Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients

TEG® 6s-Guided Algorithm for Optimizing Patient Blood Management in Cardiovascular Surgery: Systematic Literature Review and Expert Opinion

OBJECTIVES

To propose a comprehensive TEG 6s-based intraoperative and/or immediately postoperative treatment algorithm for bleeding patients undergoing cardiac surgery. To achieve this, TEG-based treatment algorithms in cardiac surgery were evaluated through a literature review and structured expert opinion.

DESIGN

Systematic literature review.

SETTING

Cardiac surgery.

PARTICIPANTS

Adult patients undergoing cardiac surgery with intraoperative and/or immediately postoperative bleeding.

INTERVENTIONS

TEG-guided transfusion algorithm.

MEASUREMENTS AND MAIN RESULTS

A literature search was conducted for original studies reporting TEG-based treatment algorithms in cardiac surgery settings. Of 304 identified manuscripts, fourteen met all inclusion criteria, with two further articles identified through authors' suggestions. There is limited evidence describing the use of TEG 6s assays in cardiac surgery with only one study reporting a dedicated algorithm using the TEG 6s device at a non-US center. Two additional studies assessed TEG 6s assays. The remaining manuscripts reported algorithms based on the TEG 5000 device. Following the author's review of the available data, and feedback from expert opinion, a simple transfusion algorithm was proposed as an initial framework for developing a TEG 6s-based protocol with consideration for the 2021 Society of Thoracic Surgery/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology/Society for the Advancement of Patient Blood Management Patient Blood Management Guidelines.

CONCLUSIONS

A new algorithm for cardiac surgery based on TEG 6s assays has been proposed based on the available evidence and expert opinion for research alignment and clinical validation.

Validation and optimization of a blood transfusion prediction model for low transfusion rate adult cardiac surgery

IntroductionBlood transfusion is associated with adverse events and should be prevented. Preoperative identification of patients at risk is necessary and makes subsequent preventive intervention possible. Many risk models have been developed of which the Transfusion Risk and Clinical Knowledge (TRACK) model includes criteria reflecting daily practice. The aim of this study is to validate and update the TRACK model in a low-transfusion-rate adult cardiac-surgery population.MethodsExternal validation of the TRACK model was performed using a database of 4072 adult patients receiving cardiac surgery between 2015 and 2022 (original TRACK model). Subsequently, the original TRACK model coefficients were updated by cross-validation (uTRACK model). Preoperative antiplatelet therapy was added as an extra variable to the updated TRACK model (uTRACK + APT model).ResultsIn our population, 26% of patients received red blood cell transfusions. The original TRACK model demonstrated good discrimination (AUC-ROC of 0.76; 95% CI 0.74 - 0.78) but inadequate calibration (p < .001). Updating TRACK coefficients resulted in improved discrimination (AUC-ROC of 0.78; 95% CI 0.75 - 0.81), calibration (p = .19), and reclassification (Categorical NRI: 0.21; 95% CI [0.17 - 0.24]; p < .001). Adding preoperative antiplatelet therapy did not significantly improve net reclassification improvement (Categorical NRI: 0.01; 95% CI -0.001 - 0.029; p = .40).ConclusionThe original TRACK model overestimates blood transfusion risk in a low-transfusion-rate population. Risk classification significantly improved by updating the original TRACK coefficients. Using the uTRACK model provides more accurate identification of patients at risk of receiving red blood cell transfusions in a low transfusion rate population.Trial RegistryClinicalTrials.gov (https://clinicaltrials.gov), registration number: NCT05581238.

Quality Improvement Methodologies: An Application in Cardiac Anesthesiology

Quality improvement (QI) in medicine serves as the cornerstone of best practices. It enhances medical care by maximizing safety and efficiency while minimizing errors and waste. For a QI initiative to succeed it requires careful strategizing and effective change management plans, including the application of established QI methodologies to ensure sustainable success. Today, QI processes are integral to foundational learning for students and trainees, as well as for maintaining board certification for anesthesiologists. However, many anesthesiologists, including those actively pursuing QI efforts, are often unaware of these methodologies and their associated tools. A successful QI program that leads to sustainable improvement in outcomes relies on methodologies that assess the true current state, define value-added measures, evaluate defects and opportunities for enhancement, implement solutions through a robust change management plan, and ensure the sustainability of the process. This document provides a concise summary of methodologies that can be effectively led and executed by process improvement teams. We examine these methods within the context of cardiac anesthesiology, highlighting one institution's experience in reducing surgical site infections following coronary artery bypass graft surgery. However, these principles are applicable to various healthcare situations and beyond.

Association of Anaesthetists guidelines: the use of blood components and their alternatives

BACKGROUND

The administration of blood components and their alternatives can be lifesaving. Anaemia, bleeding and transfusion are all associated with poor peri-operative outcomes. Considerable changes in the approaches to optimal use of blood components and their alternatives, driven by the findings of large randomised controlled trials and improved haemovigilance, have become apparent over the past decade. The aim of these updated guidelines is to provide an evidence-based set of recommendations so that anaesthetists and peri-operative physicians might provide high-quality care.

METHODS

An expert multidisciplinary, multi-society working party conducted targeted literature reviews, followed by a three-round Delphi process to produce these guidelines.

RESULTS

We agreed on 12 key recommendations. Overall, these highlight the importance of organisational factors for safe transfusion and timely provision of blood components; the need for protocols that are targeted to different clinical contexts of major bleeding; and strategies to avoid the need for transfusion, minimise bleeding and manage anticoagulant therapy.

CONCLUSIONS

All anaesthetists involved in the care of patients at risk of major bleeding and peri-operative transfusion should be aware of the treatment options and approaches that are available to them. These contemporary guidelines aim to provide recommendations across a range of clinical situations.

Visualization of Critical Limits and Critical Values Facilitates Interpretation

Background/Objectives: This study aimed to analyze critical limit and critical value test lists from major US medical centers, identify changes in quantitative critical limit thresholds since 1990, document notification priorities for qualitative and new listings, and visualize information alongside clinical thresholds and pathophysiological trends. Methods: A systematic search was conducted, acquiring 50 lists of critical limits and critical values from university hospitals, Level 1 trauma centers, centers of excellence, and high-performing hospitals across the US. Lists were obtained through direct contact or web-accessible postings. Statistical analysis used the Kruskal-Wallis non-parametric test and Student's t-test to determine significant differences between 1990 and 2024 critical limits. Results: Statistically significant differences were identified in various clinical tests between 1990 and 2024, comprising glucose, calcium, magnesium, CO2 content, blood gas parameters, hematology, and coagulation tests. Ranges for critical limits narrowed for several tests, and new measurands were added. Cardiac biomarkers were infrequently listed. Point-of-care testing (POCT) listings were sparse and showed significant differences from main lab values in the high median critical limit for glucose Conclusions: Visualizing this information has potential benefits, including ease of interpretation, which can improve patient care, reduce inconsistencies, and enhance the efficiency and quality of healthcare delivery.

Efficacy of Quantra-Qplus System for Rapid Diagnosis and Treatment of Hypofibrinogenemia and Thrombocytopenia After Cardiopulmonary Bypass

OBJECTIVES

To assess whether the Quantra-Qplus can provide the cutoff values for predicting transfusion thresholds after cardiopulmonary bypass.

DESIGN

Prospective observational study.

SETTING

Single-center university hospital.

PARTICIPANTS

Adult patients undergoing cardiac surgery.

INTERVENTIONS

The Quantra-Qplus and conventional laboratory coagulation test were performed.

MEASUREMENTS AND MAIN RESULTS

We enrolled 50 adult patients, and collected blood samples at 4 times (preoperative, during cardiopulmonary bypass, after protamine administration, and at the end of surgery). We obtained the values of the Quantra-Qplus (fibrinogen contribution to clot stiffness [FCS] and platelet contribution to clot stiffness [PCS]) and the values of conventional laboratory coagulation test (fibrinogen concentration and platelet count). To determine the cutoff values for FCS and PCS predicting blood transfusion thresholds at after protamine, receiver operating characteristic curve, area under the curve (AUC) with 95% confidence intervals (95% CIs), and Youden index were used. The cutoff value of FCS for predicting a fibrinogen concentration of less than 150 mg/dL was 0.95 hPa (AUC = 0.94; 95% CI, 0.86-1.00), and PCS for predicting a platelet count of less than 50,000/mm3 was 7.05 hPa (AUC = 0.97; 95% CI, 0.92-1.00) at after protamine administration. The cutoff values of FCS and PC varied during cardiac surgery.

CONCLUSIONS

Our study provides potential cutoff values of FCS and PCS to guide fibrinogen administration or platelet transfusion in cardiac surgery patients after protamine administration. These cutoff values might vary during surgery, and different cutoff values for predicting transfusion thresholds during cardiac surgery might apply.

