Does a Platelet Transfusion Independently Affect Bleeding and Adverse Outcomes in Cardiac Surgery?

Abstract Background Conflicting results have been reported concerning the effect of platelet transfusion on several outcomes. The aim of this study was to assess the independent effect of a single early intraoperative platelet transfusion on bleeding and adverse outcomes in cardiac surgery patients. Methods For this observational study, 23,860 cardiac surgery patients were analyzed. Patients who received one early (shortly after cardiopulmonary bypass while still in the operating room) platelet transfusion, and no other transfusions, were defined as the intervention group. By matching the intervention group 1:3 to patients who received no early transfusion with most comparable propensity scores, the reference group was identified. Results The intervention group comprised 169 patients and the reference group 507. No difference between the groups was observed concerning reinterventions, thromboembolic complications, infections, organ failure, and mortality. However, patients in the intervention group experienced less blood loss and required vasoactive medication 139 of 169 (82%) versus 370 of 507 (74%; odds ratio, 1.65; 95% CI, 1.05 to 2.58), prolonged mechanical ventilation 92 of 169 (54%) versus 226 of 507 (45%; odds ratio, 1.47; 94% CI, 1.03 to 2.11), prolonged intensive care 95 of 169 (56%) versus 240 of 507 (46%; odds ratio, 1.49; 95% CI, 1.04 to 2.12), erythrocytes 75 of 169 (44%) versus 145 of 507 (34%; odds ratio, 1.55; 95% CI, 1.08 to 2.23), plasma 29 of 169 (17%) versus 23 of 507 (7.3%; odds ratio, 2.63; 95% CI, 1.50–4.63), and platelets 72 of 169 (43%) versus 25 of 507 (4.3%; odds ratio, 16.4; 95% CI, 9.3–28.9) more often compared to the reference group. Conclusions In this retrospective analysis, cardiac surgery patients receiving platelet transfusion in the operating room experienced less blood loss and more often required vasoactive medication, prolonged ventilation, prolonged intensive care, and blood products postoperatively. However, early platelet transfusion was not associated with reinterventions, thromboembolic complications, infections, organ failure, or mortality.

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Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications

Future Cardiology ◽

10.2217/fca-2020-0245 ◽

2021 ◽

Author(s):

Alice Laudisio ◽

Antonio Nenna ◽

Marta Musarò ◽

Silvia Angeletti ◽

Francesco Nappi ◽

...

Keyword(s):

Cardiac Surgery ◽

Postoperative Complications ◽

Predictive Value ◽

Odds Ratio ◽

Rate Ratio ◽

Perioperative Management ◽

Incidence Rate Ratio ◽

Adverse Outcomes ◽

Elective Cardiac Surgery ◽

The Third

Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.

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Lack of Association between Preoperative Statin Use and Respiratory and Neurologic Complications after Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000001569 ◽

2017 ◽

Vol 126 (5) ◽

pp. 799-809 ◽

Cited By ~ 4

Author(s):

Ryu Komatsu ◽

Huseyin Oguz Yilmaz ◽

Jing You ◽

C. Allen Bashour ◽

Shobana Rajan ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Hospital Mortality ◽

Hospital Stay ◽

Odds Ratio ◽

Hospital Length Of Stay ◽

Neurologic Complications ◽

Prolonged Ventilation ◽

Statin Use

Abstract Background Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery. Methods The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models. Results Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay. Conclusions Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.

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Prolonged Central Venous Desaturation Measured by Continuous Oximetry Is Associated with Adverse Outcomes in Pediatric Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0b013e318233056e ◽

2011 ◽

Vol 115 (5) ◽

pp. 1033-1043 ◽

Cited By ~ 16

Author(s):

Ryan Crowley ◽

Elizabeth Sanchez ◽

Jonathan K. Ho ◽

Kate J. Lee ◽

Johanna Schwarzenberger ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Length Of Stay ◽

