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Ko SH, Nan Z, Soh S, Shim JK, Lee HW, Kwak YL, Song JW. Effect of Retrograde Autologous Priming on Coagulation Assessed by Rotation Thromboelastometry in Patients Undergoing Valvular Cardiac Surgery. J Cardiothorac Vasc Anesth 2024; 38:939-945. [PMID: 38262805 DOI: 10.1053/j.jvca.2023.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVES To investigate the effect of retrograde autologous priming (RAP) on coagulation function using rotation thromboelastometry (ROTEM) in patients undergoing valvular cardiac surgery. DESIGN A prospective, randomized, patient- and outcome assessor-blinded study. SETTING At a single-center university hospital. PARTICIPANTS Patients aged 20 years or older undergoing valvular cardiac surgery. INTERVENTIONS A total of 104 patients were allocated to the RAP or control group (1:1 ratio). In the RAP group, the prime was displaced into the collection bag before bypass initiation. ROTEM was performed at the induction of anesthesia, at the beginning of rewarming, and after the reversal of heparinization. Allogeneic plasma products and platelet concentrates were transfused according to ROTEM-based algorithms. MEASUREMENTS AND MAIN RESULTS An average volume of 635 ± 114 mL was removed using RAP (from the 1,600 mL initial prime volume). The hematocrit 10 minutes after cardiopulmonary bypass (CPB) was 24.7 ± 3.5% in the control group, and 26.1 ± 4.1% in the RAP group (p = 0.330). ROTEM, including EXTEM, INTEM, and FIBTEM, showed prolonged clotting time and decreased maximal clot firmness after CPB in both groups without intergroup differences. The number of patients who received intraoperative erythrocytes (27% v 25%, control versus RAP, p = 0.823), fresh frozen plasma (14% v 8%, control versus RAP, p = 0.339), cryoprecipitate (21% v 12%, control versus RAP, p = 0.185), or platelet concentrate transfusion (19% v 12%, control versus RAP, p = 0.277) did not differ between the groups. CONCLUSIONS Cardiopulmonary bypass induced impaired coagulation function on ROTEM. However, RAP did not improve coagulation function when compared with conventional priming in patients undergoing valvular cardiac surgery.
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Affiliation(s)
- Seo Hee Ko
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zhengyu Nan
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hee Won Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Chiba Y, Tashima Y, Ohama S, Teruaki K, Nakamura N, Sano T, Adachi K, Kimura N, Sanui M, Yamaguchi A. Effect of nadir hematocrit during cardiopulmonary bypass on the early outcomes after surgical repair of acute type A aortic dissection. J Card Surg 2022; 37:2338-2347. [PMID: 35545926 DOI: 10.1111/jocs.16590] [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: 02/25/2022] [Revised: 04/05/2022] [Accepted: 04/17/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although hemodilution during hypothermic cardiopulmonary bypass (CPB) had been thought to improve microcirculation and reduce blood viscosity, there has been no report investigating the effect of low nadir hematocrit (Hct) values caused by severe hemodilution on the surgical outcomes of patients with acute type A aortic dissection (ATAAD). METHODS We retrospectively reviewed 112 consecutive patients who emergently underwent emergency surgical repair of ATAAD at our institution. The patients were classified into the high Hct (nadir Hct ≥ 21% during CPB; n = 51) and low Hct (nadir Hct < 21% during CPB; n = 61) groups. After propensity score matching of preoperative characteristics, surgical outcomes were compared between the groups. RESULTS Although there was no difference in the surgical procedure, longer CPB time and more blood transfusion during surgery were needed in the low Hct group than in the high Hct group. After surgery, estimated glomerular filtration rate was significantly lower (p = .015), lactaic acid was higher (p = .045), and intubation time was longer (p = .018) in the low Hct group than in the high Hct group, although there was no difference in hospital mortality between the groups. The AUC of the nadir Hct during CPB as a prognostic indicator of prolonged postoperative ventilator support was 0.8, with the highest accuracy at 16.7% (sensitivity 88%, specificity 76.9%). In all cohorts, female sex was an independent risk factor for a lower nadir Hct value of <21% during CPB. CONCLUSION A lower nadir Hct value of <21% during CPB may be associated with postoperative renal dysfunction and prolonged ventilator support in patients with ATAAD.
