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Valencia Morales DJ, Klompas AM, Torbenson JM, Finney RE, Chen D, Stubbs JR, Nuttall GA. Cold platelet transfusion: The effects of a fluid warmer on platelet function. Transfusion 2024; 64:47-52. [PMID: 38115202 DOI: 10.1111/trf.17624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 10/27/2023] [Accepted: 10/29/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Recently the US Food and Drug Administration has granted variances to select blood centers to supply cold-stored platelet components (CSP). In hemorrhage resuscitation warming of blood components with approved fluid warming devices is common. STUDY DESIGN AND METHODS Pathogen-reduced apheresis platelet units were collected and stored in one of two ways: (1) CSP-I, (2) CSP-D. CSP-I were collected and immediately stored at 1-6°C until used. CSP-D were collected and stored at 20-24°C for 5 days and transferred to storage at 1-6°C until use. Aggregometry using arachidonic acid (AA), adenosine diphosphate (ADP) and collagen as agonists was performed on the unit samples before and after the units were infused through a Ranger blood-warming device. RESULTS CSP-I, 23 units, had very high aggregation responses to all agonists (all ≥47.6 ± 20.7). There was a statistically significant reduction in ADP-induced aggregometry results from 55.1 ± 23.2 before compared to 33.5 ± 14.6 following infusion of the PLT through the blood warmer (p < .001). There were no differences in AA and collagen aggregometry results before and after the infusion of the platelets through the blood warmer. CSP-D had 5 of the 15 units with visible clotting in the bag. The 10 CSP-Ds studied had lower aggregation than all agonists before and after infusion through the blood-warming device (all ≤49.9 ± 35.9). CONCLUSION We detected a statistically significant reduction in ADP-induced aggregometry in CSP-I run through a Ranger blood-warming device with no change with AA or collagen agonist aggregometry.
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Affiliation(s)
- Diana J Valencia Morales
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Division of Transfusion Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Jenna M Torbenson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Robyn E Finney
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Dong Chen
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Clinical Core Laboratory, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - James R Stubbs
- Division of Transfusion Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Skojec AJ, Christensen JM, Yalamuri SM, Smith MM, Arghami A, LeMahieu AM, Schroeder DR, Mauermann WJ, Nuttall GA, Ritter MJ. Deep Parasternal Intercostal Plane Block for Postoperative Analgesia After Sternotomy for Cardiac Surgery-A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:189-196. [PMID: 37968198 DOI: 10.1053/j.jvca.2023.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/31/2023] [Accepted: 09/29/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To examine the analgesic efficacy of postoperative deep parasternal intercostal plane (DPIP) blocks for patients having cardiac surgery via median sternotomy. DESIGN This single-center retrospective study compared patients receiving bilateral DPIP blocks with a matched cohort of patients not receiving DPIP blocks. SETTING Large quaternary referral center. PARTICIPANTS Adult patients admitted to the authors' institution from January 1, 2016, to August 14, 2020, for elective cardiac surgery via median sternotomy. INTERVENTIONS Patients received ultrasound-guided bilateral DPIP blocks. MEASUREMENTS AND MAIN RESULTS A total of 113 patients received a DPIP block; 3,461 patients did not. The estimated multiplicative change in cumulative opioid consumption through 24 hours was 0.42 (95% CI 0.32-0.56; p < 0.001), indicating that patients receiving DPIP blocks required 60% fewer opioids than patients who did not. Proportional odds ratios for the average pain score on postoperative day (POD) 0 was 0.46 (95% CI 0.32-0.65; p < 0.001), and POD 1 was 0.67 (95% CI 0.47-0.94; p = 0.021), indicating lower pain scores for patients receiving blocks. The exploratory analysis identified an inverse correlation between DPIP blocks and atrial fibrillation incidence (2% v 15%; inverse probability of treatment weighting odds ratio 0.088, 95% CI 0.02-0.41; p = 0.002). CONCLUSIONS The use of DPIP blocks in patients undergoing cardiac surgery via median sternotomy was associated with less opioid use and improved pain scores in the early postoperative period compared with patients not receiving blocks. Prospective randomized controlled studies should further elucidate the efficacy and risks of DPIP blocks in cardiac surgery.
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Affiliation(s)
- Alexander J Skojec
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Suraj M Yalamuri
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Allison M LeMahieu
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Matthew J Ritter
- Department of Anesthesiology and Perioperative Medicine, Division of Cardiothoracic Anesthesia, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Snyder EL, Sekela ME, Welsby IJ, Toyoda Y, Alsammak M, Sodha NR, Beaver TM, Pelletier JPR, Gorham JD, McNeil JS, Sniecinski RM, Pearl RG, Nuttall GA, Sarode R, Reece TB, Kaplan A, Davenport RD, Ipe TS, Benharash P, Lopez-Plaza I, Gammon RR, Sadler P, Pitman JP, Liu K, Bentow S, Corash L, Mufti N, Varrone J, Benjamin RJ. Evaluation of the efficacy and safety of amustaline/glutathione pathogen-reduced RBCs in complex cardiac surgery: the Red Cell Pathogen Inactivation (ReCePI) study-protocol for a phase 3, randomized, controlled trial. Trials 2023; 24:799. [PMID: 38082326 PMCID: PMC10712151 DOI: 10.1186/s13063-023-07831-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Red blood cell (RBC) transfusion is a critical supportive therapy in cardiovascular surgery (CVS). Donor selection and testing have reduced the risk of transfusion-transmitted infections; however, risks remain from bacteria, emerging viruses, pathogens for which testing is not performed and from residual donor leukocytes. Amustaline (S-303)/glutathione (GSH) treatment pathogen reduction technology is designed to inactivate a broad spectrum of infectious agents and leukocytes in RBC concentrates. The ReCePI study is a Phase 3 clinical trial designed to evaluate the efficacy and safety of pathogen-reduced RBCs transfused for acute anemia in CVS compared to conventional RBCs, and to assess the clinical significance of treatment-emergent RBC antibodies. METHODS ReCePI is a prospective, multicenter, randomized, double-blinded, active-controlled, parallel-design, non-inferiority study. Eligible subjects will be randomized up to 7 days before surgery to receive either leukoreduced Test (pathogen reduced) or Control (conventional) RBCs from surgery up to day 7 post-surgery. The primary efficacy endpoint is the proportion of patients transfused with at least one study transfusion with an acute kidney injury (AKI) diagnosis defined as any increased serum creatinine (sCr) level ≥ 0.3 mg/dL (or 26.5 µmol/L) from pre-surgery baseline within 48 ± 4 h of the end of surgery. The primary safety endpoints are the proportion of patients with any treatment-emergent adverse events (TEAEs) related to study RBC transfusion through 28 days, and the proportion of patients with treatment-emergent antibodies with confirmed specificity to pathogen-reduced RBCs through 75 days after the last study transfusion. With ≥ 292 evaluable, transfused patients (> 146 per arm), the study has 80% power to demonstrate non-inferiority, defined as a Test group AKI incidence increase of no more than 50% of the Control group rate, assuming a Control incidence of 30%. DISCUSSION RBCs are transfused to prevent tissue hypoxia caused by surgery-induced bleeding and anemia. AKI is a sensitive indicator of renal hypoxia and a novel endpoint for assessing RBC efficacy. The ReCePI study is intended to demonstrate the non-inferiority of pathogen-reduced RBCs to conventional RBCs in the support of renal tissue oxygenation due to acute anemia and to characterize the incidence of treatment-related antibodies to RBCs.
