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Lee J, Lee DK, Kwon WK, Lee S, Oh CS, Görlinger K, Kim TY. Effect of ultrafiltration on whole blood coagulation profile during cardiopulmonary bypass in cardiac surgery: a retrospective analysis. Korean J Anesthesiol 2024; 77:236-245. [PMID: 38287212 PMCID: PMC10982537 DOI: 10.4097/kja.23698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/02/2024] [Accepted: 01/07/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND Ultrafiltration (UF) would enhance coagulation profiles by concentrating coagulation elements during cardiopulmonary bypass (CPB) for cardiac surgery. METHODS We retrospectively reviewed electronic medical records of 75 patients who had undergone cardiac surgery with rotational thromboelastometry-based coagulation management in a university hospital and analyzed the UF-induced changes in the maximum clot firmness (MCF) of extrinsically activated test with tissue factor (EXTEM) during CPB in 30 patients. RESULTS The median volume of filtered-free water was 1,350 ml, and median hematocrit was significantly increased from 22.5% to 25.5%. As the primary measure, UF significantly increased the median MCF-EXTEM from 48.0 mm to 50.5 mm (P = 0.015, effect size r = 0.44). The area under the receiver operating characteristic curve pre-UF MCF-EXTEM for discrimination of any increase of MCF-EXTEM after applying UF was 0.89 (95% CI [0.77, 1.00], P < 0.001), and its cut-off value was 50.5 mm (specificity of 81.8% and sensitivity of 84.2% in Youden's J statistic). In the secondary analyses using the cut-off value, UF significantly increased the median MCF-EXTEM from 40.5 mm to 42.5 mm in 18 patients with pre-UF MCF-EXTEM ≤ 50.5 mm. However, it did not increase MCF-EXTEM in 12 patients with pre-UF MCF-EXTEM > 50.5 mm. There was a significant interaction between pre-UF MCF-EXTEM values and applying UF (P < 0.001 for the subgroup, P = 0.046 for UF, P = 0.003 for interaction). CONCLUSIONS Applying UF improved clot firmness, and the improvement was more pronounced when pre-UF MCF-EXTEM had been reduced during CPB.
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Affiliation(s)
- Jaemoon Lee
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Won-Kyoung Kwon
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Sookyung Lee
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Chung-Sik Oh
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, Essen, Germany
- Medical Department, TEM Innovations GmbH/Werfen PBM, Munich, Germany
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Sandeep B, Xiao Z, Zhao F, Feng Q, Gao K. Role of Platelets in Acute Lung Injury After Extracorporeal Circulation in Cardiac Surgery Patients: A Systemic Review. Curr Probl Cardiol 2022; 47:101088. [PMID: 34936908 DOI: 10.1016/j.cpcardiol.2021.101088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 11/15/2022]
Abstract
In vitro circulation (cardiopulmonary bypass, CPB) has been widely used in heart surgery. In the past, it was believed that the reduction of platelet count and impaired platelet function during cardiac surgery were the main causes of acute lung injury (ALI). ALI is a life-threatening clinical syndrome in critically ill patients due to an uncontrolled systemic inflammatory response resulting from direct injury to the lung or indirect injury in the setting of a systemic process. Platelets have an emerging and incompletely understood role in a myriad of ALI after extracorporeal circulation in cardiac surgery patients. An electronic literature search was performed using Pubmed, Scopus and Cinahl investigating ALI, pathogenesis, and role of platelets, treatment and management for ALI patients. Many studies have shown that in vitro circulation is a nonphysiological process that can lead to a decrease in the number of platelets and impaired platelet function, as well as varying degrees of lung damage. The relationship between the effects of in vitro circulation on platelets and acute lung injury is still controversial. This review article discusses the role of platelets in lung injury after cardiopulmonary bypass and resent development in the management of ALI.
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Affiliation(s)
- Bhushan Sandeep
- Department of Cardiothoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Zongwei Xiao
- Department of Cardiothoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Fengying Zhao
- Department of Intensive Care Unit, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Qianru Feng
- Department of Intensive Care Unit, Chengdu Second People's Hospital, Chengdu, Sichuan, China
| | - Ke Gao
- Department of Cardiothoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, China.
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3
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Saleem Y, Darbari A, Sharma R, Vashisth A, Gupta A. Recent advancements in pediatric cardiopulmonary bypass technology for better outcomes of pediatric cardiac surgery. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pediatric cardiac surgery is in itself very enigmatic and individualized. Presently, there has been a slew of new developments aimed primarily toward pediatric cardiopulmonary bypass for safer, patient-centered pediatric cardiac surgery. Still, lot of technological challenges need to be resolved, and their safer application in pediatric and neonate patients requires further refinement.
Main body of the abstract
Considering various significant yet unresolved issues of pediatric cardiac bypass, an exhaustive literature search was done on various internet databases with standard keywords. There are various new recent improvements; as the first oxygenator explicitly designed for neonatal patients; pediatric oxygenators with low prime volumes and surface areas that allow flows up to 2 L/min; pediatric oxygenators with integrated arterial filters; and miniature ultrafiltration devices that allow for high rates of ultrafiltrate removal. These advancements can significantly reduce cardiopulmonary bypass circuit surface areas and prime volumes. These advancements could reduce or eliminate the requirement for homologous red blood cells during or after surgery with reduction or eliminate bypass-related hemodilution, and inflammation. Because of the immaturity of the neonatal hemostatic system, conventional coagulation tests alone are insufficient to guide neonatal hemostatic therapy. Myocardial preservation techniques, safe temperature with duration are still debatable and yet to be fully explored.
Short conclusion
This review is based on Standards for Quality Improvement Reporting Excellence guidelines to provide a framework for reporting new knowledge to find better management strategy for pediatric cardiac cases.
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Lu ZY, Zhu ZY, Yang JX, Zhou YZ, Jiang YZ, Wei W, Wang X, Li SJ. Platelet Aggregation Before Aspirin Initiation in Pediatric Patients With Congenital Heart Disease at High Risk of Thrombosis. Front Cardiovasc Med 2022; 9:813190. [PMID: 35911558 PMCID: PMC9328390 DOI: 10.3389/fcvm.2022.813190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 06/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background Aspirin following unfractionated heparin is the most common anticoagulation strategy for pediatric patients who experienced cardiac surgery at high risk of thrombosis. The platelet aggregation test is the golden method to evaluate the aspirin effect on platelet function. However, the platelet aggregation basal status before postoperative aspirin initiation and the related clinical influencing factors hasn't been investigated systemically in this population. Methods In a prospective cohort of 247 children, arachidonic acid-induced platelet aggregation (PAG-AA) was measured by means of light transmission aggregometry (LTA) before the first dose of aspirin after cardiac surgical procedure and the perioperative variables were also collected. Distribution of this population's PAG-AA basal status was described. Univariate and multivariate logistic regression analysis were performed to identify the main influencing factors of PAG-AA. Results The median time of aspirin administration was 2 (1–27) days after surgery and the corresponding median value of basal PAG-AA was 20.70% (1.28–86.49%), with 67.6% population under 55% and 47.8% population under 20%. Patients undergoing cardiopulmonary bypass (CPB) had a significantly lower basal PAG-AA than those without (30.63 ± 27.35 vs. 57.91 ± 27.58, p = 0.013). While patients whose test done within 3 days after CPB had a significantly lower PAG-AA than those out of 3 days (25.61 ± 25.59 vs. 48.59 ± 26.45, p = 0.001). Univariate analysis implied that the influencing factors of the basal PAG-AA including CPB use, test time point, cyanosis, and platelet count. Multivariate regression analysis indicated that only CPB use, test time point, and platelet count were the main independent influencing factors for the basal PAG-AA. Conclusion The majority of children have impaired basal platelet aggregometry responses before postoperative aspirin initiation. The main influencing factors are CPB use, test time point, and platelet count. To establish the platelet aggregometry baseline prior to commencement of aspirin therapy, testing should be performed 3 days later following the procedure when effect of CPB is basically over.
