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Ming Y, Zhang F, Yao Y, Cheng Z, Yu L, Sun D, Sun K, Yu Y, Liu M, Ma L, HuangYang Y, Yan M. Large volume acute normovolemic hemodilution in patients undergoing cardiac surgery with intermediate-high risk of transfusion: A randomized controlled trial. J Clin Anesth 2023; 87:111082. [PMID: 36848777 DOI: 10.1016/j.jclinane.2023.111082] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/02/2023] [Accepted: 02/17/2023] [Indexed: 02/27/2023]
Abstract
STUDY OBJECTIVE To investigate whether large volume acute normovolemic hemodilution (L-ANH), compared with moderate acute normovolemic hemodilution (M-ANH), can reduce perioperative allogeneic blood transfusion in patients with intermediate-high risk of transfusion during cardiac surgery with cardiopulmonary bypass (CPB). DESIGN Prospective randomized controlled trial. SETTING University hospital. PATIENTS Patients with transfusion risk understanding scoring tool ("TRUST") ≥2 points undergoing cardiac surgery with CPB in the Second Affiliated Hospital of Zhejiang University from May 2020 to January 2021 were included. INTERVENTIONS The patients were randomly assigned with a 1:1 ratio to M-ANH (5 to 8 mL/kg) or L-ANH (12 to 15 mL/kg). MEASUREMENTS The primary outcome was perioperative red blood cell (RBC) transfusion units. The composite outcome included new-onset atrial fibrillation, pulmonary infection, cardiac surgery associated acute kidney injury (CSA-AKI) class ≥2, surgical incision infection, postoperative excessive bleeding, and resternotomy. MAIN RESULTS Total 159 patients were screened and 110 (55 L-ANH and 55 M-ANH) were included for final analysis. Removed blood volume of L-ANH is significantly higher than M-ANH (886 ± 152 vs. 395 ± 86 mL, P < 0.001). Perioperative RBC transfusion was median 0 unit ([25th, 75th] percentiles: 0-4.4) in M-ANH group vs. 0 unit ([25th, 75th] percentiles: 0-2.0) in L-ANH group (P = 0.012) and L-ANH was associated with lower incidence of transfusion (23.6% vs. 41.8%, P = 0.042, rate difference: 0.182, 95% confidence interval [0.007-0.343]). The incidence of postoperative excessive bleeding was significantly lower in L-ANH vs. M-ANH (3.6% vs. 18.2%, P = 0.029, rate difference: 0.146, 95% confidence interval [0.027-0.270]) without significant difference for other second outcomes. The volume of ANH was inversely related to perioperative RBC transfusion units (Spearman r = -0.483, 95% confidence interval [-0.708 to -0.168], P = 0.003), and L-ANH in cardiac surgery was associated with a significantly reduced risk of perioperative RBC transfusion (odds ratio: 0.43, 95% confidence interval: 0.19-0.98, P = 0.044). CONCLUSIONS Compared with M-ANH, L-ANH during cardiac surgery inclined to be associated with reduced perioperative RBC transfusion and the volume of RBC transfusion was inversely proportional to the volume of ANH. In addition, LANH during cardiac surgery was associated with a lower incidence of postoperative excessive bleeding.
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Affiliation(s)
- Yue Ming
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Fengjiang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Yuanyuan Yao
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Zhenzhen Cheng
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Lina Yu
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Dawei Sun
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Kai Sun
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Yang Yu
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong 261053, China
| | - Mingxia Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Longfei Ma
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Yuxin HuangYang
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China
| | - Min Yan
- Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang 330100, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province; Leading Health Talents of Zhejiang Province, Zhejiang Health Office No. 18(2020), China.
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Shi C, Dong C, Yao L, Weiss N, Liu H. Anesthesia management for pericardiectomy- a case series study. BMC Anesthesiol 2023; 23:191. [PMID: 37264299 DOI: 10.1186/s12871-023-02155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/26/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Constrictive pericarditis (CP) is an uncommon disease that limits both cardiac relaxation and contraction. Patients often present with right-sided heart failure as the pericardium thickens and impedes cardiac filling. Pericardiectomy is the treatment of choice for improving hemodynamics in CP patients; however, the procedure carries a high morbidity and mortality, and the anesthetic management can be challenging. Acute heart failure, bleeding and arrhythmias are all concerns postoperatively. METHODS After IRB approval, we performed the retrospective analysis of 66 consecutive patients with CP who underwent pericardiectomy from July 2018 to May 2022. RESULTS Most patients had significant preoperative comorbidities, including congestive hepatopathy (75.76%), New York Heart Association Type III/IV heart failure (59.09%) and atrial fibrillation (51.52%). Despite this, 75.76% of patients were extubated within the first 24 h and all but 2 of the patients survived to discharge (96.97%). CONCLUSIONS Anesthetic management, including a thorough understanding of the pathophysiology of CP, the use of advanced monitoring and transesophageal echocardiography (TEE) guidance, all played an important role in patient outcomes.
