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Abdolalian M, Khalaf-Adeli E, Yari F, Hosseini S, Kiaeefar P. Presurgical circulating platelet-derived microparticles level as a risk factor of blood transfusion in patients with valve heart disease undergoing cardiac surgery. Transfus Clin Biol 2024; 31:19-25. [PMID: 38029957 DOI: 10.1016/j.tracli.2023.11.004] [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: 07/23/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Cell-derived microparticles (MPs) are membrane vesicles that have emerged as a potential biomarker for various diseases and their clinical complications. This study investigates the role of MPs as a risk factor for blood transfusion in patients with valve heart disease undergoing cardiac surgery. METHODS Forty adult patients undergoing heart valve surgery with cardiopulmonary bypass (CPB) were enrolled, and venous blood samples were collected prior to surgical incision. Plasma rich in MPs was prepared by double centrifugation, and the concentration of MPs was determined using the Bradford method. Flow cytometry analysis was performed to determine MPs count and phenotype. Patients were divided into "with transfusion" (n = 18) and "without transfusion" (n = 22) groups based on red blood cell (RBC) transfusion. RESULTS There was no significant difference in MPs concentration between the "with transfusion" and "without transfusion" groups. Although the count of preoperative platelet-derived MPs (PMPs), monocyte-derived MPs (MMPs), and red cell-derived MPs (RMPs) was higher in "without transfusion" group, these differences were not statistically significant. The preoperative PMPs count was negatively correlated with RBC transfusion (P = 0.005, r = -0.65). Multivariate logistic regression analysis revealed that the count of CD41+ PMPs, Hemoglobin (Hb), and RBC count were risk factors for RBC transfusion. CONCLUSION This study suggests that the presurgical levels of PMPs, Hb, and RBC count can serve as risk factors of RBC transfusion in patients with valve heart disease undergoing cardiac surgery. The findings provide insights into the potential use of MPs as biomarkers for blood transfusion prediction in cardiac surgery.
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Affiliation(s)
- Mehrnaz Abdolalian
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Elham Khalaf-Adeli
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran; Department of Hematology, Faculty of Paramedical Sciences, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.
| | - Fatemeh Yari
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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2
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Shimoda T, Liu C, Mathis BJ, Goto Y, Ageyama N, Kato H, Matsubara M, Ohigashi T, Gosho M, Suzuki Y, Hiramatsu Y. Effect of cardiopulmonary bypass on coagulation factors II, VII and X in a primate model: an exploratory pilot study. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad194. [PMID: 38015856 PMCID: PMC10701202 DOI: 10.1093/icvts/ivad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/05/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES The use of cardiopulmonary bypass (CPB) in cardiac surgery is a major risk factor for postoperative bleeding. We hypothesized that consumptive coagulopathy and haemodilution influence the coagulation factors; therefore, we aimed to estimate the activity profiles of coagulation factors II, VII and X during CPB circulation. METHODS A 120-min bypass was surgically established in cynomolgus monkeys (n = 7). Activities of coagulation factors II, VII and X were measured at 6 time points during the experiment (baseline, 0, 30, 60, 120 min of bypass and 60 min after bypass). To assess the influence of consumptive coagulopathy, the values were adjusted for haemodilution using the haematocrit values. Data were expressed as mean (standard deviation). RESULTS Activities of coagulation factors decreased during the experiment. In particular, the activities for II, VII and X were decreased the most by 44.2% (5.0), 61.4% (4.3) and 49.0% (3.7) at 30 min following CPB initiation (P < 0.001, P < 0.001 and P < 0.001, respectively). Following adjustments for haemodilution, change magnitudes lessened but remained significant for factor VII. The adjusted concentration of factor VII was observed to decrease from the baseline to the initiation of bypass circulation. CONCLUSIONS In conclusion, coagulation factor II, VII and X concentrations decreased during CPB. Following adjustment for haemodilution, a decrease in concentration was observed with factor VII.
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Affiliation(s)
- Tomonari Shimoda
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chang Liu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Hospital, Ibaraki, Japan
| | - Yukinobu Goto
- Department of Thoracic Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naohide Ageyama
- Tsukuba Primate Research Center, National Institute of Biomedical Innovation, Tsukuba, Ibaraki, Japan
| | - Hideyuki Kato
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Muneaki Matsubara
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomohiro Ohigashi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba Hospital, Ibaraki, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuyuki Suzuki
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuji Hiramatsu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
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3
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Knio ZO, Ising MS, Yount KW, Tanaka K, McNeil JS. Undiagnosed Factor VII Deficiency in Cardiac Surgery Complicated by Bleeding: A Case Report. A A Pract 2023; 17:e01713. [PMID: 37681735 DOI: 10.1213/xaa.0000000000001713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Rare bleeding disorders in the perioperative period call for targeted resuscitation strategies. Factor VII deficiency, for instance, is often corrected with exogenous administration of recombinant factor VIIa. This activated clotting factor, initially designed for patients with hemophilia A or B with factor inhibitors, is gaining popularity as a salvage therapy for severe and persistent traumatic and surgical bleeding. This article describes the management of a cardiothoracic surgical patient with undiagnosed isolated factor VII deficiency who experienced significant postoperative bleeding which subsided after the administration of recombinant factor VIIa. In this case, EXTEM failed to detect a clotting factor deficiency.
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Affiliation(s)
| | - Mickey S Ising
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Kenan W Yount
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Oklahoma, Oklahoma City, Oklahoma
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4
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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.
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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
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5
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Lee JH. Prevention and management of difficult hemostasis in acute type A aortic dissection repair. Asian Cardiovasc Thorac Ann 2023; 31:15-19. [PMID: 35040355 DOI: 10.1177/02184923221074409] [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] [Indexed: 11/15/2022]
Abstract
Postoperative bleeding after surgery for acute aortic dissection is one of the most common complications and has an important influence on mortality and morbidity. Therefore, various methods have been introduced to prevent or manage postoperative bleeding. In this article, we investigated the causes of bleeding after surgery for acute aortic dissection, and introduce appropriate transfusion or pharmacologic treatment, topical hemostatic agents, and local compressive maneuver to manage it.
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Affiliation(s)
- Jae Hang Lee
- Department of Thoracic and Cardiovascular Surgery, 65462Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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6
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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
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Mazzeffi M, McNeil J, Singh K, Tanaka K. Retrograde Autologous Priming in Minimally Invasive Mitral Valve Surgery: Simple, Safe, and Effective. J Cardiothorac Vasc Anesth 2022; 36:3036-3037. [DOI: 10.1053/j.jvca.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 11/11/2022]
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8
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Hoghooghy A, Honarmand A, Bagheri K, Rezaei K. Evaluation of plasma fibrinogen levels before and after coronary artery bypass graft surgery and its association with the need for blood products. Adv Biomed Res 2022; 11:25. [PMID: 35720218 PMCID: PMC9201223 DOI: 10.4103/abr.abr_22_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/12/2022] Open
Abstract
Background: The present study investigated the plasma level of fibrinogen before and after removing the pump in coronary artery bypass graft (CABG) surgery and its relationship with the need for blood products. Materials and Methods: The present study was performed on 60 patients who were candidates for CABG surgery. The fibrinogen level of these patients was assessed and recorded before surgery and immediately after removing the pump. In addition, their hemoglobin level was recorded before the operation and 2 h after. In addition, the number and type of blood products transfusion were recorded intraoperatively and postoperatively and also at the intensive care unit. Results: Patients’ fibrinogen level after removing the pump with the mean of 130.53 ± 122.01 mg/dl decreased significantly compared to before surgery with the mean of mg/dl 224.95 ± 132.88 mg/dl (P < 0.001). In addition, the prognostic value of fibrinogen after removing the pump in determining the postoperative need of blood transfusion showed that the cut-off value of fibrinogen was < 196 mg/dl with a sensitivity of 16.82% and specificity of 80%, but it was not statistically significant (area under the curve [95% confidence interval]: 0.519 [0.350–0.689]; P = 0.825). Conclusion: According to the results of the present study, due to significant changes in fibrinogen levels after removing the pump compared to preoperation, it seems that this factor can play an important role in prognosis of the need to postoperative blood transfusion, although the prognostic value and the critical point mentioned in our study was not significant and it is required to do further studies.
