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Tsang YS, Kurniawan AR, Tomasek O, Hessian E, Bramley D, Daly O, Simons K, Imberger G. Effects of rotational thromboelastometry-guided transfusion management in patients undergoing surgical intervention for postpartum hemorrhage: An observational study. Transfusion 2021; 61:2898-2905. [PMID: 34455611 DOI: 10.1111/trf.16637] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 06/03/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Postpartum hemorrhage (PPH) can be associated with coagulopathy, which may be difficult to rapidly assess and may exacerbate blood loss. Rotational thromboelastometry (ROTEM) at the point of care can guide clinician choice of blood products and has been shown in some settings to reduce transfusions and improve outcomes. This hospital-based observational study aims to measure effects of a ROTEM-guided transfusion protocol on transfusion practice and clinical outcomes in patients with PPH managed in the operating theater. STUDY DESIGN AND METHODS We compared a retrospective cohort of 450 consecutive patients with PPH treated in the operating theater before the introduction of a ROTEM-guided transfusion algorithm in June 2016, with 450 patients treated after its introduction. Multivariate regression was used to evaluate the effect of ROTEM introduction on the primary outcome, patients requiring a packed red blood cell (PRBC) transfusion and adjusting for demographic and obstetric confounders. Secondary outcomes included other blood product transfusions, hysterectomy, and intensive care unit admission. RESULTS A total of 90 (20%) of patients treated prior to ROTEM introduction received a PRBC transfusion, compared with 102 (22.7%) of those treated after ROTEM introduction (95% confidence interval [CI] 1.0-2.0, p = .04). There was no difference in PRBC transfusion in patients undergoing caesarean section (95% CI 0.5-1.8, p = .99). There was a trend toward increased use of cryoprecipitate and reduced use of platelets and fresh frozen plasma after ROTEM introduction. CONCLUSION In our institution, the introduction of ROTEM-guided transfusion did not reduce PRBC transfusion in patients with PPH treated in the operating theater.
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Affiliation(s)
- Yiying Sally Tsang
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Footscray, Victoria, Australia
| | - Ade Rizki Kurniawan
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Footscray, Victoria, Australia
| | - Owen Tomasek
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Footscray, Victoria, Australia
| | - Elizabeth Hessian
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Footscray, Victoria, Australia
| | - David Bramley
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Footscray, Victoria, Australia
| | - Oliver Daly
- Department of Obstetrics and Gynaecology, Western Health, St Albans, Victoria, Australia
| | - Koen Simons
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.,Western Health Office for Research, Western Health, St Albans, Victoria, Australia
| | - Georgina Imberger
- Department of Anaesthesia, Pain and Perioperative Medicine, Western Health, Footscray, Victoria, Australia
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Darvall JN, Wang A, Nazeem MN, Harrison CL, Clarke L, Mendoza C, Parker A, Harrap B, Teale G, Story D, Hessian E. A Pedometer-Guided Physical Activity Intervention for Obese Pregnant Women (the Fit MUM Study): Randomized Feasibility Study. JMIR Mhealth Uhealth 2020; 8:e15112. [PMID: 32348280 PMCID: PMC7284400 DOI: 10.2196/15112] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/23/2019] [Accepted: 02/12/2020] [Indexed: 12/16/2022] Open
Abstract
