1
|
Wen T, Wen J, Yao C. Remimazolam inhibits postoperative cognitive impairment after cardiopulmonary bypass by alleviating neuroinflammation and promoting microglia M2 polarization. Brain Res 2024; 1838:148975. [PMID: 38702024 DOI: 10.1016/j.brainres.2024.148975] [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: 03/20/2024] [Revised: 04/22/2024] [Accepted: 04/30/2024] [Indexed: 05/06/2024]
Abstract
Postoperative cognitive impairment (POCD) is a complication of cardiopulmonary bypass (CPB). Remimazolam is an ultra-short acting benzodiazepine that can be used for anesthesia or sedation during surgery. This study investigated the role of remimazolam in inflammasome activation and microglia polarization using CPB rat model and lipopolysaccharide (LPS)-induced microglia model. The cognitive function of rats was evaluated by Morris water maze. TUNEL assay was performed to detect apoptosis. Inflammatory cytokines concentration were analyzed by enzyme-linked immunosorbent assay. Reverse transcription-polymerase chain reaction was used to assess the expression of inflammasome and M1/M2-related microglia markers. Flow cytometry was performed to evaluate the expression of CD16/32 and CD206 in microglia. The results showed that remimazolam improved the memory and learning abilities in CPB rats. CPB rats and LPS-treated microglia showed increased apoptosis, pro-inflammatory cytokines level, and inflammasome expression as well as decreased microglia activation, while the results were reversed after remimazolam treatment. Besides, remimazolam treatment promoted the expression of M2-related markers in LPS-treated microglia. Nigericin treatment reversed the increased M2-related mRNA levels and the decreased apoptosis and inflammatory responses induced by remimazolam treatment. In conclusion, remimazolam attenuated POCD after CPB through regulating neuroinflammation and microglia M2 polarization, suggesting a new insight into the clinical treatment of POCD after CPB.
Collapse
Affiliation(s)
- Tao Wen
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Jing Wen
- Laboratory Department of Peking University Shenzhen Hospital, Shenzhen, China
| | - Cuicui Yao
- Department of Anesthesiology, Shenzhen Children's Hospital, Shenzhen, China.
| |
Collapse
|
2
|
Helms J, Curtiaud A, Severac F, Tschirhart M, Merdji H, Bourdin M, Contant G, Depasse F, Abou Rjeily R, Sattler L, Meziani F, Angles-Cano E. Fibrinolysis as a Causative Mechanism for Bleeding Complications on Extracorporeal Membrane Oxygenation: A Pilot Observational Prospective Study. Anesthesiology 2024; 141:75-86. [PMID: 38502917 DOI: 10.1097/aln.0000000000004980] [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: 03/21/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is associated with a high risk of bleeding complications. The specific impact of ECMO on fibrinolysis remains unexplored. The objective of the current pilot observational prospective study was to investigate the longitudinal dynamics of fibrinolytic markers-i.e., changes over time-in the context of bleeding events in patients on ECMO. METHODS Longitudinal dynamics of contact phase components (kininogen and bradykinin) and fibrinolysis markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1], their complexes [tPA•PAI-1], plasmin-antiplasmin complexes, plasminogen, and D-dimer) were measured in patients undergoing venovenous and venoarterial ECMO, before implantation, at 0, 6, and 12 h after implantation, and daily thereafter. RESULTS The cohort consisted of 30 patients (214 ECMO days). The concentrations of tPA, D-dimer, plasmin-antiplasmin complexes, PAI-1, and tPA•PAI-1 complexes were increased, whereas plasminogen decreased compared to normal values. A noteworthy divergence was observed between hemorrhagic and nonhemorrhagic patients: in bleeding patients, D-dimer, plasmin-antiplasmin, tPA, PAI-1, and tPA•PAI-1 followed an increasing kinetics before hemorrhage and then decreased to their baseline level; conversely, nonbleeding patients showed a decreasing kinetics in these markers. Also, D-dimer and tPA followed an increasing kinetics in bleeding patients compared to nonbleeding patients (median values for D-dimer dynamics: 1,080 vs. -440 ng/ml, P = 0.05; tPA dynamics: 0.130 vs. 0.100 nM, P = 0.038), and both markers significantly increased the day before hemorrhage. A tPA concentration above 0.304 nM was associated with bleeding events (odds ratio, 4.92; 95% CI, 1.01 to 24.08; P = 0.049). CONCLUSIONS Contact activation induces fibrinolysis in ECMO patients, especially in patients experiencing bleeding. This finding supports the role of this mechanism as a possible causal factor for hemorrhages during ECMO and open new avenues for novel therapeutic perspectives. EDITOR’S PERSPECTIVE
Collapse
Affiliation(s)
- Julie Helms
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Anaïs Curtiaud
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - François Severac
- Strasbourg University Hospital, Clinical Research Methods Group (GMRC), Strasbourg, France
| | - Marine Tschirhart
- INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Hamid Merdji
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Matthieu Bourdin
- Diagnostica Stago, Prospective Research Department, Gennevilliers, France
| | - Geneviève Contant
- Diagnostica Stago, Prospective Research Department, Gennevilliers, France
| | - François Depasse
- Diagnostica Stago, Clinical Development, Asnières sur Seine, France
| | - Ramy Abou Rjeily
- Paris Cite University-INSERM U-1140, Innovative Therapies in Haemostasis, Paris, France
| | - Laurent Sattler
- Strasbourg University Hospital, Laboratory of Hematology, Hautepierre, Strasbourg, France
| | - Ferhat Meziani
- Strasbourg University (UNISTRA); Strasbourg University Hospital, Medical Intensive Care Unit (NHC), Strasbourg, France; INSERM (French National Institute of Health and Medical Research), Unit 1260, Regenerative Nanomedicine, Medicine Federation of Strasbourg, Strasbourg, France
| | - Eduardo Angles-Cano
- Paris Cite University-INSERM U-1140, Innovative Therapies in Haemostasis, Paris, France
| |
Collapse
|
3
|
Sancheti M, Rentschler M, Bolch C, Li W, Necco K, Rath T, Esfandiarei M, Darban N. Designing an experimental method for assessing biocompatibility of circuit coatings using biomarkers for platelet activation during cardiopulmonary bypass. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2024; 56:37-44. [PMID: 38888546 PMCID: PMC11185148 DOI: 10.1051/ject/2024003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/10/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION Cardiopulmonary bypass is an essential component of cardiothoracic surgeries. However, significant complications such as systemic inflammatory response syndrome (SIRS) resulting from cardiopulmonary bypass (CPB) are a common occurrence due to contact between circulating blood and foreign surfaces that leads to platelet activation. It is suggested that different available CPB circuit coatings can potentially reduce platelet activation. However, there have been no published evidence-based reports confirming these claims. In addition, there is no well-established protocol for studying platelet activation biomarkers during CPB in vitro in a laboratory setting. METHODS CPB was simulated in the laboratory using bovine blood in two different types of coated CPB circuits: Trillium® Biosurface by Medtronic, and XcoatingTM Surface by Terumo. Fresh bovine blood samples were collected and circulated through the CPB circuit following the standard protocol used in the operation rooms. Blood samples were then collected at 5 min, 30 min, and 55 min during the circulation. Blood plasmas were separated and subjected to enzyme-linked immunosorbent assay to measure most established platelet activation markers P-selectin, Platelet Factor 4 (PF4), Glycoprotein IIb/IIIa (GPIIb/IIIa), and β-thromboglobulin (β-TG) at different time points. RESULTS The biomarker values at 30 min and 55 min were compared to the base values at 5 min for each type of CPB circuit. The results of the means from all measured biomarkers showed data measurements that indicated no significant variability within each coating. All collected data points fell within ±2 SD of the means, which was considered acceptable variations across technical replicates. Conclusion: In this study, we were able to establish an in vitro protocol in the laboratory setting that is precise and reliable with minimum intra-variability. This established protocol will allow for future studies in which different coated CPB circuits can be compared for their effectiveness in blocking platelet activation during the CPB.
Collapse
Affiliation(s)
- Meghal Sancheti
-
Arizona College of Osteopathic Medicine, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Mitchell Rentschler
-
Arizona College of Osteopathic Medicine, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Charlotte Bolch
-
Office of Research & Sponsored Program, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Weidang Li
-
College of Veterinary Medicine, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Katelyn Necco
-
College of Graduate Studies, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Thomas Rath
-
College of Health Sciences, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Mitra Esfandiarei
-
College of Graduate Studies, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
-
College of Medicine Phoenix, University of Arizona 19555 N. 59th Avenue Glendale AZ 85308 USA
| | - Nathaniel Darban
-
College of Health Sciences, Midwestern University 19555 N. 59th Avenue Glendale AZ 85308 USA
| |
Collapse
|
4
|
Ise H, Oyama K, Ushioda R, Hirofuji A, Kamada K, Yoshida Y, Akhyari P, Kamiya H. Hypothermic circulatory arrest at 20 ℃ does not deteriorate coagulopathy compared to 28 ℃ in a pig model. J Artif Organs 2024:10.1007/s10047-024-01449-9. [PMID: 38780671 DOI: 10.1007/s10047-024-01449-9] [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: 07/03/2022] [Accepted: 03/28/2024] [Indexed: 05/25/2024]
Abstract
It is believed that a lower temperature setting of hypothermic circulatory arrest (HCA) in thoracic aortic surgery causes coagulopathy, resulting in excessive bleeding. However, experimental studies that eliminate clinical factors are lacking. The objective of this study is to investigate the influence of the temperature setting of HCA on coagulation in a pig model. Ten pigs were divided into the following two groups: moderate temperature at 28 °C (group M, n = 5) or lower temperature at 20 °C (group L, n = 5). Two hours of HCA during a total of 4 h of cardiopulmonary bypass (CPB) were performed. Blood samples were obtained at the beginning (T1) and the end (T2) of the surgery, and coagulation capability was analyzed through standard laboratory tests (SLTs) and rotational thromboelastometry (ROTEM). In SLTs, hemoglobin, fibrinogen, platelet count, prothrombin time, and activated partial thromboplastin time were analyzed. In ROTEM analyses, clotting time and clot formation time of EXTEM, maximum clot firmness (MCF), and maximum clot elasticity (MCE) of EXTEM and FIBTEM were analyzed. Fibrinogen decreased significantly in both groups (group M, p = 0.008; group L, p = 0.0175) at T2, and FIBTEM MCF and MCE also decreased at T2. There were no differences regarding changes in parameters of SLTs and ROTEM between groups. CPB decreases coagulation capacity, contributed by fibrinogen. However, a lower temperature setting of HCA at 20 °C for 2 h did not significantly affect coagulopathy compared to that of HCA at 28 °C after re-warming to 37 °C.
