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Man L, Yount K, Grazioli A, Padmanabhan A, Thiele R, Maitland HS, Mazzeffi M. Recrudescent Heparin-Induced Thrombocytopenia After Therapeutic Plasma Exchange in a Patient Undergoing Thoracic Aortic Replacement. J Cardiothorac Vasc Anesth 2023; 37:2592-2596. [PMID: 37827918 PMCID: PMC10802261 DOI: 10.1053/j.jvca.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/31/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Louise Man
- University of Virginia School of Medicine, Department of Medicine, Division of Hematology and Oncology, Charlottesville, VA
| | - Kenan Yount
- University of Virginia School of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Charlottesville, VA
| | | | - Anand Padmanabhan
- Mayo Clinic College of Medicine, Department of Pathology, Rochester, MN
| | - Robert Thiele
- University of Virginia, Department of Anesthesiology, Charlottesville, VA
| | - Hillary S Maitland
- University of Virginia School of Medicine, Department of Medicine, Division of Hematology and Oncology, Charlottesville, VA
| | - Michael Mazzeffi
- University of Virginia, Department of Anesthesiology, Charlottesville, VA.
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Hayes EA, Walczak AB, Goodhue Meyer E, Nicol K, Deitemyer M, Duffy V, Moore Padilla M, Gajarski RJ, Nandi D. An in vitro comparison of intra-operative isohemagglutinin and human leukocyte antigen removal techniques in pediatric heart transplantation. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:189-193. [PMID: 38099633 PMCID: PMC10723569 DOI: 10.1051/ject/2023034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 08/21/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Highly sensitized pediatric patients awaiting heart transplantation experience longer wait times and thus higher waitlist mortality. Similarly, children less than 2 years of age have increased waitlist times and mortality when compared to their older peers. To improve the likelihood of successful transplantation in these patients, various strategies have been utilized, including peri-operative plasmapheresis. However, limited data exists comparing plasmapheresis techniques for antibody reduction. This study's aim was to compare the in vitro magnitude of isohemagglutinin titers (IT) and human leukocyte antigen (HLA) antibody removal and the time required between membrane-based plasmapheresis (MP) and centrifuge-based plasmapheresis (CP) incorporated into the extracorporeal (EC) circuit. METHODS Two MP (Prismaflex) and two CP (Spectra Optia, Terumo BCT) circuits were incorporated into four separate EC circuits primed with high titer, highly sensitized type O donor whole blood. Assays were performed to determine baseline IT and anti-HLA antibodies and then at 30-minute increments until completion of the run (two plasma volume exchanges) at two hours. RESULTS There was a decrease in anti-A and anti-B IgM and IgG titers with both MP and CP. Mean anti-A and anti-B titer reduction was by 4.625 titers (93.7% change) and 4.375 titers (93.8% change) using MP and CP, respectively. At 2 h of apheresis, CP reduced 62.5% of all ITs to ≤ 1:4, while MP reduced 50% of ITs to ≤ 1:4. Additionally, reduction of anti-HLA class II antibody to mean fluorescence intensity (MFI) <3000 was achieved with both MP and CP. At 2 h of apheresis, CP reduced MFI by 2-3.5 fold and MP reduced MFI by 1.7-2.5 fold. Both demonstrated similar hemolytic and thrombotic profiles. CONCLUSIONS In this in vitro plasmapheresis model of IT and anti-HLA antibody reduction, both MP and CP incorporated into the EC circuit can be used quickly and effectively to reduce circulating antibodies. While CP may have some greater efficiency, further study is necessary to verify this in vivo.
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Affiliation(s)
- Emily A. Hayes
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Ashley B Walczak
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Erin Goodhue Meyer
- Department of Hematology/Apheresis, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Kathleen Nicol
- Department of Pathology, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Matthew Deitemyer
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Vicky Duffy
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
| | - Michelle Moore Padilla
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine Atlanta GA 30322 USA
| | | | - Deipanjan Nandi
- The Heart Center, Nationwide Children’s Hospital Columbus OH 43205 USA
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Smith C, Caesar D, Perry K, Jonna S, Villani V, Pivalizza EG. Effect of Preoperative Therapeutic Plasma Exchange With Albumin Replacement Before Kidney Transplant on Intraoperative Coagulation Measured By the Thrombelastograph (TEGR 6s): A Case Report. A A Pract 2023; 17:e01734. [PMID: 38126900 DOI: 10.1213/xaa.0000000000001734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Anesthesiologists should be aware of the coagulation implications of therapeutic plasma exchange (TPE) with albumin replacement for desensitization of kidney transplant (KT) recipients. We describe a case where the final preoperative TPE was performed with albumin. A TEGR 6s demonstrated defects in fibrinogen component to clot strength. With surgical oozing noted and the fibrinogen defect, cryoprecipitate was administered. Thereafter, fibrinogen contribution to clot strength normalized, coinciding with clinical hemostasis. With the increased use of TPE to reduce antibodies in KT recipients, visco-elastic testing may assist in the identification of coagulation defects when plasma is not used as replacement fluid.