From surgery to recovery: Measuring success through quality of life and functional improvements after cardiac surgery

Coronary artery disease and aortic valve stenosis are highly prevalent cardiovascular diseases worldwide, resulting in substantial morbidity and mortality. Surgical interventions, such as coronary artery bypass grafting and surgical aortic valve replacement, offer significant therapeutic benefits, including enhanced postoperative quality of life (QoL) and functional capacity, which are key indicators of surgical success. This editorial reviews recent studies on postoperative QoL and functional outcomes in patients undergoing cardiac surgery. Factors such as preoperative health, age, intensive care unit stay duration, surgical risk, and perioperative complications could influence these outcomes. Cardiac rehabilitation is pivotal in enhancing patient function, reducing frailty and improving long-term QoL.

New device, old algorithm? Bridging generations in perioperative coagulation management

Viscoelastic testing permits targeted correction of coagulopathy in bleeding patients. As new generations of viscoelastic testing platforms become available, research exploring similarities and differences with older devices can provide insight for institutions seeking to use the newer technologies. Care must be taken to ensure such studies are designed to produce clinically meaningful guidance for adapting existing treatment algorithms to accommodate the latest viscoelastic testing technology.

Cardiac Surgical Bleeding, Transfusion, and Quality Metrics: Joint Consensus Statement by the Enhanced Recovery After Surgery Cardiac Society and Society for the Advancement of Patient Blood Management

BACKGROUND

Excessive perioperative bleeding is associated with major complications in cardiac surgery, resulting in increased morbidity, mortality, and cost.

METHODS

An international expert panel was convened to develop consensus statements on the control of bleeding and management of transfusion and to suggest key quality metrics for cardiac surgical bleeding. The panel reviewed relevant literature from the previous 10 years and used a modified RAND Delphi methodology to achieve consensus.

RESULTS

The panel developed 30 consensus statements in 8 categories, including prioritizing control of bleeding, prechest closure checklists, and the need for additional quality indicators beyond reexploration rate, such as time to reexploration. Consensus was also reached on the need for a universal definition of excessive bleeding, the use of antifibrinolytics, optimal cessation of antithrombotic agents, and preoperative risk scoring based on patient and procedural factors to identify those at greatest risk of excessive bleeding. Furthermore, an objective bleeding scale is needed based on the volume and rapidity of blood loss accompanied by viscoelastic management algorithms and standardized, patient-centered blood management strategies reflecting an interdisciplinary approach to quality improvement.

CONCLUSIONS

Prioritizing the timely control and management of bleeding is essential to improving patient outcomes in cardiac surgery. To this end, a cardiac surgical bleeding quality metric that is more comprehensive than reexploration rate alone is needed. Similarly, interdisciplinary quality initiatives that seek to implement enhanced quality indicators will likely lead to improved patient care and outcomes.

Quality of registration and adherence to guidelines for blood management in CABG surgeries: a case study

In many hospitals, patients undergoing cardiac surgery receive a higher amount of blood products transfusions compared to other disciplines. Blood transfusion comes with risks and drawbacks, such as increased morbidity and mortality across different patient groups, and specifically patients undergoing cardiac surgery, and high costs. Patient Blood Management (PBM) practices focus on the application of evidence based medical and surgical concepts in order to preserve the patient's own blood. Unfortunately, studies suggest that only a small fraction of published guidelines are implemented and followed into daily clinical practicedue to clear guidance, concerns about risks, and lack of knowledge, interdisciplinary commitment or resources. The widespread adoption of electronic health record (EHR) offers the opportunity to improve clinical outcomes through use of decision support system to guide the healthcare providers through best practices and guidelines. Decision support systems can be active, data-based, patient-specific and act timely, and can be more useful that adding new clinical practice guidelines. This case study quantifies the quality of the data registration and provides the results for adherence to perioperative PBM guidelines for coronary artery bypass grafting (CABG) procedures during a three-year period (2018 to 2020), in the St. Antonius hospital, a single heart center that performs over 10% of the total number of heart operations in the Netherlands. With this case study we identify some of the possible improvement factors for PBM in our center. We also quantify the impact of the quality of the registration in the EHR on the analysis results and on possible implementation of decision support systems.

Analysis of the effect of initial hemostasis resuscitation with recombinant human coagulation factor VII a on the treatment of postoperative hemorrhage in cardiac surgery

OBJECTIVE

To investigate the effectiveness of initial hemostatic resuscitation(IHR) on the treatment of bleeding with recombinant human coagulation factor VIIa after cardiac surgery.

METHODS

The clinical data of patients who received rFVIIa hemostatic treatment after cardiac surgery at Beijing Anzhen Hospital, Capital Medical University, from January 1, 2021, to December 31, 2021 were retrospectively collected. A total of 152 cases were included in the study. In this study, initial hemostatic resuscitation was defined as a platelet count > 50,000 per µL and fibrinogen > 1.5 g/L when rFVIIa was used. Based on whether initial hemostatic resuscitation was completed during the application of rFVIIa, patients were divided into an initial hemostatic resuscitation group and an un-initial hemostatic resuscitation group. Baseline information, medical history, surgery-related data, postoperative bleeding volume, transfusion product volume, and overall mortality data were collected for each patient, and the postoperative bleeding volume, transfusion volume, and overall mortality rate were compared between the two groups, thus evaluating the effectiveness of initial hemostatic resuscitation on the treatment of postoperative bleeding with recombinant human coagulation factor VIIa in cardiac surgery.

RESULT

In this study, patients in the initial hemostasis resuscitation group received a lower dose of recombinant activated factor VII (rFVIIa) [29.41 (26.23, 34.63) µg/kg vs. 36.04 (28.57, 59.27) µg/kg, P = 0.002], had lower blood product requirements [41 (40.2%) vs. 31 (62%), P = 0.011], received fewer units of packed red blood cells within 24 h postoperatively [0 (0, 2) U vs. 2 (0, 6) U, P = 0.018], had a lower volume of plasma transfusion [0 (0, 0) ml vs. 0 (0, 400) ml, P = 0.021], exhibited a lower peak value of D-dimer after surgery [756 (415.5, 2140.5) ng/ml vs. 1742.5 (675.25, 3392) ng/ml, P = 0.003], experienced fewer postoperative neurological complications [4 (3.92%) vs. 12 (24%), P < 0.001], had a lower mortality rate [8 (7.84%) vs. 14 (28%), P = 0.001], and had a shorter duration of mechanical ventilation [17 (12, 60.13) hours vs. 39.5 (15.75, 115.13) hours, P = 0.022].

CONCLUSION

Initial hemostasis resuscitation can significantly reduce the bleeding volume and blood product requirements in patients with bleeding complications after cardiac surgery who were treated with rFVIIa, thus improving patient prognosis. And it is crucial to closely monitor for symptoms and signs of thromboembolic complications during the application of rFVIIa.

4-Factor prothrombin complex concentrates and factor VIII inhibitor bypass activity use in cardiac surgery

OBJECTIVES

The objective of this study was to compare total thromboembolic complications between 4-factor prothrombin complex concentrate (4F-PCC) with factor VIII inhibitor bypassing activity (FEIBA) when utilized during cardiac surgery.

DESIGN

A quasi-experimental analysis of retrospective data from consecutive patients.

SETTING

A tertiary care university hospital.

PARTICIPANTS

Patients undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

Patients received either 4F-PCC or FEIBA after discontinuation of cardiopulmonary bypass and reversal of heparin with protamine.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed for thromboembolic events (stroke, arterial or venous thrombosis, pulmonary embolism, myocardial infarction), acute kidney injury, ischemic bowel, death, duration of intensive care unit and hospital stay, clinical and surgical characteristics and blood product utilization. A comparison of the clinical and surgical variables demonstrated a mean effect size of 0.33 imbalance between groups that was reduced to 0.18 after propensity score weighting. The propensity scores weighted analysis found an incidence of composite thromboembolic events of 39% in the 4F-PCC ( n  = 90) and 47% in the FEIBA ( n  = 50) group, difference -8 (-24% to 12%), P  = 0.13. Individual thromboembolic events, acute kidney injury, ischemic bowel, mortality, and length of intensive care unit or hospital stay was not different among groups. Patients who received FEIBA had greater chest tube drainage and received more cryoprecipitate intraoperatively. Patients who received 4F-PCC received more fresh frozen plasma transfusions postoperatively.

CONCLUSIONS

Among cardiac surgery patients, there was no difference in thromboembolic events between patients who received 4F-PCC or FEIBA when used as an adjunct to blood product administration.