Collapse
Affiliation(s)
- Hayato Ise
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
- Department of Cardiac Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Kyohei Oyama
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan.
| | - Ryohei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Aina Hirofuji
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Keisuke Kamada
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Yuri Yoshida
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Payam Akhyari
- Department of Cardiac Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka-Higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| |
Collapse
|
5
|
Wang C, Jiang Y, Wang Q, Wang D, Jiang X, Dong N, Chen S, Chen X. Off-pump versus on-pump coronary artery bypass grafting in elderly patients at 30 days: a propensity score matching study. Postgrad Med J 2024; 100:414-420. [PMID: 38330496 DOI: 10.1093/postmj/qgad120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND Elderly patients are at increased risk of perioperative morbidity and mortality after conventional on-pump coronary artery bypass grafting (ONCABG). This study was to determine whether such high-risk population would benefit from off-pump coronary artery bypass grafting (OPCABG). METHODS A retrospective analysis was performed on patients aged 65 years or older who underwent isolated coronary artery bypass grafting for the first time in Wuhan Union Hospital from January 2015 to January 2021. We used propensity score matching to adjust for differences in baseline characteristics between the ONCABG and OPCABG groups. Morbidity and mortality within 30 days after surgery were compared between the two groups. All operations were performed by experienced cardiac surgeons. RESULTS A total of 511 patients (ONCABG 202, OPCABG 309) were included. After 1:1 matching, the baseline characteristics of the two groups were comparable (ONCABG 173, OPCABG 173). The OPCABG group had higher rate of incomplete revascularization (13.9% vs. 6.9%; P = .035) than the ONCABG group. However, OPCABG reduced the risk of postoperative renal insufficiency (15.0% vs. 30.1%; P = .001) and reoperation for bleeding (0.0% vs. 3.5%; P = .030). There were no significant differences in early postoperative mortality, myocardial infarction, stroke, and other outcomes between the two groups. CONCLUSIONS OPCABG is an alternative revascularization method for elderly patients. It reduces the risk of early postoperative renal insufficiency and reoperation for bleeding.
Collapse
Affiliation(s)
- Chen Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yefan Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Qingpeng Wang
- Department of Cardiovascular Surgery, Zhongnan Hospital of Wuhan University, Wuhan, 430062, China
| | - Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xionggang Jiang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Si Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xinzhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| |
Collapse
|
6
|
Kim H, Manetta F, Hartman A, Huang X, Yu PJ. Factor Eight Inhibitor Bypassing Activity as First-line Therapy for Coagulopathy in Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00324-0. [PMID: 38890083 DOI: 10.1053/j.jvca.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/06/2024] [Accepted: 05/11/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To compare the outcomes of factor eight inhibitor bypassing activity (FEIBA) versus fresh frozen plasma (FFP) as the primary treatment for postoperative coagulopathy in patients undergoing cardiac surgery. DESIGN A retrospective, propensity-matched study. SETTING A single, tertiary hospital. PARTICIPANTS Patients who underwent noncoronary cardiac surgery with cardiopulmonary bypass between 2015 and 2023. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We stratified patients into 2 groups based on whether they received intraoperative FFP or FEIBA; cases using both were excluded. We analyzed 434 cases, with 197 receiving FFP and 237 receiving FEIBA. After propensity matching, there was no significant difference in the proportion of the patients who required packed red blood cell transfusions (p = 0.08). However, of those who required packed red blood cell transfusions, patients in the FEIBA group required significantly fewer units of packed red blood cells (p < 0.001). Significantly fewer patients in the FEIBA group required platelet (p < 0.001) and cryoprecipitate (p < 0.001) transfusions. The FEIBA group showed decreased prolonged postoperative intubation (p = 0.05), decreased intensive care unit length of stay (p = 0.04), and lower 30-day readmission rates (p = 0.03). There were no differences in the rates of thrombotic complications between the 2 cohorts. CONCLUSIONS In the initial treatment of postcardiopulmonary bypass coagulopathy, FEIBA may be more effective than FFP in decreasing blood product transfusions and readmission rates. Further studies are needed to explore the potential routine use of FEIBA as first-line agent in this patient population.
Collapse
Affiliation(s)
- Hyungjoo Kim
- Division of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell, New Hyde Park, NY
| | - Frank Manetta
- Division of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell, New Hyde Park, NY
| | - Alan Hartman
- Division of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell, New Hyde Park, NY
| | - Xueqi Huang
- Biostatistics Unit, Feinstein Institute of Medical Research, Manhasset, NY
| | - Pey-Jen Yu
- Division of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell, New Hyde Park, NY.
| |
Collapse
|
7
|
Bağiş MZ, Amaç B. The Efficacy of Tranexamic Acid in Reducing Perioperative Drainage in Cardiac Surgery with Cardiopulmonary Bypass. Braz J Cardiovasc Surg 2024; 39:e20230181. [PMID: 38630021 PMCID: PMC11021030 DOI: 10.21470/1678-9741-2023-0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/13/2023] [Indexed: 04/19/2024] Open
Abstract
INTRODUCTION Although cardiopulmonary bypass procedures remain a critical treatment option for heart disease, they come with risks, including hemorrhage. Tranexamic acid is known to reduce morbidity and mortality in surgical hemorrhage. OBJECTIVE This study aimed to evaluate the efficacy of tranexamic acid, which is routinely used to treat hemorrhage, in decreasing the amount of intraoperative and postoperative drainage. METHOD A total of 80 patients who underwent cardiac surgery with cardiopulmonary bypass were included in this retrospective study. Forty patients who received tranexamic acid during the operation were assigned to Group 1, while 40 patients who did not receive tranexamic acid were assigned to Group 2. Patient data were collected from the hospital computer system and/or archive records after applying exclusion criteria, and the data were recorded. Statistical analyses were then performed to compare the data. RESULTS Age, sex, height, weight, body surface area, flow, and ejection fraction percentages, preoperative hematological parameters, and intraoperative variables (except tranexamic acid) were similar between the groups (P>0.05). However, there were statistically significant differences between the groups in terms of intraoperative (through the heart-lung machine) and postoperative red blood cell transfusion rates, intraoperative and postoperative bleeding drainage amounts, as well as postoperative hematocrit, hemoglobin, platelet, and red blood cell levels (P<0.05). CONCLUSION We concluded that intraoperative and postoperative use of tranexamic acid in patients who underwent coronary artery bypass grafting with cardiopulmonary bypass has positive effects on hematological parameters, reducing blood product use, and bleeding drainage amount.
Collapse
Affiliation(s)
- Murat Ziya Bağiş
- Clinic of Cardiovascular Surgery, Health Sciences University,
Sanliurfa Mehmet Akif Inan Training and Research Hospital, Sanliurfa, Turkey
| | - Bişar Amaç
- Department of Perfusion, Health Sciences University, Sanliurfa
Mehmet Akif Inan Training and Research Hospital, Sanliurfa, Turkey
| |
Collapse
|
8
|
Ko SH, Nan Z, Soh S, Shim JK, Lee HW, Kwak YL, Song JW. Effect of Retrograde Autologous Priming on Coagulation Assessed by Rotation Thromboelastometry in Patients Undergoing Valvular Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:939-945. [PMID: 38262805 DOI: 10.1053/j.jvca.2023.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVES To investigate the effect of retrograde autologous priming (RAP) on coagulation function using rotation thromboelastometry (ROTEM) in patients undergoing valvular cardiac surgery. DESIGN A prospective, randomized, patient- and outcome assessor-blinded study. SETTING At a single-center university hospital. PARTICIPANTS Patients aged 20 years or older undergoing valvular cardiac surgery. INTERVENTIONS A total of 104 patients were allocated to the RAP or control group (1:1 ratio). In the RAP group, the prime was displaced into the collection bag before bypass initiation. ROTEM was performed at the induction of anesthesia, at the beginning of rewarming, and after the reversal of heparinization. Allogeneic plasma products and platelet concentrates were transfused according to ROTEM-based algorithms. MEASUREMENTS AND MAIN RESULTS An average volume of 635 ± 114 mL was removed using RAP (from the 1,600 mL initial prime volume). The hematocrit 10 minutes after cardiopulmonary bypass (CPB) was 24.7 ± 3.5% in the control group, and 26.1 ± 4.1% in the RAP group (p = 0.330). ROTEM, including EXTEM, INTEM, and FIBTEM, showed prolonged clotting time and decreased maximal clot firmness after CPB in both groups without intergroup differences. The number of patients who received intraoperative erythrocytes (27% v 25%, control versus RAP, p = 0.823), fresh frozen plasma (14% v 8%, control versus RAP, p = 0.339), cryoprecipitate (21% v 12%, control versus RAP, p = 0.185), or platelet concentrate transfusion (19% v 12%, control versus RAP, p = 0.277) did not differ between the groups. CONCLUSIONS Cardiopulmonary bypass induced impaired coagulation function on ROTEM. However, RAP did not improve coagulation function when compared with conventional priming in patients undergoing valvular cardiac surgery.
Collapse
Affiliation(s)
- Seo Hee Ko
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zhengyu Nan
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Won Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
9
|
Sibai J, Karkouti K, McCluskey SA. Improving blood transfusion practice: to give or to consider. Can J Anaesth 2024:10.1007/s12630-024-02738-w. [PMID: 38509436 DOI: 10.1007/s12630-024-02738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
- Jad Sibai
- Masters of Science Program in Medical Science, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Sinai Health, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Women's College Hospital, Toronto, ON, Canada
- Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Stuart A McCluskey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, Sinai Health, Toronto, ON, Canada.
- Toronto General Hospital Research Institute, Toronto, ON, Canada.
