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Sharp S, Prasad A, Sugavanam A. Appetite for more exchange, connection and collaboration among senior health professionals. leader 2022; 6:240-242. [DOI: 10.1136/leader-2021-000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/18/2021] [Indexed: 11/04/2022]
Abstract
BackgroundThe COVID-19 pandemic has highlighted the value of global exchange around knowledge, skills and attitudes among senior healthcare professionals (SHPs). It has also revealed the need for strong peer-led networks and mentorship to tackle the high levels of burnout and ‘brain-drain’ already plaguing the National Health Service (NHS). We designed a survey to gauge the appetite for exchange programmes among SHPs.MethodsData collection was carried out via an online qualitative survey generated by SurveyMonkey software and analysed by three independent authors.Results155 responses were collected of which 87.7% were pre-COVID-19 pandemic. 74.2% had ideas to improve healthcare but could not take it forward. 86.6% felt frustrated/down-heartened about work. 74.3% wanted more sharing of teaching resources. 74.2% expressed interest in sabbatical programmes.ConclusionOur survey confirms the desire for more connection, collaboration and exchange among SHPs who are at high risk of burnout, silo-working and leaving the profession early. Sabbaticals have been used successfully in other industries, especially academia, for many years and show long-term investment and value from employers in their employees. Almost 75% of the SHPs in this survey were interested in this but logistics precluded easy access to them. HealthProMatch (HPM) is a platform where SHPs can connect, collaborate and arrange exchanges/sabbaticals with logistical ease. It focuses on bringing leadership, mentorship and quality improvement back home. HPM will pilot in the NHS within anaesthesia and hopes to increase job satisfaction and retention in this precious workforce group.
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Shah AA, Donovan K, Seeley C, Dickson EA, Palmer AJR, Doree C, Brunskill S, Reid J, Acheson AG, Sugavanam A, Litton E, Stanworth SJ. Risk of Infection Associated With Administration of Intravenous Iron: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2133935. [PMID: 34767026 PMCID: PMC8590171 DOI: 10.1001/jamanetworkopen.2021.33935] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Intravenous iron is recommended by many clinical guidelines based largely on its effectiveness in reducing anemia. However, the association with important safety outcomes, such as infection, remains uncertain. OBJECTIVE To examine the risk of infection associated with intravenous iron compared with oral iron or no iron. DATA SOURCES Medline, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomized clinical trials (RCTs) from 1966 to January 31, 2021. Ongoing trials were sought from ClinicalTrials.gov, CENTRAL, and the World Health Organization International Clinical Trials Search Registry Platform. STUDY SELECTION Pairs of reviewers identified RCTs that compared intravenous iron with oral iron or no iron across all patient populations, excluding healthy volunteers. Nonrandomized studies published since January 1, 2007, were also included. A total of 312 full-text articles were assessed for eligibility. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias assessments were performed according to the Preferred Reporting Items of Systematic Reviews and Meta-analyses (PRISMA) and Cochrane recommendations, and the quality of evidence was assessed using the GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach. Two reviewers extracted data independently. A random-effects model was used to synthesize data from RCTs. A narrative synthesis was performed to characterize the reporting of infection. MAIN OUTCOMES AND MEASURES The primary outcome was risk of infection. Secondary outcomes included mortality, hospital length of stay, and changes in hemoglobin and red blood cell transfusion requirements. Measures of association were reported as risk ratios (RRs) or mean differences. RESULTS A total of 154 RCTs (32 920 participants) were included in the main analysis. Intravenous iron was associated with an increased risk of infection when compared with oral iron or no iron (RR, 1.17; 95% CI, 1.04-1.31; I2 = 37%; moderate certainty of evidence). Intravenous iron also was associated with an increase in hemoglobin (mean difference, 0.57 g/dL; 95% CI, 0.50-0.64 g/dL; I2 = 94%) and a reduction in the risk of requiring a red blood cell transfusion (RR, 0.93; 95% CI, 0.76-0.89; I2 = 15%) when compared with oral iron or no iron. There was no evidence of an effect on mortality or hospital length of stay. CONCLUSIONS AND RELEVANCE In this large systematic review and meta-analysis, intravenous iron was associated with an increased risk of infection. Well-designed studies, using standardized definitions of infection, are required to understand the balance between this risk and the potential benefits.
