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Fletcher CM, Hinton JV, Xing Z, Perry LA, Karamesinis A, Shi J, Penny-Dimri JC, Ramson D, Liu Z, Smith JA, Segal R, Coulson TG, Bellomo R. Fresh frozen plasma transfusion after cardiac surgery. Perfusion 2023:2676591231221715. [PMID: 38085647 DOI: 10.1177/02676591231221715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Fresh frozen plasma (FFP) transfusion in the intensive care unit (ICU) is commonly used to treat coagulopathy and bleeding in cardiac surgery, despite suggestion that it may increase the risk of morbidity and mortality through mechanisms such as fluid overload and infection. METHODS We retrospectively studied consecutive adults undergoing cardiac surgery from the Medical Information Mart for Intensive Care III and IV databases. We applied propensity score matching to investigate the independent association of within-ICU FFP transfusion with mortality and other key clinical outcomes. RESULTS Of our 12,043 adults who met inclusion criteria, 1585 (13.2%) received perioperative FFP with a median of 2.48 units per recipient (interquartile range [IQR]: 2.04, 4.33) at a median time of 1.83 h (IQR: 0.75, 3.75) after ICU admission. After propensity matching of 952 FFP recipients to 952 controls, we found no significant association between FFP use and hospital mortality (odds ratio (OR): 1.58; 99% confidence interval (CI): 0.57, 3.71), suspected infection (OR: 0.72; 99% CI: 0.49, 1.08), or acute kidney injury (OR: 1.23; 99% CI: 0.91, 1.67). However, FFP was associated with increased days in hospital (adjusted mean difference (AMD): 1.28; 99% CI: 0.27, 2.41; p = .0050), days in intensive care (AMD: 1.28; 99% CI: 0.27, 2.28; p = .0011), and chest tube output in millilitres up to 8 h after transfusion (AMD: 92.98; 99% CI: 52.22, 133.74; p < .0001). CONCLUSIONS After propensity matching, FFP transfusion was not associated with increased hospital mortality, but was associated with increased length of stay and no decrease in bleeding in the early post-transfusion period.
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Affiliation(s)
- Calvin M Fletcher
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Jake V Hinton
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Zhongyue Xing
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Luke A Perry
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Alexandra Karamesinis
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jenny Shi
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jahan C Penny-Dimri
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia
| | - Dhruvesh Ramson
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia
| | - Zhengyang Liu
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Julian A Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Clayton, VIC, Australia
- Department of Cardiothoracic Surgery, Monash Health, Clayton, VIC, Australia
| | - Reny Segal
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Tim G Coulson
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
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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: 60] [Impact Index Per Article: 60.0] [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.
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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)
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Guinot PG, Durand B, Besnier E, Mertes PM, Bernard C, Nguyen M, Berthoud V, Abou-Arab O, Bouhemad B, Martin A, Duclos V, Spitz A, Constandache T, Grosjean S, Radhouani M, Anciaux JB, Missaoui A, Morgant MC, Bouchot O, Jazayeri S, Demailly Z, Huette P, Guilbart M, Besserve P, Beyls C, Dupont H, Kindo M, Wpiff T. Epidemiology, risk factors and outcomes of norepinephrine use in cardiac surgery with cardiopulmonary bypass: a multicentric prospective study. Anaesth Crit Care Pain Med 2023; 42:101200. [PMID: 36758855 DOI: 10.1016/j.accpm.2023.101200] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND The present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass. METHOD We performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intra-operative hemorrhage. RESULTS Of 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06-0.2] μg.kg-1.min-1 and a median duration of 10 h [2-24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine. CONCLUSION Norepinephrine is often used in cardiac surgical patients but for <24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events.
