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Cowart C, Roberts SM. Pro: Modified Ultrafiltration Is Beneficial for Adults Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2023; 37:1049-1052. [PMID: 36754730 DOI: 10.1053/j.jvca.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Affiliation(s)
- Christopher Cowart
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA
| | - S Michael Roberts
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S Hershey Medical Center, Hershey, PA.
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Hasegawa T, Iba Y, Naraoka S, Nakajima T, Hashimoto S, Murohashi T, Umeta R, Hosaka I, Ohkawa A, Yasuda N, Shibata T, Kawaharada N. Improvement of predicted hematocrit values after the initiation of cardiopulmonary bypass in cardiovascular surgery. J Artif Organs 2021; 25:117-124. [PMID: 34689296 DOI: 10.1007/s10047-021-01295-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/22/2021] [Indexed: 11/24/2022]
Abstract
Hematocrit (Hct) values after the initiation of cardiopulmonary bypass (CPB) must be maintained appropriately to avoid perioperative complications. Therefore, an accurate prediction is required. However, the standard prediction equation often results in actual values that are lower than the predicted values. This study aimed to clarify the limits of agreement (LOA) and bias of the prediction equations and investigate better the prediction equations. A retrospective study was performed on adult patients between April 2015 and December 2020. Study 1 included 158 patients, and Study 2 included 55 patients. The primary outcomes were the LOA and bias between the predicted and measured Hct values after the initiation of CPB, and two studies were conducted. In Study 1, total blood volume (TBV) was estimated, and the new blood volume index (BVI) was calculated. BVI was also evaluated for the overall value and gender differences. Therefore, the patient's background was compared by gender differences. In, Study 2 the conventional predicted equation (Eq. 1), the predicted equation using the new BVI (Eq. 2), and the predicted equation using the new BVI including physiological factors in the TBV equation (Eq. 3) were compared. In Study 1, BVI was 53 (44-67) mL/kg. In Study 2, bias ± LOA was - 2.5 ± 6.8% for Eq. 1, 0.1 ± 6.6% for Eq. 2, and 0.4 ± 6.2% for Eq. 3. The new equation is expected to predict the Hct value after the initiation of CPB with better LOA and bias than the conventional equation.
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Affiliation(s)
- Takeo Hasegawa
- Department of Clinical Engineering, Sapporo Medical University Hospital, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Yutaka Iba
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
| | - Shuichi Naraoka
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tomohiro Nakajima
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Syuichi Hashimoto
- Department of Clinical Engineering, Sapporo Medical University Hospital, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Takao Murohashi
- Department of Clinical Engineering, Sapporo Medical University Hospital, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Riko Umeta
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Itaru Hosaka
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Akihito Ohkawa
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Naomi Yasuda
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, West-16, South-1, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan.
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Hahm KD, Jin SJ, Cho SS, Park J, Park H, Kim DH, Choi SS. Relationship of epidural patient-controlled analgesia with postoperative bleeding after unilateral total knee arthroplasty: a propensity score-matching analysis. Sci Rep 2021; 11:11284. [PMID: 34050250 PMCID: PMC8163755 DOI: 10.1038/s41598-021-90946-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/19/2021] [Indexed: 11/09/2022] Open
Abstract
Although epidural patient-controlled analgesia (PCA) to control postoperative pain after total knee arthroplasty (TKA), the relationship of epidural PCA with postoperative bleeding remains controversial. Therefore, we aimed to evaluate the effect of epidural and intravenous PCA on postoperative bleeding in patients undergoing unilateral TKA. Total of 2467 patients who underwent TKA were divided to intravenous PCA (n = 2339) or epidural PCA (n = 128) group. After 1:1 propensity score-matching, 212 patients were analyzed to assess the associations between the perioperative blood loss and epidural PCA between the groups. Mean postoperative blood loss was significantly greater in epidural PCA than in intravenous PCA (900.9 ± 369.1 mL vs. 737.8 ± 410.1 mL; P = 0.007). The incidence of red blood cell (RBC) administration (> 3 units) was significantly higher in epidural PCA than in intravenous PCA (30.2% vs. 16.0%; OR 2.5; 95% CI 1.201–5.205; P = 0.014). Epidural PCA may be strongly related to postoperative bleeding and the incidence of RBC transfusion of more than 3 units after unilateral TKA, as compared to intravenous PCA. Therefore, the use of epidural PCA may be carefully considered for postoperative pain management in TKA.