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9
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Bolliger D, Vandyck K, Tanaka KA. Management of Patients With Hemophilia Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:539-541. [PMID: 34933808 DOI: 10.1053/j.jvca.2021.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/14/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Clinic for Anesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Kofi Vandyck
- Department for Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Kenichi A Tanaka
- Department for Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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10
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Rajasekhar A, Arnaoutakis GJ, Janelle GM, Harris N, Wynn T, Anderson RD, Ashton JN, Mandernach MW. Multidisciplinary Management of a Hemophilia A Patient Requiring Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2021; 36:534-538. [PMID: 34895963 DOI: 10.1053/j.jvca.2021.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/02/2021] [Accepted: 10/18/2021] [Indexed: 01/18/2023]
Affiliation(s)
- Anita Rajasekhar
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL.
| | - George J Arnaoutakis
- Division of Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL
| | - Gregory M Janelle
- Department of Anesthesiology, University of Florida, Gainesville, FL
| | - Neil Harris
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Tung Wynn
- Division of Hematology & Oncology, Department of Pediatrics, University of Florida, Gainesville, FL
| | - R David Anderson
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Gainesville, FL
| | - Jennifer N Ashton
- Department of Pharmacy, University of Florida Health Shands, Gainesville, FL
| | - Molly W Mandernach
- Division of Hematology & Oncology, Department of Medicine, University of Florida, Gainesville, FL
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11
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Liu C, Zhang HT, Yue LJ, Li ZS, Pan K, Chen Z, Gu SP, Pan T, Pan J, Wang DJ. Risk factors for mortality in patients undergoing continuous renal replacement therapy after cardiac surgery. BMC Cardiovasc Disord 2021; 21:509. [PMID: 34674651 PMCID: PMC8529736 DOI: 10.1186/s12872-021-02324-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To investigate the risk factors for mortality in patients with acute kidney injury requiring continuous renal replacement therapy (AKI-CRRT) after cardiac surgery. METHODS In this retrospective study, patients who underwent AKI-CRRT after cardiac surgery in our centre from January 2015 to January 2020 were included. Univariable and multivariable analyses were performed to identify the risk factors for in-hospital mortality. RESULTS A total of 412 patients were included in our study. Of these, 174 died after AKI-CRRT, and the remaining 238 were included in the survival control group. Multivariable logistic regression analysis revealed that EuroSCORE > 7 (odds ratio [OR], 3.72; 95% confidence interval [CI], 1.92-7.24; p < 0.01), intraoperative bleeding > 1 L (OR, 2.14; 95% CI, 1.19-3.86; p = 0.01) and mechanical ventilation time > 70 h (OR, 5.03; 95% CI, 2.40-10.54; p < 0.01) were independent risk factors for in-hospital mortality in patients who had undergone AKI-CRRT. Our study also found that the use of furosemide after surgery was a protective factor for such patients (odds ratio, 0.48; 95% confidence interval, 0.25-0.92; p = 0.03). CONCLUSIONS In summary, the mortality of patients with AKI-CRRT after cardiac surgery remains high. The EuroSCORE, intraoperative bleeding and mechanical ventilation time were independent risk factors for in-hospital mortality. Continuous application of furosemide may be associated with a better outcome.
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Affiliation(s)
- Chang Liu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Hai-Tao Zhang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Li-Jun Yue
- Department of Traditional Chinese Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Ze-Shi Li
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China
| | - Ke Pan
- Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China
| | - Zhong Chen
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Su-Ping Gu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Tuo Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China.,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
| | - Dong-Jin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Traditional Chinese and Western Medicine, Nanjing University of Chinese Medicine, Number 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Graduate School of Peking Union Medical College, Beijing, 100010, China. .,Nanjing Drum Tower Hospital, The Affiliated Clinical College of Xuzhou Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, Nanjing Medical University, Nanjing, 210008, Jiangsu, China. .,Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China.
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12
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Nahara I, Takeuchi M, Tanaka S, Yonekura H, Takeda C, Kawakami K. Cardiovascular Safety of Celecoxib after Cardiac Surgery with Cardiopulmonary Bypass: A Retrospective Cohort Study. ANNALS OF CLINICAL EPIDEMIOLOGY 2021; 3:101-108. [PMID: 38505473 PMCID: PMC10760469 DOI: 10.37737/ace.3.4_101] [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: 08/13/2020] [Accepted: 02/26/2021] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery is a highly invasive procedure resulting in hypercoagulability due to thoracotomy and cardiopulmonary bypass (CPB). The long-term use of selective cyclooxygenase-2 inhibitors has been shown to increase the risk of adverse cardiovascular (CV) events such as myocardial infarction. This study aimed to determine whether short-term prescription of celecoxib increases CV events in patients who have undergone cardiac surgery with CPB. METHODS This retrospective observational study included 16,141 patients (≥20 years) who had undergone cardiac surgery with CPB between April 1, 2008 and March 31, 2016. Patients who underwent coronary artery bypass grafting were excluded. Patients who received celecoxib (n = 904) and acetaminophen (n = 5,002) from postoperative day 0 to 30 were extracted and matched by propensity score (PS). The primary outcomes were all-cause death and CV events, defined as coronary artery disease, ischemic stroke, pulmonary embolism, and venous thrombosis, coded using International Classification of Diseases-10 within 30 days after the first postoperative prescription of either medication. Results were assessed using Kaplan-Meier survival analysis and multivariate Cox regression analysis. RESULTS PS matching created 885 pairs. Multivariate Cox regression analysis showed that prescription of celecoxib after cardiac surgery was not associated with an increase in the primary outcomes when compared with prescription of acetaminophen (hazard ratio, 0.76; 95% confidence interval, 0.35-1.65). CONCLUSIONS The prescription of celecoxib in patients who had undergone cardiac surgery with cardiopulmonary bypass was not statistically different from the prescription of acetaminophen in the incidence of CV events and death.
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Affiliation(s)
- Isao Nahara
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University
| | - Hiroshi Yonekura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
- Department of Clinical Anesthesiology, Graduate School of Medicine Faculty of Medicine, Mie University
| | - Chikashi Takeda
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
- Department of Anesthesia, Kyoto University Hospital
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University
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13
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Curry N. Fibrinogen Replacement in Haemostatic Resuscitation: Dose, Laboratory Targets and Product Choice. Transfus Med Rev 2021; 35:104-107. [PMID: 34565636 DOI: 10.1016/j.tmrv.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/05/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022]
Abstract
Fibrinogen is a key coagulation protein that is necessary for the formation of stable clots. Fibrinogen levels have been reported to be one of the first to fall during major haemorrhage reflecting consumption, dilution and fibrinogenolysis. Its role in acquired major haemorrhage, both in relation to the contribution it plays to the coagulopathy of major bleeding that can exacerbate bleeding and how effective fibrinogen supplementation can be at improving clinical outcomes, has received a great deal of attention over the last 10 - 15 years. This commentary focuses on just three of the more recent publications from the last 5 years that provide some of the evidence behind how we can think about fibrinogen as a haemostatic treatment for acquired major haemorrhage and how we can use the laboratory thresholds to guide therapy.
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Affiliation(s)
- Nicola Curry
- Oxford Haemophilia & Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, and Oxford University, NIHR BRC Haematology Theme, Oxford, UK.