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Affiliation(s)
- Pierre-Grégoire Guinot
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France.
| | - Bastien Durand
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Paul-Michel Mertes
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Chloe Bernard
- Department of Cardiac Surgery, Dijon University Medical Centre, 21000 Dijon, France
| | - Maxime Nguyen
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Vivien Berthoud
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Osama Abou-Arab
- Department of Anaesthesiology and Critical Care Medicine, Amiens University Medical Centre, 80000 Amiens, France
| | - Belaid Bouhemad
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France; University of Burgundy and Franche-Comté, LNC UMR1231, F-21000 Dijon, France
| | - Audrey Martin
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Valerian Duclos
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Alexandra Spitz
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Tiberiu Constandache
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Sandrine Grosjean
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Mohamed Radhouani
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Jean-Baptiste Anciaux
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Anis Missaoui
- Department of Anaesthesiology and Critical Care Medicine, Dijon University Medical Centre, 21000 Dijon, France
| | - Marie-Catherine Morgant
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Olivier Bouchot
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Saed Jazayeri
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Zoe Demailly
- Department of Anaesthesiology and Critical Care Medicine, Rouen University Medical Centre, 76000 Rouen, France
| | - Pierre Huette
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Mathieu Guilbart
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Patricia Besserve
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Christophe Beyls
- Department of Anaesthesiology and Critical Care Medicine, Strasbourg University Medical Centre, Strasbourg, France
| | - Hervé Dupont
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Thibaut Wpiff
- Department of Cardiac Surgery, Dijon University Medical Centre, 21000 Dijon, France
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Very low-dose recombinant Factor VIIa administration for cardiac surgical bleeding reduces red blood cell transfusions and renal risk: a matched cohort study. Blood Coagul Fibrinolysis 2021; 32:473-479. [PMID: 34650021 DOI: 10.1097/mbc.0000000000001079] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Outcomes following administration of very-low-dose recombinant activated factor VIIa (vld-rFVIIa) for cardiac surgical bleeding remain debatable. We sought to determine the association of vld-rFVIIa and adverse surgical outcomes. Retrospective, cohort matching of patients undergoing cardiac surgery who received vld-rFVIIa (median 13.02 μg/kg) for perioperative bleeding were matched to cardiac surgical patients who had bleeding and received standard of care for bleeding without Factor VIIa administration. Of the 362 matched patients (182 in each group), patients who received rFVIIa required significantly less red blood cell transfusions [median 3 units (range 0--60, IQR = 4 units) versus 4 units (range 2-34, IQR = 4 units); P = 0.0004], decreased length of hospital stay (median 8 versus 9 days; P = 0.0158) and decreased renal risk (P < 0.0001). Incidence of renal failure, postoperative infection, postoperative thrombosis, prolonged ventilation, total ICU hours and 30-day mortality were not different between the two groups. Vld-rFVIIa for cardiac surgical bleeding was associated with decreased red blood cell transfusion, renal risk and length of hospital stay without increased thromboembolism or mortality when compared to patients who had cardiac surgical bleeding and received standard of care without Factor VIIa.
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Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, 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, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
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Stammers AH, Francis SG, Miller R, Nostro A, Tesdahl EA, Mongero LB. Application of goal-directed therapy for the use of concentrated antithrombin for heparin resistance during cardiac surgery. Perfusion 2020; 36:171-182. [PMID: 32536326 DOI: 10.1177/0267659120926089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The maintenance of anticoagulation in adult patients undergoing cardiopulmonary bypass is dependent upon a number of factors, including heparin concentration and adequate antithrombin activity. Inadequate anticoagulation increases the risk of thrombosis and jeopardizes both vascular and extracorporeal circuit integrity. The purpose of this study was to evaluate a goal-directed approach for the use of antithrombin in patients who were resistant to heparin. Following institutional review board approval, data were obtained from quality improvement records. A goal-directed protocol for antithrombin was established based upon heparin dosing (400 IU kg-1 body weight) and achieving an activated clotting time of ⩾500 seconds prior to cardiopulmonary bypass. Two groups of patients were identified as those receiving antithrombin and those not receiving antithrombin. Outcome measures included activated clotting time values and transfusion rates. Consecutive patients (n = 140) were included in the study with 10 (7.1%) in the antithrombin group. The average antithrombin dose was 1,029.0 ± 164.5 IU and all patients had restoration to the activated clotting time levels. Patients in the antithrombin group were on preoperative heparin therapy (80.0% vs. 24.6%, p = 0.001). Prior to cardiopulmonary bypass the activated clotting time values were lower in the antithrombin group (417.7 ± 56.1 seconds vs. 581.1 ± 169.8 seconds, p = 0.003). Antithrombin patients had a lower heparin sensitivity index (0.55 ± 0.17 vs. 1.05 ± 0.44 seconds heparin-1 IU kg-1, p = 0.001), received more total heparin (961.3 ± 158.5 IU kg-1 vs. 677.5 ± 199.0 IU kg-1, p = 0.001), more cardiopulmonary bypass heparin (22,500 ± 10,300 IU vs. 12,100 ± 13,200 IU, p = 0.016), and more protamine (5.4 ± 1.2 vs. 4.1 ± 1.1 mg kg-1, p = 0.003). The intraoperative transfusion rate was higher in the antithrombin group (70.0% vs. 35.4%, p = 0.035), but no differences were seen postoperatively. Utilization of a goal-directed algorithm for the administration of antithrombin for the treatment of heparin resistance is effective in patients undergoing cardiac surgery.