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Affiliation(s)
| | | | | | | | | | | | | | | | - James D Gorham
- University of Virginia Health System, Charlottesville, VA, USA
| | - John S McNeil
- University of Virginia Health System, Charlottesville, VA, USA
| | | | | | | | - Ravi Sarode
- University of Texas, Southwestern, Dallas, TX, USA
| | | | - Alesia Kaplan
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant, Pittsburgh, PA, USA
| | | | - Tina S Ipe
- Our Blood Institute, Oklahoma City, OK, USA
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Richard R Gammon
- Scientific, Medical and Technical and Research Department, OneBlood, Orlando, FL, USA
| | | | - John P Pitman
- Cerus Corporation, 1220 Concord Ave, Concord, CA, 94520, USA
| | - Kathy Liu
- Cerus Corporation, 1220 Concord Ave, Concord, CA, 94520, USA
| | - Stanley Bentow
- Cerus Corporation, 1220 Concord Ave, Concord, CA, 94520, USA
| | - Laurence Corash
- Cerus Corporation, 1220 Concord Ave, Concord, CA, 94520, USA
| | - Nina Mufti
- Cerus Corporation, 1220 Concord Ave, Concord, CA, 94520, USA
| | - Jeanne Varrone
- Cerus Corporation, 1220 Concord Ave, Concord, CA, 94520, USA
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Nuttall GA, Reed AM, Pham Louis KD, Oyen LJ, Marsland SP, Ackerman MJ. The Incidence of Torsades de Pointes With Perioperative Triple Antiemetic Administration. Ann Pharmacother 2023:10600280231215786. [PMID: 38053391 DOI: 10.1177/10600280231215786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND The safety of triple antiemetic therapy consisting of ondansetron, haloperidol, and a steroid, to surgical patients is unknown. OBJECTIVE To determine the incidence of torsade de pointes (TdP) or death following perioperative administration of triple antiemetic therapy. METHODS A retrospective cohort study identified 19,874 patients who received 22,202 doses of triple antiemetics during the 2.5-year time frame from March 4, 2020 to September 7, 2022 for surgical nausea prophylaxis or treatment of nausea. These patients above were cross-matched with an electrocardiogram and adverse outcome database; this identified 226 patients with documentation of a QTc > 450 ms, all ventricular tachycardias including TdP within 48 hours of receiving triple antiemetic therapy, or death within 7 days of receiving ondansetron. RESULTS There were 3 patients who had documented VT (n = 3), but there were no documented incidents of TdP (n = 0). There were 9 codes called on patients within 48 hours of medication administration, and none of them were due to ventricular arrythmias (n = 0). A total of 11 patients died within 7 days of triple antiemetic therapy. Ten of the 11 deaths were determined to not be from the triple antiemetic. One patient died at home within 24 hours of the procedure of an unknown cause (n = 1). CONCLUSIONS AND RELEVANCE No episodes of TdP were identified in patients receiving triple antiemetic therapy perioperatively, though the cause of death in 1 patient could not be determined. This suggest that low-dose triple antiemetic therapy is low risk for the development of TdP.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology, Mayo Clinic College of Medicine and Science, Mayo Foundation, Rochester, MN, USA
| | - Alyssa M Reed
- Mayo School of Health Sciences, Mayo Foundation, Rochester, MN, USA
| | | | - Lance J Oyen
- Mayo Clinic College of Medicine and Science, Mayo Foundation, Rochester, MN, USA
| | | | - Michael J Ackerman
- Mayo Clinic College of Medicine and Science, Mayo Foundation, Rochester, MN, USA
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5
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Nuttall GA, Merren MP, Sandoval Y. 5-Lead Electrocardiogram Monitoring to Detect Perioperative Myocardial Infarction, Noncardiac Surgery Patients. Mayo Clin Proc 2023; 98:1581-1582. [PMID: 37793733 DOI: 10.1016/j.mayocp.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/11/2023] [Accepted: 08/01/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| | - Michael P Merren
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Yader Sandoval
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
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Charnin JE, Weingarten TN, Schroeder DR, Sviggum HP, Portner ER, Nuttall GA. Retrospective Review of Intrathecal Hydromorphone Dose Range and Complications. Pain Physician 2023; 26:E557-E565. [PMID: 37774193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Optimal intrathecal dosing regimens for hydromorphone are not well established for analgesia after abdominal surgery. OBJECTIVES We reviewed intrathecal hydromorphone doses and complications because dosing variability has been observed among anesthesiologists. We hypothesized that increasing doses of intrathecal hydromorphone would be associated with improved postoperative analgesia, but with increased rates of opioid-related adverse events. STUDY DESIGN Retrospective analysis. SETTING A high-volume academic referral center in the United States. METHODS A retrospective study was conducted of adults undergoing abdominal surgery under general anesthesia supplemented preoperatively with intrathecal hydromorphone for postoperative analgesia from May 5, 2018, through May 31, 2021. Patients were categorized into 3 hydromorphone dosing groups: low-dose (50-100 µg), middle-dose (101-199 µg), and high-dose (200-300 µg). Multivariable logistic regression models were used to assess rates of severe postoperative pain, severe opioid-related adverse events, oversedation, and pruritus in the postanesthesia care unit (PACU) and within 24 hours after PACU discharge. RESULTS Of 1,846 patients identified, 1,235 (66.9%) were in the low-dose group; 321 (17.3%), middle-dose group; and 290 (15.7%), high-dose group. Patients receiving the 2 higher doses had more extensive procedures. An unadjusted analysis showed differing rates of severe pain in the PACU by group: 306 (24.8%) in the low-dose, 73 (22.7%) middle-dose, and 45 (15.5%) in the high-dose group (P = 0.003); these differences, however, were no longer significant after an adjusted analysis (P = 0.34). Ten severe opioid-related events occurred; all were recognized in the PACU. Five events each occurred in the low-dose and high-dose groups versus none in the middle-dose group (P = 0.02). No other differences were identified with adjusted analyses. LIMITATIONS Limitations of our study include its retrospective design and its conduct at a single center, along with the apparent, but difficult to characterize, treatment biases in hydromorphone dosing. CONCLUSIONS No dose response was observed between intrathecal hydromorphone dose and postoperative analgesia, a finding that may reflect treatment bias. Higher rates of severe opioid-related events were detected for patients receiving high-dose hydromorphone in the PACU, but all other safety outcomes were similar between dosing regimens. KEY WORDS Drug-related side effects, opioid analgesics, outcome assessment, postoperative pain, spinal injections.
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Affiliation(s)
- Jonathan E Charnin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Hans P Sviggum
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Erica R Portner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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7
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Farazdaghi A, Manunga JM, Bhatti UH, Nuttall GA, Bower TC, Heins C, Harmsen WS, Kalra M. Asymptomatic myocardial injury identified on postoperative troponin testing after open or endovascular surgical procedures is a predictor of mortality. J Vasc Surg 2023; 77:1216-1223. [PMID: 36565776 DOI: 10.1016/j.jvs.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/06/2022] [Revised: 11/25/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Elevated troponin (TnT) levels after open or endovascular surgical procedures have been previously shown to correlate with significantly higher postoperative and short-term mortality. The incidence of asymptomatic myocardial injury after vascular surgical procedures has also been shown to be high. The aim of the present study was to evaluate the utility of routine postoperative TnT screening and long-term outcomes for patients with postoperative TnT elevation. METHODS Data from consecutive patients who had undergone open or endovascular surgery on an emergent or elective basis with routine postoperative TnT testing from January 2010 to December 2012 were retrospectively analyzed. Elevated postoperative TnT was considered >0.01 ng/mL. Patients with no documented postoperative TnT levels, those who had denied research authorization, and those with elevated TnT levels secondary to renal insufficiency alone were excluded. Patients were also excluded if they had required a dialysis access procedure, varicose vein procedure, or any procedure performed on an outpatient basis, because these were considered nonmajor surgeries. The end points were all-cause mortality at 30 days and 1, 2, 4, and 8 years postoperatively. Mortality data were retrieved from the electronic medical records and the Social Security Death Index and Accurint Death database. RESULTS During the 3-year study period, 1632 patients with postoperative TnT levels available had met the inclusion criteria (70% men; 30% women; mean age, 69.7 years). Postoperatively, 410 patients (25.1%) had had elevated TnT levels (TnT+) and 1222 (74.9%) had had nonelevated TnT levels (TnT-). Of the 410 TnT+ patients, 261 had undergone open, 143 had undergone endovascular, and 6 had undergone hybrid procedures. These included 180 aortic, 128 infrainguinal, 22 cerebrovascular, and 80 upper extremity or miscellaneous procedures. Of the 410 TnT+ patients, 168 had experienced asymptomatic myocardial injury. The 30-day mortality was significantly higher for the TnT+ patients than for the TnT- patients (3.9% vs 0.8%; P < .001). The cumulative probability of death for the TnT+ patients remained significantly higher than that for the TnT- patients at 1 (13% vs 3.2%), 2 (17.8% vs 4.8%), 4 (43% vs 18.5%), and 8 (81.4% vs 48.6%) years (P < .0001). The difference held true even for the 168 asymptomatic TnT+ patients compared with the TnT- patients at 30 days (2.4% vs 0.8%) and 1 (7.6% vs 3.2%), 2 (13.3% vs 4.8%), 4 (43.6 vs 18.5%) and 8 (80.8 vs 48.6%) years (P < .0001). CONCLUSIONS In the present study, patients with elevated TnT levels after vascular surgery had had significantly higher early and late all-cause mortality compared with those with normal postoperative TnT levels. This was true even for patients with asymptomatic TnT elevation, suggesting a role might exist for routine postoperative TnT screening to allow for long-term risk stratification and targeted medical management.