- Patient Blood Management Program, University Health Network, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Eaton North 4-421, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| |
Collapse
|
10
|
Wei C, Wreh D, Gressen J, Nguyen A. Anesthetic Management of Unanticipated Subglottic Stenosis in a Patient Undergoing Coronary Artery Bypass Graft Surgery. Cureus 2024; 16:e56110. [PMID: 38618313 PMCID: PMC11014738 DOI: 10.7759/cureus.56110] [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: 03/13/2024] [Indexed: 04/16/2024] Open
Abstract
A 62-year-old female presented for a scheduled coronary artery bypass graft (CABG) and was found to have an unexpected subglottic stenosis during routine intubation. The case was aborted and six days later, the patient underwent lasering of the stenotic subglottic region and airway balloon dilation. In this case report, causes of subglottic stenosis and surgical/anesthetic management of the condition are discussed. The management of subglottic stenosis in this patient was complicated by concurrent severe coronary artery disease (CAD) involving the left main coronary artery and timing of airway surgery relative to interventions for her CAD. In situations of undiagnosed subglottic stenosis, anesthesiologists should be familiar with airway management based on the location and severity of the stenosis. Close multidisciplinary team management is required for patients who have other complex comorbidities.
Collapse
Affiliation(s)
- Claudia Wei
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Dominique Wreh
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Jacy Gressen
- Anesthesiology, Baylor College of Medicine, Houston, USA
| | - Anvinh Nguyen
- Anesthesiology, Baylor College of Medicine, Houston, USA
| |
Collapse
|
11
|
Faraoni D, Guindi A, Ankola AA, Resheidat A, Binsalamah Z, Teruya J, Savorgnan F, Vener DF. Retrospective Comparison of Recombinant Activated Factor VII Versus 4-Factor Prothrombin Complex Concentrate in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2024; 38:388-393. [PMID: 38129208 DOI: 10.1053/j.jvca.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/08/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To compare the incidences of postoperative thrombotic complications, transfusion of blood products, and chest tube output in congenital cardiac surgical patients who received either recombinant activated factor VII (rFVIIa) or 4-factor prothrombin complex concentrate (4F-PCC). DESIGN We performed a retrospective study. SETTING Patients who underwent surgery at a tertiary academic hospital. PARTICIPANTS Pediatric patients who underwent cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were obtained from the Society of Thoracic Surgeons and the Pediatric Cardiac Critical Care Consortium databases, as well as from manual chart review. Adjusted p values were obtained from multivariate regression using age (days), surgeon (number), cardiopulmonary bypass time (minutes), and need for deep hypothermic circulatory arrest (yes/no). A total of 55 patients were included in the 4F-PCC group, and 89 in the rFVIIa group. The median dose of rFVIIa was 77 mcg/kg (46-88), and the median dose of 4F-PCC was 31 IU/kg (24-43). The incidences of thrombotic complications were 8% in the 4F-PCC group and 30% in the rFVIIa group (adjusted p = 0.023). No difference was reported between the groups regarding chest tube output on days 1 and 2 or transfusion of blood products. Using a sensitivity analysis with propensity matching, the incidence of thrombosis was 10% in the 4F-PCC group (n = 38), and 31% in the rFVIIa group (n = 39) (p = 0.036). No difference was reported in terms of bleeding or transfusion. CONCLUSIONS This retrospective study suggested that the administration of rFVIIa was associated with a higher risk of thrombotic complications when compared to 4F-PCC, without benefits in terms of bleeding and transfusions.
Collapse
Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Anna Guindi
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ashish A Ankola
- Division of Critical Care & Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ashraf Resheidat
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ziyad Binsalamah
- Division of Pediatric Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jun Teruya
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Fabio Savorgnan
- Division of Critical Care & Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - David F Vener
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| |
Collapse
|
12
|
Chen L, Qiu Z, Hu Y, Shen Y, Fang G, Lu H, Wu Q. An Off-Pump Repair Technique for Postinfarction Apical Left Ventricular Aneurysm. Ann Thorac Cardiovasc Surg 2024; 30:23-00131. [PMID: 37989281 PMCID: PMC10902652 DOI: 10.5761/atcs.oa.23-00131] [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: 07/31/2023] [Accepted: 10/01/2023] [Indexed: 11/23/2023] Open
Abstract
PURPOSE The conventional surgical treatment for postinfarction left ventricular aneurysm (LVA) is open-heart repair with cardiopulmonary bypass. However, the risk of the open-heart surgery under cardiopulmonary bypass may result in an unacceptable risk for many patients with multiple comorbidities. Here, we reported a new off-pump repair technique for postinfarction apical LVA. METHODS A new off-pump repair technique, circular banding and occlusion technique, was applied to repair the postinfarction apical LVA in 12 patients. Clinical data of all those 12 patients were retrospectively reviewed. Patients were followed up prospectively by direct interviews and echocardiographic examination. RESULTS The new repair technique was successfully performed in all these 12 patients. Acute reduction of the LVA mouth diameter, the left ventricular (LV) end-diastolic volume and end-systolic volume, and an increase in the LV ejection fraction (EF) were immediately obtained after the repair. Patients had an uneventful postoperative course. They were in New York Heart Association class 1-2, and the LV volume and EF detected by echocardiography remained unchanged during an average 28.4 ± 9.9 months (range 13 to 45 months) follow-up. CONCLUSIONS Circular banding and occlusion is a simple, safe, and effective off-pump repair technique for postinfarction apical LVA. It can allow effective LV remodeling and improve heart function.
Collapse
Affiliation(s)
- Liangwan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| | - Zhihuang Qiu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| | - Yunnan Hu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| | - Yue Shen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| | - Guanhua Fang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| | - Heng Lu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| | - Qingsong Wu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
- Key Laboratory of Cardio-Thoracic Surgery Fujian Medical University, Fujian Province University, Fuzhou, China
- Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, China
| |
Collapse
|
13
|
Fan Q, Lu Z, Wang Y, Wang L, Zhang H, Zheng Z, Dong H, Xiong L, Lei C. Association between postoperative nadir platelet count and postoperative cardiovascular complications following septal myectomy in patients with hypertrophic cardiomyopathy: a retrospective cohort study. BMC Cardiovasc Disord 2024; 24:57. [PMID: 38238666 PMCID: PMC10795313 DOI: 10.1186/s12872-024-03724-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 01/11/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Platelet count is associated with cardiovascular risk and mortality in several cardiovascular diseases, but the association of the nadir platelet counts post-septal myectomy with the cardiovascular complication risk in hypertrophic obstructive cardiomyopathy patients remains unclear. METHODS This retrospective cohort study reviewed all adult patients who underwent septal myectomy at a single tertiary referral center over a 5-year period. Postoperative nadir platelet count was defined as the lowest platelet count in the first 4 postoperative days or until hospital discharge. The composite outcome included cardiovascular death, myocardial infarction, heart failure, malignant arrhythmia, cardiac tamponade, and major bleeding events within 30 days postoperatively. Univariable and multivariable logistic regression and restricted cubic spline models were used to assess the association between postoperative nadir platelet count and the 30-day postoperative cardiovascular complication risk. RESULTS Among the 113 enrolled patients, 23 (20.4%) developed cardiovascular events within 30 days postoperatively. The incidence of postoperative cardiovascular complications was significantly higher in patients with a nadir platelet count ≤ 99 × 109/L than in those with a nadir platelet count > 99 × 109/L (33.3% vs. 7.1%, crude risk ratio: 4.67, 95% confidence interval: 1.69-12.85, P < 0.001). Multivariable logistic regression revealed that postoperative nadir platelet count was negatively associated with 30-day postoperative cardiovascular complications (adjusted odds ratio: 0.97; 95% confidence interval: 0.95-0.99; P = 0.005) and the association was linear (Pnonlinearity = 0.058) after full adjustment. The association between nadir platelet count and cardiovascular complications within 30 days post-surgery was consistent in all predefined subgroups (Pinteraction > 0.05). CONCLUSION The postoperative nadir platelet count was significantly associated with the 30-day post-myectomy risk of cardiovascular complications in hypertrophic obstructive cardiomyopathy patients. TRIAL REGISTRATION This trial was registered at ClinicalTrials.gov (NCT04275544).
Collapse
Affiliation(s)
- Qianqian Fan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Zhihong Lu
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Yonghui Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Lini Wang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Hui Zhang
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Hailong Dong
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China
| | - Lize Xiong
- Department of Anesthesiology and Translational Research Institute of Brain and Brain-like Intelligence, Shanghai Fourth People's Hospital Affiliated to Tongji University School of Medicine, Shanghai, 200081, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, 127 West Changle Road, Xi'an, Shaanxi, 710032, China.
| |
Collapse
|
14
|
Minns S, Tosh W, Moorjani N. Anaesthesia for adult cardiac surgery requiring repeat sternotomy. BJA Educ 2024; 24:23-30. [PMID: 38495748 PMCID: PMC10941097 DOI: 10.1016/j.bjae.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
- S. Minns
- Royal Papworth Hospital, Cambridge, UK
| | - W. Tosh
- University Hospitals Birmingham, Birmingham, UK
| | | |
Collapse
|
15
|
Navarro R, Bojic S, Fatima R, El-Tahan M, El-Diasty M. Recombinant Activated Factor VII (rFVIIa) for Bleeding After Thoracic Aortic Surgery: A Scoping Review of Current Literature. J Cardiothorac Vasc Anesth 2024; 38:275-284. [PMID: 38036397 DOI: 10.1053/j.jvca.2023.09.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Bleeding after surgery on the thoracic aorta is a frequent complication, and can be associated with a significant increase in morbidity and mortality. Recombinant activated factor VII (rFVIIa) was developed initially for treating patients with hemophilia; however, it has been used increasingly "off-label" to achieve hemostasis after thoracic aortic procedures. OBJECTIVE This scoping review aimed to present the available literature on the role of rFVIIa in the management of refractory postoperative bleeding after thoracic aortic surgery. METHODS/RESULTS An electronic database search was conducted using Medline, Embase, Cochrane Library, and Google Scholar in June 2023. The authors included studies that reported the use of rFVIIa in patients undergoing surgical repair of ascending or descending aortic aneurysm or dissection. Single-case reports were excluded. Ten publications with a pooled number of 649 patients (319 patients received rFVIIa and 330 in the control groups) were identified: 3 case series, 6 retrospective studies, and 1 nonrandomized clinical trial. All studies reported the potential role of rFVIIa in correcting coagulopathy and reducing postoperative blood loss in this group of patients. Overall, there was not enough evidence to suggest that rFVIIa was associated with higher rates of thromboembolic complications or mortality. CONCLUSION Limited evidence suggests that rFVIIa may be useful in managing postoperative refractory bleeding in patients undergoing thoracic aortic surgery. However, the impact of rFVIIa on thromboembolic complications and mortality rates remains unclear.
