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Faraoni D, Guindi A, Ankola AA, Resheidat A, Binsalamah Z, Teruya J, Savorgnan F, Vener DF. Retrospective Comparison of Recombinant Activated Factor VII Versus 4-Factor Prothrombin Complex Concentrate in Cardiac Surgical Patients. J Cardiothorac Vasc Anesth 2024; 38:388-393. [PMID: 38129208 DOI: 10.1053/j.jvca.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/08/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To compare the incidences of postoperative thrombotic complications, transfusion of blood products, and chest tube output in congenital cardiac surgical patients who received either recombinant activated factor VII (rFVIIa) or 4-factor prothrombin complex concentrate (4F-PCC). DESIGN We performed a retrospective study. SETTING Patients who underwent surgery at a tertiary academic hospital. PARTICIPANTS Pediatric patients who underwent cardiac surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were obtained from the Society of Thoracic Surgeons and the Pediatric Cardiac Critical Care Consortium databases, as well as from manual chart review. Adjusted p values were obtained from multivariate regression using age (days), surgeon (number), cardiopulmonary bypass time (minutes), and need for deep hypothermic circulatory arrest (yes/no). A total of 55 patients were included in the 4F-PCC group, and 89 in the rFVIIa group. The median dose of rFVIIa was 77 mcg/kg (46-88), and the median dose of 4F-PCC was 31 IU/kg (24-43). The incidences of thrombotic complications were 8% in the 4F-PCC group and 30% in the rFVIIa group (adjusted p = 0.023). No difference was reported between the groups regarding chest tube output on days 1 and 2 or transfusion of blood products. Using a sensitivity analysis with propensity matching, the incidence of thrombosis was 10% in the 4F-PCC group (n = 38), and 31% in the rFVIIa group (n = 39) (p = 0.036). No difference was reported in terms of bleeding or transfusion. CONCLUSIONS This retrospective study suggested that the administration of rFVIIa was associated with a higher risk of thrombotic complications when compared to 4F-PCC, without benefits in terms of bleeding and transfusions.
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Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.
| | - Anna Guindi
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ashish A Ankola
- Division of Critical Care & Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ashraf Resheidat
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Ziyad Binsalamah
- Division of Pediatric Congenital Heart Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jun Teruya
- Division of Transfusion Medicine & Coagulation, Department of Pathology & Immunology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Fabio Savorgnan
- Division of Critical Care & Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - David F Vener
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
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Moiseiwitsch N, Nellenbach KA, Downey LA, Boorman D, Brown AC, Guzzetta NA. Influence of Fibrinogen Concentrate on Neonatal Clot Structure When Administered Ex Vivo After Cardiopulmonary Bypass. Anesth Analg 2023; 137:682-690. [PMID: 36727748 DOI: 10.1213/ane.0000000000006357] [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: 02/03/2023]
Abstract
BACKGROUND Bleeding is a serious complication of cardiopulmonary bypass (CPB) in neonates. Blood product transfusions are often needed to adequately restore hemostasis, but are associated with significant risks. Thus, neonates would benefit from other effective, and safe, hemostatic therapies. The use of fibrinogen concentrate (FC; RiaSTAP, CSL Behring, Marburg, Germany) is growing in popularity, but has not been adequately studied in neonates. Here, we characterize structural and degradation effects on the neonatal fibrin network when FC is added ex vivo to plasma obtained after CPB. METHODS After approval by the institutional review board and parental consent, blood samples were collected from neonates undergoing cardiac surgery and centrifuged to yield platelet poor plasma. Clots were formed ex vivo from plasma obtained at several time points: (1) baseline, (2) immediately post-CPB, and (3) post-transfusion of cryoprecipitate. In addition, we utilized post-CPB plasma to construct the following conditions: (4) post-CPB +0.5 mg/mL FC, and (5) post-CPB +0.9 mg/mL FC. The resultant fibrin networks were imaged using confocal microscopy to analyze overall structure, fiber density, and alignment. Clots were also analyzed using a microfluidic degradation assay. Fibrinogen content was quantified for all plasma samples. RESULTS The addition of 0.5 or 0.9 mg/mL FC to post-CPB samples significantly enhanced the median fiber density when compared to untreated post-CPB samples (post-CPB = 0.44 [interquartile range {IQR}: 0.36-0.52], post-CPB +0.5 mg/mL FC = 0.69 [0.56-0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59-0.96]; P = .01 and P = .006, respectively). The addition of 0.9 mg/mL FC to post-CPB samples resulted in a greater fiber density than that observed after the in vivo transfusion of cryoprecipitate (post-transfusion = 0.54 [0.45-0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59-0.96]; P = .002). Median fiber alignment did not differ significantly between post-CPB samples and samples treated with FC. Degradation rates were not statistically significant from baseline values with either 0.5 or 0.9 mg/mL FC. In addition, we found a significant correlation between the difference in the baseline and post-CPB fibrinogen concentration with patient age ( P = .033) after controlling for weight. CONCLUSIONS Our results show that clots formed ex vivo with clinically relevant doses of FC (0.9 mg/mL) display similar structural and degradation characteristics compared to the in vivo transfusion of cryoprecipitate. These findings suggest that FC is effective in restoring structural fibrin clot properties after CPB. Future studies after the administration of FC in vivo are needed to validate this hypothesis.
