at 24 h (p<0.001) and 48 h after the operation (P < 0.01). The natural killer cells (P < 0.05) and CD4+/CD8+ T-cell ratio (P < 0.01) in the naloxone group increased significantly at 48 h after the operation. The rest VAS scores were better with naloxone at 12 and 24 h after operation(P < 0.05), and the coughing VAS scores were better with naloxone at 48 h after the operation(P < 0.05). The consumption of postoperative rescue analgesics in the naloxone group was lower (0.00(0.00–0.00) vs 25.00(0.00–62.50)), P < 0.05). Postoperative nausea scores at 24 h after operation decreased in naloxone group(0.00 (0.00–0.00) vs 1.00 (0.00–2.00), P < 0.01). Conclusion Infusion of 0.05 μg·kg− 1·h− 1 naloxone for patients undergoing sufentanil-controlled analgesia for postoperative pain can significantly increase the level of OGF, natural killer cells, and CD4+/CD8+ T-cell ratio compared with non-naloxone group, and postoperative pain intensity, request for rescue analgesics, and opioid-related side effects can also be reduced. Trial registration The trial was registered at the Chinese Clinical Trial Registry on January 26, 2019 (ChiCTR1900021043).
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Markin NW, Ringenberg KJ, Kassel CA, Walcutt CR, Chacon MM. 2018 Clinical Update in Liver Transplantation. J Cardiothorac Vasc Anesth 2019; 33:3239-3248. [DOI: 10.1053/j.jvca.2019.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022]
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Liu P, Hum J, Jou J, Scanlan RM, Shatzel J. Transfusion strategies in patients with cirrhosis. Eur J Haematol 2019; 104:15-25. [PMID: 31661175 DOI: 10.1111/ejh.13342] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022]
Abstract
Bleeding related to portal hypertension and coagulopathy is a common complication in patients with cirrhosis. Complications and management of bleeding is a significant source of healthcare cost and utilization, as well as morbidity and mortality. Due to the scarcity of evidence surrounding transfusion strategies and hemostatic interventions in patients with cirrhosis, there has been significant debate regarding the best practice. Emerging data suggest that evidence supporting transfusion of packed red blood cells to a hemoglobin threshold of 7-8 g/dL is strong. thrombopoietin (TPO) receptor agonists have shown promise in increasing platelet levels and reducing transfusions preprocedurally, although have not specifically been found to reduce bleeding risk. Data for viscoelastic testing (VET)-guided transfusions appear favorable for reducing blood transfusion requirements prior to minor procedures and during orthotopic liver transplantation. Hemostatic agents such as recombinant factor VIIa, prothrombin complex concentrates, and tranexamic acid have been examined but their role in cirrhotic patients is unclear. Other areas of growing interest include balanced ratio and whole blood transfusion. In the following manuscript, we summarize the most up to date evidence for threshold-guided, VET-guided, balanced-ratio, and whole blood transfusions as well as the use of hemostatic agents in cirrhotic patients to provide practice guidance to clinicians.
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Affiliation(s)
- Patricia Liu
- The Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Justine Hum
- The Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Janice Jou
- The Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
| | - Richard M Scanlan
- The Division of Laboratory Medicine, Department of Pathology, Oregon Health & Science University, Portland, Oregon
| | - Joseph Shatzel
- The Division of Hematology & Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon
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Subcutaneous Injection of Tranexamic Acid to Reduce Bleeding During Dermatologic Surgery: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial. Dermatol Surg 2019; 45:759-767. [PMID: 30640775 DOI: 10.1097/dss.0000000000001786] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Topical application, oral, and IV injection of tranexamic acid (TXA) have been used to reduce surgical bleeding. OBJECTIVE To evaluate the safety and efficacy of TXA injected subcutaneously to reduce bleeding during dermatologic surgery. METHODS In this double-blinded, placebo-controlled, randomized prospective study, 131 patients were randomized to subcutaneous injection of lidocaine 2% diluted 1:1 with either saline (placebo) or TXA 100 mg/1 mL before surgery. Before the second stage or closure, size measurements of bloodstain impregnation on Telfa and surgical wound size were recorded and analyzed using mixed-effects linear regression. Subjective evaluation of hemostasis was performed using 4-point scale grading and analyzed using Fischer's exact test. RESULTS One hundred twenty-seven patients completed the study. The bloodstain to surgical wound size ratio was smaller in the TXA group (1.77) compared with the placebo group (2.49) (p < .001). An improved effect of TXA on bleeding was observed in the subgroup of patients receiving anticoagulants (mean difference; 95% confidence interval; -0.83; -1.20 to -0.46 p < .001). The subjective hemostasis assessment was significantly better in the TXA group overall (p = .043) and anticoagulant subgroup (p = .001) compared with the placebo group. CONCLUSION Subcutaneous injection of TXA was safe, reduced bleeding during dermatologic surgery, and particularly effective for patients receiving anticoagulation treatment.