Collapse
Affiliation(s)
- Ryan Navarro
- Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Sandra Bojic
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rubab Fatima
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | - Mohamed El-Tahan
- Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammad El-Diasty
- Cardiac Surgery Department, Harrington Heart Institute, University Hospitals, Cleveland, Ohio, USA.
| |
Collapse
|
16
|
Suzuki H, Fujishiro A, Arai T. Successful One-Lung Ventilation With a Double Bronchial Blocker Technique in a Patient With Bronchial Anomaly and Tracheal Stenosis Caused by Kommerell Diverticulum. J Cardiothorac Vasc Anesth 2023; 37:2607-2610. [PMID: 37798241 DOI: 10.1053/j.jvca.2023.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/29/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Hiroaki Suzuki
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Koshigaya City, Japan.
| | - Asuka Fujishiro
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Koshigaya City, Japan
| | - Takero Arai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Koshigaya City, Japan
| |
Collapse
|
17
|
Hui V, Litton E, Edibam C, Geldenhuys A, Hahn R, Larbalestier R, Wright B, Pavey W. Using machine learning to predict bleeding after cardiac surgery. Eur J Cardiothorac Surg 2023; 64:ezad297. [PMID: 37669153 DOI: 10.1093/ejcts/ezad297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/29/2023] [Accepted: 09/03/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVES The primary objective was to predict bleeding after cardiac surgery with machine learning using the data from the Australia New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database, cardiopulmonary bypass perfusion database, intensive care unit database and laboratory results. METHODS We obtained surgical, perfusion, intensive care unit and laboratory data from a single Australian tertiary cardiac surgical hospital from February 2015 to March 2022 and included 2000 patients undergoing cardiac surgery. We trained our models to predict either the Papworth definition or Dyke et al.'s universal definition of perioperative bleeding. Our primary outcome was the performance of our machine learning algorithms using sensitivity, specificity, positive and negative predictive values, accuracy, area under receiver operating characteristics curve (AUROC) and area under precision-recall curve (AUPRC). RESULTS Of the 2000 patients undergoing cardiac surgery, 13.3% (226/2000) had bleeding using the Papworth definition and 17.2% (343/2000) had moderate to massive bleeding using Dyke et al.'s definition. The best-performing model based on AUPRC was the Ensemble Voting Classifier model for both Papworth (AUPRC 0.310, AUROC 0.738) and Dyke definitions of bleeding (AUPRC 0.452, AUROC 0.797). CONCLUSIONS Machine learning can incorporate routinely collected data from various datasets to predict bleeding after cardiac surgery.
Collapse
Affiliation(s)
- Victor Hui
- Department of Anaesthesia and Pain Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Heart Lung Research Institute of Western Australia, Perth, WA, Australia
| | - Edward Litton
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Cyrus Edibam
- Department of Intensive Care, Fiona Stanley Hospital, Perth, WA, Australia
| | - Agneta Geldenhuys
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Rebecca Hahn
- Heart Lung Research Institute of Western Australia, Perth, WA, Australia
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Robert Larbalestier
- Department of Cardiothoracic Surgery, Fiona Stanley Hospital, Perth, WA, Australia
| | - Brian Wright
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Warren Pavey
- Heart Lung Research Institute of Western Australia, Perth, WA, Australia
- Department of Anaesthesia, Pain and Perioperative Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| |
Collapse
|
18
|
Abbasi A, Li C, Dekle M, Bermudez CA, Brodie D, Sellke FW, Sodha NR, Ventetuolo CE, Eickhoff C. Interpretable machine learning-based predictive modeling of patient outcomes following cardiac surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01110-8. [PMID: 38040328 PMCID: PMC11133766 DOI: 10.1016/j.jtcvs.2023.11.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND The clinical applicability of machine learning predictions of patient outcomes following cardiac surgery remains unclear. We applied machine learning to predict patient outcomes associated with high morbidity and mortality after cardiac surgery and identified the importance of variables to the derived model's performance. METHODS We applied machine learning to the Society of Thoracic Surgeons Adult Cardiac Surgery Database to predict postoperative hemorrhage requiring reoperation, venous thromboembolism (VTE), and stroke. We used permutation feature importance to identify variables important to model performance and a misclassification analysis to study the limitations of the model. RESULTS The study dataset included 662,772 subjects who underwent cardiac surgery between 2015 and 2017 and 240 variables. Hemorrhage requiring reoperation, VTE, and stroke occurred in 2.9%, 1.2%, and 2.0% of subjects, respectively. The model performed remarkably well at predicting all 3 complications (area under the receiver operating characteristic curve, 0.92-0.97). Preoperative and intraoperative variables were not important to model performance; instead, performance for the prediction of all 3 outcomes was driven primarily by several postoperative variables, including known risk factors for the complications, such as mechanical ventilation and new onset of postoperative arrhythmias. Many of the postoperative variables important to model performance also increased the risk of subject misclassification, indicating internal validity. CONCLUSIONS A machine learning model accurately and reliably predicts patient outcomes following cardiac surgery. Postoperative, as opposed to preoperative or intraoperative variables, are important to model performance. Interventions targeting this period, including minimizing the duration of mechanical ventilation and early treatment of new-onset postoperative arrhythmias, may help lower the risk of these complications.
Collapse
Affiliation(s)
- Adeel Abbasi
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI.
| | - Cindy Li
- Brown University, Providence, RI
| | | | - Christian A Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Daniel Brodie
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Neel R Sodha
- Division of Cardiothoracic Surgery, Department of Surgery, Warren Alpert School of Medicine at Brown University, Providence, RI
| | - Corey E Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI; Department of Health Services, Policy and Practice, Brown School of Public Health, Providence, RI
| | - Carsten Eickhoff
- Department of Computer Science, Brown University, Providence, RI; Faculty of Medicine, University of Tübingen, Tübingen, Germany; Institute for Bioinformatics and Medical Informatics, University of Tübingen, Tübingen, Germany
| |
Collapse
|
19
|
Beairsto B, Serrick C, Fernandez A, Lafreniere-Roula M, Badiwala M, Karkouti K, Rao V. Platelet preservation in cardiac surgery using minimally invasive extracorporeal circulation versus optimized cardiopulmonary bypass. Perfusion 2023; 38:1705-1713. [PMID: 36172835 PMCID: PMC10612373 DOI: 10.1177/02676591221130173] [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: 11/17/2022]
Abstract
BACKGROUND Minimally invasive extracorporeal circulation (MiECC) is employed as a strategy to attenuate the physiologic disturbance caused by cardiopulmonary bypass. The aim of this study was to compare the coagulation profile of MiECC to an optimized conventional extracorporeal circuit (OpECC) with regards to platelet function, rotational thromboelastometry and blood product usage. METHODS A retrospective analysis of coronary artery bypass grafting operations using either MiECC or OpECC was performed at a single institution. RESULTS A total of 112 patients were included, with 61 receiving MiECC and 51 OpECC patients. OpECC patients had a significantly larger BSA (1.95+/- 0.22m2 vs 1.88 +/- 0.18m2, p = 0.034), than those who received MiECC. No difference between groups was observed regarding red blood cell, plasma, and platelet transfusions. Functional platelet count during the warming phase of cardiopulmonary bypass was found to be higher in the MiECC group ((136 (102-171) x109/L vs 109 (94-136) x109/L), p = 0.027), as were functional platelets as a percent of total platelet count ((86 (77-91)% vs 76 (63-82)%), p = 0.003). There were no significant differences between other outcomes such as operative mortality, incidence of stroke, and intensive care unit length of stay. CONCLUSION While we did not see a difference in blood transfusions, MiECC resulted in a statistically significant advantage over OpECC with regards to preservation of functional platelets.
Collapse
Affiliation(s)
- Brian Beairsto
- Department of Perfusion, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Department of Perfusion, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Amanda Fernandez
- Department of Perfusion, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | | | - Mitesh Badiwala
- Department of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesiology, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Department of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| |
Collapse
|
20
|
Nakajima T, Iba Y, Shibata T, Kawaharada N. A case of multiple median sternotomy for infection and expanding hematoma in 10 years. Egypt Heart J 2023; 75:80. [PMID: 37801192 PMCID: PMC10558406 DOI: 10.1186/s43044-023-00411-z] [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: 08/01/2023] [Accepted: 09/30/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND After a median sternotomy, mediastinitis may develop, necessitating reopening of the chest. Rarely, reoperation due to hematoma after cardiovascular surgery is experienced. In the present case, we experienced a patient who initially had mediastinitis, but later developed a chronic hematoma and underwent multiple surgeries. CASE PRESENTATION The patient was a 40-year-old man who underwent aortic valve replacement for a bicuspid aortic valve and a graft for a dilated ascending aorta. Postoperatively, he developed hematoma in the anterior mediastinum on multiple occasions with repeated episodes of infection that required multiple median sternotomies. CONCLUSIONS We reported our experience with a rare case of multiple median sternotomies. In the early stage, mediastinitis due to infection was observed, and in the late stage, mediastinal dilatation due to hemorrhage was observed.