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Affiliation(s)
- Nina Moiseiwitsch
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Kimberly A Nellenbach
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Laura A Downey
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David Boorman
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ashley C Brown
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
- Department of Material Science and Engineering, North Carolina State University, Raleigh, North Carolina
| | - Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Quinlan CA, Latham GJ, Joffe D, Ross FJ. Perioperative and Anesthetic Considerations in Tetralogy of Fallot With Pulmonary Atresia. Semin Cardiothorac Vasc Anesth 2021; 25:218-228. [DOI: 10.1177/10892532211027395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Tetralogy of Fallot with pulmonary atresia (ToF-PA) is a rare diagnosis that includes an extraordinarily heterogeneous group of complex anatomical findings with significant implications for physiology and prognosis. In addition to the classic findings of ToF, this particular diagnosis is characterized by complete failure of forward flow from the right ventricle to the pulmonary arterial system. As such, pulmonary blood flow is entirely dependent on shunting from the systemic circulation, most frequently via a patent ductus arteriosus, major aortopulmonary collaterals, or a combination of the two. The pathophysiology of ToF-PA is largely attributable to the abnormalities of the pulmonary vasculature. Ultimately, these patients require operative intervention to create a reliable, controlled source of pulmonary blood flow and ideally complete intracardiac repair. Even after operative correction, these patients remain at risk for pulmonary arterial stenoses and pulmonary hypertension. Although there have been significant advances in surgical and interventional management of ToF-PA leading to dramatic improvements in survival and long-term functional status, there is ongoing debate about the optimal management strategy given the risk of development of irreversible abnormalities of the pulmonary vasculature and the morbidity and mortality associated with sometimes multiple, complex operative interventions often occurring early in infancy. This review will discuss the findings in patients with ToF-PA with a focus on the perioperative and anesthetic management and will highlight challenges faced by the anesthesiologist in caring for these patients.
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Understanding and managing the complex balance between bleeding and thrombosis following cardiopulmonary bypass in paediatric cardiac surgical patients. Cardiol Young 2021; 31:1251-1257. [PMID: 34024303 DOI: 10.1017/s1047951121001955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Bleeding in the perioperative period of congenital heart surgery with cardiopulmonary bypass is associated with increased morbidity and mortality both from the direct effects of haemorrhage as well as the therapies deployed to restore haemostasis. Perioperative bleeding is complex and multifactorial with both patient and procedural contributions. Moreover, neonates and infants are especially at risk. The objective of this review is to summarise the evidence regarding bleeding management in paediatric surgical patients and identify strategies that might facilitate appropriate bleeding management while minimising the risk of thrombosis. We will address the use of standard and point-of-care tests, and the role of contemporary coagulation factors and other novel drugs.
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Wise-Faberowski L, Irvin M, Quinonez ZA, Long J, Asija R, Margetson TD, Hanley FL, McElhinney DB. Transfusion Outcomes in Patients Undergoing Unifocalization and Repair of Tetralogy of Fallot With Major Aortopulmonary Collaterals. World J Pediatr Congenit Heart Surg 2020; 11:159-165. [PMID: 32093560 DOI: 10.1177/2150135119892192] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical repair of tetralogy of Fallot and major aortopulmonary collaterals (TOF/MAPCAs) involves unifocalization of MAPCAs and reconstruction of the pulmonary arterial circulation. Surgical and cardiopulmonary bypass (CPB) times are long and suture lines are extensive. Maintaining patency of the newly anastomosed vessels while achieving hemostasis is important, and assessment of transfusion practices is critical to successful outcomes. METHODS Clinical, surgical, and transfusion data in patients with TOF/MAPCAs repaired at our institution (2013-2018) were reviewed. Types and volumes of blood products used in the perioperative period, in addition to the use of antifibrinolytics and/or procoagulants (factor VIII inhibitor bypassing activity [FEIBA]; anti-inhibitor coagulant complex), were assessed. Outcome measures included days on mechanical ventilation (DOMV), postoperative intensive care unit and hospital length of stay (LoS), and incidence of thrombosis. RESULTS Perioperative transfusion data from 279 patients were analyzed. Surgical (879 ± 175 minutes vs 684 ± 257 minutes) and CPB times (376 ± 124 minutes vs 234 ± 122 minutes) were longer in patients who received FEIBA than those who did not. Although the indexed volume of packed red blood cells (128.4 ± 82.2 mL/kg) and fresh frozen plasma (64.2 ± 41.1 mL/kg) was similar in patients who did and did not receive FEIBA, the amounts of cryoprecipitate (5.5 ± 5.2 mL/kg vs 5.8 ± 4.8 mL/kg) and platelets (19.5 ± 20.7 mL/kg vs 20.8 ± 13 mL/kg) transfused were more in those who did receive FEIBA. CONCLUSION Perioperative transfusion is an important component in the overall surgical and anesthetic management of patients with TOF/MAPCAs. The intraoperative use of FEIBA was not associated with a decrease in the amount of blood products transfused, DOMV, or LoS or with an increase in thrombotic complications.
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Affiliation(s)
- Lisa Wise-Faberowski
- Department of Anesthesiology, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Matthew Irvin
- Clinical and Translational Research Program, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Zoel A Quinonez
- Department of Anesthesiology, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Jin Long
- Quantitative Sciences Unit, Department of Medicine, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Ritu Asija
- Department of Pediatrics, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Tristan D Margetson
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Frank L Hanley
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
| | - Doff B McElhinney
- Clinical and Translational Research Program, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA.,Department of Pediatrics, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA.,Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital Heart Center, Stanford University, Stanford, CA, USA
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6
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Carroll RB, Zaki H, McCracken C, Figueroa J, Guzzetta NA. Use of Factor VIIa and Anti-inhibitor Coagulant Complex in Pediatric Cardiac Surgery Patients. J Pediatr Pharmacol Ther 2020; 25:540-546. [PMID: 32839658 DOI: 10.5863/1551-6776-25.6.540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Postoperative bleeding is a common cause of morbidity and mortality in cardiac patients who undergo cardiopulmonary bypass (CPB). Pediatric patients are especially at risk for adverse effects of surgery and CPB on the coagulation system. This can result in bleeding, transfusions, and poor outcomes. Excessive bleeding unresponsive to blood products can warrant the off-label use of recombinant activated clotting factor VIIa (rFVIIa) and/or anti-inhibitor coagulant complex (FEIBA). Several studies have shown the utility in these agents off-label in patients who have undergone cardiac bypass surgery with acute bleeding episodes that are refractory to blood products. However, data regarding use of these agents in pediatrics are sparse. The purpose of this study is to report the use of rFVIIa and FEIBA in pediatric cardiac surgery patients in our institution. METHODS This was a retrospective chart review of pediatric cardiothoracic surgery patients who received rFVIIa or FEIBA at Children's Healthcare of Atlanta during the study period. RESULTS Thirty-three patients received rFVIIa and 9 patients received FEIBA either intraoperatively or postoperatively for bleeding related to the cardiac procedure. Approximately 13% of rFVIIa patients and 55% of FEIBA patients required repeat doses. There were decreases for all blood products administered after rFVIIa and FEIBA were given. However, the doses used did not correlate with either positive or negative outcomes. Seventeen percent (n = 7) of rFVIIa patients experienced a thrombus and 22% (n = 2) of FEIBA patients experienced a thrombus. CONCLUSIONS Both rFVIIa and FEIBA reduced blood product usage in pediatric patients following cardiac procedures.