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Affiliation(s)
| | | | | | - Anthony Nostro
- Department of Anesthesia, Pocono Medical Center, East Stroudsburg, PA, USA
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Bogdanić D, Bogdanić N, Karanović N. Evaluation of platelet count and platelet function analyzer - 100 testing for prediction of platelet transfusion following coronary bypass surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:296-302. [PMID: 32125177 DOI: 10.1080/00365513.2020.1731847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Platelet transfusions are commonly administered to treat bleeding in cardiac surgery. The aim of this study was to compare platelet (PLT) count and values of collagen adenosine diphosphate closure time (cADP-CT) measured by Platelet Function Analyzer (PFA) for prediction of PLT transfusion therapy following coronary bypass surgery. For this prospective observational study, 66 patients scheduled for coronary artery bypass grafting (CABG) who received early PLT transfusions (within 60 min after the operation) were enrolled. To assess changes in platelets, count and function, two time points were selected: 15 min before and 30 - 60 min after the end of PLT transfusion. The patients were divided into transfused and non-transfused with further PLT in the 48 h postoperatively. We used the receiver operating characteristics (ROC) curve to investigate whether the PLT count and cADP-CT values were predictors of PLT transfusion. The positive predictive values (PPV) of PLT count and cADP-CT after PLT transfusion for further PLT transfusion were 33% and 86% respectively, with a PLT count threshold of ≤200 × 109/L and cADP-CT threshold of ≥118 s. The comparison among the ROC curves showed a statistical difference (p = .0002). In multiple regression analysis, cADP-CT was the strongest predictor for the number of PLT transfusion doses in the 48 h postoperatively. In CABG patients, the results of cADP-CT after PLT transfusion have a better predictive capacity for further PLT transfusions than the PLT count.
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Affiliation(s)
- Dejana Bogdanić
- Department of Transfusion Medicine, University Hospital Center Split, Split, Croatia
| | - Nikolina Bogdanić
- University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | - Nenad Karanović
- Department of Anesthesiology and Intensive Care, University Hospital Center Split, Split, Croatia
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Oakland K, Chadwick G, East JE, Guy R, Humphries A, Jairath V, McPherson S, Metzner M, Morris AJ, Murphy MF, Tham T, Uberoi R, Veitch AM, Wheeler J, Regan C, Hoare J. Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology. Gut 2019; 68:776-789. [PMID: 30792244 DOI: 10.1136/gutjnl-2018-317807] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/07/2019] [Accepted: 01/16/2019] [Indexed: 01/28/2023]
Abstract
This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.