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Affiliation(s)
- Connor Smith
- From the McGovern Medical School at UTHealth-Houston, Houston, Texas
| | - D'Andrea Caesar
- Department of Anesthesiology, McGovern Medical School at UTHealth-Houston, Houston, Texas
| | - Kenneth Perry
- Department of Anesthesiology, McGovern Medical School at UTHealth-Houston, Houston, Texas
| | - Srikar Jonna
- Department of Anesthesiology, McGovern Medical School at UTHealth-Houston, Houston, Texas
| | - Vincenzo Villani
- Department of Surgery, McGovern Medical School at UTHealth-Houston, Houston, Texas
| | - Evan G Pivalizza
- Department of Anesthesiology, McGovern Medical School at UTHealth-Houston, Houston, Texas
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Cardiovascular Outcomes in Children with Multisystem Inflammatory Syndrome Treated with Therapeutic Plasma Exchange. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9111640. [PMID: 36360368 PMCID: PMC9688591 DOI: 10.3390/children9111640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/07/2022]
Abstract
Background: Multisystem inflammatory syndrome in children is a new, rare, post-infectious complication of SARS-CoV-2 infection in children. The aim of this study was to display the role of therapeutic plasma exchange on cardiovascular outcomes in children with multisystem inflammatory syndrome. Methods: This study included children who met the diagnostic criteria for multisystem inflammatory syndrome and who were admitted to the intensive care unit. This is a prospective single-center study conducted between August 2020 and September 2021. Subjects had cardiac involvement which was defined as elevated troponin I, abnormal electrocardiographic and echocardiographic findings. Patients were followed by a pediatric cardiologist throughout the intensive care unit stay and after discharge for 12 months. Patients were divided into two groups which received therapeutic plasma exchange and which did not. Results: 38 children were included in this study. There were 16 patients in the no plasma exchange group and 22 patients in the plasma exchange group. The two groups were similar in age, sex, leucocyte, thrombocyte count, neutrophil percentage, hemoglobin, C-reactive protein, erythrocyte sedimentation rate, alanine aminotransferase, albumin, ferritin, fibrinogen, D-dimer, IL-6, troponin I, number of electrocardiographic abnormalities and patients with mitral valve regurgitation detected at admission (p > 0.05). There was no significant difference between the two groups in terms of duration of normalization of electrocardiographic abnormalities and disappearance of mitral valve regurgitation (p > 0.05). Duration of normalization of troponin I (2, IQR 1−4, versus 5, IQR 3−9 days; p = 0.044) and length of hospital stay (7, IQR 6−10, versus 13, 8−20 days; p = 0.001) was longer in the plasma exchange group. Conclusions: We did not observe any significant improvement in children having undergone plasma exchange as compared to children who did not. On the opposite, their length of hospital stay and time to troponin I normalisation were even longer. Some baseline differences in cardiac attainment severity may partly explain this finding.
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Zhou Z, Kuang H, Ma Y, Zhang L. Application of extracorporeal therapies in critically ill COVID-19 patients. J Zhejiang Univ Sci B 2021; 22:701-717. [PMID: 34514751 PMCID: PMC8435342 DOI: 10.1631/jzus.b2100344] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is a major public health event caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has spread widely all over the world. A high proportion of patients become severely or critically ill, and suffer high mortality due to respiratory failure and multiple organ dysfunction. Therefore, providing timely and effective treatment for critically ill patients is essential to reduce overall mortality. Convalescent plasma therapy and pharmacological treatments, such as aerosol inhalation of interferon-α (IFN-α), corticosteroids, and tocilizumab, have all been applied in clinical practice; however, their effects remain controversial. Recent studies have shown that extracorporeal therapies might have a potential role in treating critically ill COVID-19 patients. In this review, we examine the application of continuous renal replacement therapy (CRRT), therapeutic plasma exchange (TPE), hemoadsorption (HA), extracorporeal membrane oxygenation (ECMO), and extracorporeal carbon dioxide removal (ECCO2R) in critically ill COVID-19 patients to provide support for the further diagnosis and treatment of COVID-19.
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Affiliation(s)
- Zhifeng Zhou
- Department of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Huang Kuang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Yuexian Ma
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu 610072, China
| | - Ling Zhang
- Department of Nephrology, Kidney Research Institute, West China Hospital, Sichuan University, Chengdu 610041, China.
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Koster A, Erdoes G, Nagler M, Birschmann I, Alberio L. How would we treat our own heparin-induced thrombocytopenia during cardiac surgery? J Cardiothorac Vasc Anesth 2020; 35:1585-1593. [PMID: 33342734 DOI: 10.1053/j.jvca.2020.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 12/29/2022]
Abstract
The aim of this article is to provide a comprehensive review of the current state of knowledge on heparin-induced thrombocytopenia (HIT) in cardiac surgery. The management of HIT patients undergoing cardiac surgery with cardiopulmonary bypass is complex and requires an interdisciplinary and patient-tailored approach because available evidence is limited and current anticoagulation strategies have potential risks. An index case is used to discuss both the established and new perioperative therapeutic options in HIT patients undergoing urgent cardiac surgery with cardiopulmonary bypass.
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Affiliation(s)
- Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Heart, and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Bochum, Germany
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ingvild Birschmann
- Institute of Laboratory and Transfusion Medicine, Heart, and Diabetes Center NRW, Bad Oeynhausen, Ruhr-University Bochum, Bochum, Germany
| | - Lorenzo Alberio
- Division of Hematology and Central Hematology Laboratory, Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
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