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Affiliation(s)
- Zhong-Yuan Lu
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhi-Yuan Zhu
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ju-Xian Yang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yu-Zi Zhou
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ya-Zhou Jiang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Wei Wei
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xu Wang
- Pediatric Intensive Care Unit, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
- *Correspondence: Xu Wang
| | - Shou-Jun Li
- Department of Cardiac Surgery, Pediatric Cardiac Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Cholette JM, Muszynski JA, Ibla JC, Emani S, Steiner ME, Vogel AM, Parker RI, Nellis ME, Bembea MM. Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e25-e36. [PMID: 34989703 PMCID: PMC8769357 DOI: 10.1097/pcc.0000000000002856] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements. CONCLUSIONS Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.
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Affiliation(s)
- Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Robert I Parker
- Professor Emeritus, Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, SUNY at Stony Brook, Stony Brook, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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6
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Sandeep B, Xiao Z, Zhao F, Feng Q, Gao K. Role of Platelets in Acute Lung Injury After Extracorporeal Circulation in Cardiac Surgery Patients: A Systemic Review. Curr Probl Cardiol 2021. [DOI: https://doi.org/10.1016/j.cpcardiol.2021.101088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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7
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Perek B, Rzymski P, Komosa A, Olasińska-Wiśniewska A, Puślecki M, Jemielity M, Lesiak M, Aboul-Hassan SS, Stankowski T, Xia Z, Stelmark K, Siller-Matula J, Poniedziałek B. Mean platelet volume-to-platelet count ratio after elective cardiac surgical procedures is superior in reflecting platelets metabolic hyperactivity compared to other routine morphological platelet indices: A preliminary report. Cardiol J 2021; 30:VM/OJS/J/83339. [PMID: 34787889 PMCID: PMC10713209 DOI: 10.5603/cj.a2021.0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Excessive metabolic excitation of platelets after cardiac procedures may be related to some adverse events but assessment of their metabolic activity is not routine. The purpose of this study was to evaluate which of the basic platelet morphological parameters best reflects their metabolic status. METHODS The blood samples of 22cardiac surgical patients (mean age of 62.3 ± 10.3 years) were taken before surgery (BS), and 1, 24 and 48 hours after the operation. Correlations between morphological platelet parameters (platelet count [PLT], mean platelet volume [MPV], platelet distribution width [PDW] and MPV/PLT) and their metabolic activity (total concentration of malondialdehyde [MDA] and MDA/PLT) were estimated. RESULTS Significant decline in PLT after operation (from 223 ± 44 × 10¹²/L to 166 ± 57 × 10¹²/L) was accompanied by marked increase in MPV (from 8.4 ± 0.9 fL to 9.1 ± 1.2 fL) and no change of PDW. Consequently, MPV/PLT index increased significantly after procedures from (median with IQR) 0.038 (0.030-0.043) to 0.053 (0.043-0.078). Simultaneously, a significant increase in total platelet MDA content and MDA/PLT was noted reaching peak levels soon after operation. The strongest correlation was observed between MPV/PLT and MDA/PLT (r = 0.56; p < 0.001), although the others were also found to be significant (MDA/PLT vs. MPV; r = 0.35; MDA/PLT vs. PDW; r = 0.34). CONCLUSIONS Among basic morphological parameters and indices, the MPV-to-PLT ratio reflects the best metabolic status of platelets in cardiac surgical patients.
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Affiliation(s)
- Bartłomiej Perek
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland.
| | - Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Integrated Science Association (ISA), Universal Scientific Education and Research Network (USERN)
| | - Anna Komosa
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poland
| | - Anna Olasińska-Wiśniewska
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Mateusz Puślecki
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
- Department of Medical Rescue, Poznan University of Medical Sciences, Poland
| | - Marek Jemielity
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Maciej Lesiak
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poland
| | - Sleiman Sebastian Aboul-Hassan
- Department of Cardiac Surgery, Medinet Heart Center Ltd, Nowa Sol, Poland
- Department of Cardiac Surgery and Interventional Cardiology, Faculty of Medicine and Medical Sciences, University of Zielona Gora, Zielona Gora, Poland
| | | | - Zhengyuan Xia
- Shenzhen Institute of Research and Innovation, The University of Hong Kong, China
| | - Konrad Stelmark
- Department of Cardiac Surgery and Transplantology, Chair of Cardio-Thoracic Surgery, Poznan University of Medical Sciences, Poznan, Poland
| | - Jolanta Siller-Matula
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Austria
| | - Barbara Poniedziałek
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznan, Poland
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8
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Görlinger K, Gandhi A. Utility of Platelet Function Testing in Cardiac Surgery in 2021. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1732839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Klaus Görlinger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- Medical Affairs, TEM Innovations GmbH, Munich, Germany
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9
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Pode Shakked N, Rosenblat O, Sagiv D, Molad J, Weinberg H, Shlomo M, Tokatly Latzer I, Pleniceanu O, Mishali D, Vardi A, Hemi R, Kanety H, Paret G. Protective effect of soluble Klotho in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass support-A pilot study. J Card Surg 2021; 36:3567-3576. [PMID: 34350997 DOI: 10.1111/jocs.15849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/17/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The Klotho protein family plays important roles in several metabolic pathways. Soluble Klotho has been recently put forward as an antiaging protein, demonstrating renal and cardiovascular protective traits. Cardiopulmonary bypass (CPB) support during cardiac surgery has been implicated in several adverse outcomes in pediatric and adult patients. Our goal was to assess whether serum Klotho levels can be used to predict outcomes in children undergoing cardiac surgery with CPB due to congenital heart defects (CHDs). METHODS This prospective study was conducted on pediatric patients admitted to two Pediatric Cardiac Intensive Care Units, between 2012 and 2018. All patients were born with CHD and underwent corrective surgery with CPB. Sequential blood samples were analyzed by enzyme-linked immunosorbent assay for soluble Klotho levels at baseline, 2, 6, and 24 h after surgery. The association between Klotho levels and several demographic, intraoperative, and postoperative clinical and laboratory parameters was studied. RESULTS Twenty-nine children undergoing cardiac surgery with CPB support were included. Serum Klotho levels were shown to significantly decrease 2 h after surgery and increase to baseline levels after 6 h (p < .001 and p < .05, respectively). Patients with low Klotho levels 2 h after surgery were at a 32-fold higher risk for developing postoperative complications (p = .015, odds ratio < 0.03). Moreover, Klotho levels at each of the four time points were lower in patients who developed postoperative complications. CONCLUSIONS Cardiac surgery with CPB results in a significant decrease of serum Klotho levels 2 h after surgery in pediatric patients with CHDs, which can be used to predict development of postoperative complications in this patient population.
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Affiliation(s)
- Naomi Pode Shakked
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel.,The Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel
| | - Orgad Rosenblat
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel
| | - Doron Sagiv
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel.,Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Jeremy Molad
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Hagai Weinberg
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Internal Medicine B, Meir Medical Center, Kfar Saba, Israel
| | - Meital Shlomo
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Itay Tokatly Latzer
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
| | - Oren Pleniceanu
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Kidney Research Lab, The Institute of Nephrology and Hypertension, Sheba Medical Center, Tel-Hashomer, Israel
| | - David Mishali
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond and Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Amir Vardi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Pediatric Cardiac Intensive Care Unit, Edmond and Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | - Rina Hemi
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Institute of Endocrinology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Hannah Kanety
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Institute of Endocrinology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Gideon Paret
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Department of Pediatric Intensive Care, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Tel-Hashomer, Israel
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10
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Risk Factors of Thrombotic Complications and Antithrombotic Therapy in Paediatric Cardiosurgical Patients. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.2.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The development of cardiosurgical care for paediatric and neonatal patients is undergoing the rapid growth. Complex, multi-stage reconstructive operations and the use of invasive monitoring are associated with high risk of venous and arterial thrombosis.The cardiac surgery patient is inherently unique, since it requires controlled anticoagulation during cardiopulmonary bypass. Moreover, the most cardiovascular pediatric patients require antithrombotic measures over the perioperative period. In addition to medication support with the use of various groups of antithrombotic agents, vascular access management is justified in order to minimize the risk of thromboembolic complications, which can affect both the functional status, and common and inter-stage mortality.The purpose of this review was to systematize the available data on risk factors contributing to the development of thrombotic complications in patients with congenital heart disease.An information search was carried out using Internet resources (PubMed, Web of Science, eLibrary.ru); literature sources for period 2015–2020 were analysed. As a result of the analysis of the literature data age-dependent features of the haemostatic system, and associated with the defect pathophysiology, and undergone reconstructive interventions were described. The issues of pathophysiology of univentricular heart defects and risk factors associated with thrombosis were also covered.Moreover, aspects of intraoperative anti-thrombotic support are discussed, as well as measures to prevent thromboembolic complications in this population.Coordinated actions of haematologists, cardiologists, anaesthesiologists, intensivists, and cardiac surgeons will allow achieving a fine balance between risks of bleeding and thrombosis in the population of paediatric patients undergoing cardiovascular surgery.