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Affiliation(s)
- Akshay A. Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Killian Donovan
- Adult Intensive Care Unit, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Claire Seeley
- Department of Anaesthesia, Royal Berkshire Hospitals NHS Foundation Trust, Reading, United Kingdom
| | - Edward A. Dickson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Antony J. R. Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Carolyn Doree
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
| | - Jack Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Austin G. Acheson
- National Institute for Health Research Biomedical Research Centre in Gastrointestinal and Liver Diseases, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- Department of Colorectal Surgery, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, United Kingdom
| | - Anita Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, United Kingdom
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Australia
| | - Simon J. Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Biomedical Research Centre Haematology Theme, Oxford, United Kingdom
- Systematic Review Initiative, NHS Blood & Transplant, Oxford, United Kingdom
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Kanga K, Dickson E, Van Huellen H, De Las Casas R, Cadd M, Stanworth SJ, Grant-Casey J, Sugavanam A. Under-recognised burden of postoperative anaemia in patients undergoing emergency abdominal surgery in the UK. Br J Anaesth 2021; 127:e105-e108. [PMID: 34330412 DOI: 10.1016/j.bja.2021.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Kate Kanga
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK.
| | - Edward Dickson
- Nottingham Digestive Diseases Centre Biomedical Research Unit, University of Nottingham, Nottingham, UK
| | - Hans Van Huellen
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Ruth De Las Casas
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Matthew Cadd
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John Grant-Casey
- National Comparative Audit of Blood Transfusion, NHS Blood and Transplant, Oxford, UK
| | - Anita Sugavanam
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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Boyd-Carson H, Shah A, Sugavanam A, Reid J, Stanworth SJ, Oliver CM. The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy. Anaesthesia 2020; 75:904-912. [PMID: 32315080 DOI: 10.1111/anae.15021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2020] [Indexed: 01/28/2023]
Abstract
Pre-operative anaemia is associated with poor outcomes after elective surgery but its relationship with outcomes after emergency surgery is unclear. We analysed National Emergency Laparotomy Audit data from 1 December 2013 to 30 November 2017, excluding laparotomy for haemorrhage. Anaemia was classified as 'mild' 129-110 g.l-1; 'moderate' 109-80 g.l-1; or 'severe' ≤ 79 g.l-1. The primary outcome was 90-day mortality. Secondary outcomes were 30-day mortality, return to theatre and postoperative hospital stay. The primary outcome was available for 86,763 patients, of whom 45,306 (52%) were anaemic. There were 12,667 (15%) deaths at 90 postoperative days and 9246 (11%) deaths at 30 postoperative days. Anaemia was associated with increased 90-day and 30-day mortality, odds ratio (95%CI): mild, 1.15 (1.09-1.21); moderate, 1.44 (1.36-1.52); and severe, 1.42 (1.24-1.63), p < 0.001 for all; mild, 1.07 (1.00-1.12), p = 0.030; moderate, 1.30 (1.21-1.38), p < 0.001; and severe, 1.22 (1.05-1.43), p = 0.010, respectively. All categories of anaemia were associated with prolonged hospital stay, adjusted coefficient (95%CI): mild, 1.31 (1.01-1.62); moderate, 3.41 (3.04-3.77); severe, 2.80 (1.83-3.77), p < 0.001 for all. Moderate and severe anaemia were associated with increased risk of return to the operating theatre, odds ratio (95%CI): moderate 1.13 (1.06-1.21), p < 0.001; and severe 1.23 (1.06-1.43), p = 0.006. Pre-operative anaemia is common in patients undergoing emergency laparotomy and is associated with increased postoperative mortality and morbidity.