Budget Impact Analysis of Implementing Patient Blood Management in the Cardiovascular Surgery Department of a Turkish Private Hospital

Purpose

In cardiovascular surgeries, iron deficiency anemia and transfusion of blood products are associated with mortality and morbidity, prolonged hospital stay and poor patient outcomes. Patient blood management (PBM) is a patient-centered approach based on a 'three pillar' model that promotes optimum use of blood and blood products to improve outcomes. This study assessed the potential budget impact of implementing PBM in patients undergoing elective cardiovascular surgery in a private hospital in Turkey.

Methods

Two models were developed to estimate the hospital budget impact of PBM. The first model encompassed implementation of the first pillar of PBM, which proposes treatment of iron deficiency anemia before a surgical procedure. The second covered implementation of all three pillars of PBM. Budget impact was estimated from the number of avoided complications after treating iron deficiency anemia and reducing blood transfusions. Rates of complication (sepsis, myocardial infarction, renal failure and stroke) with and without PBM were taken from published meta-analyses. Data on 882 cardiovascular operations performed during 2020-2022 were taken from the Florence Nightingale Istanbul Hospital. The costs of treating complications were estimated by applying Turkish Social Security Institution prices to a healthcare resource utilization tool for each complication completed by experts.

Results

Results from the budget impact analysis showed that, by implementing the first pillar of PBM, the department could have avoided 30 complications and saved 4,189,802 TRY. For the second model based on implementing all three pillars of PBM, 29 complications could have been avoided by reducing the number of transfusions, with budget savings of 6,174,434 TRY. Reducing the length of hospital stay could have enabled 137 additional operations in the given period.

Conclusion

Implementation of PBM in patients undergoing elective cardiovascular surgery in private hospitals could be a budget-saving strategy in Turkey and may provide an opportunity to increase revenue.

Factor Eight Inhibitor Bypass Activity Use in Cardiac Surgery: A Propensity-matched Analysis of Safety Outcomes

BACKGROUND

Bleeding during cardiac surgery may be refractory to standard interventions. Off-label use of factor eight inhibitor bypass activity (FEIBA) has been described to treat such bleeding. However, reports of safety, particularly thromboembolic outcomes, show mixed results, and reported cohorts have been small.

METHODS

Adult patients undergoing cardiac surgery on cardiopulmonary bypass between July 1, 2018, and June 30, 2023, at Stanford Hospital (Stanford, California) were reviewed (n = 3,335). Patients who received FEIBA to treat postcardiopulmonary bypass bleeding were matched with those who did not by propensity scores in a 1:1 ratio using nearest neighbor matching (n = 352 per group). The primary outcome was a composite outcome of thromboembolic complications including any one of deep vein thrombosis, pulmonary embolism, unplanned coronary artery intervention, ischemic stroke, and acute limb ischemia, in the postoperative period. Secondary outcomes included renal failure, reoperation, postoperative transfusion, intensive care unit length of stay, and 30-day mortality.

RESULTS

A total of 704 encounters was included in this propensity-matched analysis. The mean dose of FEIBA administered was 7.3 ± 5.5 U/kg. In propensity-matched multivariate logistic regression models, there was no statistically significant difference in odds ratios for thromboembolic outcomes, intensive care unit length of stay, or mortality. Patients who received more than 750 U FEIBA had an increased odds ratio for acute renal failure (odds ratio, 4.14; 95% CI, 1.61 to 10.36; P < 0.001). In multivariate linear regression, patients receiving FEIBA were transfused more plasma and cryoprecipitate postoperatively. However, only the dose range of 501 to 750 U was associated with an increase in transfusion of erythrocytes (β, 2.73; 95% CI, 0.68 to 4.78; P = 0.009) and platelets (β, 1.74; 95% CI, 0.85 to 2.63; P < 0.001).

CONCLUSIONS

Low-dose FEIBA administration during cardiac surgery does not increase risk of thromboembolic events, intensive care unit length of stay, or mortality in a propensity-matched cohort. Higher doses were associated with increased acute renal failure and postoperative transfusion. Further studies are required to establish the efficacy of activated factor concentrates to treat refractory bleeding during cardiac surgery.

EDITOR’S PERSPECTIVE

Fibrinogen and Prothrombin Complex Concentrate: The Importance of the Temporal Sequence-A Post-Hoc Analysis of Two Randomized Controlled Trials

Background/Objectives: A low level of soluble coagulation factors after cardiac surgery may cause excessive bleeding and trigger clinical correction using prothrombin complex concentrate (PCC). According to the current guidelines, the trigger values for PCC administration are not defined. In the published algorithms, when driven by ROTEM®, the triggers vary from 80 s to >100 s of coagulation time (CT) during an EXTEM test. Two randomized controlled trials on fibrinogen (FC) supplementation after cardiac surgery previously pointed out that the patients receiving FC supplementation had a significant decrease in their EXTEM CT. This study investigates the hypothesis that after increasing the availability of a substrate (fibrinogen), thrombin generation induces fibrin network formation faster, and that, before considering PCC administration, the normalization of fibrinogen levels should be sought. Methods: A retrospective study based on a post-hoc analysis of the data collected in two previous RCTs involving 85 patients, all of whom received FC supplementation. Results: The results of this post-hoc analysis demonstrate that there is a significant negative association between FIBTEM maximum clot firmness (MCF) and the EXTEM CTs before and after FC supplementation; FC supplementation decreases the EXTEM CTs both in patients with a low FIBTEM MCF and a normal FIBTEM MCF. After FC supplementation, 45 (53%) of the patients had an EXTEM CT of >80 s, 22 (26%) had an EXTEM CT of >90 s, and 8 (9%) had an EXTEM CT of >100 s. Conclusions: Our study confirms and quantifies the effects of reducing EXTEM CTs through FC supplementation. A stepwise strategy of factors correction with FC supplementation should be used before considering PCC administration as it might reduce the need for PCC.

Bleeding Risk of Anticoagulation Reversal Strategies Before Heart Transplantation: A Retrospective Comparative Cohort Study

Heart transplantation (HT) poses high bleeding risks, especially for patients on anticoagulation. This study evaluates the use of idarucizumab for dabigatran (DBG) reversal compared to vitamin K antagonist (VKA) strategies in HT. A retrospective analysis of HT patients from January 2018 to December 2022, excluding those requiring ECMO immediately before or after surgery, was conducted. Outcomes included transfusion needs, re-surgery due to bleeding, ICU stay lengths, and 30-day survival. A cost analysis compared the direct expenses of each strategy. Among 34 patients, 20 were on DBG and 14 on VKAs or not anticoagulated. Idarucizumab significantly reduced the number of patients requiring transfusion (p = 0.034) and ICU stay lengths (p = 0.014), with no significant impact on re-surgery rates (p = 0.259) or survival (p = 0.955). Despite higher initial costs, overall expenses for idarucizumab were comparable to VKA reversal due to reduced transfusion needs and shorter ICU stays. Idarucizumab offers a viable and potentially cost-neutral anticoagulation reversal option for HT patients on DBG, presenting an alternative to VKA strategies. However, due to the retrospective nature of the study and the small sample size, further prospective studies are needed to confirm these findings.

The Diagnostic Accuracy of EXTEM and HEPTEM Clotting Times Versus Standard Laboratory Tests in Cardiac Surgical Patients With and Without Normal FIBTEM Values

OBJECTIVES

There is extensive evidence to support the use of FIBTEM to identify hypofibrinogenemia during cardiac surgery, but less to support the use of EXTEM and INTEM clotting times (CTs) to identify other plasmatic coagulation factor deficiencies. The aim of the current study was to assess the diagnostic accuracy of EXTEM, INTEM, and HEPTEM CTs, using laboratory international normalized ratio (INR) and activated partial thromboplastin time (aPTT) as reference standards.

DESIGN

This was a retrospective diagnostic accuracy study.

SETTING

The work took place at a tertiary referral hospital.

PARTICIPANTS

A total of 176 cardiac surgical patients were enrolled.

INTERVENTIONS

INR, aPTT, ROTEM EXTEM, INTEM, and HEPTEM were measured post-heparin reversal after cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

Sensitivity, specificity, and positive (PPVs) and negative predictive values (NPVs) for EXTEM CT >80 seconds and HEPTEM CT >280 seconds to detect INR ≥2.0, and INTEM CT >205 seconds to detect aPTT ≥38.5 seconds were calculated for all patients and the subset with normal FIBTEM A5 (>6 mm). The prevalence of INR ≥2.0 was 13%. EXTEM CT >80 seconds had a sensitivity of 1.00, specificity of 0.25, PPV of 0.17, and NPV of 1.00. HEPTEM CT >280 seconds had a sensitivity of 0.91, specificity of 0.38, PPV of 0.18, and NPV of 0.97. INTEM CT >205 seconds had a sensitivity of 0.97, specificity of 0.11, PPV of 0.57, and NPV of 0.75 for aPTT ≥38.5 seconds. These values were similar for the subset of patients with normal FIBTEM A5.