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Affiliation(s)
| | | | - James E East
- Translational Gastroenterology Unit, Experimental Medicine Division, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK
| | - Richard Guy
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Vipul Jairath
- Robarts Clinical Trials, Inc., London, Ontario, Canada.,Medicine and Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | | | - Magdalena Metzner
- Department of Gastroenterology, Hutt Valley District Health Board, Lower Hutt, New Zealand
| | - A John Morris
- Gastroenterology, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Tony Tham
- Division of Gastroenterology, Ulster Hospital, Dundonald, UK
| | - Raman Uberoi
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - James Wheeler
- Department of Colorectal Surgery, Addenbrooke's Hospital, Cambridge, UK
| | | | - Jonathan Hoare
- Department of Surgery and Cancer, Imperial College, London, UK
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Braga DV, Brandão MAG. Diagnostic evaluation of risk for bleeding in cardiac surgery with extracorporeal circulation. Rev Lat Am Enfermagem 2018; 26:e3092. [PMID: 30517580 PMCID: PMC6280528 DOI: 10.1590/1518-8345.2523.3092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 09/17/2018] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to identify the risk factors associated with cases of excessive bleeding in patients submitted to cardiac surgery with extracorporeal circulation. METHOD case-control study on the factors of risk for bleeding based on the analysis of data from the medical charts of 216 patients submitted to cardiac surgery with elective extracorporeal circulation during a three-year period. RESULTS variables that are commonly associated with excessive bleeding in studies in the field were analyzed, and the following were considered as risk factors for the nursing diagnosis "risk for bleeding" (00206) in cardiac surgery with extracorporeal circulation: Body mass index lower than 26.35kg/m² (Odds ratio = 3.64); Extracorporeal circulation longer than 90 minutes (Odds ratio = 3.57); Hypothermia lower than 32°C (Odds ratio = 2.86); Metabolic acidosis (Odds ratio = 3.50) and Activated partial thromboplastin time longer than 40 seconds (Odds ratio= 2.55). CONCLUSION such variables may be clinical indicators of an operational nature for a better characterization of the risk factor "treatment regimen" and a refinement of knowledge related to coagulopathy induced by extracorporeal circulation, which is currently presumably incorporated into the "treatment regimen" category of the nursing diagnostic classification by NANDA International, Inc.
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Affiliation(s)
- Damaris Vieira Braga
- Universidade Federal do Rio de Janeiro, Escola de Enfermagem Anna Nery, Rio de Janeiro, RJ, Brazil
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Fabbro M, Gutsche JT, Miano TA, Augoustides JG, Patel PA. Comparison of Thrombelastography-Derived Fibrinogen Values at Rewarming and Following Cardiopulmonary Bypass in Cardiac Surgery Patients. Anesth Analg 2017; 123:570-7. [PMID: 27541720 DOI: 10.1213/ane.0000000000001465] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The inflated costs and documented deleterious effects of excess perioperative transfusion have led to the investigation of targeted coagulation factor replacement strategies. One particular coagulation factor of interest is factor I (fibrinogen). Hypofibrinogenemia is typically tested for using time-consuming standard laboratory assays. The thrombelastography (TEG)-based functional fibrinogen level (FLEV) provides an assessment of whole blood clot under platelet inhibition to report calculated fibrinogen levels in significantly less time. If FLEV values obtained on cardiopulmonary bypass (CPB) during rewarming are similar to values obtained immediately after the discontinuation of CPB, then rewarming values could be used for preemptive ordering of appropriate blood product therapy. METHODS Fifty-one cardiac surgery patients were enrolled into this prospective nonrandomized study to compare rewarming fibrinogen values with postbypass values using TEG FLEV assays. Baseline, rewarming, and postbypass fibrinogen values were recorded for all patients using both standard laboratory assay (Clauss method) and FLEV. Mixed-effects regression models were used to examine the change in TEG FLEV values over time. Bland-Altman analysis was used to examine bias and the limits of agreement (LOA) between the standard laboratory assay and FLEVs. RESULTS Forty-nine patients were included in the analysis. The mean FLEV value during rewarming was 333.9 mg/dL compared with 332.8 mg/dL after protamine, corresponding to an estimated difference of -1.1 mg/dL (95% confidence interval [CI], -25.8 to 23.6; P = 0.917). Rewarming values were available on average 47 minutes before postprotamine values. Bland-Altman analysis showed poor agreement between FLEV and standard assays: mean difference at baseline was 92.5 mg/dL (95% CI, 71.1 to 114.9), with a lower LOA of -56.5 mg/dL (95% CI, -94.4 to -18.6) and upper LOA of 242.4 mg/dL (95% CI, 204.5 to 280.3). The difference between assays increased after CPB and persisted after protamine administration. CONCLUSIONS Our results revealed negligible change in FLEV values from the rewarming to postbypass periods, with a CI that does not include clinically meaningful differences. These findings suggest that rewarming samples could be utilized for ordering fibrinogen-specific therapies before discontinuation of CPB. Mean FLEV values were consistently higher than the reference standard at each time point. Moreover, bias was highly heterogeneous among samples, implying a large range of potential differences between assays for any 1 patient.