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Affiliation(s)
- Armin Farazdaghi
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Jesse M Manunga
- Division of Vascular and Endovascular Surgery, Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN
| | - Umer H Bhatti
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Gregory A Nuttall
- Division of Cardiac Anesthesia, Department of Anesthesia, Mayo Clinic, Rochester, MN
| | - Thomas C Bower
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | | | | | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
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Vinzant NJ, Christensen JM, Yalamuri SM, Smith MM, Nuttall GA, Arghami A, LeMahieu AM, Schroeder DR, Mauermann WJ, Ritter MJ. Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00099-X. [PMID: 36948910 DOI: 10.1053/j.jvca.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVES This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. DESIGN A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. SETTING This investigation was performed at a large quaternary referral center. PARTICIPANTS Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. INTERVENTIONS Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. MEASUREMENTS AND MAIN RESULTS One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. CONCLUSIONS The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.
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Affiliation(s)
- Nathan J Vinzant
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Suraj M Yalamuri
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Matthew J Ritter
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Ripoll JG, Warner MA, Hanson AC, Marquez A, Dearani JA, Nuttall GA, Kor DJ, Mauermann WJ, Smith MM. Coagulation Tests and Bleeding Classification After Cardiopulmonary Bypass: A Prospective Study. J Cardiothorac Vasc Anesth 2023; 37:933-941. [PMID: 36863984 PMCID: PMC10149589 DOI: 10.1053/j.jvca.2023.01.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVE No recent prospective studies have analyzed the accuracy of standard coagulation tests and thromboelastography (TEG) to identify patients with excessive microvascular bleeding following cardiopulmonary bypass (CPB). The aim of this study was to assess the value of coagulation profile tests, as well as TEG, for the classification of microvascular bleeding after CPB. DESIGN A prospective observational study. SETTING At a single-center academic hospital. PARTICIPANTS Patients ≥18 years of age undergoing elective cardiac surgery. INTERVENTIONS Qualitative assessment of microvascular bleeding post-CPB (surgeon and anesthesiologist consensus) and the association with coagulation profile tests and TEG values. MEASUREMENTS AND MAIN RESULTS A total of 816 patients were included in the study-358 (44%) bleeders and 458 (56%) nonbleeders. Accuracy, sensitivity, and specificity for the coagulation profile tests and TEG values ranged from 45% to 72%. The predictive utility was similar across tests, with prothrombin time (PT) (62% accuracy, 51% sensitivity, 70% specificity), international normalized ratio (INR) (62% accuracy, 48% sensitivity, 72% specificity), and platelet count (62% accuracy, 62% sensitivity, 61% specificity) displaying the highest performance. Secondary outcomes were worse in bleeders versus nonbleeders, including higher chest tube drainage, total blood loss, transfusion of red blood cells, reoperation rates (p < 0.001, respectively), readmission within 30 days (p = 0.007), and hospital mortality (p = 0.021). CONCLUSIONS Standard coagulation tests and individual components of TEG in isolation agree poorly with the visual classification of microvascular bleeding after CPB. The PT-INR and platelet count performed best but had low accuracy. Further work is warranted to identify better testing strategies to guide perioperative transfusion decisions in cardiac surgical patients.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Matthew A Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Andrew C Hanson
- Statistician, Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Alberto Marquez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Daryl J Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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10
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Smith MM, Nuttall GA. Prothrombin Complex Concentrate and Cardiac Surgery-Reply. JAMA Surg 2023; 158:223-224. [PMID: 36449296 DOI: 10.1001/jamasurg.2022.5802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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11
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Nuttall GA, Voogd SC, Danke H, Warner PA, Oyen LJ, Marienau MS, Ackerman MJ. The incidence of torsades de pointes with peri‐operative low‐dose ondansetron administration. Pharmacotherapy 2022; 42:292-297. [DOI: 10.1002/phar.2668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Gregory A. Nuttall
- Department of Anesthesiology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Sarah C. Voogd
- Department of Anesthesiology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Heather Danke
- Department of Anesthesiology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Paul A. Warner
- Department of Anesthesiology Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Lance J. Oyen
- Department of Pharmacy Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Mary Shirk Marienau
- Department of Anesthesiology Nurse Anesthesia Program Mayo Clinic College of Medicine Rochester Minnesota USA
| | - Michael J. Ackerman
- Department of Medicine, Pediatrics and Pharmacology Mayo Clinic College of Medicine Rochester Minnesota USA
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12
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Nuttall GA, Smith MM, Smith BB, Christensen JM, Santrach PJ, Schaff HV. A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients. Ann Thorac Cardiovasc Surg 2021; 28:204-213. [PMID: 34937821 PMCID: PMC9209891 DOI: 10.5761/atcs.oa.21-00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/16/2022] Open
Abstract
Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy. Materials and Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements. Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups. Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paula J Santrach
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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13
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Naranjo J, Portner ER, Jakub JW, Cheville AL, Nuttall GA. Ipsilateral Intravenous Catheter Placement in Breast Cancer Surgery Patients. Anesth Analg 2021; 133:707-712. [PMID: 34043309 DOI: 10.1213/ane.0000000000005597] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is a continued perception that intravenous line (IV) placement is contraindicated in the arm ipsilateral to prior breast cancer surgery to avoid breast cancer-related lymphedema (BCRL). The aim of this retrospective study was to determine the risk for development of BCRL in ipsilateral arm IV placement compared to contralateral arm IV placement to prior breast cancer surgery. METHODS We performed a retrospective review, via our Integrated Clinical Systems and Epic Electronic Heath Record of IV placement for anesthesia and surgery in patients with a prior history of breast cancer surgery with or without axillary lymph node dissection. Complication rates were compared for IVs placed in the ipsilateral and contralateral arms. We identified 3724 patients undergoing 7896 IV placements between January 1, 2015, and May 5, 2018, with a prior history of breast cancer surgery via their index anesthesia and surgical procedures. RESULTS The median time from breast cancer surgery to IV placement was 1.5 years (range, 1 day to 17.8 years). Of 2743 IVs placed in the arm contralateral to prior breast cancer surgery, 2 had a complication, corresponding to an incidence of 7.3 per 10,000 (95% confidence interval [CI], 0.9-26.3 per 10,000). Of 5153 IVs placed in the arm ipsilateral to prior breast cancer surgery, 2 IVs had a complication, for an incidence of 3.9 per 10,000 (95% CI, 0.5-14.0 per 10,000). The frequency of complications was not found to differ significantly between the groups (P = .91), and the 95% CI for the risk difference (ipsilateral minus contralateral) was -23 to +8 complications per 10,000. The complication rate is similar when only the first IV placed following breast cancer surgery is considered (overall 5.4 per 10,000 [95% CI, 0.7-19.4] per 10,000; contralateral 7.0 [95% CI, 0.2-39.0] per 10,000, ipsilateral 4.4 [95% CI, 0.1-24.2] per 10,000; P = 1.00; 95% CI for risk difference [ipsilateral minus contralateral], -41 to +22 per 10,000). CONCLUSIONS We found very few complications in patients who had an IV placed for surgery following a previous breast cancer surgery and no complications in those patients with IV placement ipsilateral with axillary node dissection. Avoidance of IV placement in the arm ipsilateral to breast cancer surgery is not necessary.
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Affiliation(s)
- Julian Naranjo
- From the Department of Anesthesiology and Perioperative Medicine
| | - Erica R Portner
- From the Department of Anesthesiology and Perioperative Medicine
| | | | | | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Mattson MK, Groves C, Smith MM, Christensen JM, Chen D, Stubbs JR, Karon BS, Nuttall GA. Platelet transfusion: The effects of a fluid warmer on platelet function. Transfusion 2020; 61:52-56. [PMID: 33078463 DOI: 10.1111/trf.16139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 01/09/2023]
Abstract
Platelet (PLT) transfusions are an important component of hemostatic resuscitation. The AABB has published several guidelines recommending that PLT units should not be infused through blood warming devices. STUDY DESIGN AND METHODS Thirty-one units of hospital blood bank apheresis PLTs were obtained. PLT-rich plasma (PRP) aggregometry and thromboelastography (TEG) were performed on the unit samples before and after the units were infused through a Ranger blood/fluid warming device. RESULTS There were no differences in any of the aggregometry results before and after infusion of the PLTs through the blood warmer (all P > .32). There was a significant reduction in the TEG maximum amplitude (MA) of 69.8 ± 7.9 mm before and 66.0 ± 8.8 mm after (P < .001) infusion of the PLTs through the blood warmer and α angle 61.8 ± 9.4° before and 59.3 ± 8.2° after (P = .044) infusion of the PLTs through the blood warmer, although both mean values were within normal range for the TEG and not clinically significant. There were very good correlations of aggregometry and TEG results before and after infusion of the PLTs through the blood warmer device. CONCLUSION This study did not demonstrate significant deleterious effect on PLT function from infusing apheresis PLT units through a blood warming device by PRP aggregometry. We did detect a statistically significant-but not clinically significant-reduction in TEG MA and α angle. The prohibition of transfusing PLT units though the Ranger blood warming device is not indicated.