Adverse Events ◽

Clinical Outcomes ◽

Pediatric Patients ◽

Adverse Outcomes ◽

Central Venous ◽

Major Adverse Events

Background The role of continuous central venous oxygen saturation (ScvO₂) oximetry during pediatric cardiac surgery for predicting adverse outcomes is not known. Using a recently available continuous ScvO₂ oximetry catheter, we examined the association between venous oxygen desaturations and patient outcomes. We hypothesized that central venous oxygen desaturations are associated with adverse clinical outcomes. Methods Fifty-four pediatric patients undergoing cardiac surgery were prospectively enrolled in an unblinded observational study. ScvO₂ was measured continuously in the operating room and for up to 24 h post-Intensive Care Unit admission. The relationships between ScvO₂ desaturations, clinical outcomes, and major adverse events were determined. Results More than 18 min of venous saturations less than 40% were associated with major adverse events with 100% sensitivity and 97.6% specificity. Significant correlations resulted between the ScvO₂ area under the curve less than 40% and creatinine clearance at 12 h in the Intensive Care Unit (r = -0.58), Intensive Care Unit length of stay (r = 0.56), max inotrope use (r = 0.52), inotrope use at 24 h (r = 0.40), inotrope index score (r = 0.39), hospital length of stay (r = 0.36), and length of intubation (r = 0.32). Conclusions We demonstrate that ScvO₂ desaturations by continuous oximetry are associated with major adverse events in pediatric patients undergoing cardiac surgery. The most significant associations with major adverse events are seen in patients with greater than 18 min of central venous saturations less than 40%. Our results support the further investigation of ScvO₂ as a potential target parameter in high-risk pediatric patients to minimize the risk of major adverse events.

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Cerebral Oximetry Monitoring to Maintain Normal Cerebral Oxygen Saturation during High-risk Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000001029 ◽

2016 ◽

Vol 124 (4) ◽

pp. 826-836 ◽

Cited By ~ 114

Author(s):

Alain Deschamps ◽

Richard Hall ◽

Hilary Grocott ◽

C. David Mazer ◽

Peter T. Choi ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Intervention Group ◽

Perioperative Outcomes ◽

Control Group ◽

Cerebral Oxygen ◽

Cerebral Desaturation ◽

Cerebral Saturation

Abstract Background Cerebral oxygen desaturation during cardiac surgery has been associated with adverse perioperative outcomes. Before a large multicenter randomized controlled trial (RCT) on the impact of preventing desaturations on perioperative outcomes, the authors undertook a randomized prospective, parallel-arm, multicenter feasibility RCT to determine whether an intervention algorithm could prevent desaturations. Methods Eight Canadian sites randomized 201 patients between April 2012 and October 2013. The primary outcome was the success rate of reversing cerebral desaturations below 10% relative to baseline in the intervention group. Anesthesiologists were blinded to the cerebral saturation values in the control group. Intensive care unit personnel were blinded to cerebral saturation values for both groups. Secondary outcomes included the area under the curve of cerebral desaturation load, enrolment rates, and a 30-day follow-up for adverse events. Results Cerebral desaturations occurred in 71 (70%) of the 102 intervention group patients and 56 (57%) of the 99 control group patients (P = 0.04). Reversal was successful in 69 (97%) of the intervention group patients. The mean cerebral desaturation load (SD) in the operating room was smaller for intervention group patients compared with control group patients (104 [217] %.min vs. 398 [869] %.min, mean difference, −294; 95% CI, −562 to −26; P = 0.03). This was also true in the intensive care unit (P = 0.02). There were no differences in adverse events between the groups. Conclusions Study sites were successful in reversal of desaturation, patient recruitment, randomization, and follow-up in cardiac surgery, supporting the feasibility of conducting a large multicenter RCT.

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The independent effect of a platelet transfusion on bleeding and adverse outcomes in cardiac surgery

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2016.03.018 ◽

2016 ◽

Vol 30 ◽

pp. S36

Author(s):

Fabienne van Hout ◽

EK Hogervorst ◽

PMJ Rosseel ◽

JG van der Bom ◽

M. Bentala ◽

...