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11
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Preoperative heart failure is not associated with impaired coagulation in paediatric cardiac surgery. Cardiol Young 2021; 31:979-984. [PMID: 33551018 DOI: 10.1017/s1047951120005004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The objectives of the present study were to determine whether there was any association between the grade of heart failure, as expressed by preoperative levels of brain natriuretic peptide and Ross score, and the preoperative coagulation status in patients with non-restrictive ventricular shunts and determine whether there were any postoperative disturbances of the coagulation system in these patients, as measured by thromboelastometry and standard laboratory analyses of coagulation. DESIGN Perioperative coagulation was analysed with laboratory-based coagulation tests and thromboelastometry before, 8 hours after, and 18 hours after cardiac surgery. In addition, brain natriuretic peptide was analysed before and 18 hours after surgery. PATIENTS 40 children less than 12 months old with non-restrictive congenital ventricular or atrio-ventricular shunts scheduled for elective repair of their heart defects. RESULTS All coagulation parameters measured were within normal ranges preoperatively. There was a significant correlation between brain natriuretic peptide and plasma fibrinogen concentration preoperatively. There was no statistically significant correlation between brain natriuretic peptide and INTEM-MCF, FIBTEM-MCF, plasma fibrinogen, activated partial thromboplastin time, prothrombin time, or platelet count at any other time point, either preoperatively or postoperatively. Postoperatively, fibrinogen plasma concentration and FIBTEM-MCF decreased significantly at 8 hours, followed by a large increase at 18 hours to higher levels than preoperatively. CONCLUSIONS There was no evidence of children with non-restrictive shunts having coagulation abnormalities before cardiac surgery. Brain natriuretic peptide levels or Ross score did not correlate with coagulation parameters in any clinically significant way.
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12
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Di Gregorio G, Sella N, Spiezia L, Menin E, Boscolo A, Pasin L, Pittarello D, Vida V, Simioni P, Navalesi P. Cardiopulmonary bypass-induced coagulopathy in pediatric patients: The role of platelets in postoperative bleeding. A preliminary study. Artif Organs 2021; 45:852-860. [PMID: 33432593 DOI: 10.1111/aor.13912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 01/19/2023]
Abstract
Pediatric patients are particularly prone to cardiopulmonary bypass (CPB)-induced coagulopathy mainly due to hemodilution, consumption of coagulation factors and hypothermia. The aim of the present study was to examine the possible role of platelet count and function as it relates to the bleeding risk after CPB in the pediatric population. All consecutive patients (age <13 years) scheduled for elective cardiac surgery between January 2019 and November 2019 were retrospectively considered for the study. We gathered demographic characteristics, perioperative laboratory data (mainly platelet count and function), transfusion requirements, and blood loss for each patient. Patients with a chest tube output during the first 24 hours after surgery >75th percentile were bleeders (cases). Controls were nonbleeders. A total of 31 patients were enrolled [median age 17 (4-57) months]. A significant postoperative reduction in platelet count (P < .001) and function either in ADP-test (P < .001), TRAP-test (P < .001) and ASPI-test (P < .001) was found, with positive correlations between chest tube output within the first 24 hours after surgery and postoperative impairment of platelet count (R = 0.553, P = .001), ADP-test (R = 0.543, P = .001), TRAP-test (R = 0.627, P < .001) and ASPI-test (R = 0.436, P = .014). Eight children (26%) experienced major postoperative bleeding. Bleeders were significantly younger (P = .015) and underwent longer CPB duration (P = .015). Despite no significant differences in postoperative platelet count and function between cases and controls, the postoperative reduction (Δ) in platelet count (P = .002) and function in ADP-test (P = .007), TRAP-test (P = .020) and ASPI-test (P = .042) was significantly greater in bleeders vs. nonbleeders. A ΔPLT >262 500 ×109 /L, a ΔADP-test >29 U, a ΔTRAP-test >44 U and a ΔASPI-test >26 U showed to be predictive of major postoperative bleeding. Postoperative bleeding in children undergoing cardiac surgery with CPB was linked to younger age, longer CPB duration, and significant postoperative reduction in platelet count and function. Larger studies are needed to confirm our results and define strategies to reduce postoperative bleeding in these patients.
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Affiliation(s)
- Guido Di Gregorio
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
| | - Nicolò Sella
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
| | - Luca Spiezia
- Department of Medicine (DIMED), Thrombotic and Haemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - Eugenia Menin
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
| | - Annalisa Boscolo
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
| | - Laura Pasin
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
| | - Demetrio Pittarello
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
| | - Vladimiro Vida
- Department of Cardiac, Thoracic and Vascular Sciences, Paediatric and Congenital Cardiac Surgery Unit, Padova University Hospital, Padova, Italy
| | - Paolo Simioni
- Department of Medicine (DIMED), Thrombotic and Haemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - Paolo Navalesi
- Department of Medicine (DIMED), Anaesthesia and Intensive Care Unit, Padova University Hospital, Padova, Italy
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Epstein D, Vishnepolsky A, Bolotin G, Atweh N, Bonstein L, Lehavi A. Effect of Prolonged Hypothermic Cardiopulmonary Bypass, Heparin, and Protamine on Platelet: A Small-Group Study. Thorac Cardiovasc Surg 2021; 69:719-722. [PMID: 33465799 DOI: 10.1055/s-0040-1721477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiopulmonary bypass (CPB) is associated with platelet dysfunction (PD), an important cause of postoperative bleeding. The etiology of PD is not completely understood. We mapped the platelets' function during CPB to determine the etiology of PD. Platelets activation, measured by procaspase activating compound-1 and P-selectin expression (CD62P), after activation by adenosine diphosphate and thrombin receptor activator peptide, were decreased by protamine. Changes during CPB were insignificant. Platelet-leukocyte aggregation was increased by CPB but not by protamine. Platelet apoptosis marker, annexin V, was increased by protamine. Changes during CPB were insignificant. Our findings demonstrate that protamine given after CPB plays a central role in PD and count decrease.
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Affiliation(s)
- Danny Epstein
- Department of Internal Medicine "B," Rambam Health Care Campus, Haifa, Israel
| | | | - Gil Bolotin
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Nardeen Atweh
- Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
| | - Lilach Bonstein
- Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Blood Bank and Platelet Immunology Laboratories, Rambam Health Care Campus, Haifa, Israel
| | - Amit Lehavi
- Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Harris JM, Sheehan K, Rogers CA, Murphy T, Caputo M, Mumford AD. Prediction of Bleeding in Pediatric Cardiac Surgery Using Clinical Characteristics and Prospective Coagulation Test Results. Semin Thorac Cardiovasc Surg 2021; 34:277-288. [PMID: 33444767 DOI: 10.1053/j.semtcvs.2021.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Abstract
Bleeding caused by coagulopathy is common in children undergoing cardiac surgery and causes adverse outcomes. Coagulation testing assists selection of treatments to stop bleeding but has an uncertain role for predicting bleeding. We aimed to evaluate how well prospective coagulation testing predicted excessive bleeding during and after cardiac surgery compared to prediction using clinical characteristics alone. The study was a single-center, prospective cohort study in children having a range of cardiac surgery procedures with coagulation testing at anesthetic induction and immediately after cardiopulmonary bypass. The primary outcome was clinical concern about bleeding (CCB), a composite of either administration of prohemostatic treatments in response to bleeding or a high chest drain volume after surgery. In 225 children, CCB occurred in 26 (12%) during surgery and in 68 (30%) after surgery. Multivariable fractional polynomial models using the clinical characteristics of the children alone predicted CCB during surgery (c-statistic 0.64; 95% confidence interval 0.53, 0.76) and after surgery (0.74; 0.67, 0.82). Incorporating coagulation test results into these models improved prediction (c-statistics 0.79; 0.70, 0.87, and 0.80; 0.74, 0.87, respectively). However, this increased the overall proportion of children classified correctly as CCB or not CCB during surgery by only 0.9% and after surgery by only 0.4%. Incorporating coagulation test results into predictive models had no effect on prediction of blood transfusion or postoperative complications. Prospective coagulation testing marginally improves prediction of CCB during and after cardiac surgery but the clinical impact of this is small when compared to prediction using clinical characteristics.