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Affiliation(s)
- Melissa K Mattson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Cory Groves
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Dong Chen
- Division of Hematopathology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - James R Stubbs
- Division of Transfusion Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Brad S Karon
- Division of Laboratory Medicine, Department of Laboratory Medicine and Pathology, Clinical Core Laboratory, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota
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15
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Ashikhmina E, Johnson PM, Aganga DO, Nuttall GA, Lahr BD, Schaff HV, Dearani JA. Thrombin Generation and Antithrombin Activity in Infants Undergoing Cardiopulmonary Bypass—An Exploratory Study. J Cardiothorac Vasc Anesth 2020; 34:2083-2090. [DOI: 10.1053/j.jvca.2019.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/11/2022]
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16
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Assawakawintip C, Nuttall GA, Garrity JA, Smith MM, Dearani JA. Incidence of Ischemic Optic Neuropathy After Cardiopulmonary Bypass: 20-Year Experience. J Cardiothorac Vasc Anesth 2020; 35:35-38. [PMID: 32843271 DOI: 10.1053/j.jvca.2020.07.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVE This study evaluated the incidence and risk factors for ischemic optic neuropathy (ION) as a complication of cardiac surgery requiring cardiopulmonary bypass (CPB). DESIGN Retrospective chart review of prospectively collected data at a tertiary care center. SETTING Single tertiary academic referral center. PARTICIPANTS This study comprised 44,568 cardiac surgery patients who underwent CPB between January 1, 1995, and January 5, 2017, using the Society of Thoracic Surgeons database and cross-matching it with International Classification of Diseases codes for visual changes. INTERVENTIONS None; this was a retrospective chart review. MEASUREMENTS AND MAIN RESULTS Six patients initially were identified as experiencing visual changes. Only 1 patient from 44,568 cardiac surgeries with CPB between January 1, 1995, and January 5, 2017, experienced ION, for an incidence 0.22 per 10,000. Because only 1 patient experienced ION, the authors were unable to determine risk factors for this complication; however, the nadir perioperative hemoglobin in the affected patient was 7.3 g/dL (postoperative). CONCLUSION The incidence of ION decreased from 6 per 10,000 in the authors' previous study from 1976-1994 to 0.22 per 10,000 in the present study. Because of the low incidence of this dreaded complication, the authors were not able to identify risk factors for ION. Practice improvements (eg, transition to membrane oxygenators, blood transfusion guidelines, less- invasive surgical options for high-risk patients) during the time between the authors' studies likely affected the incidence reduction.
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Affiliation(s)
- Chalailak Assawakawintip
- Mayo Clinic College of Medicine, Rochester, MN; Department of Anesthesiology, Wetchakarunrasm Hospital, Bangkok, Thailand
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
| | - James A Garrity
- Department of Ophthmology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN
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17
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Smith BB, Nuttall GA, Mauermann WJ, Schroeder DR, Scott PD, Smith MM. Coagulation test changes associated with acute normovolemic hemodilution in cardiac surgery. J Card Surg 2020; 35:1043-1050. [DOI: 10.1111/jocs.14532] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Bradford B. Smith
- Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and SciencePhoenix Arizona
| | - Gregory A. Nuttall
- Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceRochester Minnesota
| | - William J. Mauermann
- Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceRochester Minnesota
| | - Darrell R. Schroeder
- Division of Biomedical Statistics and InformaticsMayo Clinic College of Medicine and ScienceRochester Minnesota
| | - Phillip D. Scott
- Division of Cardiovascular PerfusionMayo Clinic College of Medicine and ScienceRochester Minnesota
| | - Mark M. Smith
- Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceRochester Minnesota
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18
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Raphael J, Mazer CD, Shore-Lesserson L, Bollen B, Levy JH, Schwann N, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Patel N, Welsby I, Greilich PE, Harvey R, Ranucci M, Heller LB, Boer C, Wilkey A, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Wilkey B, Gaitan B, Hill SS, Kwa J, Klick J, Abernathy J, Lau WT. In Response. Anesth Analg 2020; 130:e154-e156. [PMID: 32102015 DOI: 10.1213/ane.0000000000004709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, Department of Anesthesiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Northshore University Hospital, Manhasset, New York Missoula Anesthesiology, Affiliate with International Heart Institute of Montana at Providence St Patrick Hospital, Missoula, Montana Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina Department of Anesthesiology, Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Tampa, Florida, AAA Anesthesia Associates, PhyMed Healthcare Group, Allentown, Pennsylvania
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19
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Smith BB, Warner MA, Warner NS, Hanson AC, Smith MM, Rihal CS, Gulati R, Bell MR, Nuttall GA. Cardiac Risk of Noncardiac Surgery After Percutaneous Coronary Intervention With Second-Generation Drug-Eluting Stents. Anesth Analg 2019; 128:621-628. [PMID: 30169404 DOI: 10.1213/ane.0000000000003408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) with stenting is sometimes associated with major adverse cardiac events (MACEs). Second-generation drug-eluting stents (DES) were developed to decrease the incidence of MACE seen with bare metal and first-generation DES. METHODS The medical records of all adult patients who underwent second-generation DES placement between July 29, 2008 and July 28, 2011 followed by NCS between September 22, 2008 and July 1, 2013 were reviewed. All episodes of MACE following surgery were recorded. RESULTS A total of 282 patients (74.8% male) were identified who underwent NCS after PCI with second-generation DES. MACE occurred in 15 patients (5.3%), including 11 deaths. The incidence of MACE changed significantly with time from PCI to NCS: 17.1%, 10.0%, 0.0%, and 3.1% for patients undergoing NCS at 0-90, 91-180, 181-365, and ≥366 days, respectively. Compared with those having NCS ≥366 days after PCI, the odds ratio for MACE (95% confidence interval) was 6.4 (1.9 to 21.3) at 0-90 days and 3.4 (0.8 to 15.3) at 91-180 days. Seven days prior to NCS, 146 (52%) patients were on dual antiplatelet therapy (DAPT), 106 (38%) were on aspirin, and 30 (11%) did not receive antiplatelet therapy. Excessive surgical bleeding occurred in 19 cases (6.7%). While observed bleeding rates were lowest in those not receiving antiplatelet therapy, there were no statistically significant differences based on the presence or absence of antiplatelet therapy (3% [1/30] for no antiplatelet therapy compared to 6% [6/106] for aspirin monotherapy and 8% [12/146] for DAPT; Fisher exact test: P = .655). CONCLUSIONS The incidence of MACE in patients with second-generation DES undergoing NCS was 5.3% and was highest in the first 180 days following DES implantation. The rate of excessive surgical bleeding was 6.7% with the highest observed rate in those on DAPT. However, differences by the presence or absence of antiplatelet therapy were not significant, and future large observational studies will be necessary to further define bleeding risk with continued DAPT.