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Richards JE, Samet RE, Koerner AK, Grissom TE. Tranexamic Acid in the Perioperative Period: Yes, No, Maybe? Adv Anesth 2019; 37:87-110. [PMID: 31677661 DOI: 10.1016/j.aan.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Justin E Richards
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Ron E Samet
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - A Kennedy Koerner
- Department of Anesthesiology, University of Maryland School of Medicine, Center for the Sustainment of Trauma and Readiness Skills (CSTARS)-Baltimore, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA
| | - Thomas E Grissom
- Department of Anesthesiology, University of Maryland School of Medicine, R Adams Cowley Shock Trauma Center, 22 South Greene Street, Suite T1R77, Baltimore, MD 21201, USA.
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Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2019. [PMID: 31640900 PMCID: PMC9391867 DOI: 10.1016/j.bjane.2019.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background and objectives Contents Conclusions
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Sampaio AM, Guimarães GMN, Medeiros GP, Damasceno GMM, Silva RMDA, Nunes RR, Rocha HAL, Nascimento JCR. [Efficacy and safety of antifibrinolytics in oncological surgery: a systematic review and meta-analysis]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2019; 69:484-492. [PMID: 31640900 PMCID: PMC9391867 DOI: 10.1016/j.bjan.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/09/2019] [Accepted: 06/11/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES The administration of antifibrinolytics has been shown to be effective in reducing blood loss and the need for transfusions in surgeries. However, few studies have evaluated these drugs in cancer surgery. The objective was to review the efficacy and safety of the treatment with antifibrinolytics in patients who underwent oncologic surgeries. CONTENTS An electronic bibliographic research was conducted in PubMed, OVID, MEDLINE, EMBASE, EBSCO and in the Cochrane Library data basis in order to identify randomized clinical trials performed in any type of oncologic surgery. The data evaluated were blood loss, need for transfusion and incidence of arteriovenous thromboembolism. Five randomized controlled trials evaluating 838 patients met the inclusion requirements. In the analysis of the incidence of thromboembolic events in the five RCTs, there was no statistically significant difference between the administration of tranexamic acid when compared with the placebo (OR=0.36, 95% IC: 0.11-1.19, p=0.09, I2=0%). However, when total estimated blood loss and need for blood transfusion are analyzed, the use of tranexamic acid was associated with a significant reduction over placebo (MD=-135.79, 95% CI: -179.50 to -92.08, p<0.00001, I2=68%) and (OR=0.45, 95% CI: 0.32-0.65, p<0.00001, I2=60%), respectively. CONCLUSIONS This meta-analysis found no evidence that the administration of antifibrinolytics increases the risk of thromboembolic complications in patients submitted to oncologic surgery, and has shown evidence that it is effective in reducing total perioperative blood loss and the need for blood transfusion.
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Affiliation(s)
| | | | | | | | | | | | - Hermano Alexandre Lima Rocha
- Universidade Federal do Ceará (UFC), Departamento de Saúde Materno Infantil, Fortaleza, CE, Brasil; Chan School of Public Health, Harvard T.H., Boston, Estados Unidos
| | - José Carlos Rodrigues Nascimento
- Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brasil; Universidade Federal do Ceará (UFC), Escola de Medicina, Departamento de Morfologia e Instituto de Biomedicina, Ontogenia e Nutrição, Fortaleza, CE, Brasil.