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Affiliation(s)
- Jessica M Harris
- Bristol Trials Centre, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Karen Sheehan
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Tim Murphy
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK
| | - Massimo Caputo
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK; Bristol Heart Institute, University Hospitals Bristol, Bristol, UK; Department of Paediatric Cardiac Surgery, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Andrew D Mumford
- Department of Haematology, School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK.
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Development and Internal Validation of Model Predicting Postoperative Blood Loss Risk Among Children with Pulmonary Atresia Undergoing Cardiopulmonary Bypass. Pediatr Cardiol 2021; 42:47-58. [PMID: 32886153 DOI: 10.1007/s00246-020-02451-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022]
Abstract
To develop and internally validate nomogram predicting postoperative blood loss risk among pediatric patients with pulmonary atresia (PA) undergoing cardiopulmonary bypass (CPB). All patients aged from 6 months to 6 years with PA who underwent surgery at Fuwai Hospital from June 2015 to December 2019 were selected. And the prediction nomogram model was developed in the training set based on the selected patients. The demographic characteristics and laboratory data from each enrolled patient were gathered. Postoperative blood loss was defined as a blood loss exceeding 20.0 ml/kg within the first 24 postoperative hours. The least absolute shrinkage and selection operator (LASSO) method was used to optimize feature selection for multivariate logistic regression analysis that was applied to build a nomogram composed of all the features selected in the LASSO algorithm. The concordance index (C-index), calibration plot, and decision curve analysis (DCA) were used to evaluate the discrimination, calibration, and clinical net benefit of the nomogarm, respectively. Finally, internal validation was performed using the bootstrap technique. Of the 66 pediatric patients in the training set, 21 (31.82%) and 45 (68.18%) patients were assigned into bleeding group and non-bleeding group, respectively. The first postoperative 24-h blood loss in the bleeding group was significantly higher than that in the non-bleeding group during ICU stay (P = 0.000). Multivariate logistic regression analysis showed that, the immediate postoperative prothrombin time (odds ratio = 1.419, 95% confidence interval: 1.094-1.841, P = 0.008), the immediate postoperative platelet count (odds ratio = 0.985, 95% confidence interval: 0.973-0.997, P = 0.015) and the immediate postoperative red blood cell (RBC) count (odds ratio = 0.335, 95% confidence interval: 0.166-0.667, P = 0.002) were independent predictors of postoperative blood loss risk. The model presented favorable calibration and good discrimination with satisfactory calibration curve and a C-index of 0.858 (95% confidence interval: 0.758-0.958). High C-index value of 0.837 was achieved in the internal validation. The DCA revealed that the nomogram was great clinical effect when intervention was decided among nearly the entire range of threshold probabilities. We developed and internally validated an accurate nomogram to assist in the clinical decision-making concerning the presence of postoperative blood loss in pediatric patients with PA undergoing CPB. However, the nomogram should be endorsed by external validation before it can be recommended for routine practice.
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Dennhardt N, Sümpelmann R, Horke A, Keil O, Nickel K, Heiderich S, Boethig D, Beck CE. Prevention of postoperative bleeding after complex pediatric cardiac surgery by early administration of fibrinogen, prothrombin complex and platelets: a prospective observational study. BMC Anesthesiol 2020; 20:302. [PMID: 33339495 PMCID: PMC7747387 DOI: 10.1186/s12871-020-01217-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 12/07/2020] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative bleeding is a major problem in children undergoing complex pediatric cardiac surgery. The primary aim of this prospective observational study was to evaluate the effect of an institutional approach consisting of early preventive fibrinogen, prothrombin complex and platelets administration on coagulation parameters and postoperative bleeding in children. The secondary aim was to study the rate of re-intervention and postoperative transfusion, the occurrence of thrombosis, length of mechanical ventilation, ICU stay and mortality. Methods In fifty children (age 0–6 years) with one or more predefined risk factors for bleeding after cardiopulmonary bypass (CPB), thrombelastography (TEG) and standard coagulation parameters were measured at baseline (T1), after CPB and reversal of heparin (T2), at sternal closure (T3) and after 12 h in the ICU (T4). Clinical bleeding was evaluated by the surgeon at T2 and T3 using a numeric rating scale (NRS, 0–10). Results After CPB and early administration of fibrinogen, prothrombin complex and platelets, the clinical bleeding evaluation score decreased from a mean value of 6.2 ± 1.9 (NRS) at T2 to a mean value of 2.1 ± 0.8 at T3 (NRS; P < 0.001). Reaction time (R), kinetic time (K), maximum amplitude (MA) and maximum amplitude of fibrinogen (MA-fib) improved significantly (P < 0.001 for all), and MA-fib correlated significantly with the clinical bleeding evaluation (r = 0.70, P < 0.001). The administered total amount of fibrinogen (mg kg− 1) correlated significantly with weight (r = − 0.42, P = 0.002), priming volume as percentage of estimated blood volume (r = 0.30, P = 0.034), minimum CPB temperature (r = − 0.30, P = 0.033) and the change in clinical bleeding evaluation from T2 to T3 (r = 0.71, P < 0.001). The incidence of postoperative bleeding (> 10% of estimated blood volume) was 8%. No child required a surgical re-intervention, and no cases of thrombosis were observed. Hospital mortality was 0%. Conclusion In this observational study of children with an increased risk of bleeding after CPB, an early preventive therapy with fibrinogen, prothrombin complex and platelets guided by clinical bleeding evaluation and TEG reduced bleeding and improved TEG and standard coagulation parameters significantly, with no occurrence of thrombosis or need for re-operation. Trial registration German Clinical Trials Register DRKS00018109 (retrospectively registered 27th August 2019).
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany.
| | - Robert Sümpelmann
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Alexander Horke
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Oliver Keil
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Katja Nickel
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Sebastian Heiderich
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Christiane E Beck
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
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Dieu A, Van Regemorter V, Detaille T, Houtekie L, Eeckhoudt S, Khalifa C, Kahn D, Clement De Clety S, Poncelet A, Momeni M. Combined Use of Rotational Thromboelastometry (Rotem) and Platelet Impedance Aggregometry (Multiplate Analyzer) in Cyanotic and Acyanotic Infants and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass: Subgroup Analysis of a Randomized Clinical Trial. J Cardiothorac Vasc Anesth 2020; 35:2115-2123. [PMID: 33127287 DOI: 10.1053/j.jvca.2020.09.133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/27/2020] [Accepted: 09/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Few studies have investigated the Multiplate platelet function analyzer in pediatrics. The authors evaluated Multiplate combined with Rotem in terms of guiding platelet transfusion after pediatric cardiac surgery with cardiopulmonary bypass (CPB). The authors further compared coagulation parameters between cyanotic and acyanotic patients. DESIGN Subgroup analysis of a randomized clinical trial. SETTING Tertiary hospital. PARTICIPANTS Patients weighing between seven and 15 kg. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Rotem and Multiplate tests were performed (1) after anesthesia induction, (2) upon CPB separation, and (3) upon intensive care unit arrival. Among a total of 59 subjects, 9 patients required platelet transfusion. In multivariate linear regression, analysis EXTEM maximum clot firmness upon CPB separation was associated with the volume of transfused platelets (regression coefficient = -0.348 [95% confidence interval -1.006 to -0.028]; p = 0.039). No such association was found for the Multiplate test. Acyanotic and cyanotic heart disease were present in 32 and 27 children, respectively. There were no significant differences between these two groups in terms of platelet count and function. Postoperative blood loss was significantly higher in the cyanotic group compared with the acyanotic arm (p = 0.015; difference [95% confidence interval -2.40 {-4.20 to -0.60}]). There were no differences between groups regarding transfusion of allogeneic blood products. CONCLUSIONS This study showed that Rotem, but not Multiplate results, were associated with platelet transfusion in pediatric cardiac surgery with no intake of platelet inhibitors. The usefulness of combining these tests in platelet transfusion decision-making needs to be evaluated in larger populations.