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Affiliation(s)
- Chunxia Shi
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Chao Dong
- Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
| | - Lan Yao
- Department of Anesthesiology, Peking University International Hospital, Beijing, China
| | - Nicole Weiss
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, 4150 V Street, Suite 1200, Sacramento, CA, 95817, USA
| | - Hong Liu
- Department of Anesthesiology and Pain Medicine, University of California Davis Health, 4150 V Street, Suite 1200, Sacramento, CA, 95817, USA.
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Ramanujam V, DiMaria S, Varma V. Thromboelastography in the Perioperative Period: A Literature Review. Cureus 2023; 15:e39407. [PMID: 37362492 PMCID: PMC10287184 DOI: 10.7759/cureus.39407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Assessing coagulation status is essential for prompt intervention to reduce morbidity and mortality related to bleeding and thrombotic complications during the perioperative period. Traditional coagulation tests such as platelet count, activated partial thromboplastin time (aPTT), prothrombin time (PT), international normalized ratio (INR), and activated clotting time (ACT) provide only static evaluation. These tests are not designed for assessment of dynamically changing coagulation conditions during the perioperative time. However, viscoelastic coagulation testing such as thromboelastography (TEG) produces a rapid numerical and graphical representation that helps to detect and direct targeted hemostatic therapy. Searching the literature through PubMed, Medline, Ovid, CINAHL, and ClinicalTrials.gov we retrieved 210 studies, which represent the use of TEG in the perioperative period. The included studies were categorized under various settings such as trauma, obstetrics, orthopedics, intensive care unit (ICU), cardiovascular, transplant, and miscellaneous scenarios. TEG showed promising results in trauma surgeries in predicting mortality, hypercoagulability, and bleeding even when it was compared to conventional methods. TEG was also useful in monitoring anticoagulant therapy in orthopedic and obstetric surgeries; however, its role in predicting thrombotic events, hypercoagulability, or complications was questionable. In ICU patients, it showed promising results, especially in the prediction or improvement of sepsis, coagulopathy, thrombotic events, ICU duration, hospital stay, and ventilator duration. TEG parameters effectively predicted hypercoagulation in transplant surgeries. Regarding cardiovascular surgeries, they were effective in the prediction of the need for blood products, coagulopathy, thrombotic events, and monitoring anticoagulation therapy. More randomized clinical trials comparing TEG parameters with standardized tools are needed to produce robust results to standardize its use in different perioperative settings.
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Affiliation(s)
- Vendhan Ramanujam
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Stephen DiMaria
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
| | - Vivek Varma
- Department of Anesthesiology, Rhode Island Hospital/The Warren Alpert Medical School of Brown University, Providence, USA
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Muacevic A, Adler JR, Murata H, Sekino M, Hara T. Management of Combined Cardiac Surgery Using Cardiopulmonary Bypass With Acute Normovolemic Hemodilution in a Jehovah's Witness: A Case Report. Cureus 2023; 15:e33442. [PMID: 36751150 PMCID: PMC9897691 DOI: 10.7759/cureus.33442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 01/09/2023] Open
Abstract
Combined cardiac surgery under cardiopulmonary bypass (CPB) has a high risk of requiring blood transfusion. Performing this surgery on Jehovah's Witnesses (JWs) is challenging as they strictly refuse allogeneic blood transfusions due to their religious beliefs. A 73-year-old female JW patient underwent combined surgery involving coronary artery bypass grafting and mitral valvuloplasty under CPB. Preoperative hematopoiesis maintained the hemoglobin (Hb) level at >12 g/dL preoperatively; the Hb level was maintained at >7 g/dL during CPB for effective acute normovolemic hemodilution (ANH). Compared with the values obtained immediately after CPB weaning, the Hb level and coagulation functions (measured using viscoelastic tests) improved after autologous transfusion at the end of the surgery. When cardiac surgery under CPB is performed on JWs, ANH can be useful for maintaining postoperative Hb levels and coagulation factors. Sufficient preoperative hematopoiesis and determination of an appropriate volume for intraoperative ANH may be important for effective ANH.