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14
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Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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Karkouti K, Bartoszko J, Grewal D, Bingley C, Armali C, Carroll J, Hucke HP, Kron A, McCluskey SA, Rao V, Callum J. Comparison of 4-Factor Prothrombin Complex Concentrate With Frozen Plasma for Management of Hemorrhage During and After Cardiac Surgery: A Randomized Pilot Trial. JAMA Netw Open 2021; 4:e213936. [PMID: 33792729 PMCID: PMC8017469 DOI: 10.1001/jamanetworkopen.2021.3936] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Approximately 15% of patients undergoing cardiac surgery receive frozen plasma (FP) for bleeding. Four-factor prothrombin complex concentrates (PCCs) have logistical and safety advantages over FP and may be a suitable alternative. OBJECTIVES To determine the proportion of patients who received PCC and then required FP, explore hemostatic effects and safety, and assess the feasibility of study procedures. DESIGN, SETTING, AND PARTICIPANTS Parallel-group randomized pilot study conducted at 2 Canadian hospitals. Adult patients requiring coagulation factor replacement for bleeding during cardiac surgery (from September 23, 2019, to June 19, 2020; final 28-day follow-up visit, July 17, 2020). Data analysis was initiated on September 15, 2020. INTERVENTIONS Prothrombin complex concentrate (1500 IU for patients weighing ≤60 kg and 2000 IU for patients weighing >60 kg) or FP (3 U for patients weighing ≤60 kg and 4 U for patients weighing >60 kg), repeated once as needed within 24 hours (FP used for any subsequent doses in both groups). Patients and outcome assessors were blinded to treatment allocation. MAIN OUTCOMES AND MEASURES Hemostatic effectiveness (whether patients received any hemostatic therapies from 60 minutes to 4 and 24 hours after initiation of the intervention, amount of allogeneic blood components administered within 24 hours after start of surgery, and avoidance of red cell transfusions within 24 hours after start of surgery), protocol adherence, and adverse events. The analysis set comprised all randomized patients who had undergone cardiac surgery, received at least 1 dose of either treatment, and provided informed consent after surgery. RESULTS Of 169 screened patients, 131 were randomized, and 101 were treated (54 with PCC and 47 with FP), provided consent, and were included in the analysis (median age, 64 years; interquartile range [IQR], 54-73 years; 28 [28%] were female; 82 [81%] underwent complex operations). The PCC group received a median 24.9 IU/kg (IQR, 21.8-27.0 IU/kg) of PCC (2 patients [3.7%; 95% CI, 0.4%-12.7%] required FP). The FP group received a median 12.5 mL/kg (IQR, 10.0-15.0 mL/kg) of FP (4 patients [8.5%; 95% CI, 2.4%-20.4%] required >2 doses of FP). Hemostatic therapy was not required at the 4-hour time point for 43 patients (80%) in the PCC group and for 32 patients (68%) in the FP group (P = .25) nor at the 24-hour time point for 41 patients (76%) in the PCC group and for 31 patients (66%) patients in the FP group (P = .28). The median numbers of units for 24-hour cumulative allogeneic transfusions (red blood cells, platelets, and FP) were 6.0 U (IQR, 4.0-11.0 U) in the PCC group and 14.0 U (IQR, 8.0-20.0 U) in the FP group (ratio, 0.58; 95% CI, 0.45-0.77; P < .001). After exclusion of FP administered as part of the investigational medicinal product, the median numbers of units were 6.0 U (IQR, 4.0-11.0 U) in the PCC group and 10.0 U (IQR, 6.0-16.0 U) in the FP group (ratio, 0.80; 95% CI, 0.59-1.08; P = .15). For red blood cells alone, the median numbers were 1.5 U (IQR, 0.0-4.0 U) in the PCC group and 3.0 U (IQR, 1.0-5.0 U) in the FP group (ratio, 0.69; 95% CI, 0.47-0.99; P = .05). During the first 24 hours after start of surgery, 15 patients in the PCC group (28%) and 8 patients in the FP group (17%) received no red blood cells (P = .24). Adverse event profiles were similar. CONCLUSIONS AND RELEVANCE This randomized clinical trial found that the study protocols were feasible. Adequately powered randomized clinical trials are warranted to determine whether PCC is a suitable substitute for FP for mitigation of bleeding in cardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04114643.
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Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia and Pain Management; University Health Network, Sinai Health System, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management; University Health Network, Sinai Health System, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Deep Grewal
- Department of Anesthesia and Pain Management; University Health Network, Sinai Health System, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cielo Bingley
- Department of Anesthesia and Pain Management; University Health Network, Sinai Health System, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Chantal Armali
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jo Carroll
- Department of Anesthesia and Pain Management; University Health Network, Sinai Health System, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Amie Kron
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stuart A. McCluskey
- Department of Anesthesia and Pain Management; University Health Network, Sinai Health System, Women’s College Hospital, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Vivek Rao
- Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen’s University, Kingston, Ontario, Canada
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Bastopcu M, Özhan A, Erdoğan SB, Kehlibar T. Factors associated with excessive bleeding following elective on-pump coronary artery bypass grafting. J Card Surg 2021; 36:1277-1281. [PMID: 33484200 DOI: 10.1111/jocs.15364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Excessive bleeding following cardiac surgery is associated with worse outcomes. We aimed to analyze preoperative and operative factors associated with excessive bleeding in coronary artery bypass patients to better understand which patients are under increased risk. METHODS The study was conducted as an observational study in a tertiary center for cardiac surgery by retrospective analysis of the hospital database. Patients were grouped according to chest tube output within the postoperative 24 h. Patients in the 4th percentile of chest tube output per kilogram were categorized as having excessive bleeding. Patients with excessive bleeding were compared with the other patients for preoperative and operative factors. Factors significant in univariate analysis were carried onto the multivariate analysis. RESULTS Patients with excessive bleeding were more likely to be males (91.4% vs. 78.7%, p = .002), have lower body mass index (BMI) (27.4 vs. 29.2, p < .001), and low platelets (6.9% vs. 1.5%, p = .006). Cardiopulmonary bypass (101.8 vs. 110.9 min, p = .022) time was longer in the excessive bleeding group. Patients with excessive bleeding were more likely to have more than three vessels revascularized. Male sex, lower BMI, low platelets, and longer cardiopulmonary bypass time were independently associated with increased bleeding. CONCLUSION Male sex, lower BMI, low platelet count, and longer cardiopulmonary bypass time are associated with extensive bleeding after elective coronary artery bypass surgery (CABG). Patients with higher bleeding risk should be identified preoperatively to account for adverse outcomes after CABG.
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Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Abdulkerim Özhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç B Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tamer Kehlibar
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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17
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Henderson RA, Judd M, Strauss ER, Gammie JS, Mazzeffi MA, Taylor BS, Tanaka KA. Hematologic evaluation of intraoperative autologous blood collection and allogeneic transfusion in cardiac surgery. Transfusion 2021; 61:788-798. [DOI: 10.1111/trf.16259] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 11/27/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Reney A. Henderson
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Miranda Judd
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Erik R. Strauss
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - James S. Gammie
- Division of Cardiac Surgery, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Michael A. Mazzeffi
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Bradley S. Taylor
- Division of Cardiac Surgery, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
| | - Kenichi A. Tanaka
- Division of Cardiovascular Anesthesia, Department of Surgery University of Maryland School of Medicine Baltimore Maryland USA
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18
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Li H, Zhang L, Xia M, Zhang C, Jiang T. The Comparison of Therapeutic Efficacy Between Dabigatran Versus Warfarin in Patients With Nonvalvular Atrial Fibrillation. Clin Appl Thromb Hemost 2021; 27:10760296211044722. [PMID: 34559016 PMCID: PMC8495536 DOI: 10.1177/10760296211044722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/18/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Novel oral anticoagulants and warfarin are widely used for stroke prevention in patients with atrial fibrillation. The anticoagulation status of patients receiving warfarin or rivaroxaban has been studied. In this study, we aimed to evaluate the effect of dabigatran and warfarin on preventing thrombin generation (TG). METHODS This retrospective study enrolled 237 nonvalvular atrial fibrillation (NVAF) subjects treated with 110 mg dabigatran etexilate twice daily and 224 NVAF patients received adjusted-dose warfarin (international normalized ratio [INR] of 2 to 3)). Coagulation assays, prothrombin fragment 1 + 2 (F1+2), calibrated automated thrombogram, and thrombin-antithrombin complex (TAT) were detected at the steady state. RESULTS Activated partial thromboplastin time (APTT), antithrombin III activity, fibrinogen, and lag time showed no difference between the two groups. Compared to the dabigatran group, prothrombin time and INR values were higher in the warfarin group (all P < .001). Thrombin time, endogenous thrombin potential, peak TG (Cmax), F1+2, and TAT were lower in the warfarin group. The inhibition of TG was still stronger in the warfarin group when the patients were divided into subgroups. CONCLUSION Conventional coagulation assays are suboptimal for assessing the coagulation status of dabigatran. TG could be used as supplementary assays to evaluate the anticoagulation effect of oral anticoagulants. Our results suggest that warfarin may inhibit TG more aggressively than dabigatran in patients regardless of age and kidney function.