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Zhao T, Houng A, Reed GL. Termination of bleeding by a specific, anticatalytic antibody against plasmin. J Thromb Haemost 2019; 17:1461-1469. [PMID: 31136076 PMCID: PMC7359864 DOI: 10.1111/jth.14522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 05/18/2019] [Accepted: 05/21/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Excessive, plasmin-mediated fibrinolysis augments bleeding and contributes to death in some patients. Current therapies for fibrinolytic bleeding are limited by modest efficacy, low potency, and off-target effects. OBJECTIVES To determine whether an antibody directed against unique loop structures of the plasmin protease domain may have enhanced specificity and potency for blocking plasmin activity, fibrinolysis, and experimental hemorrhage. METHODS The binding specificity, affinity, protease cross-reactivity and antifibrinolytic properties of a monoclonal plasmin inhibitor antibody (Pi) were examined and compared with those of epsilon aminocaproic acid (EACA), which is a clinically used fibrinolysis inhibitor. RESULTS Pi specifically recognized loop 5 of the protease domain, and did not bind to other serine proteases or nine other non-primate plasminogens. Pi was ~7 logs more potent in neutralizing plasmin cleavage of small-molecule substrates and >3 logs more potent in quenching fibrinolysis than EACA. Pi was similarly effective in blocking catalysis of a small-molecule substrate as α2 -antiplasmin, which is the most potent covalent inhibitor of plasmin, and was a more potent fibrinolysis inhibitor. Fab or chimerized Fab fragments of Pi were equivalently effective. In vivo, in a humanized model of fibrinolytic surgical bleeding, Pi significantly reduced bleeding to a greater extent than a clinical dose of EACA. CONCLUSIONS A mAb directed against unique loop sequences in the protease domain is a highly specific, potent, competitive plasmin inhibitor that significantly reduces experimental surgical bleeding in vivo.
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MESH Headings
- Aminocaproic Acid/pharmacology
- Aminocaproic Acid/therapeutic use
- Animals
- Antibodies, Monoclonal, Humanized/immunology
- Antibodies, Monoclonal, Humanized/pharmacology
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antibody Affinity
- Antifibrinolytic Agents/therapeutic use
- Binding, Competitive
- Catalytic Domain/immunology
- Cross Reactions
- Drug Evaluation, Preclinical
- Female
- Fibrinolysin/antagonists & inhibitors
- Fibrinolysin/chemistry
- Fibrinolysin/immunology
- Fibrinolysis/drug effects
- Hemorrhage/blood
- Hemorrhage/drug therapy
- Humans
- Mice
- Mice, Inbred C57BL
- Models, Molecular
- Protein Conformation
- Protein Domains
- Random Allocation
- Recombinant Fusion Proteins/immunology
- Species Specificity
- Substrate Specificity
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Affiliation(s)
- Tieqiang Zhao
- Department of Medicine, University of Arizona, College of Medicine,
Phoenix, AZ, USA 85004
| | - Aiilyan Houng
- Department of Medicine, University of Arizona, College of Medicine,
Phoenix, AZ, USA 85004
| | - Guy L. Reed
- Department of Medicine, University of Arizona, College of Medicine,
Phoenix, AZ, USA 85004
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Kodali S, Holmes CE, Tipirneni E, Cahill CR, Goodwin AJ, Cushman M. Successful management of refractory bleeding in liver failure with tranexamic acid: Case report and literature review. Res Pract Thromb Haemost 2019; 3:424-428. [PMID: 31294331 PMCID: PMC6611358 DOI: 10.1002/rth2.12203] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/05/2019] [Accepted: 03/08/2019] [Indexed: 12/13/2022] Open
Abstract
A 50-year-old woman with advanced cirrhosis presented with spontaneous subdural hematoma. She had a worsening clinical course following craniotomy despite administration of multiple blood products. With elevation in D-dimer, persistently low fibrinogen and poor response to factor/fibrinogen replacement therapies, we had a suspicion for uncontrolled fibrinolysis. A literature review was conducted on treatment of hyperfibrinolysis in cirrhosis, finding 4 reports in which antifibrinolytics were used to control bleeding with different outcomes. The dose of tranexamic acid used in our patient was employed from previous experience in trauma patients. We transitioned from intravenous to oral administration based on expected pharmacokinetics. Our patient had a successful outcome with resolution of bleeding.