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Affiliation(s)
- Audrey Dieu
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Victoria Van Regemorter
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Thierry Detaille
- Department of Pediatric Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Laurent Houtekie
- Department of Pediatric Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Stéphane Eeckhoudt
- Department of Hematology, Laboratoires des Hôpitaux Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Céline Khalifa
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - David Kahn
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Stéphan Clement De Clety
- Department of Pediatric Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alain Poncelet
- Department of Cardiac Surgery, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium.
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Bianchi P, Beccaris C, Norbert M, Dunlop B, Ranucci M. Use of Coagulation Point-of-Care Tests in the Management of Anticoagulation and Bleeding in Pediatric Cardiac Surgery: A Systematic Review. Anesth Analg 2020; 130:1594-1604. [PMID: 32224832 DOI: 10.1213/ane.0000000000004563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Bleeding and coagulation management are essential aspects in the management of neonates and children undergoing cardiac surgery. The use of point-of-care tests (POCTs) in a pediatric setting is not as widely used as in the adult setting. This systematic review aims to summarize the evidence showed by the literature regarding the use of POCTs in children undergoing cardiac surgery. We included all studies examining the pediatric population (<18 years old) undergoing cardiac surgery in which the coagulation profile was assessed with POCTs. Three electronic databases (PubMed, Embase, and the Cochrane Controlled Clinical Trials register) were searched. Tests involved were heparin effect tests, viscoelastic tests, and platelet function tests. Due to the wide heterogeneity of the patients and tests studied, a formal meta-analysis was impossible, and the results are therefore presented through a systematic review. Eighty articles were found, of which 47 are presented in this review. At present, literature data are too weak to define POCTs as a "gold standard" for the treatment of perioperative bleeding in pediatric cardiac surgery. Nevertheless, introduction of POCTs into postoperative algorithms has shown to improve bleeding management, patient outcome, and cost efficiency.
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Affiliation(s)
- Paolo Bianchi
- From the Department of Anesthesia and Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Camilla Beccaris
- Great Ormond Street Hospital NHS Foundation Trust, Cardiac Intensive Care Unit, London, United Kingdom
| | | | | | - Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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Bogdanić D, Bogdanić N, Karanović N. Evaluation of platelet count and platelet function analyzer - 100 testing for prediction of platelet transfusion following coronary bypass surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2020; 80:296-302. [PMID: 32125177 DOI: 10.1080/00365513.2020.1731847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Platelet transfusions are commonly administered to treat bleeding in cardiac surgery. The aim of this study was to compare platelet (PLT) count and values of collagen adenosine diphosphate closure time (cADP-CT) measured by Platelet Function Analyzer (PFA) for prediction of PLT transfusion therapy following coronary bypass surgery. For this prospective observational study, 66 patients scheduled for coronary artery bypass grafting (CABG) who received early PLT transfusions (within 60 min after the operation) were enrolled. To assess changes in platelets, count and function, two time points were selected: 15 min before and 30 - 60 min after the end of PLT transfusion. The patients were divided into transfused and non-transfused with further PLT in the 48 h postoperatively. We used the receiver operating characteristics (ROC) curve to investigate whether the PLT count and cADP-CT values were predictors of PLT transfusion. The positive predictive values (PPV) of PLT count and cADP-CT after PLT transfusion for further PLT transfusion were 33% and 86% respectively, with a PLT count threshold of ≤200 × 109/L and cADP-CT threshold of ≥118 s. The comparison among the ROC curves showed a statistical difference (p = .0002). In multiple regression analysis, cADP-CT was the strongest predictor for the number of PLT transfusion doses in the 48 h postoperatively. In CABG patients, the results of cADP-CT after PLT transfusion have a better predictive capacity for further PLT transfusions than the PLT count.
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Affiliation(s)
- Dejana Bogdanić
- Department of Transfusion Medicine, University Hospital Center Split, Split, Croatia
| | - Nikolina Bogdanić
- University Hospital for Infectious Diseases "Dr. Fran Mihaljević", Zagreb, Croatia
| | - Nenad Karanović
- Department of Anesthesiology and Intensive Care, University Hospital Center Split, Split, Croatia
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20
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Platelet dysfunction during pediatric cardiac ECMO. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Wise-Faberowski L, Machovec K. Platelet Administration During Cardiopulmonary Bypass in Neonates: A Universal Therapy Applied in a Novel Way. World J Pediatr Congenit Heart Surg 2019; 11:77-78. [DOI: 10.1177/2150135119890248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Advances in pharmaceuticals (eg, factor concentrates), laboratory testing (eg, rotational thromboelastometry), and processes (eg, transfusion protocols) have contributed to improved outcomes regarding transfusion in neonates undergoing surgical repair for congenital heart disease. A novel strategy, platelets administered during the rewarming phase of cardiopulmonary bypass, as a solution to improved hemostasis, was prospectively evaluated in 42 neonates. Improved intraoperative and postoperative hemostasis was observed in neonates given platelets during the rewarming phase of cardiopulmonary bypass.
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22
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Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines. J Cardiothorac Vasc Anesth 2019; 33:3249-3263. [DOI: 10.1053/j.jvca.2019.03.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
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23
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Napolitano M, Mancuso S, Raso S, LoCoco L, Arfò PS, De Francisci G, Dieli F, Caccamo N, Reina A, Dolce A, Agliastro R, Siragusa S. Buffy coat-derived platelets cryopreserved using a new method: Results from a pivotal clinical trial on thrombocytopenic patients with acute leukaemia. Transfus Apher Sci 2019; 58:102666. [PMID: 31753773 DOI: 10.1016/j.transci.2019.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
The administration of cryopreserved platelets (PLTs) may overcome the limits of platelet shortage and availability, especially during some seasons or in specific contexts like rural areas. After in vitro validation studies, ad hoc prepared buffy coat-derived pooled platelet concentrates (BC-PLTs), treated with dimethyl sulphoxide (DMSO) and cryopreserved (CRY BC-PLTs) at -80 °C with a modified Valeri method, were transfused in patients with severe thrombocytopenia secondary to chemotherapy for acute leukaemia (AL). Five inpatients were enrolled in the pivotal clinical trial NCT02032134: 4 males and 1 female with a mean age of 71 years (range: 65-80). Four patients were diagnosed with acute myeloid leukaemia and 1 had acute lymphoblastic leukaemia.Transfusion of one Unit of CRY BC-PLTs resulted effective in active bleeding control in two patients without any adverse reaction or concomitant antihaemorrhagic therapies. CRY BC-PLTs met the currently accepted criteria for cryopreserved PLTs, their transfusion in patients with AL was safe. (Clinical trial: NCT02032134).