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7
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Post-operative blood loss is higher among African American neonates undergoing open-heart surgery with cardiopulmonary bypass for CHD. Cardiol Young 2020; 30:74-81. [PMID: 31806066 DOI: 10.1017/s1047951119002683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neonates are at high risk of bleeding after open-heart surgery. We sought to determine pre-operative and intra-operative risk factors for increased bleeding after neonatal open-heart surgery with cardiopulmonary bypass. METHODS We conducted a retrospective cohort study of neonates (0-30 days old) who underwent open-heart surgery with cardiopulmonary bypass from January, 2009, to March, 2013. Cardiac diagnosis; demographic and surgical data; and blood products, haemostatic agents, and anti-thrombotic agents administered before, during, and within 24 hours after surgery were abstracted from the electronic health record and anaesthesia records. The outcome of interest was chest tube output (in ml/kg body weight) within 24 hours. Relationships between chest tube output and putative associated factors were evaluated by unadjusted and adjusted linear regression. RESULTS The cohort consisted of 107 neonates, of whom 79% had a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Category of 4 or 5. Median chest tube output was 37 ml/kg (range 9-655 ml/kg). Age, African-American race, and longer durations of surgery and cardiopulmonary bypass each had statistically significant associations with increased chest tube output in unadjusted analyses. In multivariable analysis, African-American race retained an independent, statistically significant association with increased chest tube output; the geometric mean of chest tube output among African-American neonates was 71% higher than that of Caucasians (95% confidence interval, 29-125%; p = 0.001). CONCLUSION Among neonates with CHD undergoing open-heart surgery with cardiopulmonary bypass, African-American race is independently associated with greater chest tube output over the first 24 hours post-operatively.
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8
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Scott JP. Recombinant activated factor seven in pediatric cardiac surgery-does thrombotic risk outweigh hemostatic benefit? Transl Pediatr 2019; 8:465-467. [PMID: 31993363 PMCID: PMC6970117 DOI: 10.21037/tp.2019.10.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- John P Scott
- Department of Anesthesiology and Pediatrics, Sections of Pediatric Anesthesiology and Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
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Ghorbaninezhad K, Bakhsha F, Yousefi Z, Halakou S, Mehrbakhsh Z. Comparison Effect of Tranexamic Acid (TA) and Tranexamic Acid Combined with Vitamin C (TXC) on Drainage Volume and Atrial Fibrillation Arrhythmia in Patients Undergoing Cardiac Bypass Surgery: Randomized Clinical Trial. Anesth Pain Med 2019; 9:e96096. [PMID: 31903334 PMCID: PMC6935295 DOI: 10.5812/aapm.96096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Tranexamic acid and vitamin C are potent antifibrinolytic and oxidative stress agents that reduce blood loss and transfusion blood in cardiopulmonary bypass (CPB). OBJECTIVES The aim of this study was to evaluate the efficacy of tranexamic acid (TA) and tranexamic acid combined with vitamin C (TXC) on drainage volume (blood loss) and atrial fibrillation (AF) in patients undergoing cardiac bypass surgery in Gorgan, Shafa hospital, Iran. METHODS This study is a double-blind randomized clinical trial. A sample size of 120 candidates of cardiac bypass surgery were included in this prospective study. Patients were randomly assigned to treatments in two groups. In both groups, 50 mg/kg tranexamic acid was administered intravenously directly before sternotomy: group A (N = 58) patients received tranexamic acid (TA) only and group B (N = 62) tranexamic acid with vitamin C (TXC) half an hour before surgery and 2 g vitamin C with 100 mL 0.9% saline were injected. Subsequently, during 4 days after surgery, 1000 mg of vitamin C and 100 cc 0.9% saline was infused every day. Intraoperative and postoperative blood loss (volume of blood in the drain) and atrial fibrillation complications were recorded for 24 hours after the operation. RESULTS The patients who received vitamin C had less bleeding during operation and in the early hours post-operation. Patients in (TA) group had mean drainage of 34.41 milliliter more than patients in (TXC) group (P < 0.001). Chi-square test showed that arrhythmia (AF) condition was the same in the two groups during 14 times of study (four times during operation and ten times up to 24 hours after the operation), and AF arrhythmia in the two groups was less than 5%. CONCLUSIONS In this study tranexamic acid with vitamin C have a positive effect on the amount of drainage (blood loss) and there was no significant difference in the incidence of AF between two groups.