Background Obesity in pregnancy is a growing problem worldwide, with excessive gestational weight gain (GWG) occurring in the majority of pregnancies. This significantly increases risks to both mother and child. A major contributor to both prepregnancy obesity and excessive GWG is physical inactivity; however, past interventions targeting maternal weight gain and activity levels during the antenatal period have been ineffective in women who are already overweight. Pedometer-guided activity may offer a novel solution for increasing activity levels in this population. Objective This initial feasibility randomized controlled trial aimed to test a pedometer-based intervention to increase activity and reduce excessive GWG in pregnant women. Methods We supplied 30 pregnant women with obesity a Fitbit Zip pedometer and randomized them into 1 of 3 groups: control (pedometer only), app (pedometer synced to patients’ personal smartphone, with self-monitoring of activity), or app-coach (addition of a health coach–delivered behavioral change program). Feasibility outcomes included participant compliance with wearing pedometers (days with missing pedometer data), data syncing, and data integrity. Activity outcomes (step counts and active minutes) were analyzed using linear mixed models and generalized estimating equations. Results A total of 30 participants were recruited within a 10-week period, with a dropout rate of 10% (3/30; 2 withdrawals and 1 stillbirth); 27 participants thus completed the study. Mean BMI in all groups was ≥35 kg/m2. Mean (SD) percentage of missing data days were 23.4% (20.6%), 39.5% (32.4%), and 21.1% (16.0%) in control, app group, and app-coach group patients, respectively. Estimated mean baseline activity levels were 14.5 active min/day and 5455 steps/day, with no significant differences found in activity levels between groups, with mean daily step counts in all groups remaining in the sedentary (5000 steps/day) or low activity (5000-7499 steps/day) categories for the entire study duration. There was a mean decrease of 7.8 steps/day for each increase in gestation day over the study period (95% CI 2.91 to 12.69, P=.002). Conclusions Activity data syncing with a personal smartphone is feasible in a cohort of pregnant women with obesity. However, our results do not support a future definitive study in its present form. Recruitment and retention rates were adequate, as was activity data syncing to participants’ smartphones. A follow-up interventional trial seeking to reduce GWG and improve activity in this population must focus on improving compliance with activity data recording and behavioral interventions delivered. Trial Registration Australian and New Zealand Clinical Trials Registry ACTRN12617000038392; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=370884
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Affiliation(s)
- Jai N Darvall
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia.,Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Andrew Wang
- Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | | | - Cheryce L Harrison
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lauren Clarke
- Department of Physiotherapy, Western Health, Melbourne, Australia
| | | | - Anna Parker
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Benjamin Harrap
- Melbourne Epicentre, University of Melbourne, Melbourne, Australia
| | - Glyn Teale
- Department of Women's and Children's Services, Western Health, Melbourne, Australia
| | - David Story
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Elizabeth Hessian
- Department of Anaesthesia and Pain Management, Western Health, Melbourne, Australia
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Dennis AT, Lamb KE, Story D, Tew M, Dalziel K, Clarke P, Lew J, Parker A, Hessian E, Teale G, Simmons S, Casalaz D. Associations between maternal size and health outcomes for women undergoing caesarean section: a multicentre prospective observational study (The MUM SIZE Study). BMJ Open 2017; 7:e015630. [PMID: 28667219 PMCID: PMC5734348 DOI: 10.1136/bmjopen-2016-015630] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m2 higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS). DESIGN A prospective multicentre observational study. SETTING Seven secondary or tertiary referral obstetric hospitals. PARTICIPANTS One thousand and four hundred and fifty-seven women undergoing all categories of CS. DATA COLLECTION Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs. RESULTS Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m2. Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women. CONCLUSIONS Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider these clinical risks, time implications and financial costs when managing pregnant women.