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Affiliation(s)
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, UK.,Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - A Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.,Department of Anaesthesia, Danube Hospital, Vienna, Austria
| | - J Reid
- Department of Anaesthesia, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - S J Stanworth
- Radcliffe Department of Medicine, University of Oxford, UK.,Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C M Oliver
- Royal College of Anaesthetists, London, UK.,UCL Division of Surgery and Interventional Science, London, UK
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Shah A, Sugavanam A, Reid J, Palmer AJ, Dickson E, Brunskill S, Doree C, Oliver CM, Acheson A, Baikady RR, Bampoe S, Litton E, Stanworth S. Risk of infection associated with intravenous iron preparations: protocol for updating a systematic review. BMJ Open 2019; 9:e024618. [PMID: 31167861 PMCID: PMC6561462 DOI: 10.1136/bmjopen-2018-024618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The benefits and risk of intravenous iron have been documented in previous systematic reviews and continue to be the subject of randomised controlled trials (RCTs). An ongoing issue that continues to be raised is the relationship between administering iron and developing infection. This is supported by biological plausibility from animal models. We propose an update of a previously published systematic review and meta-analysis with the primary focus being infection. METHODS AND ANALYSIS We will include RCTs and non-randomised studies (NRS) in this review update. We will search the relevant electronic databases. Two reviewers will independently extract data. Risk of bias for RCTs and NRS will be assessed using the relevant tools recommended by The Cochrane Collaboration. Data extracted from RCTs and NRS will be analysed and reported separately. Pooled data from RCTs will be analysed using a random effects model. We will also conduct subgroup analyses to identify any patient populations that may be at increased risk of developing infection. We will provide a narrative synthesis on the definitions, sources and responsible pathogens for infection in the included studies. Overall quality of evidence on the safety outcomes of mortality and infection will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. ETHICS AND DISSEMINATION This systematic review will only investigate published studies and therefore ethical approval is not required. The results will be broadly distributed through conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER PROSPERO (CRD42018096023).
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Anita Sugavanam
- Department of Anaesthetics, Brighton and Sussex University Hospitals NHS Trust, Brighton and Hove, UK
| | - Jack Reid
- Department of Anaesthetics, Brighton and Sussex University Hospitals NHS Trust, Brighton and Hove, UK
| | - Antony J Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Edward Dickson
- Department of Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Susan Brunskill
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Carolyn Doree
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | | | - Austin Acheson
- Department of Colorectal Surgery and NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases, Queen’s Medical Centre, Nottingham, UK
| | - Ravi Rao Baikady
- Department of Anaesthetics, Perioperative Medicine and Pain, Royal Marsden NHS Foundation Trust, London, UK
| | - Sohail Bampoe
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Edward Litton
- Intensive Care Unit, St John of God Hospital, Perth, Western Australia, Australia
| | - Simon Stanworth
- Department of Haematology/Transfusion Medicine, Oxford Radcliffe Hospitals Trust, Oxford, UK
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Shah A, Palmer AJR, Fisher SA, Rahman SM, Brunskill S, Doree C, Reid J, Sugavanam A, Stanworth SJ. What is the effect of perioperative intravenous iron therapy in patients undergoing non-elective surgery? A systematic review with meta-analysis and trial sequential analysis. Perioper Med (Lond) 2018; 7:30. [PMID: 30559962 PMCID: PMC6290500 DOI: 10.1186/s13741-018-0109-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 11/13/2018] [Indexed: 01/01/2023] Open
Abstract
Background Guidelines to treat anaemia with intravenous (IV) iron have focused on elective surgical patients with little attention paid to those undergoing non-elective/emergency surgery. Whilst these patients may experience poor outcomes because of their presenting illness, observational data suggests that untreated anaemia may also be a contributing factor to poor outcomes. We conducted a systematic review to investigate the safety and efficacy of IV iron in patients undergoing non-elective surgery. Methods We followed a pre-defined review protocol and included randomised controlled trials (RCTs) in patients undergoing non-elective surgery who received IV iron. Primary outcomes were all-cause infection and mean difference in haemoglobin (Hb) at follow-up. Secondary outcomes included transfusion requirements, hospital length of stay (LOS), health-related quality of life (HRQoL), mortality and adverse events. Results Three RCTs (605 participants) were included in this systematic review of which two, in both hip fracture (HF) patients, provided data for meta-analysis. Both of these RCTs were at low risk of bias. We found no evidence of a difference in the risk of infection (RR 0.99, 95% CI 0.55 to 1.80, I 2 = 9%) or in the Hb concentration at 'short-term' (≤ 7 days) follow-up (mean difference - 0.32 g/L, 95% CI - 3.28 to 2.64, I 2 = 37%). IV iron did not reduce the risk of requiring a blood transfusion (RR 0.90, 95% CI 0.73 to 1.11, p = 0.46, I 2 = 0%), and we observed no difference in mortality, LOS or adverse events. One RCT reported on HRQoL and found no difference between treatment arms. Conclusion We found no conclusive evidence of an effect of IV iron on clinically important outcomes in patients undergoing non-elective surgery. Further adequately powered trials to evaluate its benefit in emergency surgical specialties with a high burden of anaemia are warranted. Trial registration This systematic review was registered on PROSPERO (CRD42018096288).