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Affiliation(s)
- Saranya Kodali
- Division of Hematology Oncology, Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermont
| | - Chris E. Holmes
- Division of Hematology Oncology, Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermont
| | - Eswar Tipirneni
- Division of Hematology Oncology, Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermont
| | | | - Andrew J. Goodwin
- Department of Pathology & Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVermont
| | - Mary Cushman
- Division of Hematology Oncology, Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermont
- Department of Pathology & Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVermont
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Biancofiore G, Blasi A, De Boer MT, Franchini M, Hartmann M, Lisman T, Liumbruno GM, Porte RJ, Saner F, Senzolo M, Werner MJ. Perioperative hemostatic management in the cirrhotic patient: a position paper on behalf of the Liver Intensive Care Group of Europe (LICAGE). Minerva Anestesiol 2019; 85:782-798. [PMID: 30945514 DOI: 10.23736/s0375-9393.19.13468-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent data demonstrated that amongst patients undergoing elective surgery the prevalence of cirrhosis is 0.8% equating to approximately 25 million cirrhotic patients undergoing surgery each year worldwide. Overall, the presence of cirrhosis is independently associated with 47% increased risk of postoperative complications and over two and a half-increased risk of in-hospital mortality in patients undergoing elective surgery. In particular, perioperative patients with chronic liver disease have long been assumed to have a major bleeding risk on the basis of abnormal results for standard tests of hemostasis. However, recent evidence outlined significant changes to traditional knowledge and beliefs and, nowadays, with more sophisticated laboratory tests, it has been shown that patients with chronic liver disease may be in hemostatic balance as a result of concomitant changes in both pro- and antihemostatic pathways. The aim of this paper endorsed by the Liver Intensive Care Group of Europe was to provide an up-to-date overview of coagulation management in perioperative patients with chronic liver disease focusing on patient blood management, monitoring of hemostasis, and current role of hemostatic agents.
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Affiliation(s)
- Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy -
| | - Annabel Blasi
- Department of Anesthesia, Hospital Clinic, Barcelona, Spain
| | - Marieke T De Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Hospital of Mantua, Mantua, Italy
| | - Matthias Hartmann
- Department of Anesthesiology and Critical Care, University of Duisburg-Essen, Duisburg, Germany
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Fuat Saner
- Department of General-, Visceral- and Transplant Surgery, University Duisburg-Essen, Duisburg, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Maureen J Werner
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Significant Hyperfibrinolysis in a Patient With Intracardiac Thrombosis: To Give Antifibrinolytics or Not? Transplant Direct 2019; 5:e431. [PMID: 30882036 PMCID: PMC6411226 DOI: 10.1097/txd.0000000000000875] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 12/12/2018] [Accepted: 01/25/2019] [Indexed: 11/26/2022] Open
Abstract
The hemostatic system is a delicate balance between the coagulation, anticoagulation, and fibrinolytic systems and is responsible for preventing both hemorrhage and thrombosis. End stage liver disease is characterized by a rebalanced hemostatic system that is fragile and easily tipped towards either hemorrhage or thrombosis. During an orthotopic liver transplantation, patients are exposed to a wide variety of factors that can shift them from a hypercoagulable state to a hypocoagulable state almost instantaneously. The treatment for these two disease states contradict each other, and therefore patients in this condition can be extremely difficult to manage. Here, we present a patient who underwent an orthotopic liver transplantation and suffered an intracardiac thrombosis shortly after reperfusion of the donor graft, that resolved with supportive care, who then went on to develop severe persistent hyperfibrinolysis and massive hemorrhage that was successfully treated with an antifibrinolytic agent.