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Affiliation(s)
- Alicia Therese Dennis
- Department of Obstetrics and Gynaecology and Department of Pharmacology, The University of Melbourne, Parkville, Victoria, Australia
- Department of Anaesthesia, The Royal Women’s Hospital, Parkville, Victoria, Australia
| | - Karen Elaine Lamb
- Institute for Physical Activity and Nutrition (IPAN), School of Exercise & Nutrition Science, Deakin University, Burwood, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
| | - David Story
- Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Michelle Tew
- Health Economics Unit, Centre for Health Policy, The University of Melbourne, Parkville, Victoria, Australia
| | - Kim Dalziel
- Health Economics Unit, Centre for Health Policy, The University of Melbourne, Parkville, Victoria, Australia
| | - Philip Clarke
- Health Economics Unit, Centre for Health Policy, The University of Melbourne, Parkville, Victoria, Australia
| | - Jospeh Lew
- Department of Anaesthesia, The Northern Hospital, Epping, Victoria, Australia
| | - Anna Parker
- Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Elizabeth Hessian
- Departments of Anaesthesia and Pain Medicine, Western Health, Footscray, Victoria, Australia
| | - Gyln Teale
- Women’s and Children’s Services, Sunshine Hospital, Western Health, Albans, Victoria, Australia
| | - Scott Simmons
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Dan Casalaz
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
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McCrossin KE, Bramley DEP, Hessian E, Hutcheon E, Imberger G. Viscoelastic testing for hepatic surgery: a systematic review with meta-analysis-a protocol. Syst Rev 2016; 5:151. [PMID: 27600291 PMCID: PMC5013585 DOI: 10.1186/s13643-016-0326-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 08/24/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Viscoelastic tests, including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), provide a global assessment of haemostatic function at the point of care. The use of a TEG or ROTEM system to guide blood product administration has been shown in some surgical settings to reduce transfusion requirements. The aim of this review is to evaluate all published evidence regarding viscoelastic testing in the setting of hepatic surgery. METHODS We will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials databases to identify randomised controlled trials examining the use of viscoelastic testing for hepatic surgery. Two reviewers will independently screen titles and abstracts of studies identified and will independently extract data. Any disagreements will be resolved by discussion with a third reviewer. A meta-analysis will be conducted if feasible. DISCUSSION Viscoelastic devices such as TEG and ROTEM are increasingly available to clinicians as a bedside test. Patients undergoing hepatic surgery have a significant risk of blood loss and coagulopathy requiring transfusion. Theoretical benefits of use of a TEG or ROTEM system in the hepatic surgical setting include a rationalisation of blood products, a reduction in transfusion-related side effects, an improvement in patient outcomes including mortality, and a reduction in cost. This systematic review will summarise the current evidence regarding the use of viscoelastic testing for hepatic surgery. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016036732.
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Affiliation(s)
- Kate Elizabeth McCrossin
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4006, Australia.
| | - David Edmund Piers Bramley
- Department of Anaesthesia and Pain Medicine, Western Health, Gordon Street, Footscray, VIC, 3011, Australia
| | - Elizabeth Hessian
- Department of Anaesthesia and Pain Medicine, Western Health, Gordon Street, Footscray, VIC, 3011, Australia
| | - Evelyn Hutcheon
- Western Health Library Service, Western Health, Gordon Street, Footscray, VIC, 3011, Australia
| | - Georgina Imberger
- Department of Anaesthesia and Pain Medicine, Western Health, Gordon Street, Footscray, VIC, 3011, Australia
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Abstract
We conducted a survey of Australian specialist anaesthetists about their practice of sedation for elective and emergency gastroscopy, endoscopic retrograde cholangiopancreatography (ERCP), and colonoscopy. A 24-item survey was emailed to 1,000 anaesthetists in August 2015. Responses were received from 409 anaesthetists (response rate = 41%) with responses from 395 anaesthetists analysed. Pulse oximetry and oxygen administration were routine for all procedures for all respondents. Blood pressure was routinely measured by most respondents during gastroscopy (elective = 88%; emergency = 97%), ERCP (elective = 99%; emergency = 99%) and colonoscopy (elective = 91%; emergency = 98%). The airway was routinely managed with jaw lift or oral or nasal airway by 99%, 76% and 97% of respondents during gastroscopy, ERCP and colonoscopy, whereas in emergency procedures endotracheal intubation was routine in 49%, 64% and 17% of procedures. Propofol was routinely administered by 99% of respondents for gastroscopy and 100% of respondents for ERCP and colonoscopy. A maximum depth of sedation in which patients were unresponsive to painful stimulation was targeted by the majority of respondents for all procedures except for elective gastroscopy. These results may be used to facilitate comparison of practice in Australia and overseas, and give an indication of compliance by Australian anaesthetists with the relevant Australian and New Zealand College of Anaesthetists guideline.
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Affiliation(s)
- K. Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Perioperative and Pain Medicine Unit, Melbourne Medical School, and Department of Pharmacology and Therapeutics, University of Melbourne, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria
| | - M. L. Allen
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - E. Hessian
- Department of Anaesthesia and Pain Medicine, Western Health Victoria, Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, University of Melbourne, Melbourne, Victoria
| | - A. Y-S. Lee
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria
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