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Affiliation(s)
- Michael Fabbro
- From the *Department of Anesthesiology, University of Miami, Miami, Florida; †Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania; and ‡Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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Levy JH, Grottke O, Fries D, Kozek-Langenecker S. Therapeutic Plasma Transfusion in Bleeding Patients. Anesth Analg 2017; 124:1268-1276. [DOI: 10.1213/ane.0000000000001897] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Corral M, Ferko N, Hogan A, Hollmann SS, Gangoli G, Jamous N, Batiller J, Kocharian R. A hospital cost analysis of a fibrin sealant patch in soft tissue and hepatic surgical bleeding. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:507-519. [PMID: 27703386 PMCID: PMC5036832 DOI: 10.2147/ceor.s112762] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Despite hemostat use, uncontrolled surgical bleeding is prevalent. Drawbacks of current hemostats include limitations with efficacy on first attempt and suboptimal ease-of-use. Evarrest® is a novel fibrin sealant patch that has demonstrated high hemostatic efficacy compared with standard of care across bleeding severities. The objective of this study was to conduct a hospital cost analysis of the fibrin sealant patch versus standard of care in soft tissue and hepatic surgical bleeding. Methods The analysis quantified the 30-day costs of each comparator from a hospital perspective. Published US unit costs were applied to resource use (ie, initial treatment, retreatment, operating time, hospitalization, transfusion, and ventilator) reported in four trials. A “surgical” analysis included resources clinically related to the hemostatic benefit of the fibrin sealant patch, whereas a “hospital” analysis included all resources reported in the trials. An exploratory subgroup analysis focused solely on coagulopathic patients defined by abnormal blood test results. Results The surgical analysis predicted cost savings of $54 per patient with the fibrin sealant patch compared with standard of care (net cost impact: −$54 per patient; sensitivity range: −$1,320 to $1,213). The hospital analysis predicted further cost savings with the fibrin sealant patch (net cost impact of −$2,846 per patient; sensitivity range: −$1,483 to −$5,575). Subgroup analyses suggest that the fibrin sealant patch may provide dramatic cost savings in the coagulopathic subgroup of $3,233 (surgical) and $9,287 (hospital) per patient. Results were most sensitive to operating time and product units. Conclusion In soft tissue and hepatic problematic surgical bleeding, the fibrin sealant patch may result in important hospital cost savings.