Collapse
Affiliation(s)
- Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| |
Collapse
|
21
|
Lu J, Karkouti K, Peer M, Englesakis M, Spinella PC, Apelseth TO, Scorer TG, Kahr WHA, McVey M, Rao V, Abrahamyan L, Lieberman L, Mewhort H, Devine DV, Callum J, Bartoszko J. Cold-stored platelets for acute bleeding in cardiac surgical patients: a narrative review. Can J Anaesth 2023; 70:1682-1700. [PMID: 37831350 DOI: 10.1007/s12630-023-02561-9] [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: 01/17/2023] [Revised: 03/19/2023] [Accepted: 04/30/2023] [Indexed: 10/14/2023] Open
Abstract
PURPOSE Cold-stored platelets (CSP) are an increasingly active topic of international research. They are maintained at 1-6 °C, in contrast to standard room-temperature platelets (RTP) kept at 20-24 °C. Recent evidence suggests that CSP have superior hemostatic properties compared with RTP. This narrative review explores the application of CSP in adult cardiac surgery, summarizes the preclinical and clinical evidence for their use, and highlights recent research. SOURCE A targeted search of MEDLINE and other databases up to 24 February 2022 was conducted. Search terms combined concepts such as cardiac surgery, blood, platelet, and cold-stored. Searches of trial registries ClinicalTrials.gov and WHO International Clinical Trials Registry Platform were included. Articles were included if they described adult surgical patients as their population of interest and an association between CSP and clinical outcomes. References of included articles were hand searched. PRINCIPAL FINDINGS When platelets are stored at 1-6 °C, their metabolic rate is slowed, preserving hemostatic function for increased storage duration. Cold-stored platelets have superior adhesion characteristics under physiologic shear conditions, and similar or superior aggregation responses to physiologic agonists. Cold-stored platelets undergo structural, metabolic, and molecular changes which appear to "prime" them for hemostatic activity. While preliminary, clinical evidence supports the conduct of trials comparing CSP with RTP for patients with platelet-related bleeding, such as those undergoing cardiac surgery. CONCLUSION Cold-stored platelets may have several advantages over RTP, including increased hemostatic capacity, extended shelf-life, and reduced risk of bacterial contamination. Large clinical trials are needed to establish their potential role in the treatment of acutely bleeding patients.
Collapse
Affiliation(s)
- Justin Lu
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Miki Peer
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - Philip C Spinella
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Torunn O Apelseth
- Department of Immunology and Transfusion Medicine, Haukeland University Hospital, University of Bergen, Bergen, Norway
- Norwegian Armed Forces Joint Medical Services, Norwegian Armed Forces, Oslo, Norway
| | - Thomas G Scorer
- Centre of Defence Pathology, Royal Centre for Defence Medicine, Birmingham, UK
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Walter H A Kahr
- Division of Haematology/Oncology, The Hospital for Sick Children (SickKids), Toronto, ON, Canada
- Cell Biology Program, SickKids Research Institute, Toronto, ON, Canada
- Departments of Paediatrics and Biochemistry, University of Toronto, Toronto, ON, Canada
| | - Mark McVey
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children (SickKids), Toronto, ON, Canada
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Research Institute, Toronto, ON, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Holly Mewhort
- Department of Surgery, School of Medicine, Queen's University, Kingston, ON, Canada
| | - Dana V Devine
- Canadian Blood Services, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Jeannie Callum
- Quality in Utilization, Education and Safety in Transfusion Research Program, University of Toronto, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, School of Medicine, Queen's University, Kingston, ON, Canada
- Kingston Health Sciences Centre, Kingston General Hospital, Kingston, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto General Hospital, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada.
| |
Collapse
|
22
|
Zheng Q, Zhang L, Liu T, Guan D, Feng W, Luo S. Association of prothrombin complexe concentrate with venous thrombosis after cardiac surgery: a case-control study. Front Cardiovasc Med 2023; 10:1237227. [PMID: 37781297 PMCID: PMC10540229 DOI: 10.3389/fcvm.2023.1237227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Abstract
Background Prothrombin complex concentrate (PCC) enhances coagulation and controls bleeding. We aimed to assess whether perioperative infusion of PCC is associated with venous thrombosis after cardiac surgery. Methods We conducted a case-control study of patients undergoing cardiac surgery at our hospital in 2021. Multivariate logistic regression was used to assess the correlation between perioperative PCC infusion and postoperative venous thrombosis in cardiac surgery. Stratified analysis was also performed by age, hospitalization days, and whether warfarin, warfarin combined with heparin, warfarin combined with antiplatelet drugs were used postoperatively. Results Data from 161 patients undergoing cardiac surgery were included in the analysis. Of these, 37 (23.0%) patients in the case group developed venous thrombosis, and 124 (77.0%) patients in the control group did not develop venous thrombosis. In the analysis without adjustment for confounders (model 1), perioperative PCC infusion significantly increased the risk of postoperative venous thrombosis (OR: 3.10, 95% CI: 1.26-7.59, P = 0.0135). In the model analysis adjusted for sex, age, and hospitalization days (model 2), perioperative PCC infusion was no longer significantly associated with the risk of postoperative venous thrombosis (OR: 1.76, 95% CI: 0.56-7.59, P = 0.3317). In the fully adjusted model (model 3), there was a marginally significant association between perioperative infusion of PCC and the risk of postoperative venous thrombosis (OR: 0.03, 95% CI: 0.00-1.23, P = 0.0637). Conclusions Our findings show no significant association between perioperative PCC infusion in cardiac surgery and the development of postoperative venous thrombosis. Randomized controlled trials are needed to determine the causal relationship between perioperative PCC infusion and venous thrombosis in cardiac surgery.
Collapse
Affiliation(s)
| | | | | | | | | | - Saisai Luo
- Department of Pharmacy, The First Affiliated Hospital, Xi’an Jiaotong University, Xi’an, China
| |
Collapse
|
23
|
Karkouti K, Gross PL. What can ex vivo experiments contribute to clinical haemostasis management? Br J Anaesth 2023; 131:424-425. [PMID: 37438219 DOI: 10.1016/j.bja.2023.06.041] [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: 04/19/2023] [Revised: 05/11/2023] [Accepted: 06/18/2023] [Indexed: 07/14/2023] Open
Abstract
A recent ex vivo study found that post-cardiopulmonary bypass platelet defects can be restored with supplemental fibrinogen, but the clinical significance of this finding will require further study. We propose that the best management strategy for achieving haemostasis in bleeding surgical patients is to identify individualised coagulation defects and then use a targeted therapeutic approach that addresses each identified defect systematically.
Collapse
Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health, and Women's College Hospital, University of Toronto, Toronto, ON, Canada.
| | - Peter L Gross
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| |
Collapse
|
24
|
Schoerghuber M, Bärnthaler T, Prüller F, Mantaj P, Cvirn G, Toller W, Klivinyi C, Mahla E, Heinemann A. Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo. Br J Anaesth 2023; 131:452-462. [PMID: 37087333 PMCID: PMC10485366 DOI: 10.1016/j.bja.2023.03.010] [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: 09/04/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation. METHODS Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis. RESULTS Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline. CONCLUSIONS Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.
Collapse
Affiliation(s)
- Michael Schoerghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria.
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Polina Mantaj
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Cvirn
- Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria
| |
Collapse
|
25
|
Ishida O, Hagisawa K, Yamanaka N, Nakashima H, Kearney BM, Tsutsumi K, Takeoka S, Kinoshita M. In vitro study on the effect of fibrinogen γ-chain peptide-coated ADP-encapsulated liposomes on postcardiopulmonary bypass coagulopathy using patient blood. J Thromb Haemost 2023; 21:1934-1942. [PMID: 36990156 DOI: 10.1016/j.jtha.2023.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Fibrinogen γ-chain peptide-coated, adenosine 5'-diphosphate (ADP)-encapsulated liposomes (H12-ADP-liposomes) are potent hemostatic adjuvants that promote platelet thrombi formation at bleeding sites. Although we have reported the efficacy of these liposomes in a rabbit model of cardiopulmonary bypass coagulopathy, we are yet to address the possibility of their hypercoagulative potential, especially in human beings. OBJECTIVES Considering its future clinical applications, we herein investigated the safety of using H12-ADP-liposomes in vitro using blood samples from patients who had received platelet transfusion after cardiopulmonary bypass surgeries. METHODS Ten patients receiving platelet transfusions after cardiopulmonary bypass surgery were enrolled. Blood samples were collected at the following 3 points: at the time of incision, at the end of the cardiopulmonary bypass, and immediately after platelet transfusion. After incubating the samples with H12-ADP-liposomes or phosphate-buffered saline (PBS, as a control), blood coagulation, platelet activation, and platelet-leukocyte aggregate formation were evaluated. RESULTS Patients' blood incubated with H12-ADP-liposomes did not differ from that incubated with PBS in coagulation ability, degree of platelet activation, and platelet-leukocyte aggregation at any of the time points. CONCLUSION H12-ADP-liposomes did not cause abnormal coagulation, platelet activation, or platelet-leukocyte aggregation in the blood of patients who received platelet transfusion after a cardiopulmonary bypass. These results suggest that H12-ADP-liposomes could likely be safely used in these patients, providing hemostasis at the bleeding sites without causing considerable adverse reactions. Future studies are needed to ensure robust safety in human beings.
Collapse
Affiliation(s)
- Osamu Ishida
- Department of Cardiovascular Surgery, National Defense Medical College, Tokorozawa, Japan.
| | - Kohsuke Hagisawa
- Department of Physiology, National Defense Medical College, Tokorozawa, Japan
| | - Nozomu Yamanaka
- Department of Cardiovascular Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Hiroyuki Nakashima
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
| | - Bradley M Kearney
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
| | - Koji Tsutsumi
- Department of Cardiovascular Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Shinji Takeoka
- Research Institute for Science and Engineering, Waseda University, Tokyo, Japan
| | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
| |
Collapse
|
26
|
Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [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: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
Collapse
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| |
Collapse
|
27
|
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: 0] [Impact Index Per Article: 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.