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Das SK, Reddy MM, Ray S. Hemostatic Agents in Critically Ill Patients. Indian J Crit Care Med 2019; 23:S226-S229. [PMID: 31656384 PMCID: PMC6785814 DOI: 10.5005/jp-journals-10071-23258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Das SK, Reddy MM, Ray S. Hemostatic Agents in Critically Ill Patients. Indian J Crit Care Med 2019;23(Suppl 3):S226–S229.
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Affiliation(s)
- Saurabh Kumar Das
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India
| | | | - Sumit Ray
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India
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Carrier FM, Chassé M, Wang HT, Aslanian P, Bilodeau M, Turgeon AF. Effects of perioperative fluid management on postoperative outcomes in liver transplantation: a systematic review protocol. Syst Rev 2018; 7:180. [PMID: 30382884 PMCID: PMC6211404 DOI: 10.1186/s13643-018-0841-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/12/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Liver transplant recipients suffer many complications, but few intraoperative interventions supported by high-quality evidence have been found effective to reduce their incidence or severity. Fluid balance has been proposed as an important aspect of perioperative care in high-risk recipients. We will conduct a systematic review aimed at evaluating the effects of restrictive perioperative fluid management strategies compared to liberal ones on clinically significant postoperative outcomes. METHODS We will search through major databases (CINAHL Complete, EMB Reviews, EMBASE, MEDLINE, PubMed, and the gray literature (CADTH, Clinical Trials, National Guideline Clearing House, NICE, MedNar, Google Scholar and Open Grey)), from inception up to a date close to the review submission for publication, for eligible studies. Randomized controlled trials and comparative non-randomized studies (prospective or retrospective) comparing two fluid management strategies (or two outcomes with available data on fluid volume received for observational studies) on adult liver recipients will be included. Eligible studies will have to report at least one postoperative complication or mortality. Our primary outcome will be acute renal failure and our secondary exploratory outcomes will be all other postoperative complications and mortality. Study selection and data abstraction using an electronic standardized form will be performed by three authors. Risk of bias will be evaluated and data will be pooled if limited clinical diversity is observed. DISCUSSION Human organs available for transplantation are scarce resources. Strategies to improve recipients' survival are needed. We hypothesize that restrictive fluid management strategies will be associated with better postoperative outcomes than liberal fluid management strategies. This systematic review will improve our understanding of the available evidence and help us better inform future clinical trials. SYSTEMATIC REVIEW REGISTRATION This systematic review protocol is registered in PROSPERO ( CRD42017054970 ).
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Affiliation(s)
- François Martin Carrier
- Department of Anesthesiology, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 4e étage, Pavillon D, porte D04-5028, Montréal, Québec, H2X 0C1, Canada. .,Department of Medicine - Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 10e étage, Pavillon D, porte D10-2143, Montréal, Québec, H2X 0C1, Canada. .,Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.
