Bank blood shortage, transfusion containment and viscoelastic point-of-care coagulation testing in cardiac surgery

AbstractBleeding complications after cardiac surgery are common and are associated with increased morbidity and mortality. Their etiology is multifactorial, and treatment decisions are time sensitive. Point-of-care (POC) testing has an advantage over standard laboratory tests for faster turn-around times, and timely decision on coagulation intervention(s). The most common POC coagulation testing is the activated clotting time (ACT), used to monitor heparin therapy while on cardiopulmonary bypass. Viscoelastic coagulation tests including thromboelastometry (ROTEM) and thromboelastography (TEG) have been recommended for the treatment of postoperative bleeding after cardiac surgery because the ROTEM/TEG-guided treatment algorithms reduced the use of blood products. Other POC tests are commercially available, but there is sparse evidence for their routine use in cardiac surgery. These devices include heparin management systems, POC prothrombin time and activated partial thromboplastin time, POC fibrinogen assay, and whole blood platelet function tests. There are multiple confounding elements and conditions associated with cardiac surgery, which can significantly alter test results. Anemia and thrombocytopenia are regularly associated with deviations in many POC devices. In summary, POC coagulation testing allows for rapid clinical decisions in hematological interventions, and, when used in conjunction with a proper transfusion algorithm, may reduce blood product usage, and potentially complications associated with blood transfusion.

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Comparison of Standard Coagulation Testing with Thromboelastometry Tests in Cardiac Surgery

Journal of Cardiovascular and Thoracic Research ◽

10.15171/jcvtr.2019.48 ◽

2019 ◽

Vol 11 (4) ◽

pp. 300-304 ◽

Cited By ~ 1

Author(s):

Elham Khalaf- Adeli ◽

Mostafa Alavi ◽

Alireza Alizadeh-Ghavidel ◽

Ali Akbar Pourfathollah

Keyword(s):

Cardiac Surgery ◽

Reference Range ◽

Point Of Care ◽

Valve Surgery ◽

Limited Data ◽

Point Of Care Test ◽

Transfusion Requirements ◽

Coagulation Testing ◽

Coagulation Tests ◽

Before And After

Introduction: According to the several evidences, using thromboelastometry as a point of care test canbe effective in reduction in blood loss and transfusion requirements in cardiac surgeries. However,there are limited data regarding to the comparison of thromboelastometry and the standard coagulationtests. In this study, we compared thromboelastometry and standard coagulation tests (PT, PTT andfibrinogen level) in patients under combined coronary-valve surgery. Methods: Forty adult patients who were under on-pump combined coronary-valve surgery wereincluded in this study. Thromboelastometry tests Fibtem, Intem, Extem and Heptem), along withstandard coagulation tests (PT, PTT and fibrinogen assay) were simultaneously performed in two timepoints, before and after the pump (pre-CPB and post-CPB, respectively). Results: A total of 80 blood samples were analyzed. There were no significant correlation between PTtest and the CT-Extem parameter as well as PTT and CT-Intem parameter either in pre-CPB and post-CPB (P > 0.05). On the contrary, fibrinogen level had high correlation with A10-Fibtem and A10-Extemin pre-PCB (P < 0.05). 82% of PT and 84% of PTT measurements were outside the reference range,while abnormal CT in Extem and Intem was observed in 17.9%. Conclusion: For management of bleeding, adequate perioperative haemostatic monitoring isindispensable during cardiac surgery. Standard coagulation tests are time consuming and cannot beinterchangeably used with thromboelastomety and relying on their results to decide whether bloodtransfusion is necessary, leads to the inappropriate transfusion.

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Evaluation of a Novel Transfusion Algorithm Employing Point-of-care Coagulation Assays in Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000000556 ◽

2015 ◽

Vol 122 (3) ◽

pp. 560-570 ◽

Cited By ~ 52

Author(s):

Keyvan Karkouti ◽

Stuart A. McCluskey ◽

Jeannie Callum ◽

John Freedman ◽

Rita Selby ◽

...

Keyword(s):

Cardiac Surgery ◽

Time Trends ◽

Point Of Care ◽

Interrupted Time Series ◽

Blood Products ◽

Interrupted Time Series Analysis ◽

Point Of Care Testing ◽

Coagulation Testing ◽

Coagulation Tests ◽

The Many

Abstract Background: Cardiac surgery requiring the use of cardiopulmonary bypass is frequently complicated by coagulopathic bleeding that, largely due to the shortcomings of conventional coagulation tests, is difficult to manage. This study evaluated a novel transfusion algorithm that uses point-of-care coagulation testing. Methods: Consecutive patients who underwent cardiac surgery with bypass at one hospital before (January 1, 2012 to January 6, 2013) and after (January 7, 2013 to December 13, 2013) institution of an algorithm that used the results of point-of-care testing (ROTEM®; Tem International GmBH, Munich, Germany; Plateletworks®; Helena Laboratories, Beaumont, TX) during bypass to guide management of coagulopathy were included. Pre- and postalgorithm outcomes were compared using interrupted time-series analysis to control for secular time trends and other confounders. Results: Pre- and postalgorithm groups included 1,311 and 1,170 patients, respectively. Transfusion rates for all blood products (except for cryoprecipitate, which did not change) were decreased after algorithm institution. After controlling for secular pre- and postalgorithm time trends and potential confounders, the posttransfusion odds ratios (95% CIs) for erythrocytes, platelets, and plasma were 0.50 (0.32 to 0.77), 0.22 (0.13 to 0.37), and 0.20 (0.12 to 0.34), respectively. There were no indications that the algorithm worsened any of the measured processes of care or outcomes. Conclusions: Institution of a transfusion algorithm based on point-of-care testing was associated with reduced transfusions. This suggests that the algorithm could improve the management of the many patients who develop coagulopathic bleeding after cardiac surgery. The generalizability of the findings needs to be confirmed.