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Affiliation(s)
| | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
| | - Andrew Hogan
- Cornerstone Research Group, Burlington, ON, Canada
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Corral M, Ferko N, Hollmann S, Broder MS, Chang E. Health and economic outcomes associated with uncontrolled surgical bleeding: a retrospective analysis of the Premier Perspectives Database. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:409-21. [PMID: 26229495 PMCID: PMC4516034 DOI: 10.2147/ceor.s86369] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Bleeding remains a common occurrence in surgery. Data describing the burden of difficult-to-control bleeding and topical absorbable hemostat use are sparse. This study was conducted to estimate the clinical and economic impact that remains associated with uncontrolled surgical bleeding, even when hemostats are used during surgery. Methods This US retrospective analysis used the Premier Perspectives Database. Hospital discharges from 2012 were used to identify patients treated with hemostats during eight surgery types. Patients were included if they were ≥18 years, had an inpatient hospitalization with one of the eight surgeries, and received a hemostat on the day of surgery. Patients were stratified by procedure and presence or absence of major bleeding (uncontrolled) despite hemostat use. Outcomes were all-cause hospitalization costs, hemostat costs, length of stay, reoperation, and surgery-related complications (eg, mortality). Statistical significance was tested through chi-square or t-tests. Multivariate analyses were conducted for all-cause costs and length of stay using analysis of covariance. Results Among 25,048 procedures, major bleeding events occurred in 14,251 cases. Despite treatment with hemostats, major bleeding occurred in 32%–68% of cases. All-cause costs were significantly higher in patients with uncontrolled bleeding despite hemostat use versus controlled bleeding (US$24,203–$61,323 [uncontrolled], US$14,420–$45,593 [controlled]; P<0.001). Hemostat costs were significantly greater in the uncontrolled bleeding cohort for all surgery types except cystectomy and pancreatic surgery. Reoperation and mortality rates were significantly higher in the uncontrolled bleeding cohort in all surgical procedures except cystectomy and radical hysterectomy. Conclusion Uncontrolled intraoperative bleeding despite hemostat use is prevalent and associated with significantly higher hospital costs and worse clinical outcomes across several surgical procedures compared to controlled bleeding. There is an unmet need for newer hemostats that can more effectively control bleeding, improve outcomes, and reduce hospital resource use.
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Affiliation(s)
| | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
| | | | - Michael S Broder
- Partnership for Health Analytic Research, Beverly Hills, CA, USA
| | - Eunice Chang
- Partnership for Health Analytic Research, Beverly Hills, CA, USA
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Desborough M, Sandu R, Brunskill SJ, Doree C, Trivella M, Montedori A, Abraha I, Stanworth S. Fresh frozen plasma for cardiovascular surgery. Cochrane Database Syst Rev 2015; 2015:CD007614. [PMID: 26171897 PMCID: PMC8406941 DOI: 10.1002/14651858.cd007614.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Fresh frozen plasma (FFP) is a blood component containing procoagulant factors, which is sometimes used in cardiovascular surgery with the aim of reducing the risk of bleeding. The purpose of this review is to assess the risk of mortality for patients undergoing cardiovascular surgery who receive FFP. OBJECTIVES To evaluate the risk to benefit ratio of FFP transfusion in cardiovascular surgery for the treatment of bleeding patients or for prophylaxis against bleeding. SEARCH METHODS We searched 11 bibliographic databases and four ongoing trials databases including the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2015), MEDLINE (OvidSP, 1946 to 21 April 2015), EMBASE (OvidSP, 1974 to 21 April 2015), PubMed (e-publications only: searched 21 April 2015), ClinicalTrials.gov, World Health Organization (WHO) ICTRP and the ISRCTN Register (searched 21 April 2015). We also searched the references of all identified trials and relevant review articles. We did not limit the searches by language or publication status. SELECTION CRITERIA We included randomised controlled trials in patients undergoing major cardiac or vascular surgery who were allocated to a FFP group or a comparator (no plasma or an active comparator, either clinical plasma (any type) or a plasma-derived blood product). We included participants of any age (neonates, children and adults). We excluded studies of plasmapheresis and plasma exchange. DATA COLLECTION AND ANALYSIS Two authors screened all electronically derived citations and abstracts of papers identified by the review search strategy. Two authors assessed risk of bias in the included studies and extracted data independently. We took care to note whether FFP was used therapeutically or prophylactically within each trial. MAIN RESULTS We included 15 trials, with a total of 755 participants for analysis in the review. Fourteen trials compared prophylactic use of FFP against no