Effects of Cardiac Surgery on Hemostasis

Essentials Near‐patient testing improves coagulopathy diagnosis in cardiac surgery patients with severe bleeding.We investigated how well pre‐emptive near‐patient testing predicted severe bleeding.Severe bleeding could be predicted using both near‐patient tests and patient clinical characteristics.Near‐patient test results gave little additional predictive value over clinical characteristics alone. BackgroundCoagulopathic bleeding is common after cardiac surgery and is associated with increased morbidity, mortality and healthcare costs. Implementation of blood management algorithms in which patients with severe bleeding undergo near‐patient coagulation testing results in less overall bleeding and transfusion. However, it is unknown whether there is additional value from pre‐emptive near‐patient testing to predict whether severe bleeding will occur.ObjectivesTo evaluate how well a comprehensive panel of 28 near‐patient platelet and viscoelastometry tests predict bleeding after cardiac surgery, compared to prediction using baseline clinical characteristics alone.MethodsSingle‐center, prospective cohort study in adults undergoing a range of cardiac surgery procedures. The primary outcome was clinical concern about bleeding (CCB), a composite of high blood loss (chest drain volume >600 mL within 6 hours), re‐operation for bleeding or administration of a pro‐haemostatic treatment directed by clinician judgement.ResultsIn 1833 patients recruited between March 2010 and August 2012, the median number of abnormal near‐patient test results was 5/28 per patient (range 0‐18). CCB occurred in 449/1833 patients (24.5%). The c‐statistic for a predictive model for CCB using only baseline clinical characteristics (baseline‐only model) was 0.72 (95% CI 0.69‐0.75). Addition of near‐patient test results to this model (baseline‐plus‐test model) improved the prediction of CCB (c‐statistic 0.75 [0.72‐0.77]), but increased the number of correctly classified patients by only 18 (0.98%).ConclusionsNear‐patient coagulation testing predicts bleeding in cardiac surgery patients, but offers little improvement in prediction compared to baseline clinical characteristics alone. trial registration: ISRNCTN 20778544 (http://www.isrctn.com/).

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“…Together, these suggest impaired clot formation and fibrinogen component of clot strength, both previously reported after cardiac surgery 41, 42…”

Section: Discussionsupporting

confidence: 71%

Near‐patient coagulation testing to predict bleeding after cardiac surgery: a cohort study

Mumford

Harris

Plummer

et al. 2017

Research and Practice in Thrombosis and Haemostasis

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“…1 As a result, 23.8-51.9% of patients require blood transfusion, and re-exploration is performed in 2-6% of the cases to control bleeding. 2 In spite of the recent advances in surgical techniques and the perioperative care, the amount of bleeding remains as high as 600-1200 ml. Hence, in most centres, a median of 2 to 3 units of red blood cells (RBCs) per patient is required.…”

Section: Introductionmentioning

confidence: 99%

Topical application of antifibrinolytic drugs for on-pump cardiac surgery: a systematic review and meta-analysis