CONCLUSIONS

EXTEM CT >80 seconds and HEPTEM CT >280 seconds have high sensitivities and NPVs for INR >2.0, which would effectively "rule out" INR >2.0 as a cause for excessive bleeding. However, the low specificities and PPVs indicate they would be less effective in ruling it in. INTEM CT >205 seconds had low PPV and NPV in identifying aPTT >38.5 seconds.

Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass?

BACKGROUND

Heparin rebound is a common observed phenomenon after cardiac surgery with CPB and is associated with increased postoperative blood loss. However, the administration of extra protamine may lead to increased blood loss as well. Therefore, we want to investigate the relation between heparin rebound and postoperative blood loss and the necessity to provide extra protamine to reverse heparin rebound.

METHODS

We searched PubMed, Cochrane, EMBASE, Google Scholar and Web of Science to review the question: "Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass." Combination of search words were framed within four major categories: heparin rebound, blood loss, cardiac surgery and cardiopulmonary bypass. All studies that met our question were included. Quality assessment was performed using the Cochrane risk of bias (RoB2) tool for randomized controlled trials and the risk of bias in non-randomized studies of intervention (ROBINS-I) for non-randomised trials.

RESULTS

4 randomized and 17 non-randomized studies were included. The mean incidence of heparin rebound was 40%. The postoperative heparin levels, due to heparin rebound, were often below or equal to 0.2 IU/mL. We could not demonstrate an association between heparin rebound and postoperative blood loss or transfusion requirements. However the quality of evidence was poor due to a broad variety of definitions of heparin rebound, measured by various coagulation tests and studies with small sample sizes.

CONCLUSION

The influence of heparin rebound on postoperative bleeding seems to be negligible, but might get significant in conjunction with incomplete heparin reversal or other coagulopathies. For that reason, it might be useful to get a picture of the entire coagulation spectrum after cardiac surgery, as can be done by the use of a viscoelastic test in conjunction with an aggregometry test.

Huaxi integrated blood management reduces the red blood cell transfusion for on-pump cardiac surgery: A quasi-experimental study

OBJECTIVE

As many as half of patients undergoing on-pump cardiac surgery require red blood cell transfusion, emphasizing the need for effective strategies that can reduce this need. We conducted this analysis to assess the effectiveness of Huaxi Integrated Blood Management strategy at our medical center.

DESIGN

Before and after study.

PARTICIPANTS

Patients who underwent on-pump cardiac surgery were included from January 2019 to December 2021. Two cohorts were compared, one before implementation of the strategy (1 January 2019 until 31 May 2020) and one after implementation (1 June 2020 until 31 December 2021).

MEASUREMENTS

We evaluated temporal trends in blood transfusion, safety, and efficacy of this strategy. Primary outcomes were the incidence and volume of intra- and postoperative blood transfusions of packed red blood cells. Secondary outcomes are intraoperative and postoperative transfusion of other blood products, all-cause mortality during hospitalization, and incidence of new-onset complications.

MAIN RESULTS

Our results demonstrated that this integrated strategy effectively decreased both the perioperative packed red blood cell transfusion volume and incidence for patients who underwent the on-pump cardiac surgery. Following the implementation, the incidence of packed red blood cell transfusions decreased by 8.1% during the intraoperative period and by 12.3% during the postoperative period. The mean volume of such transfusions decreased by 0.28 units during the intraoperative period and by 0.49 units during the postoperative period. Hemoglobin concentrations were significantly higher after implementation, and the maximal mean increase was 4.72 g/l on postoperative day 1. Similar benefit of the strategy was observed across subgroups of patients who underwent different types of surgery.

CONCLUSIONS

The Huaxi Integrated Blood Management strategy may be effective at reducing the need for packed red blood cell transfusion and enhancing patient care.

Comprehensive perioperative blood management in patients undergoing elective bypass cardiac surgery: Benefit effect of health care education and systematic correction of iron deficiency and anemia on red blood cell transfusion

STUDY OBJECTIVE

The aim of this study was to investigate the efficacy of a two-step patient blood management (PBM) program in red blood cell (RBC) transfusion requirements among patients undergoing elective cardiopulmonary bypass (CPB) surgery.

DESIGN

Prospective, non-randomized, two-step protocol design.

SETTING

Cardiac surgery department of Clinique Pasteur, Toulouse, France.

PATIENTS

897 patients undergoing for elective CPB surgery.

INTERVENTIONS

We conducted a two-steps protocol: PBMe and PBMc. PBMe involved a short quality improvement program for health care workers, while PBMc introduced a systematic approach to pre- and postoperative correction of deficiencies, incorporating iron injections, oral vitamins, and erythropoiesis-stimulating agents.

MEASUREMENTS

The PBM program's effectiveness was evaluated through comparison with a pre-PBM retrospective cohort after propensity score matching. The primary objective was the proportion of patients requiring RBC transfusions during their hospital stay. Secondary objectives were also analyzed.

MAIN RESULTS

After matching, 343 patients were included in each group. Primary outcomes were observed in 35.7% (pre-PBM), 26.7% (PBMe), and 21.1% (PBMc) of patients, resulting in a significant reduction (40.6%) in the overall RBC transfusion rate. Both the PBMe and PBMc groups exhibited significantly lower risks of RBC transfusion compared to the pre-PBM group, with adjusted odds ratios of 0.59 [95% CI 0.44-0.79] and 0.44 [95% CI 0.32-0.60], respectively. Secondary endpoints included reductions in transfusions exceeding 2 units, total RBC units transfused, administration of allogeneic blood products, and total bleeding volume recorded on Day 1. There were no significant differences noted in mortality rates or the duration of hospital stays.

CONCLUSIONS

This study suggests that health care education and systematic deficiency correction are associated with reduced RBC transfusion rates in elective CPB surgery. However, further randomized, controlled studies are needed to validate these findings and refine their clinical application.

Evaluation of Red Blood Cell Biochemical Markers and Coagulation Profiles Following Cell Salvage in Cardiac Surgery: A Systematic Review and Meta-Analysis

Background: Individuals undergoing cardiac surgery face an increased risk of bleeding, as well as alterations in biochemical and coagulation patterns. Therefore, assessing the effectiveness of systems such as Cell Salvage is necessary to prevent potential surgical complications. Objective: To evaluate the efficacy of Cell Salvage in relation to the biochemical parameters of the red blood series and coagulation, as well as the risk of hemorrhage. Methods: A systematic review, accompanied by a meta-analysis, was executed via an extensive literature exploration encompassing Medline, CINAHL, Scopus, Web of Science, and the Cochrane Library. The inclusion criteria comprised studies in English or Spanish, without year restrictions, conducted in adults and with a randomized controlled trial design. Results: Twenty-six studies were included in the systematic review, involving a total of 2850 patients (experimental group = 1415; control group = 1435). Cell Salvage did not demonstrate superior outcomes compared to allogeneic transfusions in the management of post-surgical hemorrhage, as well as in total blood loss, platelet count, fresh frozen plasma, and fibrinogen. However, Cell Salvage showed a greater effectiveness for hemoglobin (moderate evidence), hematocrit (low evidence), post intervention D-dimer (low evidence), and some coagulation-related parameters (low evidence) compared to allogeneic transfusions. Finally, better results were found in the control group for INR parameters. Conclusions: The use of the Cell Salvage system holds high potential to improve the postoperative levels of biochemical and coagulation parameters. However, the results do not provide definitive evidence regarding its effectiveness for hemorrhage control, platelet count, fresh frozen plasma, and fibrinogen. Therefore, it is recommended to increase the number of studies to assess the impact of the Cell Salvage system on improvements in the red blood cell count and patient coagulation patterns. In addition, protocols should be homogenized, and variables such as the sex of the participants should be taken into account.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients. To address this challenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung Transplantation Standards and Guidelines Committee. International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods. Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria. These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

Postoperative intravenous iron to treat iron-deficiency anaemia in patients undergoing cardiac surgery: a protocol for a pilot, multicentre, placebo-controlled randomized trial (the POAM trial)

Background

Iron-deficiency anaemia, occurring in 30-40% of patients undergoing cardiac surgery, is an independent risk factor for adverse outcomes. Our long-term goal is to assess if postoperative i.v. iron therapy improves clinical outcomes in patients with preoperative iron-deficiency anaemia undergoing cardiac surgery. Before conducting a definitive RCT, we first propose a multicentre pilot trial to establish the feasibility of the definitive trial.