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Affiliation(s)
- Hongxia Li
- First Affiliated Hospital of Soochow
University, Suzhou 215006, Jiangsu, China
| | - Lei Zhang
- Binzhou Medical University
Hospital, Shandong, China
| | - Ming Xia
- Zhejiang Hospital, Hangzhou 310013, Zhejiang, China
| | - Chi Zhang
- First Affiliated Hospital of Soochow
University, Suzhou 215006, Jiangsu, China
| | - Tingbo Jiang
- First Affiliated Hospital of Soochow
University, Suzhou 215006, Jiangsu, China
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19
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Saour M, Zeroual N, Aubry E, Blin C, Gaudard P, Colson PH. Blood Loss Kinetics During the First 12 Hours After On-Pump Cardiac Surgical Procedures. Ann Thorac Surg 2020; 111:1308-1315. [PMID: 32896545 DOI: 10.1016/j.athoracsur.2020.06.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/04/2020] [Accepted: 06/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Anemia and coagulation management and a restrictive transfusion strategy are key points of blood management in patients undergoing cardiac surgical procedures. However, little consideration has been given to the kinetics of postoperative bleeding. This prospective observational study investigated bleeding kinetics from chest tubes to assess whether it was possible to predict, within the early postoperative hours, major bleeding at 12 postoperative hours. METHODS Adult cardiac surgical patients who were admitted consecutively to the postoperative intensive care unit in a tertiary academic hospital from January to June 2016 were included. Blood volume was collected from the chest drains, and major bleeding was defined as bleeding exceeding the 90th percentile of the volume distribution at 12 postoperative hours. Receiver operating characteristics curve analysis was performed with hourly bleeding thresholds to determine the best predictor of major bleeding. RESULTS In 292 patients, bleeding at 12 postoperative hours ranged from 60 to 2190 mL (median, 350 mL), and 30 patients had major bleeding, with a threshold of 675 mL. Bleeding volume declined logarithmically, 54% [IQR, 45% to 63%] within the first 4 hours. Patients with major bleeding had a higher bleeding volume every hour (P < .004). A good predictive value was observed within the first 2 hours (2.73 mL/kg; receiver operating characteristics area under the curve, 0.87 ± 0.04 [IQR, 0.79 to 0.94]; P< .001). CONCLUSIONS The hourly rate of chest tube blood loss seems to be relevant to predict, within the first postoperative hours after cardiac surgical procedures, major bleeding at 12 postoperative hours. Early detection of blood loss may help to improve a patient's blood conservation strategy because it may prompt preemptive treatments.
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Affiliation(s)
- Marine Saour
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Norddine Zeroual
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Emmanuelle Aubry
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Cinderella Blin
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; Department of Physiology and Experimental Medicine Heart Muscles, National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Montpellier University, Montpellier, France
| | - Pascal H Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Center, Montpellier, France; Institute for Functional Genomics, National Institute of Health and Medical Research (INSERM), National Center for Scientific Research (CNRS), Montpellier University, Montpellier, France.
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20
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Kwak J, Mazzeffi M, Boggio LN, Simpson ML, Tanaka KA. Hemophilia: A Review of Perioperative Management for Cardiac Surgery. J Cardiothorac Vasc Anesth 2020; 36:246-257. [DOI: 10.1053/j.jvca.2020.09.118] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 02/08/2023]
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21
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Shirozu K, Karashima Y, Yamaura K. Effect of antithrombin in fresh frozen plasma on hemostasis after cardiopulmonary bypass surgery. Perfusion 2020; 36:395-400. [PMID: 32781884 DOI: 10.1177/0267659120948435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Supplementation of fresh frozen plasma immediately after cardiopulmonary bypass is an effective method to enhance clotting ability as coagulation factors are consumed in the extracorporeal circuit during cardiopulmonary bypass. On the other hand, the anticoagulation factors in fresh frozen plasma can also deter the clotting ability. This study investigated the effect of fresh frozen plasma administration on the comprehensive clotting ability following cardiopulmonary bypass. METHODS This prospective observational study included 22 patients scheduled for cardiac surgery. Clotting times and maximum clot firmness were evaluated using the types of rotational thromboelastometry, intrinsic rotational thromboelastometry, and heparinase thromboelastography preoperatively, immediately after cardiopulmonary bypass, and 1 hour after cardiopulmonary bypass. Activated clotting time, antithrombin activity, and heparin concentration were also measured at these time-points. RESULTS Antithrombin activity (62.9 ± 7.2% vs. 51.1 ± 7.4%, p < 0.0001) and activated clotting time (132.6 ± 9.6% vs. 120.0 ± 9.0%, p < 0.001) were significantly higher 1 hour after cardiopulmonary bypass compared to measurements taken immediately after cardiopulmonary bypass. Heparin concentration 1 hour after cardiopulmonary bypass was significantly decreased compared to that immediately after cardiopulmonary bypass. On the other hand, maximum clot firmness determined via intrinsic rotational thromboelastometry was significantly greater 1 hour after cardiopulmonary bypass (53.8 ± 4.8 mm) than that immediately after cardiopulmonary bypass (49.5 ± 4.8 mm). Clotting time determined via intrinsic rotational thromboelastometry and heparinase thromboelastography was also significantly shorter 1 hour after cardiopulmonary bypass than that immediately after cardiopulmonary bypass. CONCLUSION Fresh frozen plasma administration increased antithrombin activity and caused activated clotting time prolongation, but then increased clotting ability. Thus, testing by rotational thromboelastometry after cardiopulmonary bypass could be valuable in the detection of comprehensive clotting ability.
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Affiliation(s)
- Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Yuji Karashima
- Operating Rooms, Kyushu University Hospital, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Lin PS, Yao YT. Perioperative Management of Hemophilia A Patients Undergoing Cardiac Surgery: A Literature Review of Published Cases. J Cardiothorac Vasc Anesth 2020; 35:1341-1350. [PMID: 32723585 DOI: 10.1053/j.jvca.2020.06.074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To investigate the perioperative management of patients with hemophilia A (HA) who undergo cardiac surgery. DESIGN Retrospective analysis of the published literature. SETTING University hospital. PARTICIPANTS HA patients undergoing cardiac surgery. INTERVENTIONS The PubMed, Embase, Web of Science Core Collection, CNKI, VIP, and WANFANG databases were searched with the terms "hemophilia A," "cardiac surgery," "cardiopulmonary bypass," "coronary artery bypass graft," "valve disease," and "congenital heart disease" to identify relevant articles. Data regarding patient characteristics, perioperative management protocols, and clinical outcomes were extracted and analyzed. MEASUREMENTS AND MAIN RESULTS Fifty articles, with 72 patients aging from 12 days to 80 years, were included. The analyzed population consisted of 36 (50%) mild HA, 10 (14%) moderate HA, and 25 (35%) severe HA patients. Factor VIII inhibitors were detected in 7 cases. Surgical procedures included 27 coronary artery bypass grafting procedures, 15 valve surgeries, 8 combined coronary artery bypass grafting with valve surgery procedures (1 with left ventricular assist device), 1 ventricular aneurysm resection with valve surgery, 11 corrections of congenital heart disease, 7 adult aortic surgeries, 3 heart transplantations, and 1 repair of heart injury. Factor VIII concentrates were used as a substitution therapy to ensure normalization of perioperative coagulation function. Although an uneventful clinical outcome was achieved in the majority of cases, 20% of patients developed complications with different severities. CONCLUSIONS Execution of a perioperative management strategy with a multidisciplinary approach, a thorough factor replacement protocol, and careful monitoring of factor levels facilitate an optimal outcome for HA patients undergoing cardiac surgery.