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Affiliation(s)
- Bradford B Smith
- From the Department of Anesthesiology and Perioperative Medicine
| | - Matthew A Warner
- From the Department of Anesthesiology and Perioperative Medicine
| | | | | | - Mark M Smith
- From the Department of Anesthesiology and Perioperative Medicine
| | - Charanjit S Rihal
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Malcolm R Bell
- Division of Cardiology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Raphael J, Mazer CD, Wilkey A, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Welsby I, Greilich PE, Ranucci M, Heller LB, Boer C, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Patel N, Wilkey B, Gaitan B, Hill SS, Harvey R, Kwak J, Klick J, Bollen BA, Shore-Lesserson L, Abernathy J, Schwann N, Lau WT. Corrigendum to 'Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement (CPI) Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients' [Journal of Cardiothoracic and Vascular Anesthesia 33 (2019) 2887-2899]. J Cardiothorac Vasc Anesth 2019; 34:840-841. [PMID: 31759860 DOI: 10.1053/j.jvca.2019.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jacob Raphael
- University of Virginia Health System, 1215 Lee St, Charlottesville, VA 22903.
| | | | - Andrew Wilkey
- Abbott Northwestern Hospital, 800E 28(th) St, Minneapolis, MN 55407
| | | | - Andrew Schroeder
- University of Wisconsin Medical Center, 600 Highland Ave, Madison, WI 53792
| | | | - Renata Ferreira
- University of Washington Medical Center, 1959 NE Pacific St, Seattle, WA 98195
| | - Philip E Roman
- Centura St. Anthony Hospital, 11600W 2(nd) Pl, Lakewood, CO 80228
| | - Ian Welsby
- Duke University Hospital, 2301 Erwin Rd, Durham, NC 27710
| | - Philip E Greilich
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Marco Ranucci
- IRCC Policlinico San Donato, Piazza Edmondo Malan, 2, 20097, San Donato Milaniese, Milan, Italy
| | - Lori B Heller
- Swedish Medical Center, 550 17(th) Ave, Seattle, WA 98122
| | - Christa Boer
- VU University Medical Center, De Boelelaan 1117, 1081, HV Amsterdam, Netherlands
| | - Steven E Hill
- UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | | | | | - Prakash A Patel
- University of Pennsylvania Medical Center, 3400 Spruce St, Philadelphia, PA 19104
| | - Nichlech Patel
- University of California San Francisco, 505 Parnassus Ave, San Francisco, CA 94143
| | - Barbara Wilkey
- University of Colorado, 12605 E 16(th) Ave, Denver, CO 80045
| | | | - Shanna S Hill
- Weill Cornell Medical Center, 1300 York Ave, New York, NY 10065
| | - Reed Harvey
- UCLA Medical Center, 757 Westwood Plaza, Los Angeles, CA 90095
| | - Jenny Kwak
- Loyola University Medical Center, 2160 S 1(st) Ave, Maywood, IL 60153
| | - John Klick
- Case Western University Medical Center, 11100 Euclid Ave, Cleveland, OH 44106
| | - Bruce A Bollen
- Missoula Anesthesiology, 2827 Fort Missoula Rd, Missoula, MT 59804
| | - Linda Shore-Lesserson
- Hofstra Northshore-Long Island Jewish Medical Center, 270-05 76(th) Ave, New Hyde Park, NY 11040
| | - James Abernathy
- Johns Hopkins Medical Center, 1800 Orleans St, Baltimore, MD 21287
| | - Nanette Schwann
- Allentown Anesthesia Associates, 4905 W Tilghman St, Allentown, PA 18104
| | - W Travis Lau
- Pacific Anesthesia, 321 North Kuakini St, Ste 306, Honolulu, Hawaii 96817
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21
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Raphael J, Mazer CD, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Patel N, Welsby I, Greilich PE, Harvey R, Ranucci M, Heller LB, Boer C, Wilkey A, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Wilkey B, Gaitan B, Hill SS, Kwak J, Klick J, Bollen BA, Shore-Lesserson L, Abernathy J, Schwann N, Lau WT. Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2019; 33:2887-2899. [DOI: 10.1053/j.jvca.2019.04.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/03/2019] [Accepted: 04/05/2019] [Indexed: 01/28/2023]
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22
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Raphael J, Mazer CD, Subramani S, Schroeder A, Abdalla M, Ferreira R, Roman PE, Patel N, Welsby I, Greilich PE, Harvey R, Ranucci M, Heller LB, Boer C, Wilkey A, Hill SE, Nuttall GA, Palvadi RR, Patel PA, Wilkey B, Gaitan B, Hill SS, Kwak J, Klick J, Bollen BA, Shore-Lesserson L, Abernathy J, Schwann N, Lau WT. Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients. Anesth Analg 2019; 129:1209-1221. [PMID: 31613811 DOI: 10.1213/ane.0000000000004355] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.
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Affiliation(s)
- Jacob Raphael
- From the University of Virginia Health System, Charlottesville, Virginia
| | - C David Mazer
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Renata Ferreira
- University of Washington Medical Center, Seattle, Washington
| | | | - Nichlesh Patel
- University of California San Francisco, San Francisco, California
| | - Ian Welsby
- Duke University Hospital, Durham, North Carolina
| | | | - Reed Harvey
- UCLA Medical Center, Los Angeles, California
| | - Marco Ranucci
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Christa Boer
- VU University Medical Center, Amsterdam, the Netherlands
| | - Andrew Wilkey
- Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | | | | | - Prakash A Patel
- University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Jenny Kwak
- Loyola University Medical Center, Maywood, Illinois
| | - John Klick
- Case Western University Medical Center, Cleveland, Ohio
| | | | - Linda Shore-Lesserson
- Zucker School of Medicine at Hofstra/Northwell, Northshore University Hospital, Manhasset, New York
| | | | - Nanette Schwann
- Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, Tampa, Florida
- AAA Anesthesia Associates, PhyMed Healthcare Group, Allentown, Pennsylvania
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Gurrieri C, Smith BB, Nuttall GA, Pruthi RK, Said SM, Smith MM. Essential Thrombocythemia and Cardiac Surgery: A Case Series and Review of the Literature. Ann Thorac Surg 2018; 106:482-490. [DOI: 10.1016/j.athoracsur.2018.03.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 02/09/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
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Joyce DL, Lahr BD, Maltais S, Said SM, Stulak JM, Nuttall GA, Joyce LD. Integration of simulation components enhances team training in cardiac surgery. J Thorac Cardiovasc Surg 2018; 155:2518-2524.e5. [DOI: 10.1016/j.jtcvs.2018.01.076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/29/2017] [Accepted: 01/02/2018] [Indexed: 10/18/2022]
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Smith MM, Smith BB, Lahr BD, Nuttall GA, Mauermann WJ, Weister TJ, Dearani JA, Barbara DW. Selective Serotonin Reuptake Inhibitors and Serotonin–Norepinephrine Reuptake Inhibitors Are Not Associated With Bleeding or Transfusion in Cardiac Surgical Patients. Anesth Analg 2018; 126:1859-1866. [DOI: 10.1213/ane.0000000000002668] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Harper PC, Smith MM, Brinkman NJ, Passe MA, Schroeder DR, Said SM, Nuttall GA, Oliver WC, Barbara DW. Outcomes Following Three-Factor Inactive Prothrombin Complex Concentrate Versus Recombinant Activated Factor VII Administration During Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:151-157. [DOI: 10.1053/j.jvca.2017.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Indexed: 11/11/2022]
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Ashikhmina E, Said S, Smith MM, Rodriguez V, Oliver WC, Nuttall GA, Dearani JA, Schaff HV. Prothrombin Complex Concentrates in Pediatric Cardiac Surgery: The Current State and the Future. Ann Thorac Surg 2017. [PMID: 28648539 DOI: 10.1016/j.athoracsur.2017.04.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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] [Indexed: 01/11/2023]
Abstract
BACKGROUND After decades of practice of pediatric cardiac surgery, postoperative bleeding due to the immaturity of hemostasis, hemodilution, and hypothermia remains a concern. Recently, a new approach for adult coagulopathy after bypass has emerged. Prothrombin complex concentrates (PCCs), designed to treat bleeding in hemophilia patients, are safely and efficiently used off label for hemorrhage after bypass. However, optimal dosing, indications and contraindications, and laboratory tests to assess the efficacy of PCC use in children have not yet been established. This literature review outlines the challenges of bypass-related coagulopathy, the pharmacology, and the experience in use of PCCs, with a focus on their potential in pediatric cardiac surgery. METHODS After a thorough literature search of MEDLINE, Scopus, and Ovid databases using the term "prothrombin complex concentrate AND pediatric," 23 relevant articles were selected. RESULTS The data supporting successful use of PCCs in acquired coagulopathy after cardiac surgery in adults have been increasing. Although small volume, low immunogenicity, efficiency, and speed in correcting coagulopathy are attractive qualities of PCCs for pediatric practice, current evidence is only anecdotal. The main concerns are unknown dosing regimens, the inability to closely monitor the effects of PCCs in real time, and a possibility of thrombotic complications, which can be particularly devastating in young congenital cardiac patients whose lives frequently depend upon the patency of artificial shunts. CONCLUSIONS Extensive, high-quality research is warranted to fill in the gaps of knowledge regarding using PCCs in pediatric cardiac practice.