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Affiliation(s)
- Akshay Shah
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK
| | - Antony J R Palmer
- 2Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Sheila A Fisher
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Shah M Rahman
- 3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK
| | - Susan Brunskill
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Carolyn Doree
- 4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
| | - Jack Reid
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Anita Sugavanam
- 5Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Simon J Stanworth
- 1Radcliffe Department of Medicine, John Radcliffe Hospital, University of Oxford, Level 4 Academic Block, Oxford, OX3 9DU UK.,3Frimley Health NHS Foundation Trust, Camberley, Surrey GU16 7UJ UK.,4Systematic Review Initiative, NHS Blood & Transplant, Oxford, UK
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Chakladar A, Fludder V, Sugavanam A. Association of Anaesthetists recommendations for cell salvage in obstetric anaesthesia. Anaesthesia 2018; 73:1575-1576. [PMID: 30412289 DOI: 10.1111/anae.14488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A Chakladar
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - V Fludder
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - A Sugavanam
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Mallett SV, Sugavanam A, Krzanicki DA, Patel S, Broomhead RH, Davidson BR, Riddell A, Gatt A, Chowdary P. Alterations in coagulation following major liver resection. Anaesthesia 2016; 71:657-68. [PMID: 27030945 DOI: 10.1111/anae.13459] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2016] [Indexed: 12/13/2022]
Abstract
The international normalised ratio is frequently raised in patients who have undergone major liver resection, and is assumed to represent a potential bleeding risk. However, these patients have an increased risk of venous thromboembolic events, despite conventional coagulation tests indicating hypocoagulability. This prospective, observational study of patients undergoing major hepatic resection analysed the serial changes in coagulation in the early postoperative period. Thrombin generation parameters and viscoelastic tests of coagulation (thromboelastometry) remained within normal ranges throughout the study period. Levels of the procoagulant factors II, V, VII and X initially fell, but V and X returned to or exceeded normal range by postoperative day five. Levels of factor VIII and Von Willebrand factor were significantly elevated from postoperative day one (p < 0.01). Levels of the anticoagulants, protein C and antithrombin remained significantly depressed on postoperative day five (p = 0.01). Overall, the imbalance between pro- and anticoagulant factors suggested a prothrombotic environment in the early postoperative period.