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Reduced Complication of Cardiac Surgery Using Point-of-Care Coagulation Testing

Point of Care The Journal of Near-Patient Testing & Technology ◽

10.1097/00134384-200209000-00023 ◽

2002 ◽

Vol 1 (3) ◽

pp. 222-227

Author(s):

D. R. Jobes ◽

J. D. Tew ◽

D. A. Etzioni ◽

K. Dzien ◽

L. Stepsis ◽

...

Keyword(s):

Cardiac Surgery ◽

Point Of Care ◽

Coagulation Testing

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Faculty Opinions recommendation of Platelet dysfunction as measured by a point-of-care monitor is an independent predictor of high blood loss in cardiac surgery.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.718250501.793490132 ◽

2014 ◽

Author(s):

Michael Ganter

Keyword(s):

Cardiac Surgery ◽

Blood Loss ◽

Independent Predictor ◽

Point Of Care ◽

Platelet Dysfunction ◽

High Blood Loss

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Optimal patient blood management in cardiac surgery using viscoelastic point-of-care testing

British Journal of Anaesthesia ◽

10.1093/bja/aex284 ◽

2017 ◽

Vol 119 (3) ◽

pp. 544-545 ◽

Cited By ~ 2

Author(s):

E.A. Vlot ◽

S. Rigter ◽

P.G. Noordzij

Keyword(s):

Cardiac Surgery ◽

Point Of Care ◽

Patient Blood Management ◽

Blood Management ◽

Point Of Care Testing

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Point-of-care (POC) measurement of coagulation after cardiac surgery

Intensive Care Medicine ◽

10.1007/s001340050743 ◽

1998 ◽

Vol 24 (11) ◽

pp. 1187-1193 ◽

Cited By ~ 33

Author(s):

J. Boldt ◽

G. Walz ◽

J. Triem ◽

S. Suttner ◽

B. Kumle

Keyword(s):

Cardiac Surgery ◽

Point Of Care

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Point of Care Testing in Cardiac Surgery: Diagnostic Modalities to Assess Coagulation and Platelet Function

Drug Development Research ◽

10.1002/ddr.21099 ◽

2013 ◽

Vol 74 (7) ◽

pp. 418-427 ◽

Cited By ~ 2

Author(s):

Marshall Stafford ◽

Nathaen Weitzel

Keyword(s):

Cardiac Surgery ◽

Platelet Function ◽

Point Of Care ◽

Point Of Care Testing ◽

Diagnostic Modalities

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Point-of-Care Measurement of Activated Clotting Time for Cardiac Surgery as measured by the Hemochron Signature Eliteand the Abbott i-STAT: Agreement, Concordance, and Clinical Reliability

10.21203/rs.2.199/v2 ◽

2019 ◽

Author(s):

Daniel Dirkmann ◽

Elisabeth Nagy ◽

Martin Walter Britten ◽

Juergen Peters

Keyword(s):

Cardiac Surgery ◽

Linear Correlation ◽

Point Of Care ◽

Clotting Time ◽

Cohen’S Kappa ◽

Cohen's Kappa ◽

Activated Clotting Time ◽

Target Values ◽

Heparin Anticoagulation ◽

Parallel Measurements

Abstract Background: Since inadequate heparin anticoagulation and insufficient reversal can result in complications during cardiopulmonary bypass (CPB) surgery, heparin anticoagulation monitoring by point-of-care (POC) activated clotting time (ACT) measurements is essential for CPB initiation, maintainance, and anticoagulant reversal. However, concerns exist regarding reproducibility of ACT assays and comparability of devices. Methods: We evaluated the agreement of ACT assays using four parallel measurements performed on two commonly used devices each (i.e., two Hemochron Signature Elite (Hemochron) and two Abbott i-STAT (i-STAT) devices, respectively). Blood samples from 30 patients undergoing cardiac surgery on CPB were assayed at specified steps (baseline, after heparin administration, after protamine administration) with four parallel measurements (two of each device type) using commercial Kaolin activated assays provided by the respective manufactures. Measurements were compared between identical and different device types using linear regression, Bland-Altman analyses, and calculation of Cohen’s kappa coefficient. Results: Parallel i-STAT ACTs demonstrated a good linear correlation (r=0.985). Bias, as determined by Bland-Altman analysis, was low (-3.8s; 95% limits of agreement (LOA): -77.8 -70.2s), and Cohen’s Kappa demonstrated good agreement (kappa=0.809). Hemochron derived ACTs demonstrated worse linear correlation (r=0.782), larger bias with considerably broader LOA (-13.14s; 95%LOA:-316.3-290s), and lesser concordance between parallel assays (kappa=0.554). Although demonstrating a fair linear correlation (r=0.815), parallel measurements on different ACT-devices showed large bias (-20s; 95% LOA: -290-250s) and little concordance (kappa=0.368). Overall, disconcordant results according to clinically predefined target values were more frequent with the Hemochron than i-STAT. Furthermore, while discrepancies in ACT between two parallel iSTAT assays showed little or no clinical relevance, deviations from parallel Hemochron assays and iSTAT versus Hemochron measurements revealed marked and sometimes clinically critical deviations. Conclusion: Currently used ACT point-of-care devices cannot be used interchangeably. Furthermore, our data question the reliability of the Hemochron in assessing adequacy of heparin anticoagulation monitoring for CPB.

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