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Affiliation(s)
- Elena Ashikhmina
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Sameh Said
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Vilmarie Rodriguez
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - William C Oliver
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Smith BB, Nuttall GA, Pruthi RK, Joyce DL, Schuldes MS, Smith MM. A Novel Approach to Essential Thrombocythemia and Cardiac Surgery. Ann Thorac Surg 2017; 103:e249-e250. [DOI: 10.1016/j.athoracsur.2016.08.065] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 08/08/2016] [Accepted: 08/18/2016] [Indexed: 10/20/2022]
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Pietras CM, Spittell PC, Nuttall GA, Eleid MF, Said SM. Pulmonary Venous Obstruction From a Large Left Atrial Sarcoma: Resection Combined With Mitral Valve Bypass. Ann Thorac Surg 2016; 102:e237-e239. [DOI: 10.1016/j.athoracsur.2016.02.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 02/03/2016] [Accepted: 02/11/2016] [Indexed: 11/26/2022]
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Riley JB, Schears GJ, Nuttall GA, Oliver WC, Ereth MH, Dearani JA. Coagulation Parameter Thresholds Associated with Non-Bleeding in the Eighth Hour of Adult Cardiac Surgical Post-Cardiotomy Extracorporeal Membrane Oxygenation. J Extra Corpor Technol 2016; 48:71-78. [PMID: 27578897 PMCID: PMC5001524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 06/06/2016] [Indexed: 06/06/2023]
Abstract
Excessive bleeding and allogeneic transfusion during adult post-cardiotomy venoarterial extracorporeal membrane oxygenation (ECMO) are potentially harmful and expensive. Balancing the inhibition of clotting and distinguishing surgical from non-surgical bleeding in post-operative period is difficult. The sensitivity of coagulation tests including Thromboelastography(®) (TEG) to predict chest tube drainage in the early hours of ECMO was examined with the use of receiver-operating characteristics (ROC). The results are useful to incorporate in clinical evidence-based algorithms to guide management decisions. In the eighth hour of ECMO, 26 of the 53 adult patients (49%) studied were identified as non-bleeders (less than 2.0 mL/kg/h). All had experienced various types of cardiac surgical procedures. Fifty-two percent were female and the group was 54 ± 19 (mean ± 1 SD) years old. The coagulation parameter threshold with the maximum sensitivity and specificity to predict non-bleeding at 8 hours on ECMO was the kaolin plus heparinase TEG maximum amplitude (KH-TEG MA) at a significant ROC threshold (t) > 50 mm. The activated partial thromboplastin time (aPTT) t < 49 seconds, KH-TEG alpha-angle t > 51°, and the kaolin activated clotting time (ACT) t < 148 seconds were sensitive predictors of non-bleeders. The whole-blood KH-TEG MA was superior to the plasma-based aPTT or International Normalization Ratio (INR) to predict bleeding in the eighth hour of ECMO. Using coagulation laboratory thresholds that predict non-bleeding can begin a process of identifying patients earlier that are likely to bleed. Awareness of these parameter thresholds may improve care through patient protection from unnecessary transfusion and prolonging the life of the ECMO circuit. An algorithm incorporating the ROC thresholds was created to help recognize surgical bleeding to minimize unnecessary transfusions.
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Affiliation(s)
| | | | | | | | - Mark H. Ereth
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
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Feyissa AM, Pochettino A, Bower TC, Nuttall GA, Britton JW. Rhythmic electrographic discharges during deep hypothermic circulatory arrest. Clin Neurophysiol 2016; 127:1901-6. [DOI: 10.1016/j.clinph.2015.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
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Steiner ME, Ness PM, Assmann SF, Triulzi DJ, Sloan SR, Delaney M, Granger S, Bennett-Guerrero E, Blajchman MA, Scavo V, Carson JL, Levy JH, Whitman G, D'Andrea P, Pulkrabek S, Ortel TL, Bornikova L, Raife T, Puca KE, Kaufman RM, Nuttall GA, Young PP, Youssef S, Engelman R, Greilich PE, Miles R, Josephson CD, Bracey A, Cooke R, McCullough J, Hunsaker R, Uhl L, McFarland JG, Park Y, Cushing MM, Klodell CT, Karanam R, Roberts PR, Dyke C, Hod EA, Stowell CP. Effects of red-cell storage duration on patients undergoing cardiac surgery. N Engl J Med 2015; 372:1419-29. [PMID: 25853746 PMCID: PMC5442442 DOI: 10.1056/nejmoa1414219] [Citation(s) in RCA: 334] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Some observational studies have reported that transfusion of red-cell units that have been stored for more than 2 to 3 weeks is associated with serious, even fatal, adverse events. Patients undergoing cardiac surgery may be especially vulnerable to the adverse effects of transfusion. METHODS We conducted a randomized trial at multiple sites from 2010 to 2014. Participants 12 years of age or older who were undergoing complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions. The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge. RESULTS The median storage time of red-cell units provided to the 1098 participants who received red-cell transfusion was 7 days in the shorter-term storage group and 28 days in the longer-term storage group. The mean change in MODS was an increase of 8.5 and 8.7 points, respectively (95% confidence interval for the difference, -0.6 to 0.3; P=0.44). The 7-day mortality was 2.8% in the shorter-term storage group and 2.0% in the longer-term storage group (P=0.43); 28-day mortality was 4.4% and 5.3%, respectively (P=0.57). Adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group. CONCLUSIONS The duration of red-cell storage was not associated with significant differences in the change in MODS. We did not find that the transfusion of red cells stored for 10 days or less was superior to the transfusion of red cells stored for 21 days or more among patients 12 years of age or older who were undergoing complex cardiac surgery. (Funded by the National Heart, Lung, and Blood Institute; RECESS ClinicalTrials.gov number, NCT00991341.).
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Affiliation(s)
- Marie E Steiner
- From Fairview-University Medical Center, Minneapolis (M.E.S., S.P., J.M.), and Mayo Clinic, Rochester (G.A.N.) - both in Minnesota; Johns Hopkins University (P.M.N., G.W.) and University of Maryland (R.C.) - both in Baltimore; New England Research Institutes, Data Coordinating Center, Watertown (S.F.A., S.G.), Boston Children's Hospital (S.R.S.), Massachusetts General Hospital (L.B., C.P.S.), Brigham and Women's Hospital (R.M.K.), Tufts University (R.E.), St. Elizabeth's Medical Center (R.H.), and Beth Israel Deaconess Medical Center (L.U.), Boston, and Baystate Medical Center, Springfield (R.E.) - all in Massachusetts; University of Pittsburgh and University of Pittsburgh-Mercy Hospital, Pittsburgh (D.J.T., P.D.); Puget Sound Blood Center and University of Washington (M.D.) and Swedish Medical Center (S.Y.) - all in Seattle; Duke University, Durham (E.B.-G., J.H.L., T.L.O.), and University of North Carolina, Chapel Hill (Y.P.) - both in North Carolina; McMaster University, Hamilton, ON, Canada (M.A.B.); Indiana-Ohio Heart and St. Joseph Hospital (V.S.) - both in Fort Wayne, IN; Rutgers Robert Wood Johnson Medical School, New Brunswick (J.L.C.), and Newark Beth Israel Medical Center, Newark (R.K.) - both in New Jersey; University of Iowa, Iowa City (T.R.); Aurora St. Luke's Medical Center (K.E.P.) and Froedert Memorial Lutheran Hospital (J.G.M.), Milwaukee, and Aspirus Heart and Vascular Institute, Wausau (R.M.) - all in Wisconsin; Vanderbilt University, Nashville (P.P.Y.); University of Texas Southwestern Medical Center, Dallas (P.E.G.); Children's Healthcare of Atlanta, Emory University, and Emory University Hospital, Atlanta (C.D.J.); St. Luke's-Texas Heart Institute, Houston (A.B.); Weill Cornell Medical College (M.M.C.) and Columbia University Medical Center (E.A.H.) - both in New York; University of Florida, Gainesville (C.T.K.); University of Oklahoma, Oklahoma City (P.R.R.); and University of North Dakota School of Medicine and Health Sciences, Fargo (C.D.)