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Affiliation(s)
- Pei-Shuang Lin
- Department of Anesthesiology, Fujian Medical University Affiliated First Quanzhou Hospital, Fujian, China
| | - Yun-Tai Yao
- Department of Anesthesiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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23
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Judd M, Strauss ER, Hasan S, Abuelkasem E, Li J, Deshpande S, Mazzeffi MA, Ogawa S, Tanaka KA. Clotting Time Results Are Not Interchangeable Between EXTEM and FIBTEM on Rotational Thromboelastometry. J Cardiothorac Vasc Anesth 2020; 34:1467-1473. [DOI: 10.1053/j.jvca.2019.12.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
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Kabutoya T, Ohmori T, Fujiwara T, Kario K. Combination therapy with an Xa inhibitor and antihypertensive agent improved anticoagulant activity in patients with nonvalvular atrial fibrillation: the hypertension and atrial fibrillation treated by rivaroxaban for the morning and night with sYnergy with calcium antagonists (HARMONY) study. Clin Exp Hypertens 2020; 42:365-370. [PMID: 31542950 DOI: 10.1080/10641963.2019.1665678] [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: 10/25/2022]
Abstract
Background: Anticoagulant activity and blood pressure increase in the morning. The aim of this study was to evaluate changes of anticoagulant activity, blood pressure and target organ damage in patients with nonvalvular atrial fibrillation (AF) given combination treatment with Xa inhibitor and antihypertensive agent.Methods: We enrolled 72 patients with nonvalvular AF. Rivaroxaban (10-15 mg) was continuously administered once daily over 8 weeks (study period I). For subjects (n = 50) who exhibited uncontrolled morning hypertension (home systolic blood pressure [SBP]≥125 mmHg) at the end of study period I (at 8 weeks), nifedipine CR (20-40 mg) was added at bedtime, and rivaroxaban administration was continued an additional 8 weeks. We assessed prothrombin fragment 1 + 2 (optimal range: 69-229 pmol/L) and D-dimer (negative D-dimer measurement: <1.0 μg/mL).Results: The percentage of patients with optimal-range prothrombin fragment 1 + 2 was significantly increased at 4 weeks compared to baseline (70.8% vs. 86.1%, p = .033). In period II, office and home morning SBP were reduced at 12 compared to 8 weeks (office SBP: 135.2 ± 15.7 vs. 125.6 ± 18.4mmHg, p < .001; home morning SBP: 133.5 ± 10.5 vs. 119.9 ± 12.1mmHg, p<.001).The percentage of patients with negative D-dimer was increased at 8 weeks compared to baseline (92% vs. 100%, p = .044), and remained at 100% at 16 weeks.Conclusions: Xa inhibitor therapy improved anticoagulant activity, and additional antihypertensive therapy maintained the anticoagulant activity in patients with nonvalvular AF.
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Affiliation(s)
- Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke-shi, Japan
| | - Tsukasa Ohmori
- Department of Biochemistry, Jichi Medical University School of Medicine, Shimotsuke, Japan
| | - Takeshi Fujiwara
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke-shi, Japan
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine, Shimotsuke-shi, Japan
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Kwapisz MM, Kent B, DiQuinzio C, LeGare J, Garnett S, Swyer W, Whynot S, Mingo H, Scheffler M. The prophylactic use of fibrinogen concentrate in high-risk cardiac surgery. Acta Anaesthesiol Scand 2020; 64:602-612. [PMID: 31889306 DOI: 10.1111/aas.13540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 12/12/2019] [Accepted: 12/14/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Perioperative blood loss is a major contributor to morbidity and mortality in cardiac surgery. Plasma fibrinogen levels play an essential role in hemostasis and deplete quickly during hemorrhage. The objective of this study was to determine whether prophylactic fibrinogen concentrate administration lowers overall blood product transfusion requirements in high-risk cardiac surgery in patients with low fibrinogen plasma levels. METHODS The study was performed in a prospective, randomized, and double-blinded design. The investigation included 62 patients undergoing elective, high-risk cardiac surgery. After weaning from cardiopulmonary bypass and reversal of heparin patients received either fibrinogen concentrate or placebo. The primary outcome variable was overall blood product usage 24 hours after intervention. RESULTS The fibrinogen group received numerically fewer total units of blood products than the placebo group, but the difference was not statistically or clinically significant (for groups n = 27; n = 29 and 19 vs 37 units, respectively, P = .908). The overall transfusion rate in both groups was significantly lower than the institutional average suggested (fibrinogen group 26%, placebo group 28%). The fibrinogen group showed significantly higher fibrinogen levels (2.38 vs 1.83 g/L (end of surgery), P < .001; 3.33 vs 2.68 g/L (12 hours after intervention), P = .003) and improved viscoelastic coagulation parameters (FIBTEM MCF, 27 vs 23 mm, P = .022). CONCLUSION This randomized, controlled trial demonstrates that point-of-care guided and prophylactic treatment with fibrinogen concentrate does not reduce transfusion of blood products in a setting of unexpectedly low transfusion rate as tested in this cohort, but may improve coagulation parameters in the setting of high-risk cardiac surgery.
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Affiliation(s)
- Myron M. Kwapisz
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Blaine Kent
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Claudio DiQuinzio
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Jean‐François LeGare
- Department of Surgery Division of Cardiac Surgery New Brunswick Heart Centre Saint John NB Canada
| | - Shirley Garnett
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Willi Swyer
- Department of Surgery, Perfusion Services Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Sara Whynot
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Heather Mingo
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
| | - Matthias Scheffler
- Department of Anesthesia Pain Management and Perioperative Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax NS Canada
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Bolliger D, Lancé MD. Factor Concentrate-Based Approaches to Blood Conservation in Cardiac Surgery: European Perspectives in 2020. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00382-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Thrombin generation and bleeding in cardiac surgery: a clinical narrative review. Can J Anaesth 2020; 67:746-753. [PMID: 32133581 DOI: 10.1007/s12630-020-01609-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 12/27/2022] Open
Abstract
This narrative review discusses the role of thrombin generation in coagulation and bleeding in cardiac surgery, the laboratory methods for clinical detection of impaired thrombin generation, and the available hemostatic interventions that can be used to improve thrombin generation. Coagulopathy after cardiopulmonary bypass (CPB) is associated with excessive blood loss and adverse patient outcomes. Thrombin plays a crucial role in primary hemostasis, and impaired thrombin generation can be an important cause of post-CPB coagulopathy. Existing coagulation assays have significant limitations in assessing thrombin generation, but whole-blood assays designed to measure thrombin generation at the bed-side are under development. Until then, clinicians may need to institute therapy empirically for non-surgical bleeding in the setting of normal coagulation measures. Available therapies for impaired thrombin generation include administration of plasma, prothrombin complex concentrate, and bypassing agents (recombinant activated factor VII and factor eight inhibitor bypassing activity). In vitro experiments have explored the relative potency of these therapies, but clinical studies are lacking. The potential incorporation of thrombin generation assays into clinical practice and treatment algorithms for impaired thrombin generation must await further clinical development.
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Application of a Modified Extracorporeal Circulation Perfusion Method During Surgery for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2020; 29:1203-1209. [PMID: 32059950 DOI: 10.1016/j.hlc.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/10/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
AIM The aim of this study was to investigate the effect of the modified extracorporeal circulation perfusion method during surgery for acute Stanford type A aortic dissection in patients who underwent stented elephant trunk implantation and arch replacement. METHOD A total of 69 patients with acute Stanford type A aortic dissection who underwent stented elephant trunk implantation and arch replacement were retrospectively analysed from 2017 to 2018. According to the perfusion method of extracorporeal circulation, patients were divided into a routine perfusion (RP) group and a modified perfusion (MP) group. Clinical data were collected, including the time of extracorporeal circulation and deep hypothermic circulatory arrest, incidence of acute kidney injury and neurological complications, and comparisons between the two groups were conducted by using independent sample t-tests for normally distributed qualitative data, the Mann-Whitney U-test for skewed qualitative data, and the chi square test or Fisher's exact test for categorical data. RESULTS There were 55 (80%) males and 14 (20%) females in the entire cohort, and the mean ± standard deviation age was 50.4±9.0 years. A total of 53 (77%) patients were included in the RP group, and 16 (23%) were included in the MP group. Patients in the MP group were older (55.5±7.8 vs 48.8±8.9 years), and the difference was significant (p=0.008). Compared with the RP group, the time of extracorporeal circulation (218.0 [44.7] vs 246.0 [58.0] min; p=0.005) and deep hypothermic circulatory arrest (4.0 [2.0] vs 25.0 [10.0] min; p<0.001) was shorter, and the incidence of postoperative acute kidney injury (n=6 [37.5%] vs n=36 [67.9%]; p=0.029) was lower in the MP group; the differences were significant. Six (6) patients died in the RP group; no patients died in the MP group. The total in-hospital mortality rate was 8.7%. CONCLUSIONS The modified extracorporeal circulation perfusion method is feasible, with satisfactory results.