Collapse
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.
| |
Collapse
|
28
|
Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
Collapse
Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Yoshikawa Y, Maeda M, Ohno S, Takahashi K, Sawashita Y, Hirahata T, Iba Y, Kawaharada N, Edanaga M, Yamakage M. Validity and Utility of Early Parameters in TEG6s Platelet Mapping to Assess the Coagulation Status During Cardiovascular Surgery With Cardiopulmonary Bypass. Cureus 2023; 15:e38044. [PMID: 37228566 PMCID: PMC10208008 DOI: 10.7759/cureus.38044] [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: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Background The aim of this retrospective observational study was to explore the early predictive parameters for maximum amplitudein the kaolin with heparinase (HKH) assay (MAHKH) of TEG6s Platelet Mapping in cardiovascular surgery including cardiopulmonary bypass (CPB) period. The relationship between each parameter of the assay and laboratory data was also assessed. Methods We included the patients who underwent TEG6s Platelet Mapping during cardiovascular surgery under CPB between November 2021 and May 2022. The correlation between MAHKH and the early parameters was assessed. The association between each parameter of Platelet Mapping and a combination of fibrinogen concentration > 150 mg/dL and platelet count > 100,000µL was also evaluated by the receiver operating characteristic (ROC) curve. Results In 23 patients who underwent TEG6s Platelet Mapping during the study period, 62 HKH assay data including 59 pairs of data (HKH assay and laboratory data) were analyzed. K and angle, but not R, were significantly correlated with MAHKH (r [95% CI]: -0.90 [-0.94, -0.83], p < 0.0001 for K, and 0.87 [0.79, 0.92], p < 0.0001 for angle). Furthermore, ROC curves suggested that these parameters predicted a combination of fibrinogen concentration > 150 mg/dL and platelet count > 100,000/µL with high accuracy. Similar results were confirmed in the heparinized blood samples obtained during CPB. Conclusion These findings suggest that not only MAKHK but also K and angle, which are early parameters in the HKH assay, provide clinically significant information that will facilitate rapid decision-making regarding coagulation strategies during cardiovascular surgery including the CPB period.
Collapse
Affiliation(s)
- Yusuke Yoshikawa
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Makishi Maeda
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Sho Ohno
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Kanako Takahashi
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Yasuaki Sawashita
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Tomoki Hirahata
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | | | - Mitsutaka Edanaga
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| | - Michiaki Yamakage
- Department of Anaesthesiology, Sapporo Medical University, Sapporo, JPN
| |
Collapse
|
30
|
Stoneham MD, Barbosa A, Maher K, Douglass P, Desborough MJR, Von Kier S. Intraoperative cell salvage using swab wash and serial thromboelastography in elective abdominal aortic aneurysm surgery involving massive blood loss. Br J Haematol 2023; 200:652-659. [PMID: 36253085 DOI: 10.1111/bjh.18523] [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: 08/05/2022] [Revised: 10/05/2022] [Accepted: 10/07/2022] [Indexed: 11/29/2022]
Abstract
The loss of 50% blood volume is one accepted definition of massive haemorrhage, which ordinarily would trigger the massive transfusion protocol, involving the administration of high ratios of fresh frozen plasma and platelets to allogeneic red cells. We investigated 53 patients who experienced >50% blood loss during open elective abdominal aortic aneurysm surgery to assess allogeneic blood component usage and coagulopathy. Specialist patient blood management practitioners used a tailored cell salvage technique including swab wash to maximise blood return. We assessed the proportion of patients who did not require allogeneic blood components and develop evidence of coagulopathy by thromboelastography (TEG) parameters. Blood loss was 50%-174% (mean [SD] 68% [27%]) of blood volume. The mean (SD) intraoperative decrease in haemoglobin concentration, assessed by arterial blood gas analysis, was 5 (13) g/l. No patient received allogeneic red cells intraoperatively. Four of the 53 (8%) patients received blood components in the first 24 h postoperatively at the anaesthetists' discretion. No patient had intraoperative TEG changes indicative of fibrinolysis or coagulopathy. The 30-day mortality was 2% (one of 53). Reduction of allogeneic transfusion is one aim of patient blood management techniques. We have demonstrated virtual avoidance of allogeneic blood product transfusion despite massive blood loss. These data show possible alternatives to the current massive transfusion protocols to the management of elective vascular surgical patients.
Collapse
Affiliation(s)
- Mark D Stoneham
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Antonio Barbosa
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, Oxon, UK
| | - Keith Maher
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, Oxon, UK
| | - Paul Douglass
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael J R Desborough
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Steve Von Kier
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, Oxon, UK
| |
Collapse
|
31
|
Yamada Y, Iemura J, Kambara A, Tateishi N, Kozaki Y, Yamada M, Maruyama J, Azuma E. Association of postoperative atrial fibrillation with higher dosing ratios of protamine-to-heparin. THE JOURNAL OF EXTRACORPOREAL TECHNOLOGY 2023; 55:23-29. [PMID: 37034101 PMCID: PMC10071503 DOI: 10.1051/ject/2023003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 12/29/2022] [Indexed: 03/29/2023]
Abstract
Background: Postoperative atrial fibrillation (POAF) is defined as new-onset AF in the immediate postoperative period. The relatively high incidence of POAF after cardiac surgery is well described, but pathophysiological mechanisms underlying the initiation, maintenance, and progression of POAF may be multifactorial and have not yet been comprehensively characterized. One of the mechanisms includes altered Ca2+ kinetics. Accumulating evidence has suggested that altered atrial cytosolic calcium handling contributes to the development of POAF, protamine reversibly modulates the calcium release channel/ryanodine receptor 2 (RyR2) and voltage-dependent cardiac RyR2. However, it is currently unknown whether such abnormalities contribute to the arrhythmogenic substrate predisposing patients to the development of POAF. Methods: We have retrospectively analyzed 147 patients who underwent cardiac surgery with cardiopulmonary bypass support. Of these, 40 patients were excluded from the analysis because of pre-existing AF. All patients received heparin followed by protamine at different dosing ratios of protamine-to-heparin, depending on the periods studied. Results: The dosing ratio of protamine-to-heparin = 1.0 was compared with higher dosing ratios of protamine-to-heparin >1.0 up to 1.7. POAF developed in 15 patients (15/107 = 14%), of these, 5 out of 57 patients (33.3%) in the dosing ratio of protamine-to-heparin = 1.0 and 10 out of 35 patients (66.7%) in the higher dosing ratios of protamine-to-heparin. Statistical significance was observed in patients with higher dosing ratios of protamine-to-heparin, compared with the dosing ratio of protamine-to-heparin = 1.0 (odds ratio = 3.890, 95% CI = 1.130–13.300, p-value = 0.031). When types of diseases were analyzed in terms of higher dosing ratios of protamine-to-heparin, only valvular disorders were significantly associated with POAF (p = 0.04). Conclusions: Protamine is clinically utilized to reverse heparin overdose and has been shown to display immunological and inflammatory alterations. However, its association with POAF has not been reported. Our results provide evidence that higher dosing ratios of protamine-to-heparin may increase the incidence of POAF.
Collapse
Affiliation(s)
- Yasuharu Yamada
-
Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science Mie 513-8670 Japan
- Corresponding author:
| | - Junzo Iemura
-
Department of Cardiovascular Surgery, Okanami General Hospital Mie 518-0121 Japan
| | - Atushi Kambara
-
Department of Cardiovascular Surgery, Okanami General Hospital Mie 518-0121 Japan
| | - Noboru Tateishi
-
Division of Clinical Engineering, Okanami General Hospital Mie 518-0121 Japan
| | - Yuji Kozaki
-
Division of Clinical Engineering, Okanami General Hospital Mie 518-0121 Japan
| | - Masako Yamada
-
Department of Clinical Engineering, Mie University Hospital Mie 514-0001 Japan
| | - Junko Maruyama
-
Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science Mie 513-8670 Japan
| | - Eiichi Azuma
-
Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science Mie 513-8670 Japan
| |
Collapse
|
32
|
Zeng Y, Yamamoto Y, Hayashi Y, Uchida T. Evaluation of fibrinogen concentration by clot firmness using a dielectric blood coagulation test system. J Anesth 2023; 37:56-63. [PMID: 36316533 DOI: 10.1007/s00540-022-03131-x] [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: 05/19/2022] [Accepted: 10/20/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE To determine if fibrinogen concentration can be evaluated by dielectric permittivity changes in dielectric blood coagulation testing (DBCM) during cardiovascular surgery with cardiopulmonary bypass (CPB). METHODS We performed a single-center prospective observational study at a university hospital. One hundred patients undergoing cardiovascular surgery with CPB were enrolled. Whole-blood samples were obtained after weaning from CPB, and dielectric clot strength (DCS) was measured by intrinsic pathway testing with or without heparinase in DBCM. The FIBTEM test was performed during rotational thromboelastometry using the same samples, and maximum clot firmness (MCF) was evaluated. Spearman's correlation analysis was performed, and receiver operating characteristics (ROC) curve analyses were used to evaluate the performance of hypofibrinogenemia detection. RESULTS DCS showed a strong positive correlation with plasma fibrinogen concentration (Rs = 0.76, P < 0.0001). The area under the ROC curve for evaluating plasma fibrinogen concentration < 200 mg/dL was 0.91 (95% confidence interval (CI) 0.85-0.97) for DCS, compared with 0.88 (95% CI 0.81-0.94) for FIBTEM MCF. The optimal cutoff value of DCS was 17.0 (sensitivity 94%, specificity 80%). CONCLUSIONS DCS variables showed a significantly strong correlation with plasma fibrinogen concentration, and the diagnostic performance for hypofibrinogenemia was comparable to that for FIBTEM MCF. This novel methodology has the potential to provide a point-of-care test with sufficient accuracy for the detection of perioperative hypofibrinogenemia during cardiovascular surgery with CPB.
Collapse
Affiliation(s)
- Yulin Zeng
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yudai Yamamoto
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yoshihito Hayashi
- Biomedical R&D Department, R&D Division, Medical Business Group, Sony Imaging Products & Solutions Inc., Bunkyo-Ku, Tokyo, 113-8519, Japan
- Tokyo Laboratory 11, R&D Center, Sony Group Corporation, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Tokujiro Uchida
- Department of Anesthesiology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
| |
Collapse
|
33
|
Li X, Wang R, Sun D, Yao Y, Wang T, Luo G, Liu M, Xu J, Cheng Z, Gao Q, Wang Y, Wu C, Xu G, Lv T, Zou J, Yan M. Risk Factors for Hypocoagulability After Cardiac Surgery: A Retrospective Study. Clin Appl Thromb Hemost 2023; 29:10760296231209927. [PMID: 37933155 PMCID: PMC10631354 DOI: 10.1177/10760296231209927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023] Open
Abstract
Hemostatic disturbances after cardiac surgery can lead to excessive postoperative bleeding. Thromboelastography (TEG) was employed to evaluate perioperative coagulative alterations in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), investigating the correlation between factors concomitant with cardiac surgery and modifications in coagulation. Coagulation index as determined by TEG correlated significantly with postoperative bleeding at 24-72 h after cardiac surgery (P < .001). Among patients with a normal preoperative coagulation index, those with postoperative hypocoagulability showed significantly lower nadir temperature (P = .003), larger infused fluid volume (P = .003), and longer CPB duration (P = .033) than those with normal coagulation index. Multivariate logistic regression showed that nadir intraoperative temperature was an independent predictor of postoperative hypocoagulability (adjusted OR: 0.772, 95% CI: 0.624-0.954, P = .017). Multivariate linear regression demonstrated linear associations of nadir intraoperative temperature (P = .017) and infused fluid volume (P = .005) with change in coagulation index as a result of cardiac surgery. Patients are susceptible to hypocoagulability after cardiac surgery, which can lead to increased postoperative bleeding. Ensuring appropriate temperature and fluid volume during cardiac surgery involving CPB may reduce risk of postoperative hypocoagulability and bleeding.