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Affiliation(s)
| | - Fozieh Bakhsha
- Department of Paramedical School, Golestan University of Medical Sciences, Gorgan, Iran
| | - Zahra Yousefi
- Department of Paramedical School, Golestan University of Medical Sciences, Gorgan, Iran
| | - Solmaz Halakou
- Department of Paramedical School, Golestan University of Medical Sciences, Gorgan, Iran
| | - Zahra Mehrbakhsh
- Department of Biostatistics, Faculty of Healt, Golestan University of Medical Sciences, Gorgan, Iran
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Machovec KA, Jooste EH. Pediatric Transfusion Algorithms: Coming to a Cardiac Operating Room Near You. J Cardiothorac Vasc Anesth 2019; 33:2017-2029. [DOI: 10.1053/j.jvca.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 01/27/2023]
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Christoff AS, Winlaw DS, Curtin J, Barnes EH, Egan JR. Recombinant activated factor VII in neonatal cardiac surgery. Eur J Cardiothorac Surg 2019; 55:817-822. [DOI: 10.1093/ejcts/ezy483] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/10/2018] [Accepted: 12/21/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrea S Christoff
- Paediatric Intensive Care Unit, The Children’s Hospital at Westmead, Sydney, Australia
| | - David S Winlaw
- Cardiothoracic Surgery Department, The Children’s Hospital at Westmead, Sydney, Australia
- Heart Centre for Children, Sydney Children’s Hospitals Network, Sydney, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
| | - Julie Curtin
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
- Haematology Department, Sydney Children’s Hospitals Network, Sydney, Australia
| | - Elizabeth H Barnes
- Faculty of Medicine and Health, National Health and Medical Research Council Clinical Trials Centre, The University of Sydney, Sydney, Australia
| | - Jonathan R Egan
- Paediatric Intensive Care Unit, The Children’s Hospital at Westmead, Sydney, Australia
- Heart Centre for Children, Sydney Children’s Hospitals Network, Sydney, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, Australia
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Takeshita S, Ogawa S, Nakayama Y, Mukai N, Nakajima Y, Mizobe T, Sawa T, Tanaka KA. Prohemostatic Activity of Factor X in Combination With Activated Factor VII in Dilutional Coagulopathy. Anesth Analg 2018; 129:339-345. [PMID: 30320649 DOI: 10.1213/ane.0000000000003858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) concentrate reduces allogeneic blood transfusions, but it may increase thromboembolic complications in complex cardiac surgery. The mixture of activated factor VII (FVIIa) and factor X (FX) (FVIIa/FX) (FVIIa:FX = 1:10) is a novel bypassing agent for hemophilia patients. We hypothesized that the combination of FX and FVIIa could improve thrombin generation (TG) in acquired multifactorial coagulation defects such as seen in cardiac surgery and conducted in vitro evaluation of FVIIa/FX in parallel with other coagulation factor concentrates using in vitro and in vivo diluted plasma samples. METHODS Plasma samples were collected from 9 healthy volunteers and 12 cardiac surgical patients. We measured TG (Thrombinoscope) using in vitro 50% dilution plasma and in vivo dilution plasma after cardiopulmonary bypass, in parallel with thromboelastometry (ROTEM) and standard coagulation assays. In vitro additions of FVIIa/FX (0.35, 0.7, and 1.4 μg/mL, based on the FVIIa level), rFVIIa (1.4, 2.8, and 6.4 μg/mL), prothrombin complex concentrate (0.3 international unit), and 20% plasma replacement were evaluated. RESULTS In diluted plasma, the addition of either FVIIa/FX or rFVIIa shortened the lag time and increased the peak TG, but the effect in lag time of FVIIa/FX at 0.35 μg/mL was more extensive than rFVIIa at 6.4 μg/mL. Prothrombin complex concentrate increased peak TG by increasing the prothrombin level but failed to shorten the lag time. No improvement in any of the TG variables was observed after 20% volume replacement with plasma. The addition of factor concentrates normalized prothrombin time/international normalized ratio but not with plasma replacement. In cardiac patients, similar patterns were observed on TG in post-cardiopulmonary bypass samples. FVIIa/FX shortened clotting time (CT) in a concentration-dependent manner on CT on thromboelastometry. Plasma replacement did not improve CT, but a combination of plasma and FVIIa/FX (0.35 μg/mL) more effectively shortened CT than FVIIa/FX alone. CONCLUSIONS The combination of FVIIa and FX improved TG more efficiently than rFVIIa alone or plasma in dilutional coagulopathy models. The required FVIIa dose in FVIIa/FX was considerably lower than those reported during bypassing therapy in hemophilia patients (1.4-2.8 μg/mL). The combination of plasma could restore coagulation more efficiently compared to FVIIa/FX alone. Lesser FVIIa requirement to exert procoagulant activity may be favorable in terms of reducing systemic thromboembolic complications.
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Affiliation(s)
- Shusuke Takeshita
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoru Ogawa
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinobu Nakayama
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuhiro Mukai
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kansai Medical University, Osaka, Japan
| | - Toshiki Mizobe
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- From the Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenichi A Tanaka
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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15
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Abstract
PURPOSE OF REVIEW Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SUMMARY This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.
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Guzzetta NA, Zabala L, Mossad EB. The Congenital Cardiac Anesthesia Society: An Update on the First Twelve Years. J Cardiothorac Vasc Anesth 2017; 31:1939-1942. [DOI: 10.1053/j.jvca.2017.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Indexed: 11/11/2022]
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Smith MM, Ashikhmina E, Brinkman NJ, Barbara DW. Perioperative Use of Coagulation Factor Concentrates in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1810-1819. [DOI: 10.1053/j.jvca.2017.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 11/11/2022]
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Downey L, Brown ML, Faraoni D, Zurakowski D, DiNardo JA. Recombinant Factor VIIa Is Associated With Increased Thrombotic Complications in Pediatric Cardiac Surgery Patients. Anesth Analg 2017; 124:1431-1436. [PMID: 28319507 DOI: 10.1213/ane.0000000000001947] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is routinely used as an off-label hemostatic agent in children undergoing cardiac surgery. Despite evidence that rFVIIa use is associated with an increased incidence of thrombotic complications in adult cardiac surgery, the safety of rFVIIa as a rescue hemostatic agent in the pediatric cardiac surgical population is less definitively delineated. In this retrospective study, we used propensity score matching to compare the incidence of thrombotic complications between children treated with rFVIIa and their matched controls. METHODS We retrospectively reviewed medical records and pharmacy data from all neonates and children who underwent congenital cardiac surgery between May 1, 2011, and October 31, 2013, at Boston Children's Hospital, and identified those who received rFVIIa during the perioperative period. Using existing knowledge, we chose 10 factors associated with bleeding after cardiac surgery to be used in our propensity score: age, sex, body weight, neonates, prematurity, previous sternotomy, cardiopulmonary bypass time, deep hypothermic circulatory arrest time, aortic cross-clamp time, and the operative surgeon. We then used propensity-matched analysis to match children treated with rFVIIa with 2 controls. The primary outcome was thrombotic complications. Secondary outcomes included reexploration for bleeding, length of cardiac intensive care unit stay, length of hospital stay, and 30-day mortality. RESULTS One hundred forty-nine patients received perioperative rFVIIa during the study period. Propensity matching yielded 143 rFVIIa patients matched to 2 control patients each (n = 286). Three control patients were found to have received rFVIIa during the perioperative course and were removed from the analysis, for a total of 283 control patients. The administration of rFVIIa was associated with an increased incidence of thrombotic complications (20% vs 8%; odds ratio [OR]: 3.9 [95% confidence interval {CI}: 2.6-5.9], P < .001). Administration of rFVIIa was associated with a prolonged median length of cardiac intensive care unit stay (8 days [interquartile range {IQR}: 4-24] vs 5 days [IQR: 2-10], P < .001) and prolonged length of hospital stay (20 [IQR: 9-44] vs 11 days [IQR: 7-23], P < .001). No difference in reexploration for bleeding (rFVII = 14% vs controls = 9%; OR: 1.7 [95% CI, 0.92-3.1], P = .12) or 30-day mortality was observed (8% vs 6%; OR 1.3 [95% CI, 0.60-2.89], P = .51). CONCLUSIONS This retrospective analysis confirmed that perioperative administration of rFVIIa is associated with an increased incidence of postoperative thrombotic complications in neonates and children undergoing cardiac surgery, without increase in 30-day mortality. In conclusion, rFVIIa should be used with extreme caution in pediatric patients undergoing cardiac surgery.