Abrishami

Chung

Wong

2009

Can J Anesth/J Can Anesth

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Purpose This systematic review aimed to evaluate the efficacy and safety of topical application of antifibrinolytic drugs to reduce postoperative bleeding and transfusion requirements in patients undergoing on-pump cardiac surgery. Methods We searched The Cochrane Library, MED-LINE, EMBASE and SCI-EXPANDED for all randomized controlled trials on the topic. Trial inclusion, quality assessment, and data extraction were performed independently by two authors. Standard meta-analytic techniques were applied. Results Eight trials (n = 622 patients) met our inclusion criteria. The medication/placebo was applied into the pericardial cavity and/or mediastinum at the end of cardiac surgery. Seven trials compared antifibrinolytic agents (aprotinin or tranexamic acid) versus placebo. They showed that, on average, topical use of antifibrinolytic agents reduced the amount of 24-h postoperative chest tube (blood) loss by 220 ml (95% confidence interval: -318 to -126, P \ 0.00001, I 2 = 93%) and resulted in a saving of 1 unit of allogeneic red blood cells per patient (95% confidence interval: -1.54 to -0.53, P \ 0.0001, I 2 = 55%). The incidence of blood transfusion was not significantly changed following topical application of the medications. One study comparing topical versus intravenous administration of aprotinin found comparable results between the two methods of administration for the abovementioned outcomes. No adverse effects were reported following topical use of the medications. Conclusion This review suggests that topical application of antifibrinolytics can reduce postoperative bleeding and transfusion requirements in patients undergoing on-pump cardiac surgery. These promising findings need to be confirmed by more trials with large sample size using patient-related outcomes and more assessments regarding the systemic absorption of the medications. RésuméObjectif Le but de cette e´tude me´thodique e´tait d'e´valuer l'efficacite´et l'innocuite´de l'application topique d'agents anti-fibrinolytiques afin de re´duire les saignements et les besoins transfusionnels postope´ratoires chez les patients subissant une chirurgie cardiaque avec circulation extracorporelle. Méthode Nous avons fouille´les bases de donne´es suivantes afin d'extraire toutes les e´tudes randomise´es contrôle´es traitant de cette question : The Cochrane Library, MEDLINE, EMBASE et SCI-EXPANDED. L'inclusion des e´tudes, l'e´valuation de la qualite´et l'extraction des donne´es ont e´te´re´alise´es de façon inde´-pendante par deux auteurs. Des techniques de me´ta-analyse standard ont e´te´utilise´es. Résultats Huit e´tudes (n = 622 patients) ont satisfait aǹ os crite`res d'inclusion. Le me´dicament/placebo a e´teá pplique´dans la cavite´pe´ricardique et/ou dans le me´dia-stin a`la fin de la chirurgie cardiaque. Sept e´tudes ont compare´des agents anti-fibrinolytiques (aprotinine ou acide tranexamique) a`un placebo. Ces e´tudes ont montre´que, en moyenne, l'application topique d'agents

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“…Coagulation monitoring is of utmost importance during ECC and also in various diseases [21]. Here, we investigated the viscoelastic properties over time during coagulation using the oscillatory rheometer and compared the obtained data to a medical reference device (ball coagulometer KC 1A).…”

Section: Resultsmentioning

confidence: 99%

Dynamic and Quantitative Assessment of Blood Coagulation Status with an Oscillatory Rheometer

et al. 2018

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During open heart surgery, the haemostasis status of a patient has to be monitored permanently in order to quickly and reliably detect bleeding or coagulation-based disorders. Currently, no single medical device is available to provide a comprehensive solution for monitoring the coagulation status (coagulation, platelets and fibrinolysis). We intend to approach this problem with a rheological method. Here, we compared the performance of an oscillatory rheometer with a medical reference device, a ball coagulometer. Measuring the extrinsic coagulation (prothrombin time; PT), various heparin concentrations (0.5-2.0 IU/mL) could be differentiated and also discriminated from the intrinsic coagulation (activated partial thromboplastin time; aPTT) providing comparable clotting times between rheometer and ball coagulometer. In addition, the oscillatory rheometer was capable to detect the antagonising of heparin with the equimolar concentration of protamine and also the titration of various protamine concentrations (0.5-3.0 IU/mL) to a fixed heparin concentration (2 IU/mL). The addition of increasing concentrations of heparin to citrated blood prolonged the clotting time (CT), changed the slope calculated by linear regression of the elastic and viscous shear moduli (i.e., information of the coagulation process) and changed the value of the shear moduli at the end of the measurement (300 s). These results indicate that the oscillatory rheometer is capable to dynamically measure the haemostasis status with different activators and various inhibitor concentrations.

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Effects of Cardiac Surgery on Hemostasis

Cited by 93 publications

References 110 publications

Near‐patient coagulation testing to predict bleeding after cardiac surgery: a cohort study

Near‐patient coagulation testing to predict bleeding after cardiac surgery: a cohort study

Topical application of antifibrinolytic drugs for on-pump cardiac surgery: a systematic review and meta-analysis

Dynamic and Quantitative Assessment of Blood Coagulation Status with an Oscillatory Rheometer

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