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Mladinov D, Padilla LA, Leahy B, Norman JB, Enslin J, Camp RS, Eudailey KW, Tanaka K, Davies JE. Hemodilution in high-risk cardiac surgery: Laboratory values, physiological parameters, and outcomes. Transfusion 2022; 62:826-837. [PMID: 35244229 DOI: 10.1111/trf.16844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 01/20/2022] [Accepted: 02/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability, and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. STUDY DESIGN AND METHODS This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N = 66) and non-ANH controls (N = 103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass. RESULTS Intraoperatively, the ANH group received more albumin (p = .04) and vasopressor medications (p = .01), while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO2 ) values were similar before and after hemodilution. During bypass, rSO2 were discretely lower in the ANH versus control group (right rSO2 p = .03, left rSO2 p = .05). No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, intensive care unit length of stay, kidney injury, stroke, or infection were demonstrated. DISCUSSION This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better understanding and wider acceptance of ANH protocols in high-risk cardiac surgeries.
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Affiliation(s)
- Domagoj Mladinov
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Leahy
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph B Norman
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacob Enslin
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Riley S Camp
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - James E Davies
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Abstract
Background: Fibrinogen is a substrate for blood clots formation. In cardiac surgery, a number of different mechanisms lead to a decrease in fibrinogen levels and consequent impaired haemostasis. Patients undergoing cardiac surgery are therefore frequently exposed to blood loss and allogeneic blood transfusion, which are risk factors associated with morbidity and mortality. Thus, particular efforts in fibrinogen management should be made to decrease bleeding and the need for blood transfusion. Therefore, fibrinogen remains an active focus of investigations from basic science to clinical practice. This review aims to summarise the latest evidence regarding the role of fibrinogen and current practices in fibrinogen management in adult cardiac surgery. Methods: The PubMed database was systematically searched for literature investigating the role and disorders of fibrinogen in cardiac surgery and diagnostic and therapeutic procedures related to fibrinogen deficiency aimed at reducing blood loss and transfusion requirements. Clinical trials and reviews from the last 10 years were included. Results: In total, 146 articles were analysed. Conclusion: The early diagnosis and treatment of fibrinogen deficiency is crucial in maintaining haemostasis in bleeding patients. Further studies are needed to better understand the association between fibrinogen levels, bleeding, and fibrinogen supplementation and their impacts on patient outcomes in different clinical settings.
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Mladinov D, Eudailey KW, Padilla LA, Norman JB, Leahy B, Enslin J, Parker K, Cornelius KF, Davies JE. Effects of acute normovolemic hemodilution on post-cardiopulmonary bypass coagulation tests and allogeneic blood transfusion in thoracic aortic repair surgery: An observational cohort study. J Card Surg 2021; 36:4075-4082. [PMID: 34431128 DOI: 10.1111/jocs.15943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/22/2021] [Accepted: 08/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. METHODS Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair with cardiopulmonary bypass (CPB) from 2019 to 2021. RESULTS A total of 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p < 0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH versus control group: FFP 1.1 ± 1.6 versus 1.9 ± 2.3 (p = 0.003), platelets 0.6 ± 0.8 versus 1.2 ± 1.3 (p = 0.0008), and cryoprecipitate 0.3 ± 0.7 versus 0.7 ± 1.1 (p = 0.008). Reduction in red blood cell transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p = 0.42). There was no significant difference in major adverse outcomes. CONCLUSIONS ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests ANH can improve some coagulation values after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.
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Affiliation(s)
- Domagoj Mladinov
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kyle W Eudailey
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Joseph B Norman
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin Leahy
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jacob Enslin
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Keli Parker
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katherine F Cornelius
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James E Davies
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Patel PA, Henderson RA, Bolliger D, Erdoes G, Mazzeffi MA. The Year in Coagulation: Selected Highlights from 2020. J Cardiothorac Vasc Anesth 2021; 35:2260-2272. [PMID: 33781668 DOI: 10.1053/j.jvca.2021.02.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 01/28/2023]
Abstract
This is the second annual review in the Journal of Cardiothoracic and Vascular Anesthesia to cover highlights in coagulation for cardiac surgery. The goal of this article is to provide readers with a focused summary from the literature of the prior year's most important coagulation topics. In 2020, this included a discussion covering allogeneic transfusion, antiplatelet and anticoagulant therapy, factor concentrates, coagulation testing, mechanical circulatory support, and the effects of coronavirus disease 2019.
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Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology, Cardiothoracic Division, Yale University School of Medicine, New Haven, CT.
| | - Reney A Henderson
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Bolliger
- Department of Anesthesiology, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University Hospital of Bern, Bern, Switzerland
| | - Michael A Mazzeffi
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, University of Maryland School of Medicine, Baltimore, MD; Department of Anesthesiology, Division of Critical Care Medicine, University of Maryland School of Medicine, Baltimore, MD
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