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Affiliation(s)
- Yoshihiko Chiba
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Anesthesiology and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Yasushi Tashima
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shinnosuke Ohama
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Kano Teruaki
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Noriyuki Nakamura
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Taichi Sano
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koichi Adachi
- Department of Cardiovascular Surgery, Yokosuka General Hospital Uwamachi, Yokosuka, Kanagawa, Japan.,Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Naoyuki Kimura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Gupta S, McEwen C, Basha A, Panchal P, Eqbal A, Wu N, Belley-Cote EP, Whitlock R. Retrograde autologous priming in cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2021; 60:1245-1256. [PMID: 34417595 DOI: 10.1093/ejcts/ezab334] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 06/01/2021] [Accepted: 06/13/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Guidelines recommend retrograde autologous priming (RAP) of the cardiopulmonary bypass circuit. However, the efficacy and safety of RAP is not well-established. We performed a systematic review and meta-analysis to determine the effects of RAP on transfusion requirements, morbidity and mortality. METHODS We searched Cochrane Central Register of Controlled Trials, Medline, ScienceDirect, Cumulative Index to Nursing and Allied Health Literature and Embase for randomized controlled trials (RCTs) and observational studies comparing RAP to no-RAP. We performed title and abstract review, full-text screening, data extraction and risk of bias assessment independently and in duplicate. We pooled data using a random effects model. RESULTS Twelve RCTs (n = 1206) and 17 observational studies (n = 3565) were included. Fewer patients required blood transfusions with RAP [RCTs; risk ratio 0.58 [95% confidence interval (CI): 0.51, 0.65], P < 0.001, and observational studies; risk ratio 0.65 [95% CI: 0.53, 0.80], P < 0.001]. The number of units transfused per patient was also lower among patients who underwent RAP (RCTs; mean difference -0.38 unit [95% CI: -0.72, -0.04], P = 0.03, and observational studies; mean difference -1.03 unit [95% CI: -1.76, -0.29], P < 0.006). CONCLUSIONS This meta-analysis supports the use of RAP as a blood conservation strategy since its use during cardiopulmonary bypass appears to reduce transfusion requirements.
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Affiliation(s)
- Saurabh Gupta
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Charlotte McEwen
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ameen Basha
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Puru Panchal
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Adam Eqbal
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada
| | - Nicole Wu
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Emilie P Belley-Cote
- Population Health Research Institute, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Whitlock
- Department of Surgery, Division of Cardiac Surgery, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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Hensley NB, Gyi R, Zorrilla-Vaca A, Choi CW, Lawton JS, Brown CH, Frank SM, Grant MC, Cho BC. Retrograde Autologous Priming in Cardiac Surgery: Results From a Systematic Review and Meta-analysis. Anesth Analg 2021; 132:100-107. [PMID: 32947294 DOI: 10.1213/ane.0000000000005151] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Retrograde autologous priming (RAP) before cardiopulmonary bypass (CPB) may minimize allogeneic red cell transfusion. We conducted a systematic review of the literature to examine the impact of RAP on perioperative allogeneic red cell transfusions in cardiac surgical patients. METHODS This study involved a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies evaluating the use of RAP in cardiac surgery involving CPB. The primary outcome was intraoperative allogeneic red cell transfusion. Secondary outcomes included whole hospital allogeneic transfusions and adverse events such as acute kidney injury (AKI) and stroke. RESULTS A total of 11 RCTs (n = 1337 patients) were included, comparing RAP patients (n = 674) to control (n = 663). In addition, 10 observational studies (n = 2327) were included, comparing RAP patients (n = 1257) to control (n = 1070). Overall, RAP was associated with a significantly reduced incidence of intraoperative red cell transfusion (n = 18 studies; odds ratio [OR] = 0.34; 