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Rasmussen KG, Kung S, Lapid MI, Oesterle TS, Geske JR, Nuttall GA, Oliver WC, Abenstein JP. A randomized comparison of ketamine versus methohexital anesthesia in electroconvulsive therapy. Psychiatry Res 2014; 215:362-5. [PMID: 24388729 DOI: 10.1016/j.psychres.2013.12.027] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 11/11/2013] [Accepted: 12/12/2013] [Indexed: 11/29/2022]
Abstract
To assess the clinical utility of ketamine as an anesthetic agent for electroconvulsive therapy (ECT), based upon recent findings that ketamine may have antidepressant properties. Depressed ECT patients were randomly assigned to receive anesthesia with either ketamine or methohexital. Outcome measures included assessments of depressive severity, cognition, post-anesthesia side effects, and hemodynamics. Twenty one patients were treated with ketamine and 17 with methohexital. There were no significant differences in depression or cognitive outcomes between the two drugs. Additionally, there were no measures of post-anesthesia tolerability or hemodynamics which favored ketamine. Ketamine anesthesia does not accelerate the antidepressant effect of ECT or diminish the cognitive side effects, at least as measured in this study. Furthermore, there is no apparent benefit of ketamine for speed or quality of post-ECT recovery, and it is associated with higher systolic blood pressures after the treatments. Ketamine is associated with longer motor seizure duration than methohexital.
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Affiliation(s)
- Keith G Rasmussen
- Mayo Clinic Departments of Psychiatry and Psychology, Rochester, MN 55905, USA.
| | - Simon Kung
- Mayo Clinic Departments of Psychiatry and Psychology, Rochester, MN 55905, USA
| | - Maria I Lapid
- Mayo Clinic Departments of Psychiatry and Psychology, Rochester, MN 55905, USA
| | - Tyler S Oesterle
- Mayo Clinic Departments of Psychiatry and Psychology, Rochester, MN 55905, USA
| | - Jennifer R Geske
- Mayo Clinic Departments of Psychiatry and Biostatistics, Rochester, MN, USA
| | - Gregory A Nuttall
- Mayo Clinic Departments of Psychiatry and Anesthesiology, Rochester, MN, USA
| | - William C Oliver
- Mayo Clinic Departments of Psychiatry and Anesthesiology, Rochester, MN, USA
| | - John P Abenstein
- Mayo Clinic Departments of Psychiatry and Anesthesiology, Rochester, MN, USA
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Rodrigues ES, Lynch JJ, Suri RM, Burkhart HM, Li Z, Mauermann WJ, Rehfeldt KH, Nuttall GA. Robotic Mitral Valve Repair: A Review of Anesthetic Management of the First 200 Patients. J Cardiothorac Vasc Anesth 2014; 28:64-68. [DOI: 10.1053/j.jvca.2013.05.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Indexed: 11/11/2022]
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Barbara DW, Dietz NM, White RD, Pochettino A, Nuttall GA. External defibrillation failure due to antimicrobial incise drape. Mayo Clin Proc 2013; 88:1032-4. [PMID: 24001496 DOI: 10.1016/j.mayocp.2013.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/15/2013] [Revised: 06/11/2013] [Accepted: 06/28/2013] [Indexed: 11/19/2022]
Abstract
Antimicrobial incise drapes adhere to a patient's skin during surgery in an attempt to reduce surgical infections. We describe a patient undergoing repeated aortic valve replacement who experienced sudden ventricular fibrillation before median sternotomy. External defibrillation was unsuccessful on multiple attempts using several defibrillators. On removal of the incise drape from the patient's chest, external defibrillation was immediately successful. Increased transthoracic impedance can be caused by multiple factors and may prevent defibrillation. To our knowledge, this is the first reported case of an antimicrobial incise drape preventing defibrillation. If external defibrillation, cardioversion, or pacing is indicated intraoperatively, we recommend prompt removal of the antimicrobial incise drapes before electrode placement if the drapes overlay the intended pad position. Since this case, our institutional practice has now changed to placement of 2 external adhesive defibrillator electrodes onto the patient's skin lateral to the surgical field before incise drape application to allow for defibrillation.
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Affiliation(s)
- David W Barbara
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
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Nuttall GA, Abenstein JP, Stubbs JR, Santrach P, Ereth MH, Johnson PM, Douglas E, Oliver WC. Computerized bar code-based blood identification systems and near-miss transfusion episodes and transfusion errors. Mayo Clin Proc 2013; 88:354-9. [PMID: 23541010 DOI: 10.1016/j.mayocp.2012.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 09/20/2012] [Revised: 12/17/2012] [Accepted: 12/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine whether the use of a computerized bar code-based blood identification system resulted in a reduction in transfusion errors or near-miss transfusion episodes. PATIENTS AND METHODS Our institution instituted a computerized bar code-based blood identification system in October 2006. After institutional review board approval, we performed a retrospective study of transfusion errors from January 1, 2002, through December 31, 2005, and from January 1, 2007, through December 31, 2010. RESULTS A total of 388,837 U were transfused during the 2002-2005 period. There were 6 misidentification episodes of a blood product being transfused to the wrong patient during that period (incidence of 1 in 64,806 U or 1.5 per 100,000 transfusions; 95% CI, 0.6-3.3 per 100,000 transfusions). There was 1 reported near-miss transfusion episode (incidence of 0.3 per 100,000 transfusions; 95% CI, <0.1-1.4 per 100,000 transfusions). A total of 304,136 U were transfused during the 2007-2010 period. There was 1 misidentification episode of a blood product transfused to the wrong patient during that period when the blood bag and patient's armband were scanned after starting to transfuse the unit (incidence of 1 in 304,136 U or 0.3 per 100,000 transfusions; 95% CI, <0.1-1.8 per 100,000 transfusions; P=.14). There were 34 reported near-miss transfusion errors (incidence of 11.2 per 100,000 transfusions; 95% CI, 7.7-15.6 per 100,000 transfusions; P<.001). CONCLUSION Institution of a computerized bar code-based blood identification system was associated with a large increase in discovered near-miss events.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.
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Burkhart HM, Riley JB, Lynch JJ, Suri RM, Greason KL, Joyce LD, Nuttall GA, Stulak J, Schaff HV, Dearani JA. Simulation-based postcardiotomy extracorporeal membrane oxygenation crisis training for thoracic surgery residents. Ann Thorac Surg 2013; 95:901-6. [PMID: 23374448 DOI: 10.1016/j.athoracsur.2012.12.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [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: 02/01/2012] [Revised: 12/09/2012] [Accepted: 12/11/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND We developed and tested a clinical simulation program in the principles and conduct of postcardiotomy extracorporeal membrane oxygenation (ECMO) with the aim of improving confidence, proficiency, and crisis management. METHODS Twenty-three thoracic surgery residents from unique residency programs participated in an ECMO course involving didactic lectures and hands-on simulation. A current postcardiotomy ECMO circuit was used in a simulation center to give residents training with basic operations and crisis management. Pretraining and posttraining assessments concerning confidence and knowledge were administered. Before and after the training, residents were asked to identify components of the ECMO circuit and manage crisis scenarios, including venous line collapse, arterial hypertension, and arterial desaturation. RESULTS In the hands-on portion, residents had difficulty identifying the gas source and flow rate, centrifugal pump head inlet, and oxygenator outflow line. Timely and accurate ECMO component identification improved significantly after training. The arterial desaturation crisis scenario gave the residents difficulty, with only 22% providing the appropriate treatment recommendations in a timely and accurate fashion. At the end of the simulation training, most residents were able to manage the crises correctly in a timely manner. Posttraining confidence-related scores increased significantly. Most of the residents strongly recommended the course to their peers and reported simulation-based training was helpful in their postcardiotomy ECMO education. CONCLUSIONS We developed a simulation-based postcardiotomy ECMO training program that resulted in improved ECMO confidence in thoracic surgery residents. Crisis management in a simulated environment enabled residents to acquire technical and behavioral skills that are important in managing critical ECMO-related problems.
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Affiliation(s)
- Harold M Burkhart
- Division of Cardiovascular Surgery, Mayo Clinic and Foundation, Rochester, Minnesota, USA.