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Adam EH, Meier J, Klee B, Zacharowski K, Meybohm P, Weber CF, Pape A. Factor XIII activity in patients requiring surgical re-exploration for bleeding after elective cardiac surgery - A prospective case control study. J Crit Care 2019; 56:18-25. [PMID: 31805464 DOI: 10.1016/j.jcrc.2019.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/05/2019] [Accepted: 11/15/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Surgical re-exploration due to postoperative bleeding is associated with increased morbidity and mortality. The aim of our study was to assess a potential association between the level of postoperative FXIII activity and need for re-exploration due to bleeding in patients undergoing cardiothoracic surgery. MATERIALS AND METHODS In our prospective single center observational cohort study, we enrolled patients who underwent elective cardiothoracic surgery. Patients who required re-exploration (RE group) were matched to patients from the study population (non-RE group). RESULTS The study included 64 patients, out of a cohort of 678 patients, of whom 32 required surgical re-exploration due to bleeding within the first 24 h. Between patients of the RE and non-RE group, a significantly reduced FXIII activity was observed postoperatively (59.0 vs 71.1; p = .014). Multivariable analysis revealed reduced FXIII activity (p = .048) as a parameter independently associated with surgical re-exploration. Further, reduced FXIII activity (p = .037) and surgical re-exploration (p = .01) were significantly associated with increased 30 day mortality. In multivariable analysis re-exploration was independently associated with increased risk of 30 day mortality (p = .004, HR 9.68). CONCLUSIONS Reduced postoperative FXIII activity may be associated with the need for surgical re-exploration. Postoperative assessment of FXIII activity should therefore be considered in patients undergoing elective cardiothoracic surgery.
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Affiliation(s)
- Elisabeth H Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Jens Meier
- Department of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4021 Linz, Austria.
| | - Bernd Klee
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Christian F Weber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany; Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstr. 14, 22043 Hamburg, Germany.
| | - Andreas Pape
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
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Hasan S, Abuelkasem E, Williams B, Henderson R, Mazzeffi M, Tanaka K. Factor IX from prothrombin complex concentrate augments low dose tissue factor-triggered thrombin generation in vitro. Br J Anaesth 2018; 121:936-943. [DOI: 10.1016/j.bja.2018.05.063] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/14/2018] [Accepted: 06/02/2018] [Indexed: 11/17/2022] Open
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Pereira KMFSM, de Assis CS, Cintra HNWL, Ferretti-Rebustini REL, Püschel VAA, Santana-Santos E, Rodrigues ARB, de Oliveira LB. Factors associated with the increased bleeding in the postoperative period of cardiac surgery: A cohort study. J Clin Nurs 2018; 28:850-861. [PMID: 30184272 DOI: 10.1111/jocn.14670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 08/23/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
AIMS AND OBJECTIVES To identify factors associated with the increased bleeding in patients during the postoperative period after cardiac surgery. BACKGROUND Bleeding is among the most frequent complications that occur in the postoperative period after cardiac surgery, representing one of the major factors in morbidity and mortality. Understanding the factors associated with the increased bleeding may allow nurses to anticipate and prioritise care, thus reducing the mortality associated with this complication. DESIGN Prospective cohort study. METHODS Adult patients in a cardiac hospital who were in the postoperative period following cardiac surgery were included. Factors associated with the increased bleeding were investigated by means of linear regression, considering time intervals of 6 and 12 hr. RESULTS The sample comprised 391 participants. The factors associated with the increased bleeding in the first 6 hr were male sex, body mass index, cardiopulmonary bypass duration, anoxia duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative period. Predictors in the first 12 hr were body mass index, cardiopulmonary bypass duration, metabolic acidosis, higher heart rate, platelets and the activated partial thromboplastin time in the postoperative. CONCLUSIONS This study identified factors associated with the increased postoperative bleeding from cardiac surgery that have not been reported in previous studies. The nurse is important in the vigilance, evaluation and registry of chest tube drainage and modifiable factors associated with the increased bleeding, such as metabolic acidosis and postoperative heart rate, and in discussions with the multiprofessional team. RELEVANCE TO CLINICAL PRACTICE Knowledge of the factors associated with the increased bleeding is critical for nurses so they can provide prophylactic interventions and early postoperative treatment when needed.
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Affiliation(s)
- Kárla M F S M Pereira
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Caroline S de Assis
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Haulcionne N W L Cintra
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Vilanice A A Püschel
- Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de Sao Paulo, SP, BR
| | | | - Adriano Rogério B Rodrigues
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Larissa B de Oliveira
- Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR.,Medical-Surgical Nursing Department, Escola de Enfermagem da Universidade de Sao Paulo, SP, BR.,Nursing Department, Sociedade de Cardiologia do Estado de Sao Paulo, SP, BR
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Guan X, Gong M, Wang X, Zhu J, Liu Y, Sun L, Zhang H. Low preoperative fibrinogen level is risk factor for neurological complications in acute aortic dissection. Medicine (Baltimore) 2018; 97:e10830. [PMID: 29794773 PMCID: PMC6392557 DOI: 10.1097/md.0000000000010830] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aortic arch surgery in patients with acute aortic dissection is frequently complicated by neurological complications and coagulopathy. However, the relationship between the coagulation system and neurological complications in patients with acute aortic dissection has not been clarified. Thus, the aim of this study was to investigate the relationship between the coagulation system and neurological complications in patients with acute aortic dissection.From September 2014 to January 2016, a total of 126 patients with acute type A aortic dissection were enrolled. Perioperative characteristics and standard laboratory tests upon admission were analyzed using univariate and multivariate logistic regression analysis in this study. The primary outcome was the correlation between the coagulation system and neurological complications.Univariate logistic regression analysis showed that the neurological complications (+) group underwent more serious and complicated postoperative outcomes. Multivariable logistic regression analysis revealed serum creatinine level (OR, 1.049; 95% CI, 1.011-1.089; P = .01), white blood cell counts (OR, 1.581; 95% CI, 1.216-2.057; P = .001) and fibrinogen concentration upon admission (OR, 0.189; 95% CI, 0.060-0.596; P = .004) as predictors of neurological complications. However, we found that there was no association between the coagulation system and in-hospital mortality.Low preoperative fibrinogen level is the preferred marker for predicting clinical neurological complications in patients with acute type A aortic dissection treated with surgical repair.
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Nammas W, Dalén M, Rosato S, Gherli R, Reichart D, Gatti G, Onorati F, Faggian G, De Feo M, Bancone C, Chocron S, Khodabandeh S, Santarpino G, Rubino AS, Maselli D, Nardella S, Salsano A, Gherli T, Nicolini F, Zanobini M, Saccocci M, Bounader K, D’Errigo P, Kiviniemi T, Kinnunen EM, Perrotti A, Airaksinen J, Mariscalco G, Ruggieri VG, Biancari F. Impact of preoperative thrombocytopenia on the outcome after coronary artery bypass grafting. Platelets 2018; 30:480-486. [DOI: 10.1080/09537104.2018.1466389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Wail Nammas
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Stefano Rosato
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Marisa De Feo
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Ciro Bancone
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Sorosh Khodabandeh
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Santarpino
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany; Città di Lecce Hospital GVM Care&Research, Lecce, Italy
| | | | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Saverio Nardella
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Tiziano Gherli
- Division of Cardiac Surgery, University of Parma, Parma, Italy
| | | | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico – Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico – Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Paola D’Errigo
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Eeva-Maija Kinnunen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Vito G. Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Fausto Biancari
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Surgery, University of Turku, Turku, Finland
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Karkouti K, Callum J, Rao V, Heddle N, Farkouh ME, Crowther MA, Scales DC. Protocol for a phase III, non-inferiority, randomised comparison of a new fibrinogen concentrate versus cryoprecipitate for treating acquired hypofibrinogenaemia in bleeding cardiac surgical patients: the FIBRES trial. BMJ Open 2018; 8:e020741. [PMID: 29678987 PMCID: PMC5914770 DOI: 10.1136/bmjopen-2017-020741] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Coagulopathic bleeding is a serious complication of cardiac surgery to which an important contributor is acquired hypofibrinogenaemia (plasma fibrinogen <1.5-2.0 g/L). The standard intervention for acquired hypofibrinogenaemia is cryoprecipitate, but purified fibrinogen concentrates are also available. There is little comparative data between the two therapies and randomised trials are needed. METHODS AND ANALYSIS FIBrinogen REplenishment in Surgery (FIBRES) is a multicentre, randomised (1:1), active-control, single-blinded, phase III trial in adult cardiac surgical patients experiencing clinically significant bleeding related to acquired hypofibrinogenaemia. The primary objective is to demonstrate that fibrinogen concentrate (Octafibrin/Fibryga; Octapharma) is non-inferior to cryoprecipitate. All patients for whom fibrinogen supplementation is ordered by the clinical team within 24 hours of cardiopulmonary bypass will receive 4 g of fibrinogen concentrate or 10 units of cryoprecipitate (dose-equivalent to 4 g), based on random allocation and deferred consent. The primary outcome is total red cell, platelet and plasma transfusions administered within 24 hours of bypass. Secondary outcomes include major bleeding, fibrinogen levels and adverse events within 28 days. Enrolment of 1200 patients will provide >90% power to demonstrate non-inferiority. One preplanned interim analysis will include 600 patients. The pragmatic design and treatment algorithm align with standard practice, aiding adherence and generalisability. ETHICS AND DISSEMINATION The study is approved by the local research ethics board and will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practice guidelines and regulatory requirements. Patient consent prior to treatment is waived, as per criteria in the Tri-Council Policy Statement. Results will be published in the scientific/medical literature, and at international congresses. Non-inferiority of purified fibrinogen concentrate would support its use in acquired hypofibrinogenaemia. The results are likely to improve care for cardiac surgical patients experiencing significant bleeding, an understudied yet high-risk population. TRIAL REGISTRATION NUMBER NCT03037424; Pre-results.