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Affiliation(s)
- S V Mallett
- Department of Anaesthesia, Royal Free Hospital, London, UK
| | - A Sugavanam
- Department of Anaesthesia, Brighton and Sussex University Hospitals, Brighton, UK
| | - D A Krzanicki
- Department of Anaesthesia, Royal Free Hospital, London, UK
| | - S Patel
- Department of Anaesthesia, University College London Hospital, London, UK
| | - R H Broomhead
- Department of Anaesthesia, Kings College Hospital, London, UK
| | - B R Davidson
- University Department of Surgery, Royal Free Campus, University College London, London, UK
| | - A Riddell
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
| | - A Gatt
- University of Malta, Tal-Qroqq, Msida, Malta
| | - P Chowdary
- Katharine Dormandy Haemophilia Centre and Thrombosis Unit, Royal Free Hospital, London, UK
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Schofield N, Sugavanam A, Henley M, Thompson K, Riddell A, Mallett SV. Anin vitrostudy comparing two dose regimes of fresh frozen plasma on conventional and thromboelastographic tests of coagulation after major hepatic resection. Transfus Med 2015; 25:85-91. [DOI: 10.1111/tme.12194] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 02/26/2015] [Accepted: 03/12/2015] [Indexed: 01/02/2023]
Affiliation(s)
| | | | - M. Henley
- Department of Anaesthesia; London UK
| | | | - A. Riddell
- KD Haemophilia Centre and Thrombosis Unit; Royal Free Hospital; London UK
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Schofield N, Sugavanam A, Thompson K, Mallett SV. No increase in blood transfusions during liver transplantation since the withdrawal of aprotinin. Liver Transpl 2014; 20:584-90. [PMID: 24481770 DOI: 10.1002/lt.23839] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 01/19/2014] [Indexed: 12/13/2022]
Abstract
The aims of this study were to determine whether the withdrawal of aprotinin (APRO) led to an increased bleeding risk in patients undergoing orthotopic liver transplantation (OLT). A retrospective analysis compared consecutive patients undergoing OLT and treated with aprotinin (APRO group; n = 100) with a group in which aprotinin was not used (no-APRO group; n = 100). Propensity score matching was then performed for each group to identify 2 matched cohorts. Patients were matched by their primary diagnoses and Model for End-Stage Liver Disease scores. This resulted in 2 matched cohorts with 55 patients in each group. None of the patients in the APRO group had significant fibrinolysis. In the no-APRO group, 23.6% of the patients developed fibrinolysis (P < 0.003). Tranexamic acid was used in 61.5% of the patients (n = 8) in the no-APRO group in whom lysis was present, and this resolved the fibrinolysis in all but 1 of these patients. There were no differences in red blood cell, fresh frozen plasma, platelet concentrate, or cryoprecipitate transfusions between the 2 groups. In conclusion, we have shown a significant increase in the prevalence of fibrinolysis during OLT since the withdrawal of APRO. However, there has been no increase in transfusion requirements.
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Affiliation(s)
- Nick Schofield
- Department of Anaesthesia, Royal Free Hospital, Hampstead, London, United Kingdom
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Krzanicki D, Sugavanam A, Mallett S. Intraoperative hypercoagulability during liver transplantation as demonstrated by thromboelastography. Liver Transpl 2013; 19:852-61. [PMID: 23696318 DOI: 10.1002/lt.23668] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
Thrombotic complications are more common in liver disease than might be expected because of the coagulopathy described by conventional coagulation tests. Some of these complications may be life-threatening. The phenomenon of hypercoagulation is associated with complications in many populations, but the incidence in liver transplant recipients is unclear. We performed a retrospective database review of intraoperative thromboelastography (TEG) for 124 liver transplant recipients. We assessed the prevalence of hypercoagulation in this group and investigated the relative frequency of both shortened TEG reaction times (R times) and increased net clot strength (G) values. These findings were correlated with thrombotic complications. At the baseline, the prevalence of high G values was 15.53% on native TEG, and the prevalence of shortened R times was 6.80% on native-heparinase TEG. Patients with cholestatic pathologies had particularly high rates of hypercoagulation (42.9% with primary biliary cirrhosis and 85.7% with primary sclerosing cholangitis), but hypercoagulation was also common in patients with fulminant hepatic failure (50%) and nonalcoholic steatohepatitis (37.5%). There was a poor correlation between the TEG R time and the international normalized (INR), with 37.7% of TEG analyses demonstrating a short R time with an INR > 2. Six of the patients developed early hepatic artery thrombosis (5%); 3 of these patients had TEG evidence of high G values (P = 0.25), and 4 had short R times (not significant). In conclusion, intraoperative TEG evidence of high G values and short R times is relatively common in liver transplantation. It is unclear what bearing this condition has on thrombotic complications. Conventional coagulation tests have no ability to diagnose this condition. It is conceivable that such patients may come to harm if hypercoagulability is unrecognized and, therefore, inappropriately managed.
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Affiliation(s)
- Dominik Krzanicki
- Department of Anaesthesia, Royal Free Hospital, London, United Kingdom.
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