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Affiliation(s)
- Laura Downey
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital, Stanford University, Stanford, California; †Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and ‡Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Guzzetta NA, Williams GD. Current use of factor concentrates in pediatric cardiac anesthesia. Paediatr Anaesth 2017; 27:678-687. [PMID: 28393462 DOI: 10.1111/pan.13158] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 11/29/2022]
Abstract
Excessive bleeding following pediatric cardiopulmonary bypass is associated with increased morbidity and mortality, both from the effects of hemorrhage and the therapies employed to achieve hemostasis. Neonates and infants are especially at risk because their coagulation systems are immature, surgeries are often complex, and cardiopulmonary bypass technologies are inappropriately matched to patient size and physiology. Consequently, these young children receive substantial amounts of adult-derived blood products to restore adequate hemostasis. Adult and pediatric data demonstrate associations between blood product transfusions and adverse patient outcomes. Thus, efforts to limit bleeding after pediatric cardiopulmonary bypass and minimize allogeneic blood product exposure are warranted. The off-label use of factor concentrates, such as fibrinogen concentrate, recombinant activated factor VII, and prothrombin complex concentrates, is increasing as these hemostatic agents appear to offer several advantages over conventional blood products. However, recognizing that these agents have the potential for both benefit and harm, well-designed studies are needed to enhance our knowledge and to determine the optimal use of these agents. In this review, our primary objective was to examine the evidence regarding the use of factor concentrates to treat bleeding after pediatric CPB and identify where further research is required. PubMed, MEDLINE/OVID, The Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched to identify existing studies.
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Affiliation(s)
- Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Glyn D Williams
- Department of Anesthesiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
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20
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Current and future trends in coagulation management for congenital heart surgery. J Thorac Cardiovasc Surg 2017; 153:1511-1515. [DOI: 10.1016/j.jtcvs.2016.11.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/09/2016] [Accepted: 11/15/2016] [Indexed: 01/04/2023]
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21
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Bradley SM. If it weren't for the bleeding…. J Thorac Cardiovasc Surg 2017; 153:1516-1518. [PMID: 28242016 DOI: 10.1016/j.jtcvs.2017.01.018] [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: 12/24/2016] [Accepted: 01/04/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Scott M Bradley
- Department of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC.
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Cooper JD, Ritchey AK. Response to treatment and adverse events associated with use of recombinant activated factor VII in children: a retrospective cohort study. Ther Adv Drug Saf 2016; 8:51-59. [PMID: 28255432 DOI: 10.1177/2042098616673991] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Recombinant activated factor VII (rFVIIa) is United States (US) Food and Drug Administration (FDA)-approved for patients with hemophilia with inhibitors or congenital factor VII deficiency. Initial reports of off-label use highlighted its efficacy, though newer reports have not repeated these findings. In both types of publication, though, secondary thromboses have been seen in adult patients. The data in children are less clear. METHODS This study analyzed all rFVIIa use at a large children's hospital for characteristics and outcomes. Recipients of rFVIIa were identified retrospectively via the electronic medical record. Data on patient diagnosis, lab data, other treatments, adverse events, and outcomes were collected. RESULTS Over 33 months, 66 patient episodes were treated with a total of 606 doses (median = 2). The most common indication (36.4%) was gastrointestinal bleeding (24/66 patients). Only one patient received a dose for an approved labeled indication. For control of bleeding, 33.3% of courses were unsuccessful (19/57). Bleeding from multiple sites was associated with treatment failure. In 16.7% of patients (11/66), unexpected adverse thromboses developed within 1 week of completing a course of rFVIIa. Thromboses in both intra- and extra-corporeal sites were included if they compromised patient care. CONCLUSIONS In the majority of cases reviewed, rFVIIa was successful in stopping or slowing serious bleeding episodes. It was least effective when a patient had diffuse bleeding at the time of administration. The thrombosis rate of 16.7% was higher than expected, though causality cannot be declared. Further investigation is needed to determine the risk-benefit ratio in children.