Collapse
Affiliation(s)
- Xuejie Li
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong, China
| | - Ruiyu Wang
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong, China
| | - Dawei Sun
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yuanyuan Yao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tingting Wang
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ge Luo
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Mingxia Liu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingpin Xu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhenzhen Cheng
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qi Gao
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ying Wang
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chaomin Wu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Guangxin Xu
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Tao Lv
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jingcheng Zou
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Min Yan
- School of Anesthesiology, Weifang Medical University, Weifang, Shandong, China
- Department of Anesthesiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| |
Collapse
|
34
|
Saito H, Kawana S, Saito K, Igarashi A, Inokuchi M, Yamauchi M. Sonoclot® predicts operation time and blood loss after cardiopulmonary bypass in children. Heliyon 2022; 8:e11461. [DOI: 10.1016/j.heliyon.2022.e11461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/30/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
|
35
|
Li H, Bartoszko J, Serrick C, Rao V, Karkouti K. Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial. Can J Anaesth 2022; 69:1117-1128. [PMID: 35799088 DOI: 10.1007/s12630-022-02278-1] [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: 06/20/2021] [Revised: 02/17/2022] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management. METHODS We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort. RESULTS A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did. CONCLUSIONS The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT03347201); first submitted 12 October 2017.
Collapse
Affiliation(s)
- Han Li
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Cyril Serrick
- Perfusion Services, University Health Network, Toronto, ON, Canada
| | - Vivek Rao
- Cardiovascular Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
36
|
Ma HP, Fu M, Masula M, Xing CS, Zhou Q, Tan JT, Wang J. miR-3064-5p and miR-4745-5p affect heparin sensitivity in patients undergoing cardiac surgery by regulating AT-III and factor X mRNA levels. Front Physiol 2022; 13:914333. [PMID: 36035472 PMCID: PMC9412912 DOI: 10.3389/fphys.2022.914333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
Subject: Perioperative regulation of coagulation function through heparin in patients undergoing cardiac surgery with cardiopulmonary bypass is an important part of performing cardiac surgery, and postoperative bleeding due to abnormal coagulation function caused by differences in heparin sensitivity in different individuals is an independent risk factor for postoperative complications and death.Method: Using an online database, 10 miRNAs interacting with AT-III and FX genes were predicted. Patients were divided into three groups according to the difference in activated clotting time (ACT) after the first dose of heparin (2.5 mg kg−1): group A: hyposensitive group (ACT < 480 s); group B: sensitive group (480 s ≤ ACT ≤ 760 s); and group C: hypersensitive group (ACT > 760 s). Perioperative and 24 h postoperative blood loss and other clinical data of patients in the three groups were recorded. Blood samples were collected before surgery, and RT-PCR was used to detect the levels of AT-III and FX gene mRNA and the levels of predicted 10 miRNAs.Result: Heparin sensitivity was positively correlated with AT-III mRNA levels and negatively correlated with FX gene mRNA levels in the three groups, and the blood loss in group B was significantly lower than that in groups A and C, which was statistically significant (p < 0.05). miR-3064-5p and miR-4745-5p expression levels were significantly different among group A, group B, and group C (p < 0.05) and were closely correlated with AT-III and FX gene mRNA expression levels, respectively.Conclusion: Differences in heparin sensitivity in patients undergoing cardiac surgery were associated with the mRNA expression of AT-III and FX genes, and the expression levels of miR-3064-5p and miR-4745-5p were found to be closely related to the AT-III and FX gene mRNA, respectively, indicating that miR-3064-5p and miR-4745-5p affect the differences in heparin sensitivity among different individuals by regulating the mRNA expression levels of AT-III and FX genes.Clinical Trial Registration:http://www.chictr.org.cn/abouten.aspx, identifier registration number: ChiCTR-2100047348
Collapse
|
37
|
Devine C, Bartoszko J, Callum J, Karkouti K. Weight-adjusted dosing of fibrinogen concentrate and cryoprecipitate in the treatment of hypofibrinogenaemic bleeding adult cardiac surgical patients: a post hoc analysis of the Fibrinogen Replenishment in cardiac surgery randomised controlled trial. BJA OPEN 2022; 2:100016. [PMID: 37588266 PMCID: PMC10430806 DOI: 10.1016/j.bjao.2022.100016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/27/2022] [Indexed: 08/18/2023]
Abstract
Background Hypofibrinogenaemia is associated with excessive bleeding after cardiac surgery. Our aim was to compare the efficacy and safety of weight-adjusted vs empiric dosing of fibrinogen replacement in cardiac surgery. Methods In the Fibrinogen Replenishment in Cardiac Surgery (FIBRES) RCT, patients (n=735) received fibrinogen concentrate (4 g) or cryoprecipitate (10 units). In this post-hoc analysis, patients were grouped into quartiles based on increasing weight-adjusted dosing. Generalised estimating equations were used to account for hospital site, age, sex, surgical complexity, urgency, and critical preoperative status. The primary outcome was the number of units of red blood cells transfused within 24 h of cardiopulmonary bypass. Secondary outcomes included allogeneic blood components within 24 h, tamponade or major bleeding, and thromboembolic complications, ischaemic complications, or both within 28 days of cardiopulmonary bypass. Results The median weight-adjusted doses were 52 mg kg-1 of fibrinogen concentrate (inter-quartile range [IQR], 45-61; n=372) and 1.30 units per 10 kg of cryoprecipitate (IQR, 1.11-1.54; n=363). When patients were divided into quartiles of lowest to highest weight-adjusted dosing, no differences were seen in the primary outcome of red blood cell units transfused within 24 h of cardiopulmonary bypass between the lowest and highest quartiles in either the fibrinogen group (adjusted relative risk [RR]=0.90; 95% confidence interval [CI], 0.71-1.13; P=0.36) or the cryoprecipitate group (adjusted RR=1.04; 95% CI, 0.76-1.43; P=0.80). Results were similar for all secondary outcomes. Conclusion Outcomes for the lowest and highest weight-adjusted doses of fibrinogen replacement were comparable. Weight-adjusted dosing does not appear to offer advantages over empiric dosing in this context. Clinical trial registration NCT03037424.
Collapse
Affiliation(s)
- Cian Devine
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, School of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - the FIBRES Study Investigators
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Canada
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pathology and Molecular Medicine, School of Medicine, Queen's University, Kingston, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| |
Collapse
|
38
|
Waberski Andrew T, Christopher B, Yves DD, Matisoff Andrew J. Massive clot formation following FEIBA and tranexamic acid administration in post-cardiopulmonary bypass hemorrhage. J Cardiothorac Vasc Anesth 2022; 36:3863-3866. [DOI: 10.1053/j.jvca.2022.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/30/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
|
39
|
Bartoszko J, Martinez-Perez S, Callum J, Karkouti K, Farouh ME, Scales DC, Heddle NM, Crowther M, Rao V, Hucke HP, Carroll J, Grewal D, Brar S, Brussières J, Grocott H, Harle C, Pavenski K, Rochon A, Saha T, Shepherd L, Syed S, Tran D, Wong D, Zeller M. Impact of cardiopulmonary bypass duration on efficacy of fibrinogen replacement with cryoprecipitate compared with fibrinogen concentrate: a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) randomised controlled trial. Br J Anaesth 2022; 129:294-307. [DOI: 10.1016/j.bja.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/16/2022] [Accepted: 05/06/2022] [Indexed: 11/28/2022] Open
|
40
|
A Case Report of Severe Factor XI Deficiency during Cardiac Surgery: Less Can Be More. J Cardiovasc Dev Dis 2022; 9:jcdd9040118. [PMID: 35448094 PMCID: PMC9027232 DOI: 10.3390/jcdd9040118] [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] [Received: 03/25/2022] [Revised: 04/10/2022] [Accepted: 04/14/2022] [Indexed: 01/27/2023] Open
Abstract
Severe congenital Factor XI (FXI) deficiency (<20% normal activity) can be associated with significant bleeding disorders, and there has been great concern for severe bleeding following cardiac surgery requiring cardiopulmonary bypass (CPB) in this patient population. Over the past four decades remarkably different approaches to this problem have been taken, including the administration of blood volumes of fresh frozen plasma, administration of activated recombinant Factor VII, and diminutive administration of heparin. We describe a case wherein the patient was assessed in the perioperative period with a point-of-care, viscoelastic hemostasis device (ROTEM), with changes in the intrinsic/Factor XII-dependent coagulation pathway determined before, during, and after CPB. Fresh frozen plasma was administered in small amounts (5−7.5 mL/kg) just before surgery began and just before cessation of CPB. Administering fresh frozen plasma to the patient to nearly normalize in vitro ROTEM hemostasis values at times when hemostasis was needed resulted in no important bleeding occurring or need of further transfusion of other blood products. In conclusion, by using small amounts of fresh frozen plasma guided by ROTEM, an evidenced-based, precision medicine approach resulted in optimized patient care and outcome.