Keyword(s):

Cardiac Surgery ◽

Platelet Transfusion ◽

Adverse Outcomes ◽

Independent Effect

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Topical and low-dose intravenous tranexamic acid in cyanotic cardiac surgery

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492316688416 ◽

2017 ◽

Vol 25 (2) ◽

pp. 118-122 ◽

Cited By ~ 5

Author(s):

Jigar Patel ◽

Mrugesh Prajapati ◽

Hardik Patel ◽

Hemang Gandhi ◽

Shilpa Deodhar ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Blood Loss ◽

Tranexamic Acid ◽

Low Dose ◽

Blood Product ◽

Sternal Closure ◽

Topical Tranexamic Acid ◽

Ventilator Time

Background Coagulopathy is a major problem in surgery for cyanotic congenital heart disease. Tranexamic acid has been used both topically and systemically and plays a vital role in pediatric cardiac surgery by reducing blood loss and blood product requirement. We aimed to determine the anti-fibrinolytic effectiveness of low-dose systemic or topical tranexamic acid or a combination of both. Methods Seventy-five patients were divided in 3 groups of 25. Group A patients were given tranexamic acid 20 mg kg−1 intravenously after sternotomy and 20 mg kg−1 after heparin reversal. Group B patients were given tranexamic acid 50 mg kg−1 in 20 mL of saline intrapericardially before sternal closure, with the drain clamped for 20 min. Group C patients were given tranexamic acid 20 mg kg−1 intravenously after sternotomy and 50 mg kg−1 intrapericardially before sternal closure. A number of clinical variables were recorded in the first 3 postoperative days. Ventilator time, intensive care unit stay, and outcome were also recorded. Results Chest tube drainage and blood product requirements were lowest in group C. Blood urea and serum creatinine levels were higher in groups A and C ( p < 0.05). Intensive care unit stay and ventilator time were similar in all 3 groups. No patient died and none had a seizure or other neurological event or thromboembolic complication postoperatively. Conclusion The combination of low-dose intravenous and topical tranexamic acid reduces postoperative blood loss and blood product requirement without incurring neurological, renal or thromboembolic complications. We recommend the routine use of topical and low-dose systemic tranexamic acid in cyanotic pediatric cardiac surgery.

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Post-operative Right Ventricular Failure After Cardiac Surgery: A Cohort Study

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.667328 ◽

2021 ◽

Vol 8 ◽

Author(s):

David Levy ◽

Driss Laghlam ◽

Philippe Estagnasie ◽

Alain Brusset ◽

Pierre Squara ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Cohort Study ◽

Intensive Care ◽

Right Ventricular ◽

Odds Ratio ◽

Valve Surgery ◽

Right Ventricular Failure ◽

Composite Outcome ◽

Ventricular Failure

Introduction: Right ventricular failure (RVF) after cardiac surgery is an important risk factor for morbidity and mortality. Its diagnosis is challenging, and thus, its incidence and predictors are not well-established. We investigated the incidence, complications, and variables associated with clinically relevant post-operative RVF.Methods: We included all patients who underwent cardiac surgery with cardiopulmonary bypass between 2016 and 2019 in a cardiac surgery center with standardized diagnostic and therapeutic management of RVF. RVF was considered only if clinically relevant: associated with hemodynamic instability requiring catecholamine support and inhaled nitric oxide relayed by sildenafil.Results: Overall, 3,826 patients were included, of whom, 110 (2.9%) developed post-operative RVF. Mortality was not different among patients who developed post-operative RVF, compared with the rest of the cohort (1.8 vs. 0.7%, p = 0.17). Using a composite outcome that combined death, reintubation, stroke, and prolonged intensive care unit stay (more than 14 days) yielded an incidence of 6.6%, and RVF was associated with this composite outcome with an odds ratio of 3.6 (2.2–5.8), p < 0.001. In a multivariable model, pre-operative variables independently associated with post-operative RVF were pre-operative atrial fibrillation (AF) {adjusted odds ratio (adjOR) 3.22 [95% confidence interval (95%CI) = 1.94–5.36], p < 0.001}, left ventricle ejection fraction below 50% [adjOR = 2.55 (95%CI = 1.52–4.33), p < 0.001], systolic pulmonary artery pressure above 55 mmHg [adjOR = 8.64 (95%CI = 5.27–14.1); p < 0.001], mitral valve surgery [adjOR = 2.17 CI (95%CI = 1.28–3.66), p = 0.004], and tricuspid valve surgery [adjOR = 10.33 (95%CI = 6.14–17.4), p < 0.001]. In patients who developed post-operative RVF requiring treatment, 32 (29.1%) showed RV dysfunction before surgery.Conclusion: In this cohort study, 2.9% of patients developed clinically significant post-operative RVF. Moreover, RVF was associated with severe adverse outcomes, including death, strokes, reintubation, and prolonged intensive care unit stay.