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Affiliation(s)
- James D Cooper
- Assistant Professor, Department of Pediatrics, Division of Hematology/Oncology/BMT, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Arthur K Ritchey
- Professor and Vice-Chair for Clinical Affairs, Department of Pediatrics, Division of Hematology/Oncology/BMT, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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Abstract
BACKGROUND Quantitative and qualitative differences in the hemostatic systems exist between neonates and adults, including the presence of "fetal" fibrinogen, a qualitatively dysfunctional form of fibrinogen that exists until 1 yr of age. The consequences of "fetal" fibrinogen on clot structure in neonates, particularly in the context of surgery-associated bleeding, have not been well characterized. Here, the authors examine the sequential changes in clotting components and resultant clot structure in a small sample of neonates undergoing cardiac surgery and cardiopulmonary bypass (CPB). METHODS Blood samples were collected from neonates (n = 10) before surgery, immediately after CPB, and after the transfusion of cryoprecipitate (i.e., adult fibrinogen component). Clots were formed from patient samples or purified neonatal and adult fibrinogen. Clot structure was analyzed using confocal microscopy. RESULTS Clots formed from plasma obtained after CPB and after transfusion were more porous than baseline clots. Analysis of clots formed from purified neonatal and adult fibrinogen demonstrated that at equivalent fibrinogen concentrations, neonatal clots lack three-dimensional structure, whereas adult clots were denser with significant three-dimensional structure. Clots formed from a combination of purified neonatal and adult fibrinogen were less homogenous than those formed from either purified adult or neonatal fibrinogen. CONCLUSIONS The results of this study confirm that significant differences exist in clot structure between neonates and adults and that neonatal and adult fibrinogen may not integrate well. These findings suggest that differential treatment strategies for neonates should be pursued to reduce the demonstrated morbidity of blood product transfusion.
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Punzalan RC, Gottschall JL. Use and Future Investigations of Recombinant and Plasma-Derived Coagulation and Anticoagulant Products in the Neonate. Transfus Med Rev 2016; 30:189-96. [PMID: 27576087 DOI: 10.1016/j.tmrv.2016.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 07/18/2016] [Indexed: 12/27/2022]
Abstract
Although congenital bleeding disorders can manifest in the newborn period, the most common causes of bleeding and thrombosis in neonates are acquired conditions. Factor concentrates are used for specific diagnoses (hemophilia with inhibitors, specific factor deficiency, von Willebrand disease) and approved indications, and increasingly for off-label indications (bleeding in surgery cardiopulmonary bypass, extracorporeal membrane oxygenation). We will review the approved indications for factor products in the neonate and discuss the evidence and rationale for off-label use of factor products in management of bleeding and thrombosis in the neonate.
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Affiliation(s)
- Rowena C Punzalan
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
| | - Jerome L Gottschall
- BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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Park HJ, Choi EJ. Use of Recombinant Activated Factor VII for Pulmonary Hemorrhage in Premature Infants: A Single-Center Experience. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2016. [DOI: 10.15264/cpho.2016.23.1.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Hye Jin Park
- Department of Pediatrics, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Eun Jin Choi
- Department of Pediatrics, Catholic University of Daegu School of Medicine, Daegu, Korea
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Omar HR, Enten G, Karlnoski R, Ching YH, Mangar D, Camporesi EM. Recombinant Activated Factor VII Significantly Reduces Transfusion Requirements in Cardiothoracic Surgery. Drugs R D 2016; 15:187-94. [PMID: 25862216 PMCID: PMC4488183 DOI: 10.1007/s40268-015-0093-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The off-label use of recombinant activated factor VII (rFVIIa) for intractable bleeding is associated with a risk of thrombotic events. The objective of this study was to evaluate the incidence and predictors of rFVIIa-related thrombotic events and its efficacy in the reduction of transfusion requirements during various surgeries. Methods Ninety-two cases received rFVIIa for uncontrollable bleeding despite medical and surgical hemostasis. The incidence and risk factors of thrombotic events were analyzed. Blood products transfused in the 24 h before and after rFVIIa injection were calculated. Subgroup analysis was performed to see which types of surgeries benefited most from rFVIIa. Results The main indication for rFVIIa administration was uncontrollable bleeding during cardiothoracic surgery followed by coagulopathy due to liver failure followed by neurosurgical procedures. Requirements of blood products after rFVIIa decreased significantly by 45 % (p = 0.012), 52 % (p = 0.0001), and 75 % (p = 0.0001) for red blood cells, plasma, and cryoprecipitate, respectively. Subgroup analysis showed that cardiothoracic surgery was the sole group that benefited from rFVIIa with a reduction in transfusion of red blood cells (p = 0.013), plasma (p = 0.0001), and cryoprecipitate (p = 0.0001). Thrombotic events occurred in 9.8 % of the cases mostly on the arterial side (89 %) and have not contributed to mortality. Conclusion rFVIIa can significantly reduce transfusion requirements when given for intractable bleeding during cardiothoracic surgery at the expense of thrombotic events in approximately one tenth of the cases. Further prospective studies are necessary to study if this effect of rFVIIa is translated to a favorable outcome. Electronic supplementary material The online version of this article (doi:10.1007/s40268-015-0093-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hesham R Omar
- Internal Medicine Department, Mercy Medical Center, 1410 N. Fourth Street, Clinton, IA, 52732, USA,
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Jooste EH, Machovec KA, Einhorn LM, Ames WA, Homi HM, Jaquiss RDB, Lodge AJ, Levy JH, Welsby IJ. 3-Factor Prothrombin Complex Concentrates in Infants With Refractory Bleeding After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 30:1627-1631. [PMID: 27236492 DOI: 10.1053/j.jvca.2016.01.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Indexed: 12/13/2022]
Affiliation(s)
- Edmund H Jooste
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC.