Methods

This internal pilot, double-blinded, RCT will include three centres. Sixty adults with preoperative iron-deficiency anaemia undergoing non-emergency cardiac surgery will be randomised on postoperative day 2 or 3 to receive either blinded i.v. iron (1000 mg ferric derisomaltose) or placebo. Six weeks after surgery, patients who remain iron deficient will receive a second blinded dose of i.v. iron according to their assigned treatment arm. Patients will be followed for 12 months. Clinical practice will not be otherwise modified. For the pilot study, feasibility will be assessed through rates of enrolment, protocol deviations, and loss to follow up. For the definitive study, the primary outcome will be the number of days alive and out of hospital at 90 days after surgery.

Ethics and dissemination

The trial has been approved by the University Health Network Research Ethics Board (REB # 22-5685; approved by Clinical Trials Ontario funding on 22 December 2023) and will be conducted in accordance with the Declaration of Helsinki, Good Clinical Practices guidelines, and regulatory requirements.

Clinical trial registration

NCT06287619.

A dimensional analysis of experienced intensive care unit nurses' clinical decision-making for bleeding after cardiac surgery

BACKGROUND

Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications.

AIM

To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery.

STUDY DESIGN

This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory.

RESULTS

Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability.

CONCLUSIONS

Nurses' decision-making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation.

RELEVANCE TO CLINICAL PRACTICE

This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.

Management of Post-cardiotomy Shock

Patients undergoing cardiac surgery experience significant physiologic derangements that place them at risk for multiple shock phenotypes. Any combination of cardiogenic, obstructive, hemorrhagic, or vasoplegic shock occurs commonly in post-cardiotomy patients. The approach to the diagnosis and management of these shock states has many facets that are distinct compared to non-surgical cardiac intensive care unit patients. Additionally, the approach to and associated outcomes of cardiac arrest in the post-cardiotomy population are uniquely characterized by emergent bedside resternotomy if the circulation is not immediately restored. This review focuses on the unique aspects of the diagnosis and management of post-cardiotomy shock.

How do I implement pathogen reduced Cryoprecipitated fibrinogen complex in a tertiary Hospital's blood Bank

BACKGROUND

Kaiser-Permanente Los Angeles Medical Center (LAMC) is a 560 licensed bed facility that provides regional cardiovascular services, including 1200 open heart surgeries annually. In 2021, LAMC explored alternative therapies to offset the impact of pandemic-driven cryo AHF shortages, and implemented Pathogen Reduced Cryoprecipitated Fibrinogen Complex (also known as INTERCEPT Fibrinogen Complex or IFC). IFC is approved to treat and control bleeding associated with fibrinogen deficiency. Unlike cryo AHF, IFC has 5-day post-thaw shelf life with potential operational and clinical benefits. The implementation steps and the operational advantages to the LAMC Blood Bank are described.

STUDY DESIGN AND METHODS

Eighteen months post-implementation, the institution reviewed their product implementation experience and compared IFC with cryo AHF with a retrospective review of transfusion service and cardiac post-op data.

RESULTS

IFC significantly decreased product wastage rates and order-to-issue time. It did not significantly impact post-op product utilization or hospital length of stay (LOS) in cardiac surgery patients when compared with cryo AHF.

DISCUSSION

Implementation of IFC provides improved product supply stability, shorter turnaround times, and reduced wastage.

Impact of introduction of a goal directed transfusion strategy in a patient blood management program: A single cardiac surgery centre experience

BACKGROUND

The aim of this retrospective and observational study was to analyse the impact of the introduction of a goal directed transfusion (GDT) strategy based on a viscoelastic test (ROTEM®) and specific procoagulant products in a patient blood management (PBM) Program on blood product use and perioperative bleeding in a single cardiac surgery centre.

STUDY DESIGN AND METHODS

Patient population underwent cardiac surgery from 2011 to 2021 was divided in two groups based on PBM protocol used (G#11-14, years 2011-2014, G#15-21, years 2015-2021) and compared for the following variables: intraoperative and postoperative transfusions of packed red blood cell and any procoagulant products, postoperative drain blood loss volume and rate of re-exploration surgery. The second program was defined after the introduction of a GDT protocol based on viscoelastic tests and specific procoagulant products.

RESULTS

After the introduction of a GDT protocol, about 80% less amongst patients were transfused with fresh frozen plasma and any procoagulant product (p < 0.001 for both phases). Moreover, similar results were obtained with PRBC transfusions (p < 0.001) and drain blood loss volume (p = 0.006) in the postoperative phase. The main factors affecting the use of any procoagulant and PBRC transfusion in the multivariate logistic regression analysis was Group (2 versus 1, OR 0.207, p < 0.001) and preoperative haemoglobin (OR 0.728, p < 0.001), respectively.

DISCUSSION

In our experience, a GDT strategy for the diagnosis and treatment of the coagulopathy in patients undergone cardiac surgery led to a significant reduction in bleeding and transfusion.

Impact of a bundle of care (intravenous iron, erythropoietin and transfusion metabolic adjustment) on post-operative transfusion incidence in cardiac surgery: a single-centre, randomised, open-label, parallel-group controlled pilot trial

Background

Red blood cell (RBC) transfusions are frequent in patients after cardiac surgery. This study assessed whether a bundle of care including pre-operative and post-operative administration of erythropoietin (EPO) with intravenous iron supplementation, and restrictive transfusion adjusted for ScvO2 could result in reduced postoperative transfusions.

Methods

In this single-centre, randomised, open-label, parallel-group controlled pilot study, patients undergoing elective cardiac surgery with high risk of transfusion in a University Hospital were enrolled by the investigator and the randomisation procedure using a central internet-based system was made by the clinical research assistant. Since the trial was open-label, no masking was used. Patients were assigned (1:1) to either the STOP group (40,000 IU subcutaneous EPO combined with 20 mg/kg intravenous ferric carboxymaltose if Hb < 13 g/dL the day before surgery or at ICU admission, and RBC transfusion if Hb ≤ 8 g/dL and ScvO2 ≤ 65%, or additional EPO dose if 8 < Hb < 13 g/dL) or to the control group (RBC transfusion if Hb ≤ 8 g/dL, or, if 8 < Hb < 13 g/dL, intravenous iron sucrose 200 mg or 300 mg according to weight). Primary outcome was the incidence of postoperative RBC transfusion up to hospital discharge or postoperative day 28. The trial is registered with ClinicalTrials.gov, NCT04141631.

Findings

Between Jan 20, 2020, and Sept 6, 2022, among 128 patients enrolled, 123 (male, 54.4%, 67/123) were included in the full analysis set: 62 in the STOP group and 61 in the control group. Nine patients (14.5%, 9/62) in the STOP group required RBC transfusion vs 19 (31.2%, 19/61) in the control group (odds ratio 0.37 [95% CI: 0.15-0.91], p = 0.03). The median length of follow up to transfusion was 2.6 days (1.5; 4.6) and 3.3 (1.6; 4.2) in control and STOP groups respectively (p = 0.61).

Interpretation

The bundle of care may reduce postoperative RBC transfusion. The findings should be taken with caution due to the unblinded and exploratory nature of the study.

Funding

University of Montpellier Hospital and Vifor Pharma.

Delayed cold-stored vs. room temperature stored platelet transfusions in bleeding adult cardiac surgery patients-a randomized multicentre pilot study (PLTS-1)

BACKGROUND

Platelets stored at 1-6 °C are hypothesized to be more hemostatically active than standard room temperature platelets (RTP) stored at 20-24 °C. Recent studies suggest converting RTP to cold-stored platelets (Delayed Cold-Stored Platelets, DCSP) may be an important way of extending platelet lifespan and increasing platelet supply while also activating and priming platelets for the treatment of acute bleeding. However, there is little clinical trial data supporting the efficacy and safety of DCSP compared to standard RTP.

METHODS

This protocol details the design of a multicentre, two-arm, parallel-group, randomized, active-control, blinded, internal pilot trial to be conducted at two cardiac surgery centers in Canada. The study will randomize 50 adult (≥ 18 years old) patients undergoing at least moderately complex cardiac surgery with cardiopulmonary bypass and requiring platelet transfusion to receive either RTP as per standard of care (control group) or DCSP (intervention group). Patients randomized to the intervention group will receive ABO-identical, buffy-coat, pathogen-reduced, platelets in platelet additive solution maintained at 22 °C for up to 4 days then placed at 4 °C for a minimum of 24 h, with expiration at 14 days after collection. The duration of the intervention is from the termination of cardiopulmonary bypass to 24 h after, with a maximum of two doses of DCSP. Thereafter, all patients will receive RTP. The aim of this pilot is to assess the feasibility of a future RCT comparing the hemostatic effectiveness of DCSP to RTP (defined as the total number of allogeneic blood products transfused within 24 h after CPB) as well as safety. Specifically, the feasibility objectives of this pilot study are to determine (1) recruitment of ≥ 15% eligible patients per center per month); (2) appropriate platelet product available for ≥ 90% of patients randomized to the cold-stored platelet group; (3) Adherence to randomization assignment (> 90% of patients administered assigned product).