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Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre and Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Peter Munk Cardiac Centre and Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Heddle
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Mark A Crowther
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Williams B, Wehman B, Mazzeffi MA, Odonkor P, Harris RL, Kon Z, Tanaka KA. Acute Intracardiac Thrombosis and Pulmonary Thromboembolism After Cardiopulmonary Bypass. Anesth Analg 2018; 126:425-434. [DOI: 10.1213/ane.0000000000002259] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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36
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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Paparella D, Rotunno C, Guida P, Travascia M, De Palo M, Paradiso A, Carrozzo A, Rociola R. Minimally invasive heart valve surgery: influence on coagulation and inflammatory response. Interact Cardiovasc Thorac Surg 2017; 25:225-232. [PMID: 28481998 DOI: 10.1093/icvts/ivx090] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 02/15/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Minimally invasive valve surgery (MIVS) is associated with improved clinical outcome but longer cardiopulmonary bypass (CPB) time. The aim of the present study is to compare inflammatory and coagulation parameters in patients undergoing minimally invasive or standard valve surgery. METHODS A prospective non-randomized study was performed enrolling 79 patients undergoing mitral (20 right mini-thoracotomy and 18 standard sternotomy) and aortic valve (20 mini-sternotomy and 21 standard sternotomy) procedures. Blood samples were collected perioperatively to measure prothrombin fragment 1.2 (PF1.2, thrombin generation), plasmin antiplasmin complex (PAP, fibrinolysis), interleukin-6 (IL-6, inflammation). Plasma free haemoglobin (f-Hb) was assessed to evaluate haemolysis. RESULTS Patients in the minimally invasive group were younger and had less comorbidities CPB and cross-clamp times were comparable considering both aortic and mitral procedures, but longer in the mini-thoracotomy group. IL-6 and PAP were reduced in the minimally invasive group, particularly 2 h after CPB (respectively 102 ± 114 vs 34 ± 49 pg/ml, P < 0.001 and 2137 ± 1046 vs 1207 ± 675 ng/ml, P < 0.001), PF1.2 was also reduced during and after the operation (688 ± 514 vs 571 ± 470, P = 0.02; 1600 ± 1185 vs 1042 ± 548, P < 0.001; 1487 ± 676 vs 1042 ± 541). Despite the use of vacuum-assisted active venous drainage (VAVD) f-Hb was significantly reduced in the minimally invasive group. The other routine biomarkers such as C-reactive protein, fibrinogen and cTnI were also reduced in the minimally invasive group. CONCLUSIONS In a selected cohort of patients MIVS is associated to reduced inflammatory reaction and coagulopathy, supporting the clinical evidence of reduced postoperative bleeding and lower transfusion rate. Our data offer further suggestion supporting the adoption of minimally invasive approaches.
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Affiliation(s)
- Domenico Paparella
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy.,Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Santa Maria Hospital, GVM Care and Research, Bari, Italy
| | - Crescenzia Rotunno
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy.,Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Santa Maria Hospital, GVM Care and Research, Bari, Italy
| | - Pietro Guida
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Mattia Travascia
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Micaela De Palo
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Andrea Paradiso
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Alessandro Carrozzo
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
| | - Ruggero Rociola
- Section of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari Aldo Moro, Bari, Italy
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Strauss E, Mazzeffi M, Williams B, Key N, Tanaka K. Perioperative management of rare coagulation factor deficiency states in cardiac surgery. Br J Anaesth 2017; 119:354-368. [DOI: 10.1093/bja/aex198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2017] [Indexed: 01/21/2023] Open
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40
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Murphy GJ, Mumford AD, Rogers CA, Wordsworth S, Stokes EA, Verheyden V, Kumar T, Harris J, Clayton G, Ellis L, Plummer Z, Dott W, Serraino F, Wozniak M, Morris T, Nath M, Sterne JA, Angelini GD, Reeves BC. Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gavin J Murphy
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Andrew D Mumford
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Veerle Verheyden
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jessica Harris
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Zoe Plummer
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - William Dott
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Filiberto Serraino
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Marcin Wozniak
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Mintu Nath
- Department of Cardiovascular Sciences and NIHR Leicester Biomedical Research Unit in Cardiovascular Medicine, University of Leicester, Leicester, UK
| | - Jonathan A Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Barnaby C Reeves
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
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41
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Mazzeffi MA, Lee K, Taylor B, Tanaka KA. Perioperative management and monitoring of antiplatelet agents: a focused review on aspirin and P2Y 12 inhibitors. Korean J Anesthesiol 2017; 70:379-389. [PMID: 28794832 PMCID: PMC5548939 DOI: 10.4097/kjae.2017.70.4.379] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 06/26/2017] [Indexed: 01/02/2023] Open
Abstract
Platelets play pivotal roles in hemostasis as well as pathological arterial thrombosis. The combination of aspirin and a P2Y12 inhibitor has become the mainstay therapy in the ageing population with cardiovascular conditions, particularly during and after percutaneous coronary intervention. A number of novel P2Y12 inhibitors has become available in the recent years, and they markedly vary in pharmacokinetic and pharmacodynamic properties. Perioperative physicians today face a challenge of preventing hemorrhage due to platelet inhibitors, while minimizing thrombotic risks. There are several point-of-care platelet function tests available in the peri-procedural assessment of residual platelet aggregation. However, these platelet function tests are not standardized in terms of sample processing, agonist type and potency as well as methods of detecting platelet activity. Understanding the differences in pharmacological properties of antiplatelet agents, principles of platelet function tests, and pertinent hemostatic strategies may be useful to anesthesiologists and intensivists who manage perioperative issues associated with antiplatelet agents. The objectives of this review are: 1) to discuss clinical data on aspirin and P2Y12 inhibitors relating to perioperative bleeding, 2) to outline different features of point-of-care platelet function tests, and 3) to discuss therapeutic options for the prevention and treatment of bleeding associated with antiplatelet agents.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Khang Lee
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley Taylor
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
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42
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Temporal changes in clot lysis and clot stability following tranexamic acid in cardiac surgery. Blood Coagul Fibrinolysis 2017; 28:295-302. [DOI: 10.1097/mbc.0000000000000595] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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43
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Odonkor P, Srinivas A, Strauss E, Williams B, Mazzeffi M, Tanaka KA. Perioperative Coagulation Management of a Hemophilia A Patient During Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2017; 21:312-320. [DOI: 10.1177/1089253217702747] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Perioperative management of cardiovascular surgical procedures requiring cardiopulmonary bypass (CPB) in patients with hemophilia A poses a clinical challenge in coagulation management. Use of CPB requires the administration of an anticoagulant, usually unfractionated heparin, and also causes dilutional coagulopathy, platelet dysfunction or platelet consumption coagulopathy. Hypothermia and activation of the inflammatory cascade also affect coagulation. The effects of CPB on circulating levels of factor VIII have not been clearly defined. In this review, the effects of CPB and hemodilution on FVIII are shown in a case presentation, and perioperative laboratory testing in patients with hemophilia A having cardiac surgery is discussed along with perioperative and postoperative coagulation management.