| | - Kelly A Machovec
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Lisa M Einhorn
- Department of Anesthesiology, Duke University, Durham, NC
| | - Warwick A Ames
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Hercilia M Homi
- Department of Anesthesiology, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Robert D B Jaquiss
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Andrew J Lodge
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke Children's Pediatric and Congenital Heart Center, Duke University, Durham, NC
| | - Jerrold H Levy
- Department of Anesthesiology, Division of Adult Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, NC
| | - Ian J Welsby
- Department of Anesthesiology, Division of Adult Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, NC
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Bolliger D, Tanaka K. Haemostatic efficacy of fibrinogen concentrate: is it the threshold or the timing of therapy? Br J Anaesth 2015; 115:158-61. [DOI: 10.1093/bja/aev167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Payani N, Foroughi M, Dabbagh A. The Effect of Intravenous Administration of Active Recombinant Factor VII on Postoperative Bleeding in Cardiac Valve Reoperations; A Randomized Clinical Trial. Anesth Pain Med 2015; 5:e22846. [PMID: 25789239 PMCID: PMC4350162 DOI: 10.5812/aapm.22846] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 11/15/2014] [Accepted: 11/23/2014] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Postoperative bleeding after cardiac reoperations is among the most complicating problems, both for the physicians and for the patients. Many modalities have been used to decrease its adverse effects and the need for blood products administration. OBJECTIVES In a randomized double-blinded clinical trial of redo cardiac valve surgery in adult, the effect of active recombinant factor VII (rFVIIa) on postoperative bleeding was compared with placebo. Chest tube drainage was used for comparison of bleeding between the two groups. PATIENTS AND METHODS Two groups of 18 patients undergoing redo valve surgeries were treated and compared regarding chest tube drainage, need for blood products, prothrombin time (PT), partial thromboplastin time (PTT), hemoglobin and hematocrit, platelet count, and international normalized ratio (INR) in first 24 hours after surgery. Bleeding was assessed at 3rd, 12th, and 24th hour after operation. In rFVIIa group, 40 µg/kg of AryoSeven was administered before end of surgery and same volume of normal saline was administered as placebo in the control group. RESULTS Study groups showed no difference regarding baseline variables. Three patients in rFVIIa group (16.67%) and 13 in placebo group (72.23%) received blood products (P < 0.01). Chest tube blood drainage at 24th hour after operation was 315 ± 177 mL in rFVIIa group and 557 ± 168 mL in control group (P = 0.03). At third and 12th hour after operation, the difference was not statistically significant (P = 0.71 and P = 0.22, respectively). Postoperative ICU stay was not different; while extubation was longer in the placebo group (352 ± 57 vs. 287 ± 46 minutes; P = 0.003). CONCLUSIONS Our study demonstrated the efficacy of rFVIIa in controlling postoperative bleeding in redo cardiac valve surgeries regarding subsequent blood loss and transfusion requirement; however, outcome results remains to be defined.
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Affiliation(s)
- Narges Payani
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahnoosh Foroughi
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Dabbagh
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Ali Dabbagh, Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel/Fax: +98-2122432572, E-mail:
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Ishihara M, Miyamoto Y, Taniguchi A, Kinouchi K. Successful use of recombinant activated factor VII (eptacog alfa, Novoseven®) in a refractory bleeding during pediatric cardiac surgery: a case report. JA Clin Rep 2015; 1:9. [PMID: 29497641 PMCID: PMC5818693 DOI: 10.1186/s40981-015-0012-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 08/04/2015] [Indexed: 11/29/2022] Open
Abstract
A 2-year-and-7-month-old boy underwent an emergent reconstruction surgery of the right ventricle-pulmonary artery (RV-PA) conduit. Although he was successfully weaned from cardiopulmonary bypass (CPB) after reconstruction of the RV-PA conduit, the bleeding continued despite the massive transfusion of red blood cell (RBC), fresh frozen plasma (FFP), and platelets. Because of persistent bleeding and abnormal coagulation laboratory results, we administered the recombinant activated factor VII (rFVIIa), which was not approved for use in the treatment of post-CPB coagulopathy. After administration of rFVIIa, his coagulation data dramatically improved, the bleeding decreased, and the operation was able to be finished.
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Affiliation(s)
- Mariko Ishihara
- Department of Anesthesiology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu, Shiga Japan
| | - Yoshikazu Miyamoto
- Department of Anesthesiology, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi, Osaka Japan
| | - Akihiro Taniguchi
- Department of Anesthesiology, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi, Osaka Japan
| | - Keiko Kinouchi
- Department of Anesthesiology, Osaka Medical Center and Research Institute for Maternal and Child Health, 840 Murodocho, Izumi, Osaka Japan
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Miller S, Nitzki-George D, Caprini JA. Balancing the risk of complications in foot and ankle surgical patients taking antithrombotic medication. Foot Ankle Spec 2014; 7:507-14. [PMID: 25053792 DOI: 10.1177/1938640014543356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
UNLABELLED This review intends to provide guidance regarding perioperative management of anticoagulation and antiplatelet drug therapy as they relate to foot and ankle surgery. Venous and arterial thromboembolism are conditions in which the blood clots inappropriately, causing considerable morbidity and mortality. With an increase in awareness of thromboembolic risk factors and expansion of therapeutic options, more patients are routinely taking antithrombotic medication. When these patients require invasive procedures, a decision needs to be made if antithrombotic medication should be held perioperatively and if additional precautions are needed in the interim. Understanding the factors affecting the management of thromboembolism during the perioperative period can reduce the potential for complications. LEVELS OF EVIDENCE Therapeutic, Level V: Expert opinion.