DISCUSSION

DCSP represents a promising logistical solution to address platelet supply shortages and a potentially more efficacious option for the management of active bleeding. No prospective clinical studies on this topic have been conducted. This proposed internal pilot study will assess the feasibility of a larger definitive study.

TRIAL REGISTRATION

NCT06147531 (clinicaltrials.gov).

Activated clotting time value as an independent predictor of postoperative bleeding and transfusion

OBJECTIVES

Activated clotting time (ACT) is commonly used to monitor anticoagulation during cardiac surgeries. Final ACT values may be essential to predict postoperative bleeding and transfusions, although ideal values remain unknown. Our aim was to evaluate the utility of ACT as a predictor of postoperative bleeding and transfusion use.

METHODS

Retrospective study (722 patients) submitted to surgery between July 2018-October 2021. We compared patients with final ACT < basal ACT and final ACT ≥ basal ACT and final ACT < 140 s with ≥140 s. Continuous variables were analysed with the Wilcoxon rank-sum test; categorical variables using Chi-square or Fisher's exact test. A linear mixed regression model was used to analyse bleeding in patients with final ACT < 140 and ≥140. Independent variables were analysed with binary logistic regression models to investigate their association with bleeding and transfusion.

RESULTS

Patients with final ACT ≥ 140 s presented higher postoperative bleeding than final ACT < 140 s at 12 h (P = 0.006) and 24 h (**P = 0.004). Cardiopulmonary bypass (CPB) time [odds ratio (OR) 1.009, 1.002-1.015, 95% confidence interval (CI)] and masculine sex (OR 2.842,1.721-4.821, 95% CI) were significant predictors of bleeding. Patients with final ACT ≥ 140 s had higher risk of UT (OR 1.81, 1.13-2.89, 95% CI; P = 0.0104), compared to final ACT < 140 s. CPB time (OR 1.019,1.012-1.026, 95% CI) and final ACT (OR 1.021,1.010-1.032, 95% CI) were significant predictors of transfusion. Female sex was a predictor of use of transfusion, with a probability for use of 27.23% (21.84-33.39%, 95% CI) in elective surgeries, and 60.38% (37.65-79.36%, 95% CI) in urgent surgeries, higher than in males.

CONCLUSIONS

Final ACT has a good predictive value for the use of transfusion. Final ACT ≥ 140 s correlates with higher risk of transfusion and increased bleeding. The risk of bleeding and transfusion is higher with longer periods of CPB. Males have a higher risk of bleeding, but females have a higher risk of transfusion.

Perioperative care in infective endocarditis

Patients undergoing surgery for acute infective endocarditis are among those with the highest risk. Their preoperative condition has significant impact on outcomes. There are specific issues related with the preoperative situation, intraoperative findings, and postoperative management. In this narrative review, focus is placed on the most critical aspects in the perioperative period including the management and weaning from mechanical ventilation, the management of vasoplegia, the management of the chest open, antithrombotic therapy, transfusion, coagulopathy, management of atrial fibrillation, the duration of antibiotic therapy, and pacemaker implantation.

The Adherence to an Intraoperative Blood Product Transfusion Algorithm Is Associated With Reduced Blood Product Transfusions in Cardiac Surgical Patients Undergoing Coronary Artery Bypass Grafts and Aortic and/or Valve Replacement Surgery: A Single-Center, Observational Study

OBJECTIVE

To demonstrate the value of a viscoelastic-based intraoperative transfusion algorithm to reduce non-RBC product administration in adult cardiac surgical patients.

DESIGN

A prospective observational study.

SETTING

At a quaternary academic teaching hospital.

PARTICIPANTS

Cardiac surgical patients.

INTERVENTIONS

Viscoelastic-based intraoperative transfusion algorithm.

MEASUREMENTS AND MAIN RESULTS

The study authors compared intraoperative blood product transfusion rates in 184 cardiac surgical patients to 236 historic controls after implementing a viscoelastic-based algorithm. The authors found a non-significant reduction in transfusion of 23.8% for fresh frozen plasma (FFP) units (0.84 ± 1.4 v 0.64 ± 1.38; p = ns), 33.4% for platelet units (0.90 ± 1.39 v 0.60 ± 131; p = ns), and 15.8% for cryoprecipitate units (0.19 ± 0.54 v 0.16 ± 0.50; p = ns). They found a 43.9% reduction in red blood cell (RBC) units transfused (1.98 ± 2.24 v 0.55 ± 1.36; p = 0.008). There were no statistically significant differences in time to extubation (8.0 hours (4.0-21.0) v 8.0 (4.0-22.3), reoperation for bleeding (15 [12.3%] v 10 [10.6%]), intensive care unit length of stay (ICU LOS) (51.0 hours [28.0-100.5] v 53.5 [33.3-99.0]) or hospital LOS (9.0 days [6.0-15.0] v 10.0 [7.0-17.0]). Deviation from algorithm adherence was 32.7% (48/147). Packed RBC, FFP, platelets, cryoprecipitate, and cell saver were significantly reduced in the Algorithm Compliant Cohort compared with historic controls, whereas times to extubation, ICU LOS, and hospital LOS did not reach significance.

CONCLUSIONS

After the implementation of a viscoelastic-based algorithm, patients received fewer packed RBC, FFP, platelets, cryoprecipitate, and cell saver. Algorithm-compliant patients received fewer transfusions; however, reductions in times to extubation, ICU LOS, and hospital LOS were not statistically significant compared with historic controls.

Ultrafiltration in cardiac surgery: Results of a systematic review and meta-analysis

Background: Ultrafiltration is used with cardiopulmonary bypass to reduce the effects of hemodilution and restore electrolyte balance. We performed a systematic review and meta-analysis to analyze the effect of conventional and modified ultrafiltration on intraoperative blood transfusion.Methods: Utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement, we systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library to perform a meta-analysis of studies of randomized controlled trials (RCTs) and observational studies evaluating conventional ultrafiltration (CUF) and modified ultrafiltration (MUF) on the primary outcome of intraoperative red cell transfusions.Results: A total of 7 RCTs (n = 928) were included, comparing modified ultrafiltration (n = 473 patients) to controls (n = 455 patients) and 2 observational studies (n = 47,007), comparing conventional ultrafiltration (n = 21,748) to controls (n = 25,427). Overall, MUF was associated with transfusion of fewer intraoperative red cell units per patient (n = 7); MD -0.73 units; 95% CI -1.12 to -0.35 p = 0.04; p for heterogeneity = 0.0001, I2 = 55%) compared to controls. CUF was no difference in intraoperative red cell transfusions compared to controls (n = 2); OR 3.09; 95% CI 0.26-36.59; p = 0.37; p for heterogeneity = 0.94, I2 = 0%. Review of the included observational studies revealed an association between larger volumes (>2.2 L in a 70 kg patient) of CUF and risk of acute kidney injury (AKI).Conclusion: The results of this systematic review and meta-analysis suggest that MUF is associated with fewer intraoperative red cell transfusions. Based on limited studies, CUF does not appear to be associated with a difference in intraoperative red cell transfusion.

Role of Radiology in Assessment of Postoperative Complications of Heart Transplantation

Heart transplantation is a pivotal treatment of end-stage heart failure, and recent advancements have extended median posttransplant life expectancy. However, despite the progress in surgical techniques and medical treatment, heart transplant patients still face complications such as rejection, infections, and drug toxicity. CT is a reliable tool for detecting most of these complications, whereas MR imaging is particularly adept at identifying pericardial pathologies and signs of rejection. Awareness of these nuances by radiologists, cardiologists, and surgeons is desired to optimize care, reduce morbidities, and enhance survival.

Hemostasis Using Prothrombin Complex Concentrate in Patients Undergoing Cardiac Surgery: Systematic Review with Meta-Analysis

OBJECTIVE

The purpose of present study was to comprehensívely explore the efficacy and safety of prothrombín complex concentrate (PCC) to treat massíve bleedíng in patíents undergoing cardiac surgery.

METHODS

PubMed®, Embase, and Cochrane Líbrary databases were searched for studíes ínvestigating PCC administratíon duríng cardiac surgery published before September 10, 2022. Mean dífference (MD) wíth 95% confidence interval (CI) was applíed to analyze continuous data, and dichotomous data were analyzed as risk ratio (RR) with 95% CI.