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Affiliation(s)
- Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (proMISE), University of Palermo, Palermo, Italy.
| | - Salvatrice Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (proMISE), University of Palermo, Palermo, Italy
| | - Simona Raso
- Dipartiemnto di Discipline Chirurgiche, Oncologiche e Stomatologiche (DiChir.OnS), University of Palermo, Palermo, Italy
| | - Lucio LoCoco
- Laboratorio Centralizzato Policlinico "P.Giaccone", Sezione Emostasi e Trombosi, Palermo, Italy
| | - Piera Stefania Arfò
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (proMISE), University of Palermo, Palermo, Italy
| | - Giovanni De Francisci
- Unità di Medicina Trasfusionale ed Immunoematologia, Ospedale "Civico" Palermo, Italy
| | - Francesco Dieli
- Laboratorio di Ricerca CLADIBIOR, Università di Palermo, Palermo, Italy
| | - Nadia Caccamo
- Laboratorio di Ricerca CLADIBIOR, Università di Palermo, Palermo, Italy
| | | | | | - Rosalia Agliastro
- Unità di Medicina Trasfusionale ed Immunoematologia, Ospedale "Civico" Palermo, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (proMISE), University of Palermo, Palermo, Italy
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Khalaf-Adeli E, Alavi M, Alizadeh-Ghavidel A, Pourfathollah AA. Comparison of standard coagulation testing with thromboelastometry tests in cardiac surgery. J Cardiovasc Thorac Res 2019; 11:300-304. [PMID: 31824611 PMCID: PMC6891038 DOI: 10.15171/jcvtr.2019.48] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 08/26/2019] [Indexed: 01/20/2023] Open
Abstract
Introduction: According to the several evidences, using thromboelastometry as a point of care test can be effective in reduction in blood loss and transfusion requirements in cardiac surgeries. However, there are limited data regarding to the comparison of thromboelastometry and the standard coagulation tests. In this study, we compared thromboelastometry and standard coagulation tests (PT, PTT and fibrinogen level) in patients under combined coronary-valve surgery. Methods: Forty adult patients who were under on-pump combined coronary-valve surgery were included in this study. Thromboelastometry tests Fibtem, Intem, Extem and Heptem), along with standard coagulation tests (PT, PTT and fibrinogen assay) were simultaneously performed in two time points, before and after the pump (pre-CPB and post-CPB, respectively). Results: A total of 80 blood samples were analyzed. There were no significant correlation between PT test and the CT-Extem parameter as well as PTT and CT-Intem parameter either in pre-CPB and post-CPB (P >0.05). On the contrary, fibrinogen level had high correlation with A10-Fibtem and A10-Extem in pre-PCB (P <0.05). 82% of PT and 84% of PTT measurements were outside the reference range, while abnormal CT in Extem and Intem was observed in 17.9%. Conclusion: For management of bleeding, adequate perioperative haemostatic monitoring is indispensable during cardiac surgery. Standard coagulation tests are time consuming and cannot be interchangeably used with thromboelastomety and relying on their results to decide whether blood transfusion is necessary, leads to the inappropriate transfusion.
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Affiliation(s)
- Elham Khalaf-Adeli
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Mostafa Alavi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Alizadeh-Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ali Akbar Pourfathollah
- Departments of Immunology, Faculty of Medicine, Tarbiat Modares University of Medical Sciences, Tehran, Iran.,Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
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Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72:297-322. [PMID: 31096732 PMCID: PMC6676023 DOI: 10.4097/kja.19169] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
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Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, San Sebastián de los Reyes, Madrid, Spain
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, CologneMerheim Medical Center (CMMC), Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany
| | - Ángel Augusto Pérez Calatayud
- Terapia Intensiva Adultos, Hospital de Especialidades del Niño y la Mujer, Coordinador Grupo Mexicano para el Estudio de la Medicina Intensiva, Colegio Mexicano de Especialistas en Obstetrica Critica (COMEOC), Queretarco, Mexico
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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Ames WA. Pro: The Value of Modified Ultrafiltration in Children After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2019; 33:866-869. [DOI: 10.1053/j.jvca.2018.10.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 11/11/2022]
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Björklund E, Hansson EC, Romlin BS, Jeppsson A, Malm CJ. Postoperative platelet function is associated with severe bleeding in ticagrelor-treated patients. Interact Cardiovasc Thorac Surg 2018; 28:709-715. [DOI: 10.1093/icvts/ivy336] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 11/04/2018] [Accepted: 11/09/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Erik Björklund
- Department of Internal Medicine, Södra Älvsborg Hospital, Borås, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Emma C Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Birgitta S Romlin
- Department of Paediatric Anaesthesia and Intensive Care, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carl Johan Malm
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Romlin BS, Söderlund F, Wåhlander H, Hallhagen S, Wessman C, Baghaei F, Jeppsson A. Perioperative monitoring of platelet function in paediatric cardiac surgery by thromboelastometry, or platelet aggregometry? Br J Anaesth 2018; 116:822-8. [PMID: 27199313 DOI: 10.1093/bja/aew053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Impaired platelet function increases the risk of bleeding complications in cardiac surgery. Reliable assessment of platelet function can improve treatment. We investigated whether thromboelastometry detects clinically significant preoperative, perioperative, and postoperative adenosine diphosphate (ADP)-dependent platelet dysfunction in paediatric cardiac surgery patients. METHODS Fifty-seven children were included in a single-centre prospective observational study. Clot formation (modified rotational thromboelastometry with heparinase, HEPTEM) and platelet aggregation (multiple electrode aggregometry) were analysed at five time points before, during, and after surgery. The accuracy of thromboelastometric indices of platelet function [maximal clot firmness (MCF) and clot formation time (CFT)] to detect ADP-dependent platelet dysfunction (defined as ADP-induced aggregation ≤30 units) was calculated with receiver operating characteristics analysis, which also identified optimal cut-off levels. Positive and negative predictive values for the identified cut-off levels (CFT≥166 s; MCF≤43 mm) to detect platelet function were determined. RESULTS The MCF and CFT were highly accurate in predicting platelet dysfunction during cardiopulmonary bypass [CPB; area under the aggregation curve 0.89 (95% confidence interval 0.80-0.97) and 0.86 (0.77-0.96), respectively] but not immediately after CPB [0.64 (0.48-0.79) and 0.67 (0.52-0.82), respectively] or on arrival at the intensive care unit [0.53 (0.37-0.69) and 0.60 (0.44-0.77), respectively]. The positive and negative predictive values were acceptable during CPB (87 and 67%, respectively, for MCF≤43 mm; 80 and 100% for CFT≥166 s) but markedly lower after surgery. CONCLUSION In paediatric cardiac surgery, thromboelastometry has acceptable ability to detect ADP-dependent platelet dysfunction during, but not after, CPB.
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Affiliation(s)
- B S Romlin
- Department of Paediatric Anaesthesia and Intensive Care
| | - F Söderlund
- Department of Paediatric Anaesthesia and Intensive Care
| | - H Wåhlander
- Departent of Paediatric Cardiology, Queen Silvia's Children's Hospital, Gothenburg, Sweden
| | - S Hallhagen
- Department of Paediatric Anaesthesia and Intensive Care
| | - C Wessman
- Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - F Baghaei
- Department of Medicine/Haematology and Coagulation Disorders
| | - A Jeppsson
- Department Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Haas T, Cushing MM, Varga S, Gilloz S, Schmugge M. Usefulness of multiple electrode aggregometry as a screening tool for bleeding disorders in a pediatric hospital. Platelets 2018; 30:498-505. [DOI: 10.1080/09537104.2018.1475631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Thorsten Haas
- Department of Anesthesia, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Melissa M. Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Stephanie Varga
- Department of Anesthesia, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Séverine Gilloz
- Department of Hematology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Markus Schmugge
- Department of Hematology, University Children’s Hospital Zurich, Zurich, Switzerland
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30
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Ichikawa J, Osada Y, Kodaka M, Nishiyama K, Komori M. Association Between Platelet Count and Postoperative Blood Loss in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass and Fresh Frozen Plasma Administration Guided by Thromboelastometry. Circ J 2018; 82:677-683. [DOI: 10.1253/circj.cj-17-0712] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Junko Ichikawa
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Yoshiko Osada
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Mitsuharu Kodaka
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Keiko Nishiyama
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
| | - Makiko Komori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East
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Shinkawa T, Holloway J, Tang X, Gossett JM, Imamura M. Experience Using Kaolin-Impregnated Sponge to Minimize Perioperative Bleeding in Norwood Operation. World J Pediatr Congenit Heart Surg 2017; 8:475-479. [PMID: 28696876 DOI: 10.1177/2150135117713698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE A kaolin-impregnated hemostatic sponge (QuikClot) is reported to reduce intraoperative blood loss in trauma and noncardiac surgery. The purpose of this study was to assess if this sponge was effective for hemostasis during Norwood operation. DESCRIPTION We conducted a retrospective review of patients undergoing Norwood operation in infancy between 2011 and 2016 at our institution. EVALUATION Of 31 identified Norwood operations, a kaolin-impregnated sponge was used intraoperatively in 15 (48%) patients. The preoperative profiles and cardiopulmonary bypass status were similar between the operations with or without kaolin-impregnated sponge. The comparison on each operative outcome between operations with or without kaolin-impregnated sponge showed that the intraoperative platelets, cryoprecipitate, and factor VII dosage were significantly less in the operations with kaolin-impregnated sponge (55 mL, 10 mL, 0 µg/kg vs 72 mL, 15 mL, 45 µg/kg; P = .03, .021, .019), as well as the incidence of perioperative bleeding complications (second cardiopulmonary bypass for hemostasis or postoperative mediastinal exploration, 0% vs 31%, P = .043). A logistic regression model showed that the nonuse of kaolin-impregnated sponge and longer aortic cross clamp time were associated with perioperative bleeding complication in univariable model ( P = .02 and .005). CONCLUSIONS Use of kaolin-impregnated hemostatic sponge was associated with reduced blood product use and perioperative bleeding complications in Norwood operation at a single institution.