| | - Michaël Chassé
- Department of Medicine - Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 10e étage, Pavillon D, porte D10-2143, Montréal, Québec, H2X 0C1, Canada.,Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada
| | - Han Ting Wang
- Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.,Department of Medicine - Critical Care Division, CIUSSS de l'Est-de-l'île-de-Montréal - Hôpital Maisonneuve-Rosemont, 5415 Boulevard de l'Assomption, Montréal, Québec, H1T 2M4, Canada
| | - Pierre Aslanian
- Department of Medicine - Critical Care Division, Centre hospitalier de l'Université de Montréal (CHUM), 1000, rue St-Denis, 10e étage, Pavillon D, porte D10-2143, Montréal, Québec, H2X 0C1, Canada
| | - Marc Bilodeau
- Centre de recherche du CHUM (CRCHUM), 900, rue Saint-Denis, Montréal, Québec, H2X 0A9, Canada.,Liver Unit, Centre hospitalier de l'Université de Montréal (CHUM), Université de Montréal, 1000, rue St-Denis, Montréal, Québec, H2X 0C1, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Université Laval, 1401, 18e rue, Québec, Québec, G1J 1Z4, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, 1050 Avenue de la Médecine, Québec, Québec, G1V 0A6, Canada
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Reshetnyak VI, Zhuravel SV, Kuznetsova NK, Pisarev VМ, Klychnikova EV, Syutkin VЕ, Reshetnyak ТM. The System of Blood Coagulation in Normal and in Liver Transplantation (Review). GENERAL REANIMATOLOGY 2018. [DOI: 10.15360/1813-9779-2018-5-58-84] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The review dwells on the problem of hemostatic disorders in patients undergoing liver transplantation and their correction in the perioperative period. The physiology of the hemostatic system, disorders of the blood coagulation system in patients at various stages of liver transplantation, correction of hemostatic disorders during and after orthotopic liver transplantation are discussed. Liver transplantation is performed in patients with liver diseases in the terminal stage of liver failure. At the same time, changes in the hemostatic system of these patients pose a significant risk of developing bleeding and/or thrombosis during and after liver transplantation. The hypothesis is suggested that the personalized correction of hemostasis disorder in liver transplantation should be based on considerating the nosological forms of the liver damage, mechanisms of development of recipient’s hemostatic disorders, and the stage of the surgery.
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Affiliation(s)
- V. I. Reshetnyak
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| | - S. V. Zhuravel
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - N. K. Kuznetsova
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - V. М. Pisarev
- V. A. Negovsky Research Institute of General Reanimatology, Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology
| | - E. V. Klychnikova
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
| | - V. Е. Syutkin
- N.V. Sklifosovsky Research Institute of Emergency Care, Moscow Healthcare Department
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50
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Schumacher C, Eismann H, Sieg L, Friedrich L, Scheinichen D, Vondran FWR, Johanning K. Use of Rotational Thromboelastometry in Liver Transplantation Is Associated With Reduced Transfusion Requirements. EXP CLIN TRANSPLANT 2018; 17:222-230. [PMID: 30295585 DOI: 10.6002/ect.2017.0236] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Increased transfusion requirements in liver transplantation have been reported to be associated with worsened outcomes, more frequent reinterventions, and higher expenses. Anesthesiologists might counteract this through improved coagulation management. We evaluated the effects of rotational thromboelastometry on transfusion and coagulation product requirements and on outcome measurements. MATERIALS AND METHODS Patients who were 14 years or older and who were undergoing liver transplant at Hannover Medical School between January 2005 and December 2009 were included in this retrospective analysis. Demographic, clinical, and laboratory data, use of rotational thromboelastometry, intraoperative need for blood or coagulation products and antifibrinolytic substances, and clinical course were recorded. Correlations were examined using appropriate statistical tests. RESULTS Our study included 413 patients. Use of rotational thromboelastometry was associated with less frequent intraoperative administration of red blood cell concentrates, fresh frozen plasma, platelet concentrates, prothrombin complex concentrates, and antithrombin concentrates (all P < .05). In addition, univariate and multivariate tests showed that rotational thromboelastometry was correlated with decreased need for red blood cell concentrates and fresh frozen plasma (all P < .05). Intraoperative administration rates of antifibrinolytic substances and fibrinogen concentrate were significantly increased in patients who received rotational thromboelastometry monitoring (both P < .05). However, use of rotational thromboelastometry was not associated with massive transfusion rates (> 10 units vs less), clinical outcome, or length of stay in the intensive care unit (all P > .05). CONCLUSIONS Use of rotational thromboelastometry during liver transplant may reduce the need for intraoperative transfusion and coagulation products. Relevant effects of rotational thromboelastometry on patient outcomes or lengths of stay in the intensive care unit could not be ascertained. However, readjustment of therapeutic thresholds may improve the clinical impact.
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Affiliation(s)
- Carsten Schumacher
- From the Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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