RESULTS

Twelve studies were included in the meta-analysis. Compared with other non-PCC treatment regimens, PCC was not assocíated with elevated mortality (RR=1.18, 95% CI=0.86-1.60, P=0.30, I2=0%), shorter hospital stay (MD=-2.17 days; 95% CI=-5.62-1.28, P=0.22, I2=91%), reduced total thoracic drainage (MD=-67.94 ml, 95% CI=-239.52-103.65, P=0.44, I2=91%), thromboembolíc events (RR=1.10, 95% CI=0.74-1.65, P=0.63, I2=39%), increase ín atríal fibríllatíon events (RR=0.73, 95% CI=0.52-1.05, P=0.24, I2=29%), and myocardial infarction (RR=1.10, 95% CI=0.80-1.51, P=0.57, I2=81%). However, PCC use was associated with reduced intensive care unit length of stay (MD=-0.81 days, 95% CI=-1.48- -0.13, P=0.02, I2=0%), bleeding (MD=-248.67 ml, 95% CI=-465.36- -31.97, P=0.02, I2=84%), and intra-aortic balloon pump/extracorporeal membrane oxygenation (RR=0.65, 95% CI=0.42-0.996, P=0.05, I2=0%) when compared with non-PCC treatment regimens.

CONCLUSION

The use of PCC in cardiac surgery did not correlate with mortality, length of hospítal stay, thoracic drainage, atríal fibríllatíon, myocardíal ínfarction, and thromboembolíc events. However, PCC sígnificantly improved postoperatíve intensíve care unít length of stay, bleedíng, and intra-aortic balloon pump/ extracorporeal membrane oxygenation outcomes ín patients undergoing cardíac surgery.

Implementation of Patient Blood Management in Orthotopic Heart Transplants: A Single Centre Retrospective Observational Review

BACKGROUND

Blood transfusion in the perioperative cardiothoracic setting has accepted risks including deep sternal wound infection, increased intensive care unit length of stay, lung injury, and cost. It has an immunomodulatory effect which may cause allo-immunisation. This may influence long-term survival through immune-mediated factors. Targeting coagulation defects to reduce unnecessary or inappropriate transfusions may reduce these complications.

METHODS

In 2012, an institution-wide patient blood management evidence-based algorithmic bleeding management protocol was implemented at The Prince Charles Hospital, Brisbane, Australia. The benefit of this has been previously reported in our lung transplant and cardiac surgery (excluding transplants) cohorts. This study aimed to investigate the effect of this on our orthotopic heart transplant recipients.

RESULTS

After the implementation of the protocol, despite no difference in preoperative haemoglobin levels and higher risk patients (EuroSCORE 20 vs 26; p=0.013), the use of packed red blood cells (13.0 U vs 4.4 U; p=0.046) was significantly lower postoperatively and fresh frozen plasma was significantly lower both intra- and postoperatively (7.4 U vs 0.6 U; p<0.001, and 3.3 U vs 0.6 U; p=0.011 respectively). Concurrently, the use of prothrombin complex concentrate (33% vs 78%; p<0.001) and desmopressin (5% vs 22%; p=0.0028) was significantly higher in the post-protocol group, while there was less use of recombinant factor VIIa (15% vs 4%; p=0.058). Intraoperative units of cryoprecipitate also rose from 0.9 to 2.0 (p=0.006).

CONCLUSIONS

We have demonstrated that a targeted patient blood management protocol with point-of-care testing for heart transplant recipients is correlated with fewer blood products used postoperatively, with some increase in haemostatic products and no evidence of increased adverse events.

Utilization and safety of off-label prothrombin complex concentrate (four-factor prothrombin complex concentrate) in a surgical population

The aim of this study is to evaluate and describe the utilization and safety of 4F-PCC in a nonanticoagulated, surgical patient population at an academic, tertiary care center. This retrospective, single-center chart review evaluated nonanticoagulated adult patients at least 18 years of age who had at least one dose of 4F-PCC administered between 1 January 2017 and 30 September 2022 for a surgical or peri-procedural indication. Hemostatic efficacy following 4F-PCC administration was the primary outcome, assessed by subsequent blood product administration and hemoglobin and hematocrit reduction. Secondary outcomes included an assessment of thrombotic events within 30 days post-4F-PCC administration, in-hospital mortality, and the length of hospital stay. A total of 71 patients met the inclusion criteria, with 61 patients receiving 4F-PCC for cardiac surgery and 10 patients for other intraoperative or peri-procedural indications. The mean total 4F-PCC dose was 25.0 U/kg. For the primary outcome of hemostatic efficacy, 81% of patients had excellent hemostasis; however, blood product administration was reported in 95.8% of patients post-4F-PCC. Thromboembolic events occurred in 10 (14.1%) patients and 21.1% of patients expired prior to discharge in the total cohort. Off-label 4F-PCC use in nonanticoagulated patients is reported despite a lack of robust guidance for use. Following 4F-PCC administration, hemostatic efficacy based on hemoglobin and hematocrit changes was observed; however, blood product use was frequent, and 4F-PCC administration was not without risks, including thromboembolic complications such deep vein thrombosis (DVT), pulmonary embolism, and stroke. Further studies are needed to validate the off-label administration of 4F-PCC in nonanticoagulated patients.

Protamine dosing and its impact in cardiac surgery transfusion practice-A retrospective bi-institutional analysis

BACKGROUND

Bleeding after cardiac surgery is common and continues to require 10-20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated.

STUDY DESIGN

Retrospective cohort study.

METHODS

We conducted a retrospective bi-institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)-assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)-low-ratio group (Protamine: UFH ≤ 0.8) and high-ratio group (Protamine: UFH > 0.8).

RESULTS

We observed a higher rate of blood transfusion required in high-ratio group (ratio >0.8) compared with low-ratio group (ratio ≤0.8) (p < .001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate.

CONCLUSION

High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass.

Hazardous alcohol consumption and perioperative complications in a cardiac surgery patient. A retrospective study

BACKGROUND

We investigated the prevalence and effects of hazardous alcohol consumption on perioperative complications in cardiac surgery patients. Preoperative hazardous alcohol consumption has been associated with an increased risk of postoperative complications in noncardiac patient populations.

METHODS

We retrospectively collected data from the Finnish Intensive Care Consortium database and electronic patient records on all cardiac surgery patients treated in the intensive care units (ICUs) of Helsinki University Hospital (n = 919) during 2017. Data on preoperative alcohol consumption were routinely collected using the alcohol use disorder identification test consumption (AUDIT-C) questionnaire. We analyzed perioperative data and outcomes for any associations with hazardous alcohol consumption. Outcome measures were length of stay in the ICU, re-admissions to ICU, bleeding and infectious complications, and incidence of postoperative arrhythmias.

RESULTS

AUDIT-C scores were available for 758 (82.5%) patients, of whom 107 (14.1%) fulfilled the criteria for hazardous alcohol consumption (AUDIT-C score of 5/12 or higher for women and 6/12 or higher for men). Patients with hazardous alcohol consumption were younger, median age 59 (IQR 52.0-67.0) vs. 69.0 (IQR 63.0-74.0), p < .001, and more often men 93.5% vs. 71.9%, p < .001 than other patients and had an increased risk for ICU re-admissions [adjusted OR (aOR) 4.37 (95% CI, 1.60-11.95)] and severe postoperative infections aOR 3.26 (95% CI, 1.42-7.54).

CONCLUSION

Cardiac surgery patients with a history of hazardous alcohol consumption are younger than other patients and are predominantly men. Hazardous alcohol consumption is associated with an increased risk of severe postoperative infections and ICU re-admissions.

Approach to red blood cell transfusions in post-operative congenital heart disease surgery patients: when to stop?

BACKGROUND

The best transfusion approach for CHD surgery is controversial. Studies suggest two strategies: liberal (haemoglobin ≤ 9.5 g/dL) and restrictive (waiting for transfusion until haemoglobin ≤ 7.0 g/dL if the patient is stable). Here we compare liberal and restrictive transfusion in post-operative CHD patients in a cardiac intensive care unit.

METHODS

Retrospective analysis was conducted on CHD patients who received liberal transfusion (2019-2021, n=53) and restrictive transfusion (2021-2022, n=43).

RESULTS

The two groups were similar in terms of age, gender, Paediatric Risk of Mortality-3 score, Paediatric Logistic Organ Dysfunction-2 score, Risk Adjustment for Congenital Heart Surgery-1 score, cardiopulmonary bypass time, vasoactive inotropic score, total fluid balance, mechanical ventilation duration, length of cardiac intensive care unit stay, and mortality. The liberal transfusion group had a higher pre-operative haemoglobin level than the restrictive group (p < 0.05), with no differences in pre-operative anaemia. Regarding the minimum and maximum post-operative haemoglobin levels during a cardiac intensive care unit stay, the liberal group had higher haemoglobin levels in both cases (p<0.01 and p=0.019, respectively). The number of red blood cell transfusions received by the liberal group was higher than that of the restrictive group (p < 0.001). There were no differences between the two groups regarding lactate levels at the time of and after red blood cell transfusion. The incidence of bleeding, re-operation, acute kidney injury, dialysis, sepsis, and systemic inflammatory response syndrome was similar.