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Affiliation(s)
- Takeshi Shinkawa
- 1 Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jessica Holloway
- 1 Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Xinyu Tang
- 2 Biostatistics Program, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeffrey M Gossett
- 2 Biostatistics Program, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michiaki Imamura
- 1 Division of Pediatric and Congenital Cardiothoracic Surgery, Department of Pediatrics, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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32
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Perioperative changes in platelet count and function in patients undergoing cardiac surgery. Med J Islam Repub Iran 2017; 31:37. [PMID: 29445666 PMCID: PMC5804419 DOI: 10.14196/mjiri.31.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Indexed: 11/18/2022] Open
Abstract
Background: Patients undergoing cardiac surgery are at increased risk of bleeding due to multifactorial coagulopathies. In the present
study, we aimed at investigating the changes in platelet count and function during and after surgery as well as determining the
association of the platelet dysfunction with bleeding and transfusion requirements in these patients.
Methods: A total of 40 adult patients scheduled for elective valve coronary cardiac surgery were included in this prospective observational
study. Changes in platelet count and function with ADP, acid arachidonic, and collagen (light transmission aggregometry)
were analyzed at three time points: before CPB, after CPB, and 24 hours after end of surgery. Postoperative bleeding and intraoperative
transfusion requirements were recorded.
Results: There were a significant reverse correlation between CPB time and ADP-induced aggregation, particularly after CPB and
postoperative AA-induced aggregation. There was not any significant correlation between platelet count and function at all-time
points. Both platelet count and platelet aggregation significantly reduced during CPB. While platelet aggregation increased on postoperative
Day 1, platelet count reduced by about 40% after CPB, and remained at this level postoperatively. Patients with abnormal
ADP-induced aggregation had significant increased postoperative bleeding and transfusion requirements.
Conclusion: The results of this study demonstrate that platelet count and platelet aggregation are reduced during CPB. Our results
emphasized the effect of platelet dysfunction on increased postoperative bleeding and transfusion requirements. Perioperative monitoring
of platelet function can be considered as a bleeding management strategy for implantation of PBM programs.
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33
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Milford EM, Reade MC. Comprehensive review of platelet storage methods for use in the treatment of active hemorrhage. Transfusion 2017; 56 Suppl 2:S140-8. [PMID: 27100750 DOI: 10.1111/trf.13504] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 12/21/2015] [Accepted: 12/23/2015] [Indexed: 12/14/2022]
Abstract
This review considers the various methods currently in use, or under investigation, for the storage of platelets intended for use in the treatment of active hemorrhage. The current standard practice of storing platelets at room temperature (RT) (20°C-24°C) optimizes circulating time, but at the expense of hemostatic function and logistical considerations. A number of alternatives are under investigation. Novel storage media additives appear to attenuate the deleterious changes that affect RT stored platelets. Cold storage was originally abandoned due to the poor circulating time of platelets stored at 4°C, but such platelets may actually be more hemostatically effective, with a number of other advantages, compared to RT stored platelets. Periodically re-warming cold stored platelets (temperature cycling, TC) may combine the hemostatic efficacy of cold stored platelets with the longer circulating times of RT storage. Alternatives to liquid storage include cryopreservation (freezing) or lyophilization (freeze-drying). The former has had some limited clinical use and larger clinical trials are underway, while the latter is still in the preclinical stage with promising in vitro and in vivo results. The importance of platelet transfusion in the management of active hemorrhage is now well accepted, so it is timely that platelet storage methods are reviewed with consideration of not only their circulating time, but also their hemostatic efficacy.
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Affiliation(s)
- Elissa M Milford
- Australian Defence Force, Australia.,University of Queensland, Australia
| | - Michael C Reade
- Australian Defence Force, Australia.,University of Queensland, Australia
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34
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Silvey M, Brandão LR. Risk Factors, Prophylaxis, and Treatment of Venous Thromboembolism in Congenital Heart Disease Patients. Front Pediatr 2017; 5:146. [PMID: 28674685 PMCID: PMC5476169 DOI: 10.3389/fped.2017.00146] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 06/09/2017] [Indexed: 01/19/2023] Open
Abstract
Congenital heart disease (CHD) is a common condition in the pediatric population, affecting up to 1% of all live births (i.e., around 40,000 newborns/year in the United States). Although CHD does have a wide range of severity, by the age of 5 years approximately 80% of patients will require at least one surgical intervention to achieve a complete/palliative cardiac repair. Today, in light of their much-improved surgical survival, the care of these patients focuses on morbidity prevention and/or treatment. One such morbidity has been the increased frequency of thrombotic occlusions [e.g., cardioembolic arterial ischemic strokes; arterial, cardiac, and/or newly created shunt thrombosis; venous thromboembolism (VTE)]. Patients with CHD are at high risk of developing thrombosis due to the disruption of blood flow, CHD-related coagulopathy, inflammation, and/or platelet activation secondary to extracorporeal circulation support required during open-heart surgery or as a bridge to recovery, which can increase thrombus formation. In this article, we will discuss how the coagulation system is altered in patients with CHD in regard to the patient's anatomy, procedures they undergo to correct their congenital heart defect, and other risk factors that may increase their thrombotic risk, focusing on VTE. We will also discuss the most recently published reports pertaining to guidelines on prophylaxis and treatment of VTE in this population. Finally, we will briefly address the long-term VTE outcomes for patients with CHD.
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Affiliation(s)
- Michael Silvey
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, United States
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35
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Huffmyer JL, Fernandez LG, Haghighian C, Terkawi AS, Groves DS. Comparison of SEER Sonorheometry With Rotational Thromboelastometry and Laboratory Parameters in Cardiac Surgery. Anesth Analg 2016; 123:1390-1399. [DOI: 10.1213/ane.0000000000001507] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pretransfusion Comparison of Dialyser-Based Hemoconcentrator With Cell Saver System for Perioperative Cell Salvage. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 10:334-41. [PMID: 26418303 DOI: 10.1097/imi.0000000000000180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Cell Saver system is the method of choice for red blood cell salvage from the surgical field; however, cost is a limiting factor. We at our institute have devised a cost-effective version of dialyser-based autotransfusion system. We performed pretransfusion comparison of our autotransfusion system with conventional cell saver system. METHODS A prospective randomized observational study was performed in 104 consecutive patients with coronary artery disease undergoing by off-pump coronary artery bypass grafting. Patients were divided into two groups. In the dialyser group (53 patients), blood from surgical field was salvaged by our dialyser-based system. In the cell saver group (51 patients), blood was salvaged by cell saver. In both groups, 20-mL sample from the salvaged blood was analyzed for hemoglobin, platelets, protein, albumin, free hemoglobin, osmotic fragility, and peripheral blood smear examination. RESULTS Total hemoglobin salvaged was comparable in both groups (85% vs 76%). On peripheral smear, red blood cells were swollen, but morphology was preserved. Moreover, normal osmotic fragility suggested absence of any lethal damage to red blood cells in either group. Dialyser-based system was more efficient in salvaging platelets (42.9% vs 6%), proteins (79.2% vs 0%), and albumin (65% vs 0%). Total free hemoglobin was three times more in dialyser group but was well below recommended limits. CONCLUSIONS Dialyser-based system is economical, is equally efficacious in salvaging red blood cells, is more effective in salvaging platelets and proteins, and does not contain significant amount of free hemoglobin. Therefore, this salvaged blood can be safely transfused.