95% confidence interval [CI], 0.22-0.55, P < .001) compared to controls. This effect was seen among RCTs (n = 10 studies; OR = 0.19; 95% CI, 0.08-0.45, P < .001) and observational studies (n = 8 studies; OR = 0.66; 95% CI, 0.50-0.87, P = .004) in isolation. RAP was also associated with a significantly reduced incidence of whole hospital red cell transfusion (n = 5 studies; OR = 0.28; 95% CI, 0.19-0.41, P < .001). Among the studies that reported AKI and stroke outcomes, there was no statistically significant increased odds of AKI or stroke in either RAP or control patients. CONCLUSIONS Based on the pooled results of the available literature, RAP is associated with a significant reduction in intraoperative and whole hospital allogeneic red cell transfusion. Use of RAP may prevent hemodilution of cardiac surgical patients and thus, lessen transfusions. Additional high-quality prospective studies are necessary to determine the ideal priming volume necessary to confer the greatest benefit without incurring organ injury.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard Gyi
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | | | - Chun W Choi
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer S Lawton
- Division of Cardiac Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles H Brown
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Steve M Frank
- From the Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Michael C Grant
- From the Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Brian C Cho
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University, School of Medicine, Baltimore, Maryland
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Skubas NJ, Svensson LG, Bakaeen F. To Retrograde Autologous Prime or Not? Anesth Analg 2021; 132:98-99. [PMID: 33315607 DOI: 10.1213/ane.0000000000005286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nikolaos J Skubas
- From the Department of Cardiothoracic Anesthesiology, Anesthesiology Institute and Cleveland Clinic Lerner College of Medicine, Case Western Reserve University
| | - Lars G Svensson
- Department of Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal Bakaeen
- Department of Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Singab H, Gamal MA, Refaey R, Al-Taher W. Effect of Retrograde Autologous Blood Priming of Cardiopulmonary Bypass on Hemodynamic Parameters and Pulmonary Mechanics in Pediatric Cardiac Surgery: A Randomized Clinical Study. Semin Thorac Cardiovasc Surg 2020; 33:505-512. [PMID: 32977015 DOI: 10.1053/j.semtcvs.2020.09.006] [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: 08/16/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
The present study aimed to assess the impact of retrograde autologous priming (RAP) on hemodynamics and pulmonary mechanics in children subjected to cardiothoracic surgery. This prospective randomized study analyzed the clinical records of 124 children with risk adjustment in congenital heart surgery-1 left to right lesions subjected to cardiac surgery. They comprised 64 patients in RAP group and 60 patients in the conventional priming group. The preoperative, intraoperative and postoperative data of the studied patients were reported. The outcome measures included hematocrit (Hct) value, blood gases, lung mechanics parameters, transfusion needs, ICU stay, postoperative complications and mortality. Preoperatively, there were no significant differences between the studied groups regarding the demographic data, underlying lesions, laboratory data, blood gases and pulmonary mechanics parameters. Intraoperatively, RAP group patients had significantly lower amount of blood loss, less frequent need to packed red blood cells (RBC)s transfusion and better Hct values when compared with the control group. Postoperatively, RAP group patients had significantly higher Hct% at ICU arrival, significantly better pulmonary mechanics parameters and significantly shorter duration on mechanical ventilation. RAP in children older than 12 months subjected to cardiac surgery for risk adjustment in congenital heart surgery-1 left to right lesions is associated with less transfusion needs and better pulmonary mechanics.
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Affiliation(s)
- Hamdy Singab
- Cardiothoracic Surgery Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt.
| | - Mohamed A Gamal
- Cardiothoracic Surgery Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Reda Refaey
- Cardiothoracic Surgery Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Waleed Al-Taher
- Anesthesia and Intensive Care Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
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