CONCLUSIONS

Restrictive transfusion may be preferable over liberal transfusion. Achieving similar outcomes with restrictive transfusions may provide promising evidence for future studies.

What's in Your Transfusion? A Bedside Guide to Blood Products and Their Preparation

An understanding of the contents of blood products and how they are modified before transfusion will help any physician. This article will review five basic blood products and the five most common product modifications.

The Year in Coagulation and Transfusion: Selected Highlights from 2022

This is an annual review to cover highlights in transfusion and coagulation in patients undergoing cardiovascular surgery. The goal of this article is to provide readers with a focused summary of the most important transfusion and coagulation topics published in 2022. This includes a discussion covering the management of anemia and red blood cell transfusion, the management of factor Xa inhibitors, updates in coagulation testing, updates in the use of factor concentrates, advances in platelet therapy, advances in anticoagulation management of patients on extracorporeal membrane oxygenation and other forms of mechanical circulatory support, and advances in the diagnosis and management of heparin-induced thrombocytopenia.

Red Blood Cell Transfusion Guided by Hemoglobin Only or Integrating Perfusion Markers in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVE

Strategies for red blood cell (RBC) transfusion in patients undergoing cardiac surgery have been traditionally anchored to hemoglobin (Hb) targets. A more physiologic approach would consider markers of organ hypoperfusion.

DESIGN

The authors conducted a systematic review and meta-analysis with trial sequential analysis of randomized controlled trials (RCTs).

SETTING

Cardiac surgery.

PARTICIPANTS

Adult patients.

INTERVENTION

RBC transfusion targeting only Hb levels compared with strategies combining Hb values with markers of organ hypoperfusion.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the number of RBC units transfused, the number of patients transfused at least once, and the average number of transfusions. Secondary outcomes were postoperative complications, intensive care (ICU) and hospital lengths of stay, and mortality. Only 2 RCTs were included (n = 257 patients), and both used central venous oxygen saturation (ScvO2) as a marker of organ hypoperfusion (cut-off: <70% or ≤65%). A transfusion protocol combining Hb and ScvO2 reduced the overall number of RBC units transfused (risk ratio [RR]: 1.57 [1.33-1.85]; p < 0.0001, I2 = 0%), and the number of patients transfused at least once (RR: 1.33 [1.16-1.53]; p < 0.0001, I2 = 41%), but not the average number of transfusions (mean difference [MD]: 0.18 [-0.11 to 0.47]; p = 0.24, I2 = 66%), with moderate certainty of evidence. Mortality (RR: 1.29, [0.29-5.77]; p = 0.73, I2 = 0%), ICU length-of-stay (MD: -0.06 [-0.58 to 0.46]; p = 0.81, I2 = 0%), hospital length-of-stay (MD: -0.05 [-1.49 to 1.39];p = 0.95, I2 = 0%), and all postoperative complications were not affected.

CONCLUSIONS

In adult patients undergoing cardiac surgery, a restrictive protocol integrating Hb values with a marker of organ hypoperfusion (ScvO2) reduces the number of RBC units transfused and the number of patients transfused at least once without apparent signals of harm. These findings were preliminary and warrant further multicentric research.

Perioperative Management of Heart Transplantation: A Clinical Review

In this clinical review, the authors summarize the perioperative management of heart transplant patients with a focus on hemodynamics, immunosuppressive strategies, hemostasis and hemorrage, and the prevention and treatment of infectious complications.

Combined Platelet and Red Blood Cell Recovery during On-pump Cardiac Surgery Using same™ by i-SEP Autotransfusion Device: A First-in-human Noncomparative Study (i-TRANSEP Study)

BACKGROUND

Centrifugation-based autotransfusion devices only salvage red blood cells while platelets are removed. The same™ device (Smart Autotransfusion for ME; i-SEP, France) is an innovative filtration-based autotransfusion device able to salvage both red blood cells and platelets. The authors tested the hypothesis that this new device could allow a red blood cell recovery exceeding 80% with a posttreatment hematocrit exceeding 40%, and would remove more than 90% of heparin and 75% of free hemoglobin.

METHODS

Adults undergoing on-pump elective cardiac surgery were included in a noncomparative multicenter trial. The device was used intraoperatively to treat shed and residual cardiopulmonary bypass blood. The primary outcome was a composite of cell recovery performance, assessed in the device by red blood cell recovery and posttreatment hematocrit, and of biologic safety assessed in the device by the washout of heparin and free hemoglobin expressed as removal ratios. Secondary outcomes included platelet recovery and function and adverse events (clinical and device-related adverse events) up to 30 days after surgery.

RESULTS

The study included 50 patients, of whom 18 (35%) underwent isolated coronary artery bypass graft, 26 (52%) valve surgery, and 6 (12%) aortic root surgery. The median red blood cell recovery per cycle was 86.1% (25th percentile to 75th percentile interquartile range, 80.8 to 91.6) with posttreatment hematocrit of 41.8% (39.7 to 44.2). Removal ratios for heparin and free hemoglobin were 98.9% (98.2 to 99.7) and 94.6% (92.7 to 96.6), respectively. No adverse device effect was reported. Median platelet recovery was 52.4% (44.2 to 60.1), with a posttreatment concentration of 116 (93 to 146) · 109/l. Platelet activation state and function, evaluated by flow cytometry, were found to be unaltered by the device.

CONCLUSIONS

In this first-in-human study, the same™ device was able to simultaneously recover and wash both platelets and red blood cells. Compared with preclinical evaluations, the device achieved a higher platelet recovery of 52% with minimal platelet activation while maintaining platelet ability to be activated in vitro.

EDITOR’S PERSPECTIVE

Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo

BACKGROUND

Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation.

METHODS

Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis.

RESULTS

Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline.

CONCLUSIONS

Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.

Large volume acute normovolemic hemodilution in patients undergoing cardiac surgery with intermediate-high risk of transfusion: A randomized controlled trial

STUDY OBJECTIVE

To investigate whether large volume acute normovolemic hemodilution (L-ANH), compared with moderate acute normovolemic hemodilution (M-ANH), can reduce perioperative allogeneic blood transfusion in patients with intermediate-high risk of transfusion during cardiac surgery with cardiopulmonary bypass (CPB).

DESIGN

Prospective randomized controlled trial.

SETTING

University hospital.

PATIENTS

Patients with transfusion risk understanding scoring tool ("TRUST") ≥2 points undergoing cardiac surgery with CPB in the Second Affiliated Hospital of Zhejiang University from May 2020 to January 2021 were included.

INTERVENTIONS

The patients were randomly assigned with a 1:1 ratio to M-ANH (5 to 8 mL/kg) or L-ANH (12 to 15 mL/kg).

MEASUREMENTS

The primary outcome was perioperative red blood cell (RBC) transfusion units. The composite outcome included new-onset atrial fibrillation, pulmonary infection, cardiac surgery associated acute kidney injury (CSA-AKI) class ≥2, surgical incision infection, postoperative excessive bleeding, and resternotomy.

MAIN RESULTS

Total 159 patients were screened and 110 (55 L-ANH and 55 M-ANH) were included for final analysis. Removed blood volume of L-ANH is significantly higher than M-ANH (886 ± 152 vs. 395 ± 86 mL, P < 0.001). Perioperative RBC transfusion was median 0 unit ([25th, 75th] percentiles: 0-4.4) in M-ANH group vs. 0 unit ([25th, 75th] percentiles: 0-2.0) in L-ANH group (P = 0.012) and L-ANH was associated with lower incidence of transfusion (23.6% vs. 41.8%, P = 0.042, rate difference: 0.182, 95% confidence interval [0.007-0.343]). The incidence of postoperative excessive bleeding was significantly lower in L-ANH vs. M-ANH (3.6% vs. 18.2%, P = 0.029, rate difference: 0.146, 95% confidence interval [0.027-0.270]) without significant difference for other second outcomes. The volume of ANH was inversely related to perioperative RBC transfusion units (Spearman r = -0.483, 95% confidence interval [-0.708 to -0.168], P = 0.003), and L-ANH in cardiac surgery was associated with a significantly reduced risk of perioperative RBC transfusion (odds ratio: 0.43, 95% confidence interval: 0.19-0.98, P = 0.044).

CONCLUSIONS

Compared with M-ANH, L-ANH during cardiac surgery inclined to be associated with reduced perioperative RBC transfusion and the volume of RBC transfusion was inversely proportional to the volume of ANH. In addition, LANH during cardiac surgery was associated with a lower incidence of postoperative excessive bleeding.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.