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Petricevic M, Biocina B, Dirkmann D, Goerlinger K. Bleeding risk-assessment in elective cardiac surgery - a reply. Anaesthesia 2016; 71:1121-2. [PMID: 27523069 DOI: 10.1111/anae.13610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
| | | | - D Dirkmann
- Universitätsklinikum Essen, Essen, Germany
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38
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Ranucci M, Baryshnikova E. Platelet function in paediatric cardiac surgery. Br J Anaesth 2016; 116:744-6. [PMID: 27199307 DOI: 10.1093/bja/aew108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Ranucci
- Department of Cardiothoracic-Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - E Baryshnikova
- Department of Cardiothoracic-Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
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Tan Z, Zhou L, Qin Z, Luo M, Chen H, Xiong J, Li J, Liu T, Du L, Zhou J. Low-Dose Sevoflurane May Reduce Blood Loss and Need for Blood Products After Cardiac Surgery: A Prospective, Randomized Pilot Study. Medicine (Baltimore) 2016; 95:e3424. [PMID: 27124028 PMCID: PMC4998691 DOI: 10.1097/md.0000000000003424] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Patients undergoing cardiac surgery often experience abnormal bleeding, due primarily to cardiopulmonary bypass (CPB)-induced activation of platelets. Sevoflurane may inhibit platelet activation, raising the possibility that administering it during CPB may reduce blood loss.Patients between 18 and 65 years old who were scheduled for cardiac surgery under CPB at our hospital were prospectively enrolled and randomized to receive intravenous anesthetics alone (control group, n = 77) or together with sevoflurane (0.5-1.0 vol/%) from an oxygenator (sevoflurane group, n = 76). The primary outcome was postoperative blood loss, the secondary outcome was postoperative need for blood products.Volume of blood loss was 48% lower in the sevoflurane group than the control group at 4 hours after surgery, and 33% lower at 12 hours after surgery. Significantly fewer patients in the sevoflurane group lost >700 mL blood within 24 hours (9 of 76 vs 28 of 77, P < 0.001). As a result, the sevoflurane group received significantly smaller volumes of packed red blood cells (1.25 ± 2.36 vs 2.23 ± 3.75 units, P = 0.011) and fresh frozen plasma (97 ± 237 vs 236 ± 344 mL, P = 0.004). Thus the sevoflurane group was at significantly lower risk of requiring complex blood products after surgery (adjusted odds ratio [OR] 0.34, 95% confidence interval [CI] 0.17-0.68, P = 0.002).Sevoflurane inhalation from an oxygenator during CPB may reduce blood loss and need for blood products after cardiac surgery.
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Affiliation(s)
- Zhaoxia Tan
- From the Department of Anesthesiology and Translational Neuroscience Center, West China Hospital (ZT, LZ, ZQ, ML, JX, JL, TL, LD); and Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China (HC, JZ)
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40
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Ho KM, Bham E, Pavey W. Incidence of Venous Thromboembolism and Benefits and Risks of Thromboprophylaxis After Cardiac Surgery: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2015; 4:e002652. [PMID: 26504150 PMCID: PMC4845147 DOI: 10.1161/jaha.115.002652] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Background Optimal thromboprophylaxis after cardiac surgery is uncertain. This systematic review aimed to define the incidence and risk factors for deep vein thrombosis (DVT), fatal and nonfatal pulmonary embolism (PE), and assess whether venous thromboembolism (VTE) prophylaxis was effective in reducing VTE without complications after cardiac surgery. Methods and Results Two reviewers independently searched and assessed the quality and outcomes of randomized, controlled trials (RCTs) and observational studies on VTE after cardiac surgery in the MEDLINE, EMBASE, and Cochrane controlled trial register (1966 to December 2014). Sixty‐eight studies provided data on VTE outcomes or complications related to thromboprophylaxis after cardiac surgery. The majority of the studies were observational studies (n=49), 16 studies were RCTs, and 3 were meta‐analyses. VTE prophylaxis was associated with a reduced risk of PE (relative risk [RR], 0.45; 95% confidence interval [CI], 0.28–0.72; P=0.0008) or symptomatic VTE (RR, 0.44; 95% CI, 0.28–0.71; P=0.0006) compared to the control without significant heterogeneity. Median incidence (interquartile range) of symptomatic DVT, PE, and fatal PE were 3.2% (0.6–8.1), 0.6% (0.3–2.9), and 0.3% (0.08–1.7), respectively. Previous history of VTE, obesity, left or right ventricular failure, and prolonged bed rest, mechanical ventilation, or use of a central venous catheter were common risk factors for VTE. Bleeding or cardiac tamponade requiring reoperation owing to pharmacological VTE prophylaxis alone, without systemic anticoagulation, was not observed. Conclusions Unless proven otherwise by adequately powered RCTs, initiating pharmacological VTE prophylaxis as soon as possible after cardiac surgery for patients who have no active bleeding is highly recommended.
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Affiliation(s)
- Kwok M Ho
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia (K.M.H.) School of Population Health, University of Western Australia, Perth, WA, Australia (K.M.H.) School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia (K.M.H., W.P.)
| | - Ebrahim Bham
- Department of Anesthesia, Fiona Stanley Hospital, Perth, WA, Australia (E.B., W.P.)
| | - Warren Pavey
- School of Veterinary and Life Sciences, Murdoch University, Perth, WA, Australia (K.M.H., W.P.) Department of Anesthesia, Fiona Stanley Hospital, Perth, WA, Australia (E.B., W.P.)
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41
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Garg P, Malhotra A, Desai M, Sharma P, Bishnoi AK, Tripathi P, Rodricks D, Pandya H. Pretransfusion Comparison of Dialyser-Based Hemoconcentrator with Cell Saver System for Perioperative Cell Salvage. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pankaj Garg
- Departments of Cardiovascular and Thoracic Surgery, Asarwa, Ahmedabad, India
| | - Amber Malhotra
- Departments of Cardiovascular and Thoracic Surgery, Asarwa, Ahmedabad, India
| | - Manan Desai
- Departments of Cardiovascular and Thoracic Surgery, Asarwa, Ahmedabad, India
| | - Pranav Sharma
- Departments of Cardiovascular and Thoracic Surgery, Asarwa, Ahmedabad, India
| | | | | | | | - Himani Pandya
- Departments of Medical Research, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Civil Hospital Campus, Asarwa, Ahmedabad, India
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Abstract
There has been extraordinary progress over the last half-century in the field of medical transplantation in which tissue, organs, or body parts from one human are placed into another. Solid organ transplants have allowed thousands of children with otherwise devastating inherited or acquired disorders to survive. Depending upon the clinical situation, there are many specific peri-transplant issues that must be carefully addressed to optimize outcomes. Although surgical, immunologic, and infectious concerns are usually in the forefront, important aspects regarding hemostasis frequently arise. The number of solid organs that can be successfully transplanted in children has expanded over the last decades and includes kidney, liver, heart, lung, intestine, pancreas, and thymus. Bleeding complications may occur in the setting of organ failure prior to transplantation, during the surgical procedure, or in the post-transplant setting, and can results in significant morbidity. This report will focus on preventing and managing non-surgical-related bleeding complications in children undergoing liver, heart, kidney transplantation, in whom there are often unique aspects of coagulation to be considered.
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Affiliation(s)
- L Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - C Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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