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Affiliation(s)
| | | | - Erik Strauss
- University of Maryland Medical System, Baltimore, MD, USA
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44
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Paparella D, Parolari A, Rotunno C, Vincent J, Myasoedova V, Guida P, De Palo M, Margari V, Devereaux PJ, Lamy A, Alamanni F, Yusuf S, Whitlock R. The Effects of Steroids on Coagulation Dysfunction Induced by Cardiopulmonary Bypass: A Steroids in Cardiac Surgery (SIRS) Trial Substudy. Semin Thorac Cardiovasc Surg 2017; 29:35-44. [DOI: 10.1053/j.semtcvs.2017.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2017] [Indexed: 11/11/2022]
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45
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Ghadimi K, Levy JH, Welsby IJ. Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting. Anesth Analg 2016; 122:1287-300. [PMID: 26983050 DOI: 10.1213/ane.0000000000001188] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Prothrombin complex concentrates (PCCs) contain vitamin K-dependent clotting factors (II, VII, IX, and X) and are marketed as 3 or 4 factor-PCC formulations depending on the concentrations of factor VII. PCCs rapidly restore deficient coagulation factor concentrations to achieve hemostasis, but like with all procoagulants, the effect is balanced against thromboembolic risk. The latter is dependent on both the dose of PCCs and the individual patient prothrombotic predisposition. PCCs are approved by the US Food and Drug Administration for the reversal of vitamin K antagonists in the setting of coagulopathy or bleeding and, therefore, can be administered when urgent surgery is required in patients taking warfarin. However, there is growing experience with the off-label use of PCCs to treat patients with surgical coagulopathic bleeding. Despite their increasing use, there are limited prospective data related to the safety, efficacy, and dosing of PCCs for this indication. PCC administration in the perioperative setting may be tailored to the individual patient based on the laboratory and clinical variables, including point-of-care coagulation testing, to balance hemostatic benefits while minimizing the prothrombotic risk. Importantly, in patients with perioperative bleeding, other considerations should include treating additional sources of coagulopathy such as hypofibrinogenemia, thrombocytopenia, and platelet disorders or surgical sources of bleeding. Thromboembolic risk from excessive PCC dosing may be present well into the postoperative period after hemostasis is achieved owing to the relatively long half-life of prothrombin (factor II, 60-72 hours). The integration of PCCs into comprehensive perioperative coagulation treatment algorithms for refractory bleeding is increasingly reported, but further studies are needed to better evaluate the safe and effective administration of these factor concentrates.
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Affiliation(s)
- Kamrouz Ghadimi
- From the Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
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46
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Ellis J, Valencia O, Crerar-Gilbert A, Phillips S, Meeran H, Sharma V. Point-of-care platelet function testing to predict blood loss after coronary artery bypass grafting surgery: a prospective observational pilot study. Perfusion 2016; 31:676-682. [DOI: 10.1177/0267659116656774] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aim: With an increase in the number of patients who are on antiplatelet medications until the day of surgery, we undertook a prospective observational study to assess the ability of thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate to detect platelet dysfunction and predict blood loss following coronary artery bypass grafting (CABG) surgery. Methods: Platelet function was evaluated pre- and post-cardiopulmonary bypass via thromboelastography, thromboelastography platelet mapping and aggregometry via multiplate in 52 patients undergoing coronary artery bypass grafting surgery. The median chest tube drainage of all patients in the study was ascertained to stratify patients into two groups: patients with and those without evidence of excessive blood loss after cardiac surgery. Results: Although all modalities could detect a decrease in platelet function following cardiopulmonary bypass, univariate and multivariate regression analysis identified preoperative arachidonic acid and adenosine diphosphate testing via multiplate as independent predictors of bleeding after cardiac surgery. Receiver operating curves on these multiplate parameters showed an area under the curve of 0.68 (p=0.03) and 0.66 (p=0.01) for arachidonic acid and adenosine diphosphate assays, respectively. Conclusion: This pilot study shows that preoperative multiplate testing may be a better predictor of platelet dysfunction and the resultant blood loss following cardiac surgery.
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Affiliation(s)
- James Ellis
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | | | | | - Simon Phillips
- Department of Clinical Perfusion, St George’s Hospital, London, UK
| | - Hanif Meeran
- Department of Anaesthesia, St George’s Hospital, London, UK
| | - Vivek Sharma
- Department of Anaesthesia, St George’s Hospital, London, UK
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47
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Höfer J, Fries D, Solomon C, Velik-Salchner C, Ausserer J. A Snapshot of Coagulopathy After Cardiopulmonary Bypass. Clin Appl Thromb Hemost 2016; 22:505-11. [DOI: 10.1177/1076029616651146] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cardiac surgery involving cardiopulmonary bypass (CPB) is often associated with important blood loss, allogeneic blood product usage, morbidity, and mortality. Coagulopathy during CPB is complex, and the current lack of uniformity for triggers and hemostatic agents has led to a wide variability in bleeding treatment. The aim of this review is to provide a simplified picture of the data available on patients’ coagulation status at the end of CPB in order to provide relevant information for the development of tailored transfusion algorithms. A nonsystematic literature review was carried out to identify changes in coagulation parameters during CPB. Both prothrombin time and activated partial thromboplastin time increased during CPB, by a median of 33.3% and 17.9%, respectively. However, there was marked variability across the published studies, indicating these tests may be unreliable for guiding hemostatic therapy. Some thrombin generation (TG) parameters were affected, as indicated by a median increase in TG lag time of 55.0%, a decrease in TG peak of 17.5%, and only a slight decrease in endogenous thrombin potential of 7%. The most affected parameters were fibrinogen levels and platelet count/function. Both plasma fibrinogen concentration and FIBTEM maximum clot firmness decreased during CPB (median change of 36.4% and 33.3%, respectively) as did platelet count (44.5%) and platelet component (34.2%). This review provides initial information regarding changes in coagulation parameters during CPB but highlights the variability in the reported results. Further studies are warranted to guide physicians on the parameters most appropriate to guide hemostatic therapy.
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Affiliation(s)
- Judith Höfer
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Dietmar Fries
- Department of Surgical and General Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Cristina Solomon
- Department of Anesthesiology, Perioperative Care and General Intensive Care, Paracelsus Medical University, Salzburg University Hospital, Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology and AUVA Research Centre, Vienna, Austria
- CSL Behring, Marburg, Germany
| | - Corinna Velik-Salchner
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Julia Ausserer
- Department of Anesthesiology and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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48
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Dzemali O, Ganter MT, Zientara A, Graves K, Behr R, Genoni M, Hofer CK. Evaluation of a New Sonoclot Device for Heparin Management in Cardiac Surgery. Clin Appl Thromb Hemost 2016; 23:20-26. [DOI: 10.1177/1076029616651148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient’s coagulation status by glass bead–activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. Methods: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. Results: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = −14.7%). Comparing S2 and S1, the glass bead–activated tests showed mean percentage differences of −18.9% (gbACTs), +37.4% (CR), and −3.7% (PF). Conclusion: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.
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Affiliation(s)
- Omer Dzemali
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Michael T. Ganter
- Institute of Anaesthesiology and Pain Medicine, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Alicja Zientara
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Kirk Graves
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Renate Behr
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Michele Genoni
- Division of Cardiac Surgery, Triemli City Hospital, Zurich, Switzerland
| | - Christoph K. Hofer
- Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital, Zurich, Switzerland
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49
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Fibrinogen Levels After Cardiac Surgical Procedures: Association With Postoperative Bleeding, Trigger Values, and Target Values. Ann Thorac Surg 2016; 102:78-85. [DOI: 10.1016/j.athoracsur.2016.01.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 12/15/2015] [Accepted: 01/04/2016] [Indexed: 11/24/2022]
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50
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Paparella D. Hemostatic alteration during coronary artery bypass grafting: Which is the target? Thromb Res 2016; 140:147-148. [PMID: 26928139 DOI: 10.1016/j.thromres.2016.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Accepted: 02/13/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Domenico Paparella
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari "Aldo Moro", Bari, Italy.
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