Cardiac Surgery and Blood-Saving Techniques: An Update

[Effects of desmopressin versus tranexamic acid on reducing bleeding in knee arthroplasty: a double-blind randomized study]

Introduction

although blood-sparing properties of tranexamic acid (TA) and desmopressin (Desmo) have been well described following various surgical procedures, few studies have compared the effect of Desmo to that of TA in total knee arthroplasty (TKA). The purpose of our study was to compare the effectiveness of TA and Desmo in reducing perioperative bleeding during TKA.

Methods

we conducted a prospective double-blind study including patients undergoing TKA under spinal anesthesia, randomized into 2 groups: the Desmo group (patients received 0.3 μg/kg of Desmo in 100 ml of saline over 30 minutes before incision, followed by a saline infusion of 30 ml/kg over 12 hours) and the TA group (patients received 20 mg/kg of TA in 100 ml of saline over 30 minutes before incision, followed by 10 mg/kg of TA in 30 ml/kg of saline over 12 hours). The endpoints were perioperative bleeding, transfusion requirement and postoperative complications.

Results

the study included 55 patients divided into 2 groups: TA group (28 patients) and Desmo group (27 patients). Blood accumulation in the jar during the procedure was significantly higher in the TA group (339±40 ml) than in the Desmo group (295±77 ml) (p=0.038). During the first 12 postoperative hours, additional blood accumulation in the redon was significantly higher in the Desmo group (h6: 288±55ml, H12: 383±63ml) compared to the TA group (h6: 188±42ml, h12: 287±60ml) with at H6: p= 0.001 and at H 12: p= 0.009. After 12 hours postoperatively, blood volume in the redon became similar in the 2 groups. From the time of discharge from the post-interventional monitoring room (PICU) to 2 days postoperatively, hemoglobin and hematocrit levels were similar in the 2 groups. Platelet count (PLT) was significantly higher in the Desmo group than in the TA group upon leaving the PICU (Pq desmo: 193929±25000 vs Pq AT: 157370±24300; p< 0.001) and on postoperative day 1 (Pq desmo: 178929±26200 vs Pq AT: 168929±25100; p= 0.048). By postoperative day 2, platelet counts became similar in the 2 groups. During the postoperative period, only one patient in the Desmo group required an allogeneic blood transfusion. No postoperative thromboembolic events were noted in our patients.

Conclusion

both TA and desmopressin are comparably effective in reducing perioperative blood loss during TKA under spinal anesthesia.

Desmopressin use in major cardiac surgery is associated with renal impairment: a retrospective single-center analysis

BACKGROUND

Desmopressin acetate (1-deamino-8-d-arginine vasopressin-DDAVP) is a analogue of the antidiuretic hormone vasopressin. DDAVP is suggested to reduce bleeding after cardiac surgery using cardiopulmonary bypass. The aim of this study was to determine if DDAVP has any negative impact on renal function leading to acute kidney injury (AKI) and therefore increases the need for renal replacement therapy (RRT).

METHODS

We performed a retrospective single institutional cohort analysis of 2,179 patients undergoing elective and urgent cardiac surgery with CPB from 2017 to 2021. Logistic regression analysis was used to investigate any association between DDAVP, the incidence of AKI KDIGO class 3 and the need for RRT, respectively. The model was adjusted for relevant covariates, including preexisting renal impairment, pharmacological hemodynamic support with vasopressors, complexity of the surgery and postoperative lactate. Secondary outcomes included, in hospital mortality and the need for allogenic blood transfusion.

RESULTS

A total of 992 (45.5%) patients received DDAVP intraoperatively during surgery or shortly thereafter. The use of DDAVP was associated with a significant increase in in AKI KDIGO class 3 (OR 2.27; 95% CI 1.46-3.55; p < 0,001) and the need for RRT (OR 2.19; 95%CI 1.48-3.24; p < 0,001). Both findings persisted after covariate adjusting. No increased in-hospital mortality was associated with DDAVP.

CONCLUSION

In cardiac surgery, the use of DDAVP was associated with an increased rate of server AKI and the requirement for RRT. Given the severity of the potential harm associated with DDAVP, an evidence-based reevaluation is needed to enable an accurate risk and benefit assessment.

Heparin-Bead Extraction Enhanced Fluorogenic Aptamer-Thrombin Composite Reporter Enables Sensitive and Rapid Detection of Functional Antithrombin

Antithrombin (AT) deficiency in the extracorporeal circulation during cardiac surgery leads to uncontrolled inflammation and vascular damage in patients. AT levels decrease in sepsis, major trauma, extracorporeal membrane oxygenation, and eclampsia. Monitoring plasma AT levels facilitates the accurate restoration of AT to baseline values through precise supplementation. Traditional methods of chromogenic assay and enzyme-linked immunosorbent assay (ELISA) kits encounter challenges, such as interference, inconsistency, and delayed response times, making real-time, reliable antithrombin monitoring a clinical gap. To address this critical need, we develop a heparin-bead extraction enhanced fluoroGenic aptamer-thrombin composite reporter (HExGATOR) for the rapid, sensitive, and precise detection of functional AT in plasma. Our design employs thrombin-binding aptamers and a fluorescence "turn on" technology such that a signal is produced upon the interaction of AT with the otherwise "turned off" aptamer-thrombin complex. The prominent signal-background interference originating from plasma is remarkably diminished by using a heparin-bead solid-phase extraction of AT. We achieved highly sensitive and rapid detection of AT in 5 to 20 min with a limit of detection of 15.11 nM. This approach offers a promising alternative to traditional AT tests in clinical settings, potentially facilitating personalized anticoagulant therapy.

Autologous cell salvage in off-pump coronary artery bypass surgery reduces post-operative complications: a retrospective weighted-matching analysis

OBJECTIVES

Blood transfusion plays a crucial role in coronary artery bypass grafting (CABG). The choice between autologous cell saver (CS) and allogenic blood transfusion (ABT) has been a continuous debate in the medical community, especially within cardiac surgery. This study aimed to assess the outcomes of off-pump CABG (OPCAB) surgery in patients receiving blood solely via cell salvage compared to those receiving ABT or a combination of ABT and CS perioperatively.

METHODS

A total of 414 patients who underwent isolated OPCAB surgery at our cardiovascular clinic were analyzed. Among them, 250 patients (60.4%) received blood via CS alone, while 164 patients (39.6%) received either ABT or a mix of ABT and CS. Stabilized inverse probability treatment weighted (IPTW) matching technique ensured balance in baseline covariates.

RESULTS

We found no significant differences in 30-day mortality rates between the CS and ABT groups. The CS group displayed significantly lower rates of overall complications, encompassing stroke, acute kidney injury, atrial fibrillation, and pulmonary complications. Rates of sepsis, readmission, gastrointestinal complications, heparin-induced thrombosis, and deep venous thrombosis were comparable between the two groups. However, in contrast to the ABT group, the CS group exhibited significantly shorter median lengths of hospital stay (LOHS), ICU stay, and ventilation time, along with higher rates of discharge to home rather than acute care facilities.

CONCLUSION

Our data suggest that autologous blood transfusion via CS results in fewer perioperative complications and faster recovery following OPCAB procedures as compared to ABT.