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Oliver WC, Nuttall GA, Murari T, Bauer LK, Johnsrud KH, Hall Long KJ, Orszulak TA, Schaff HV, Hanson AC, Schroeder DR, Ereth MH, Abel MD. A Prospective, Randomized, Double-Blind Trial of 3 Regimens for Sedation and Analgesia After Cardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:110-9. [DOI: 10.1053/j.jvca.2010.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Indexed: 11/11/2022]
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Mauermann WJ, Nuttall GA, Cook DJ, Hanson AC, Schroeder DR, Oliver WC. Hemofiltration during cardiopulmonary bypass does not decrease the incidence of atrial fibrillation after cardiac surgery. Anesth Analg 2009; 110:329-34. [PMID: 19933534 DOI: 10.1213/ane.0b013e3181c76bd3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) occurs in 20%-50% of patients after cardiac surgery and is associated with increased morbidity and mortality. Corticosteroids are reported to decrease the incidence of postoperative AF, presumably by attenuating inflammation caused by surgery and cardiopulmonary bypass (CPB). We hypothesized that hemofiltration during CPB, which may attenuate inflammation, might decrease the incidence of AF after cardiac surgery. METHODS This was a retrospective review of patients previously enrolled in a double-blind, placebo-controlled trial evaluating the effects of perioperative steroid therapy and hemofiltration during CPB on duration of postoperative mechanical ventilation. In that study, 192 patients undergoing cardiac surgery were randomized to 1 of 3 groups: controls (placebo), hemofiltration during CPB, or perioperative steroid therapy. Patient records were reviewed to determine the incidence of new onset AF defined as any electrocardiogram evidence of AF or AF diagnosed by the patients' clinicians. RESULTS Of the 192 enrolled patients, 3 were excluded for protocol violations and 4 were excluded for history of chronic AF. Data from 185 patients from the original study were available for review. Sixty patients (32%) had new onset AF after cardiac surgery. There was no difference among groups in the incidence of AF (control group, 21%; steroid group, 41%; hemofiltration group, 36%; P = 0.057 among groups). The only risk factor for the development of AF was age (mean age of patients with AF, 65.4 +/- 10.1 yr vs patients without AF, 61.4 +/- 11.5 yr; P = 0.024). When age, procedure type, and presence or absence of chronic obstructive pulmonary disease were controlled for in multivariate analysis, the difference among study groups remained nonsignificant (P = 0.108). CONCLUSIONS Perioperative corticosteroids or the use of hemofiltration during CPB did not decrease the incidence of AF after cardiac surgery. Further studies evaluating the efficacy and safety of perioperative corticosteroids for prevention of postoperative AF are warranted before their routine use can be recommended.
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Affiliation(s)
- William J Mauermann
- Department of Anesthesiology and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA.
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Nuttall GA, Schears GJ. Extracorporeal Membrane Oxygenation (ECMO). Introduction. Semin Cardiothorac Vasc Anesth 2009; 13:137. [PMID: 19767407 DOI: 10.1177/1089253209347893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology, College of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Ereth MH, Dong Y, Schrader LM, Henderson NA, Agarwal S, Oliver WC, Nuttall GA. Microporous Polysaccharide Hemospheres do not enhance abdominal infection in a rat model compared with gelatin matrix. Surg Infect (Larchmt) 2009; 10:273-6. [PMID: 19485784 DOI: 10.1089/sur.2007.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Residual topical hemostatic material can serve as a nidus for infection or enhance infection in an already contaminated wound. A newly approved agent, Microporous Polysaccharide Hemospheres (MPH) (Arista AH), has rapid degradation properties, which may reduce the chance of surgical site infection. MATERIALS AND METHODS With institutional approval, 170 Wister rats underwent standardized anesthesia and abdominal surgery. An Echerichia coli inoculum was added to the incision, and MPH, gelatin matrix, or no agent (control) was placed in the site. After 72 h, the animals were sacrificed, and colony-forming units (cfu)/g were counted in the harvested tissue. RESULTS Application of gelatin matrix resulted in more cfu/g of tissue and an 87% infection rate, with fewer cfu/g of tissue and a 14% and 24% infection rate in the control and MPH groups, respectively. CONCLUSION The use of MPH in this rat abdominal infection model did not enhance infection. Gelatin matrix was associated with a greater infection rate than MPH. The rapid degradation of MPH may account for these results, making it a good hemostat in the presence of infective sources.
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Affiliation(s)
- Mark H Ereth
- Transfusion, Coagulation and Cardiopulmonary Bypass Research Group, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Nuttall GA, Brown MJ, Stombaugh JW, Michon PB, Hathaway MF, Lindeen KC, Hanson AC, Schroeder DR, Oliver WC, Holmes DR, Rihal CS. Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology 2008; 109:588-95. [PMID: 18813036 DOI: 10.1097/aln.0b013e318186ddf8] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The duration of time that elective noncardiac surgery (NCS) should be delayed after percutaneous coronary intervention (PCI) with bare metal stents (BMSs) is unknown. METHODS This large, single-center, retrospective study examined the relation between complication rate in patients with BMSs undergoing NCS and the duration of time between PCI and NCS. Primary endpoints included in-hospital major adverse cardiac events (death, myocardial infarction, stent thrombosis, or repeat revascularization with either coronary artery bypass grafting or PCI of the target vessel) and bleeding events. The relation between the events and the timing of noncardiac surgery after PCI with BMS was assessed using univariate analysis and multiple logistic regression. RESULTS From January 1, 1990, to January 1, 2005, a total of 899 patients were identified. The frequency of major adverse cardiac events was 10.5% when NCS was performed less than 30 days after PCI with BMS, 3.8% when NCS was performed between 31 and 90 days after PCI with BMS, and 2.8% when NCS was performed more than 90 days after PCI with BMS. In univariate and multivariate analyses, a shorter time interval between PCI with BMS and noncardiac surgery was significantly associated with increased incidence of major adverse cardiac events (univariate: P < 0.001; odds ratio = 4.0; 95% confidence interval, 2.0-8.3; multivariate: P = 0.006; odds ratio = 3.2; 95% confidence interval, 1.5-6.9). Bleeding events were not associated with time between PCI with BMS and NCS or with the use of antiplatelet therapy in the week before NCS. CONCLUSIONS The incidence of major adverse cardiac events is lowest when NCS is performed at least 90 days after PCI with BMS.
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology, Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905, USA.
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Ereth MH, Schaff M, Ericson EF, Wetjen NM, Nuttall GA, Oliver WC. COMPARATIVE SAFETY AND EFFICACY OF TOPICAL HEMOSTATIC AGENTS IN A RAT NEUROSURGICAL MODEL. Oper Neurosurg (Hagerstown) 2008; 63:369-72; discussion 372. [DOI: 10.1227/01.neu.0000327031.98098.dd] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Nuttall GA, Gutierrez MC, Dewey JD, Johnson ME, Oyen LJ, Hanson AC, Oliver WC. A Preliminary Study of a New Tranexamic Acid Dosing Schedule for Cardiac Surgery. J Cardiothorac Vasc Anesth 2008; 22:230-5. [DOI: 10.1053/j.jvca.2007.12.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Indexed: 11/11/2022]
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Nuttall GA, Eckerman KM, Jacob KA, Pawlaski EM, Wigersma SK, Marienau MES, Oliver WC, Narr BJ, Ackerman MJ. Does low-dose droperidol administration increase the risk of drug-induced QT prolongation and torsade de pointes in the general surgical population? Anesthesiology 2007; 107:531-6. [PMID: 17893447 DOI: 10.1097/01.anes.0000281893.39781.64] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The US Food and Drug Administration issued a black box warning regarding the use of droperidol and the potential for torsade de pointes (TdP). METHODS The primary objective of this retrospective study was to determine whether low-dose droperidol administration increased the incidence of TdP in the general surgical population during a 3-yr time period before and after the Food and Drug Administration black box warning. A random sample of 150 surgical patients during each time interval was selected to estimate the droperidol use for each time period. RESULTS During the time period before the black box warning (July 1, 1998 to June 30, 2001), 2,321/139,932 patients (1.66%) had QT prolongation, TdP, or death within 48 h after surgery. We could identify no patients who clearly developed TdP before the black box warning. There was one patient for whom the cause of death could not positively be ruled out as due to TdP. In the time period after the black box warning (July 1, 2002 to June 30, 2005), 2,207 patients (1.46%) had documented QT prolongation, TdP, or death within 48 h after surgery, including only two cases (<0.1%) of TdP. The incidence of droperidol exposure was approximately 12% (exact 95% confidence interval, 7.3-18.3%) before the black box warning and 0% after placement of the black box warning on droperidol. Therefore, we estimate that approximately 16,791 patients (95% confidence interval, 10,173-25,607) were exposed to droperidol, none of whom experienced documented TdP. CONCLUSIONS This indicates that the Food and Drug Administration black box warning for low dose droperidol is excessive and unnecessary.
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Affiliation(s)
- Jennifer A Rabbitts
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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