Collapse
|
41
|
Rodríguez-Martín I, Sánchez-Mora C, Fernández-López AR, González-Fernández FJ, Téllez-Cantero JC, Blanco-Marquez V, García de la Borbolla M, Santos-Jiménez JC, González-Rodríguez C, Garnacho-Montero J, Sánchez-Margalet V. Evaluation of health outcomes after the implementation of rotational thromboelastometry in patients undergoing cardiac surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2022; 82:143-149. [PMID: 35112642 DOI: 10.1080/00365513.2022.2034038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Viscoelastic tests (rotational thromboelastometry, ROTEM®), together with the implementation of a specific algorithm for coagulation management in cardiac surgery, enable perioperative coagulopathy to be better controlled. METHODS Retrospective cohort study including 675 patients who underwent cardiac surgery with cardiopulmonary bypass. The incidence of allogeneic blood transfusions and clinical postoperative complications were analyzed before and after ROTEM® implementation. RESULTS Following viscoelastic testing and the implementation of a specific algorithm for coagulation management, the incidence of any allogeneic blood transfusion decreased (41.4% vs 31.9%, p = .026) during the perioperative period. In the group monitored with ROTEM®, decreased incidence of transfusion was observed for packed red blood cells (31.3% vs 19.8%, p = .002), fresh frozen plasma (9.8% vs 3.8%, p = .008), prothrombin complex concentrate administration (0.9% vs 0.3%, p = .599) and activated recombinant factor VII (0.3% vs 0.0%, p = .603). Increased incidence was observed for platelet transfusion (4.8% vs 6.8%, p = .530) and fibrinogen concentrate (0.9% vs 3.5%, p = .066), tranexamic acid (0.0% vs 0.6%, p = .370) and protamine administration (0.6% vs 0.9%, p = .908). Similar results were observed in the postoperative period, but with a decreased incidence of platelet transfusion (4.8% vs 3.8%, p = .813). In addition, statistically significant reductions were detected in the incidence of postoperative bleeding (9.5% vs 5.3%, p = .037), surgical reexploration (6.0% vs 2.9%, p = .035), and length of Intensive Care Unit (ICU) stay (6.0 days vs 5.3 days, p = .026). CONCLUSIONS The monitoring of hemostasis by ROTEM® in cardiac surgery, was associated with decreased incidence of allogeneic blood transfusion, clinical hematologic postoperative complications and lengths of ICU stay.
Collapse
Affiliation(s)
- Isabel Rodríguez-Martín
- Clinical Biochemistry Department, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| | - Catalina Sánchez-Mora
- Clinical Biochemistry Department, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| | | | | | - Juan Carlos Téllez-Cantero
- Cardiovascular Surgery Department, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| | - Verónica Blanco-Marquez
- Anesthesia Service, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| | | | - Juan C Santos-Jiménez
- Cardiovascular Surgery Department, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| | | | - José Garnacho-Montero
- Intensive Care Unit, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| | - Víctor Sánchez-Margalet
- Clinical Biochemistry Department, Virgen Macarena University Hospital, University of Seville, Sevilla, Spain
| |
Collapse
|
42
|
Capdevila L, Frère C, Desvages M, Harroche A, Bally C, Abbes A, d'Oiron R, Frenzel L, Borgel D, Lasne D. Emicizumab does not interfere with the activated clotting time. Haemophilia 2022; 28:362-366. [DOI: 10.1111/hae.14497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/10/2021] [Accepted: 01/09/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Ladislas Capdevila
- Haematology Laboratory AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
| | - Corinne Frère
- INSERM UMRS_1166 Institute of Cardiometabolism and Nutrition Sorbonne Université Paris France
- Haematology Laboratory AP‐HP Hôpital Universitaire Pitié‐Salpêtrière Paris France
| | - Maximilien Desvages
- Haematology Laboratory AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
- HITh, UMR_S 1176 INSERM Université Paris‐Saclay Le Kremlin‐Bicetre France
| | - Annie Harroche
- Centre de Traitement de l'Hemophilie AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
| | - Cécile Bally
- Centre de Traitement de l'Hemophilie AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
| | - Ahmed Abbes
- GRC 29; Department of Anaesthesiology and Critical Care Medicine AP‐HP Sorbonne Université Hôpital Universitaire Pitié‐Salpêtrière Paris France
| | - Roseline d'Oiron
- HITh, UMR_S 1176 INSERM Université Paris‐Saclay Le Kremlin‐Bicetre France
- Service d'hématologie AP‐HP Hôpital de Bicêtre Le Kremlin‐Bicêtre France
| | - Laurent Frenzel
- Centre de Traitement de l'Hemophilie AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
| | - Delphine Borgel
- Haematology Laboratory AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
- HITh, UMR_S 1176 INSERM Université Paris‐Saclay Le Kremlin‐Bicetre France
| | - Dominique Lasne
- Haematology Laboratory AP‐HP Hôpital Universitaire Necker‐Enfants Malades Paris France
- HITh, UMR_S 1176 INSERM Université Paris‐Saclay Le Kremlin‐Bicetre France
| |
Collapse
|
43
|
Abbasciano RG, Koulouroudias M, Chad T, Mohamed W, Leeman I, Pellowe C, Kunst G, Klein A, Murphy GJ. Role of hypothermia in adult cardiac surgery patients: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2022; 36:1883-1890. [DOI: 10.1053/j.jvca.2022.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
|
44
|
Bartoszko J, Callum J, Karkouti K. The association of prothrombin complex concentrates with postoperative outcomes in cardiac surgery: an observational substudy of the FIBRES randomized controlled trial. Can J Anaesth 2021; 68:1789-1801. [PMID: 34523108 PMCID: PMC8563600 DOI: 10.1007/s12630-021-02100-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 07/09/2021] [Accepted: 07/22/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose The mainstay of therapy for coagulation factor deficiency in cardiac surgical patients is frozen plasma (FP); however, prothrombin complex concentrates (PCCs) may offer logistical and safety advantages. As there is limited comparative evidence, we conducted this study to explore the association of comparable PCC or FP doses with transfusion and outcomes. Methods This was a post hoc analysis of a multicentre randomized trial comparing fibrinogen concentrate with cryoprecipitate (FIBRES trial) in bleeding cardiac surgical patients. This analysis included 415 patients who received only PCC (n = 72; 17%) or only FP (n = 343; 83%) for factor replacement. The main outcomes of interest were red blood cell (RBC) and platelet transfusion within 24 hr of cardiopulmonary bypass. Secondary outcomes included postoperative adverse events. Associations were examined by hierarchical generalized estimating equation models adjusted for demographic and surgical characteristics. Results The median [interquartile range (IQR)] PCC dose was 1,000 [1,000–2,000] units, while the median [IQR] FP dose was 4 [2–6] units. Each unit of FP was independently associated with increased adjusted odds of RBC (1.60; 95% confidence interval [CI], 1.36 to 1.87; P < 0.01) and platelet transfusion (1.40; 95% CI, 1.15 to 1.69; P < 0.01) while each 500 units of PCC was independently associated with reduced adjusted odds of RBC (0.67; 95% CI, 0.50 to 0.90; P < 0.01) and platelet transfusion (0.80; 95% CI, 0.70 to 0.92; P < 0.01). Adverse event rates were comparable. Conclusions In cardiac surgical patients with post-cardiopulmonary bypass bleeding, PCC use was associated with lower RBC and platelet transfusion than FP use was. Prospective, randomized clinical trials comparing FP with PCC in this setting are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s12630-021-02100-4.
Collapse
Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital,, University of Toronto, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada.
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital - University Health Network, Sinai Health System, Women's College Hospital,, University of Toronto, 200 Elizabeth Street, 3EN-464, Toronto, ON, M5G 2C4, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
45
|
Tshikudi DM, Simandoux O, Kang D, Van Cott EM, Andrawes MN, Yelin D, Nadkarni SK. Imaging the dynamics and microstructure of fibrin clot polymerization in cardiac surgical patients using spectrally encoded confocal microscopy. Am J Hematol 2021; 96:968-978. [PMID: 33971046 DOI: 10.1002/ajh.26217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 04/27/2021] [Accepted: 05/01/2021] [Indexed: 11/05/2022]
Abstract
During cardiac surgery with cardiopulmonary bypass (CPB), altered hemostatic balance may disrupt fibrin assembly, predisposing patients to perioperative hemorrhage. We investigated the utility of a novel device termed spectrally-encoded confocal microscopy (SECM) for assessing fibrin clot polymerization following heparin and protamine administration in CPB patients. SECM is a novel, high-speed optical approach to visualize and quantify fibrin clot formation in three dimensions with high spatial resolution (1.0 μm) over a volumetric field-of-view (165 × 4000 × 36 μm). The measurement sensitivity of SECM was first determined using plasma samples from normal subjects spiked with heparin and protamine. Next, SECM was performed in plasma samples from patients on CPB to quantify the extent to which fibrin clot dynamics and microstructure were altered by CPB exposure. In spiked samples, prolonged fibrin time (4.4 ± 1.8 to 49.3 ± 16.8 min, p < 0.001) and diminished fibrin network density (0.079 ± 0.010 to 0.001 ± 0.002 A.U, p < 0.001) with increasing heparin concentration were reported by SECM. Furthermore, fibrin network density was not restored to baseline levels in protamine-treated samples. In CPB patients, SECM reported lower fibrin network density in protaminized samples (0.055 ± 0.01 A.U. [Arbitrary units]) vs baseline values (0.066 ± 0.009 A.U.) (p = 0.03) despite comparable fibrin time (baseline = 6.0 ± 1.3, protamine = 6.4 ± 1.6 min, p = 0.5). In these patients, additional metrics including fibrin heterogeneity, length and straightness were quantified. Note, SECM revealed that following protamine administration with CPB exposure, fibrin clots were more heterogeneous (baseline = 0.11 ± 0.02 A.U, protamine = 0.08 ± 0.01 A.U, p = 0.008) with straighter fibers (baseline = 0.918 ± 0.003A.U, protamine = 0.928 ± 0.0006A.U. p < 0.001). By providing the capability to rapidly visualize and quantify fibrin clot microstructure, SECM could furnish a new approach for assessing clot stability and hemostasis in cardiac surgical patients.
Collapse
Affiliation(s)
- Diane M. Tshikudi
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Olivier Simandoux
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Dongkyun Kang
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
- College of Optical Sciences and Department of Biomedical Engineering University of Arizona Tucson Arizona USA
| | - Elizabeth M. Van Cott
- Department of Pathology, Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Michael N. Andrawes
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Dvir Yelin
- Faculty of Biomedical Engineering Technion—Israel Institute of Technology Haifa Israel
| | - Seemantini K. Nadkarni
- Wellman Center for Photomedicine, Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| |
Collapse
|