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Affiliation(s)
- Steven Miller
- Skokie Foot & Ankle Specialists, Skokie, Illinois (SM)Thrombosis and Anticoagulation Unit of Glenbrook Hospital, NorthShore University HealthSystem, Glenview, Illinois (DNG)Division of Vascular Surgery, NorthShore University HealthSystem, Evanston, Illinois (JAC)
| | - Diane Nitzki-George
- Skokie Foot & Ankle Specialists, Skokie, Illinois (SM)Thrombosis and Anticoagulation Unit of Glenbrook Hospital, NorthShore University HealthSystem, Glenview, Illinois (DNG)Division of Vascular Surgery, NorthShore University HealthSystem, Evanston, Illinois (JAC)
| | - Joseph A Caprini
- Skokie Foot & Ankle Specialists, Skokie, Illinois (SM)Thrombosis and Anticoagulation Unit of Glenbrook Hospital, NorthShore University HealthSystem, Glenview, Illinois (DNG)Division of Vascular Surgery, NorthShore University HealthSystem, Evanston, Illinois (JAC)
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Wu B, Wang Y, Wang C, Cheng Y, Rong R. Intraoperative platelet transfusion is associated with increased postoperative sternal wound infections among type A aortic dissection patients after total arch replacement. Transfus Med 2014; 24:400-5. [PMID: 25395085 DOI: 10.1111/tme.12162] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 06/26/2014] [Accepted: 10/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- B. Wu
- Department of Transfusion; Fudan University; Shanghai China
- Department of Hematology; Fudan University; Shanghai China
| | - Y. Wang
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital; Fudan University; Shanghai China
| | - C. Wang
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital; Fudan University; Shanghai China
| | - Y. Cheng
- Department of Hematology; Fudan University; Shanghai China
| | - R. Rong
- Department of Transfusion; Fudan University; Shanghai China
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Off-label use of recombinant activated factor VII in surgical and non-surgical patients at 16 Canadian hospitals from 2007 to 2010 (Canadian Registry Report). Can J Anaesth 2014; 61:727-35. [DOI: 10.1007/s12630-014-0184-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 05/15/2014] [Indexed: 01/21/2023] Open
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Guzzetta NA, Szlam F, Kiser AS, Fernandez JD, Szlam AD, Leong T, Tanaka KA. Augmentation of thrombin generation in neonates undergoing cardiopulmonary bypass. Br J Anaesth 2013; 112:319-27. [PMID: 24193321 DOI: 10.1093/bja/aet355] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Factor concentrates are currently available and becoming increasingly used off-label for treatment of bleeding. We compared recombinant activated factor VII (rFVIIa) with three-factor prothrombin complex concentrate (3F-PCC) for the ability to augment thrombin generation (TG) in neonatal plasma after cardiopulmonary bypass (CPB). First, we used a computer-simulated coagulation model to assess the impact of rFVIIa and 3F-PCC, and then performed similar measurements ex vivo using plasma from neonates undergoing CPB. METHODS Simulated TG was computed according to the coagulation factor levels from umbilical cord plasma and the therapeutic levels of rFVIIa, 3F-PCC, or both. Subsequently, 11 neonates undergoing cardiac surgery were enrolled. Two blood samples were obtained from each neonate: pre-CPB and post-CPB after platelet and cryoprecipitate transfusion. The post-CPB products sample was divided into control (no treatment), control plus rFVIIa (60 nM), and control plus 3F-PCC (0.3 IU ml(-1)) aliquots. Three parameters of TG were measured ex vivo. RESULTS The computer-simulated post-CPB model demonstrated that rFVIIa failed to substantially improve lag time, TG rate and peak thrombin without supplementing prothrombin. Ex vivo data showed that addition of rFVIIa post-CPB significantly shortened lag time; however, rate and peak were not statistically significantly improved. Conversely, 3F-PCC improved all TG parameters in parallel with increased prothrombin levels in both simulated and ex vivo post-CPB samples. CONCLUSIONS Our data highlight the importance of prothrombin replacement in restoring TG. Despite a low content of FVII, 3F-PCC exerts potent procoagulant activity compared with rFVIIa ex vivo. Further clinical evaluation regarding the efficacy and safety of 3F-PCC is warranted.
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Affiliation(s)
- N A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
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Strauss T, Rozenzweig N, Rosenberg N, Shenkman B, Livnat T, Morag I, Fruchtman Y, Martinowitz U, Kenet G. Surfactant impairs coagulation in-vitro: A risk factor for pulmonary hemorrhage? Thromb Res 2013; 132:599-603. [DOI: 10.1016/j.thromres.2013.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 08/07/2013] [Accepted: 09/02/2013] [Indexed: 11/24/2022]
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Babaev A, Saczkowski R, Hynes M, Boodhwani M, Hudson CCC. Use of plasma "reconstitution" during cardio pulmonary bypass for a heart transplant after previous left ventricular assist device implant surgery. Perfusion 2013; 29:29-31. [PMID: 23842615 DOI: 10.1177/0267659113494963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The case report describes a novel technique of pre-emptive plasma "reconstitution" prior to disengagement from cardiopulmonary bypass (CPB) to minimize RV volume overload. The concomitant use of hemoconcentration facilitates volume and blood product management in cardiac transplant after previous left ventricular assist device implant surgery.
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Affiliation(s)
- A Babaev
- 1Department of Cardiovascular Perfusion, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Smith AH, Gay JC, Patel NR. Trends in resource utilization associated with the inpatient treatment of neonatal congenital heart disease. CONGENIT HEART DIS 2013; 9:96-105. [PMID: 23734574 DOI: 10.1111/chd.12103] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2013] [Indexed: 11/30/2022]
Abstract
INTRODUCTION While neonates account for a significant proportion of health care expenditures related to inpatient care for congenital heart disease, key drivers of resource utilization among this population are poorly defined. METHODS Data from 2005 through 2011 were extracted from the Pediatric Health Information System for patients assigned a discharge All Patient Refined Diagnosis Related Group of 630 (neonates with birthweight >2499 g undergoing a major cardiovascular procedure). Mortality risk adjustment for patients undergoing operative interventions was performed with the Risk Adjusment in Congenital Heart Surgery (RACHS-1) score. RESULTS A total of 13 156 cases were included in the analysis. Despite only a 3% increase in case mix index and no significant change in operative acuity over the study period (RACHS classifications of 3 or greater 67% in 2005 vs. 66% in 2011, P = .64), there were inflation-adjusted increases in both total estimated cost per case of (50% to $151 760 in 2011, P < .001), and mean charge per case (33% to $433 875 in 2011, P < .001). Pharmacy charges increased by 16% (P < .001), with agents including chlorothiazide and albumin accounting for the highest patient charges over the study period. Imaging charges increased by 42% (P < .001), with an average of 5.7 echocardiograms and $6517 in associated charges per case by 2011. While the proportion of patients receiving nitric oxide remained consistent, mean duration of administration increased by 25% to 6.6 days by 2011, accounting for average charges of $52 141 per patient exposed. CONCLUSIONS Among neonates with serious congenital heart disease, increases in both institutional costs and charges to the patient are associated with relatively consistent utilization practices in recent years. Multiinstitutional collaboration may prove useful in aligning evidence-based reductions in practice variation with limitations in resource utilization without compromising the quality of care.
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Affiliation(s)
- Andrew H Smith
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn, USA; Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn, USA
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Camkiran A, Pirat A, Zeyneloglu P, Ozkan M, Arslan G. Use of recombinant activated factor VIIa for nonsurgical, refractory bleeding in neonatal cardiac surgery patients: case series. J Cardiothorac Vasc Anesth 2013; 27:e14-5. [PMID: 23507020 DOI: 10.1053/j.jvca.2012.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Indexed: 11/11/2022]
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