FFP. One study compared therapeutic use of two types of plasma. The timing of intervention varied, including FFP transfusion at the time of heparin neutralisation and stopping cardiopulmonary bypass (CPB) (seven trials), with CPB priming (four trials), after anaesthesia induction (one trial) and postoperatively (two trials). Twelve trials excluded patients having emergency surgery and nine excluded patients with coagulopathies.Overall the trials were small, with only four reporting an a priori sample size calculation. No trial was powered to determine changes in mortality as a primary outcome. There was either high risk of bias, or unclear risk, in the majority of trials included in this review.There was no difference in the number of deaths between the intervention arms in the six trials (with 287 patients) reporting mortality (very low quality evidence). There was also no difference in blood loss in the first 24 hours for neonatal/paediatric patients (four trials with 138 patients; low quality evidence): mean difference (MD) -1.46 ml/kg (95% confidence interval (CI) -4.7 to 1.78 ml/kg); or adult patients (one trial with 120 patients): MD -12.00 ml (95% CI -101.16 to 77.16 ml).Transfusion with FFP was inferior to control for preventing patients receiving any red cell transfusion: Peto odds ratio (OR) 2.57 (95% CI 1.30 to 5.08; moderate quality evidence). There was a difference in prothrombin time within two hours of FFP transfusion in eight trials (with 210 patients; moderate quality evidence) favouring the FFP arm: MD -0.71 seconds (95% CI -1.28 to -0.13 seconds). There was no difference in the risk of returning to theatre for reoperation (eight trials with 398 patients; moderate quality evidence): Peto OR 0.81 (95% CI 0.26 to 2.57). Only one included study reported adverse events as an outcome and reported no significant adverse events following FFP transfusion. AUTHORS' CONCLUSIONS This review has found no evidence to support the prophylactic administration of FFP to patients without coagulopathy undergoing elective cardiac surgery. There was insufficient evidence about treatment of patients with coagulopathies or those who are undergoing emergency surgery. There were no reported adverse events attributable to FFP transfusion, although there was a significant increase in the number of patients requiring red cell transfusion who were randomised to FFP. Variability in outcome reporting between trials precluded meta-analysis for many outcomes across all trials, and there was evidence of a high risk of bias in most of the studies. Further adequately powered studies of FFP, or comparable pro-haemostatic agents, are required to assess whether larger reductions in prothrombin time translate into clinical benefits. Overall the evidence from randomised controlled trials for the safety and efficacy of prophylactic transfusion of FFP for cardiac surgery is insufficient.
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Effect of transfusion of fresh frozen plasma on parameters of endothelial condition and inflammatory status in non-bleeding critically ill patients: a prospective substudy of a randomized trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:163. [PMID: 25880761 PMCID: PMC4407778 DOI: 10.1186/s13054-015-0828-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/20/2015] [Indexed: 12/22/2022]
Abstract
Introduction Much controversy exists on the effect of a fresh frozen plasma (FFP) transfusion on systemic inflammation and endothelial damage. Adverse effects of FFP have been well described, including acute lung injury. However, it is also suggested that a higher amount of FFP decreases mortality in trauma patients requiring a massive transfusion. Furthermore, FFP has an endothelial stabilizing effect in experimental models. We investigated the effect of fresh frozen plasma transfusion on systemic inflammation and endothelial condition. Methods A prospective predefined substudy of a randomized trial in coagulopathic non-bleeding critically ill patients receiving a prophylactic transfusion of FFP (12 ml/kg) prior to an invasive procedure. Levels of inflammatory cytokines and markers of endothelial condition were measured in paired samples of 33 patients before and after transfusion. The statistical tests used were paired t test or the Wilcoxon signed-rank test. Results At baseline, systemic cytokine levels were mildly elevated in critically ill patients. FFP transfusion resulted in a decrease of levels of TNF-α (from 11.3 to 2.3 pg/ml, P = 0.01). Other cytokines were not affected. FFP also resulted in a decrease in systemic syndecan-1 levels (from 675 to 565 pg/ml, P = 0.01) and a decrease in factor VIII levels (from 246 to 246%, P <0.01), suggestive of an improved endothelial condition. This was associated with an increase in ADAMTS13 levels (from 24 to 32%, P <0.01) and a concomitant decrease in von Willebrand factor (vWF) levels (from 474 to 423%, P <0.01). Conclusions A fixed dose of FFP transfusion in critically ill patients decreases syndecan-1 and factor VIII levels, suggesting a stabilized endothelial condition, possibly by increasing ADAMTS13, which is capable of cleaving vWF. Trial registrations Trialregister.nl NTR2262, registered 26 March 2010 and Clinicaltrials.gov NCT01143909, registered 14 June 2010.
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