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Affiliation(s)
- Kyung-Don Hahm
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Seok-Joon Jin
- Department of Pain, Shinshinplus Clinic, Anyang-si, 14401, Korea
| | - Seong-Sik Cho
- Department of Occupational and Environmental Medicine, College of Medicine, Dong-A University, Busan, 49201, Korea
| | - Jihoon Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Han Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
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Lee MH, Riley W. Factors associated with errors in the heparin dose response test: recommendations to improve individualized heparin management in cardiopulmonary bypass. Perfusion 2020; 36:513-523. [PMID: 32909506 DOI: 10.1177/0267659120952977] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND A critical aspect of cardiopulmonary bypass (CPB) is to achieve full anticoagulation to prevent thrombosis and consumptive coagulation without using excessive amount of heparin. This can be achieved with heparin dose response (HDR) test in vitro to calculate an individualized heparin bolus to reach a target activated clotting time (ACT) and heparin concentration. However, we often observe that the measured ACT (mACT) with the calculated heparin bolus gives significant errors, both positive (mACT is higher than expected) and negative (mACT is lower), from expected ACT (eACT). METHODS We performed a retrospective study of 250 patients who underwent cardiac surgery to attain an error distribution of the mACT from eACT with calculated heparin bolus. In addition, it is aimed to identify possible patterns of baseline ACT (bACT), calculated heparin concentration (CHC) and HDR slope that are associated with the significant positive and negative errors. RESULTS We found that individualized heparin bolus by HDR test is consistently underestimated while it gave a significant number of positive and negative errors. Further analysis indicates that significant negative errors correlate with high bACT and slope and low CHC while significant positive errors with low bACT and slope and high CHC. CONCLUSION The mACT can be substantially different from eACT. The accuracy of the HDR test appears to be dependent upon bACT, slope, and CHC. Based on our analysis, we provide several recommendations and a flow chart to improve the quality of individualized heparin management on CPB.
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Affiliation(s)
- Min-Ho Lee
- Massachusetts General Hospital, Boston, MA, USA
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Ichikawa J, Mori T, Kodaka M, Nishiyama K, Ozaki M, Komori M. Changes in heparin dose response slope during cardiac surgery: possible result in inaccuracy in predicting heparin bolus dose requirement to achieve target ACT. Perfusion 2017; 32:474-480. [DOI: 10.1177/0267659117692661] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: The substantial interpatient variability in heparin requirement has led to the use of a heparin dose response (HDR) technique. The accuracy of Hepcon-based heparin administration in achieving a target activated clotting time (ACT) using an HDR slope remains controversial. Methods: We prospectively studied 86 adult patients scheduled for cardiac surgery requiring cardiopulmonary bypass. The total dose of calculated heparin required for patient and pump priming was administered simultaneously to achieve a target ACT of 450 s for HDR on the Hepcon HMS system. Blood samples were obtained after the induction of anesthesia, at 3 min after heparin administration and after the initiation of CPB to measure kaolin ACT, HDR slope, whole-blood heparin concentration based on the HDR slope and anti-Xa heparin concentration, antithrombin and complete blood count. Results: The target ACT of 450 s was not achieved in 68.6% of patients. Compared with patients who achieved the target ACT, those who failed to achieve their target ACT had a significantly higher platelet count at baseline. Correlation between the HDR slope and heparin sensitivity was poor. Projected heparin concentration and anti-Xa heparin concentration are not interchangeable based on the Bland–Altman analysis. Conclusion: It can be hypothesized that the wide discrepancy in HDR slope versus heparin sensitivity may be explained by an inaccurate prediction of the plasma heparin level and/or the change in HDR of individual patients, depending on in vivo factors such as extravascular sequestration of heparin, decreased intrinsic antithrombin activity level and platelet count and/or activity.
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Affiliation(s)
- Junko Ichikawa
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
| | - Tetsu Mori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
| | - Mitsuharu Kodaka
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
| | - Keiko Nishiyama
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
| | - Makoto Ozaki
- Department of Anesthesiology, Tokyo Women’s Medical University Medical University Hospital, Tokyo, Japan
| | - Makiko Komori
- Department of Anesthesiology, Tokyo Women’s Medical University Medical Center East, Tokyo, Japan
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