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Protocol for the electroencephalography guidance of anesthesia to alleviate geriatric syndromes (ENGAGES-Canada) study: A pragmatic, randomized clinical trial

F1000Research ◽

10.12688/f1000research.19213.1 ◽

2019 ◽

Vol 8 ◽

pp. 1165 ◽

Cited By ~ 2

Author(s):

Alain Deschamps ◽

Tarit Saha ◽

Renée El-Gabalawy ◽

Eric Jacobsohn ◽

Charles Overbeek ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Postoperative Delirium ◽

Anesthetic Management ◽

Confusion Assessment Method ◽

Assessment Method ◽

Adverse Outcomes ◽

Minimum Concentration ◽

Confusion Assessment

Background: There is some evidence that electroencephalography guidance of general anesthesia can decrease postoperative delirium after non-cardiac surgery. There is limited evidence in this regard for cardiac surgery. A suppressed electroencephalogram pattern, occurring with deep anesthesia, is associated with increased incidence of postoperative delirium (POD) and death. However, it is not yet clear whether this electroencephalographic pattern reflects an underlying vulnerability associated with increased incidence of delirium and mortality, or whether it is a modifiable risk factor for these adverse outcomes. Methods: The Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES-Canada) is an ongoing pragmatic 1200 patient trial at four Canadian sites. The study compares the effect of two anesthetic management approaches on the incidence of POD after cardiac surgery. One approach is based on current standard anesthetic practice and the other on electroencephalography guidance to reduce POD. In the guided arm, clinicians are encouraged to decrease anesthetic administration, primarily if there is electroencephalogram suppression and secondarily if the EEG index is lower than the manufacturers recommended value (bispectral index (BIS) or WAVcns below 40 or Patient State Index below 25). The aim in the guided group is to administer the minimum concentration of anesthetic considered safe for individual patients. The primary outcome of the study is the incidence of POD, detected using the confusion assessment method or the confusion assessment method for the intensive care unit; coupled with structured delirium chart review. Secondary outcomes include unexpected intraoperative movement, awareness, length of intensive care unit and hospital stay, delirium severity and duration, quality of life, falls, and predictors and outcomes of perioperative distress and dissociation. Discussion: The ENGAGES-Canada trial will help to clarify whether or not using the electroencephalogram to guide anesthetic administration during cardiac surgery decreases the incidence, severity, and duration of POD. Registration: ClinicalTrials.gov (NCT02692300) 26/02/2016

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Health Outcomes with and without Use of Inotropic Therapy in Cardiac Surgery

Anesthesiology ◽

10.1097/aln.0000000000000224 ◽

2014 ◽

Vol 120 (5) ◽

pp. 1098-1108 ◽

Cited By ~ 60

Author(s):

Dorthe Viemose Nielsen ◽

Malene Kærslund Hansen ◽

Søren Paaske Johnsen ◽

Mads Hansen ◽

Karsten Hindsholm ◽

...

Keyword(s):

Myocardial Infarction ◽

Cardiac Surgery ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Adverse Outcomes ◽

Matched Cohort ◽

Inotropic Therapy ◽

Postoperative Myocardial Infarction

Abstract Background: Inotropes used to obtain short-term hemodynamic benefits in cardiac surgery may carry a risk of increased myocardial ischemia and adverse outcomes. This study investigated the association between intra- and postoperative use of inotropes and mortality and postoperative complications. Methods: A historic cohort study using prospective data from the Western Denmark Heart Registry on 6,005 consecutive cardiac surgery cases from three university hospitals. Propensity matching on pre- and intraoperative variables was used to identify a subgroup of patients receiving inotropic therapy (n = 1,170) versus comparable nonreceivers (n = 1,170) for outcome analysis. Results: Two thousand ninety-seven patients (35%) received inotropic therapy; 3,908 (65%) did not receive any inotropic or vasopressor support perioperatively. Among propensity-matched cohort including 2,340 patients 30-day mortality was 3.2% and 1-yr mortality was 7.6%. In the matched cohort, patients exposed to inotropes had a higher 30-day mortality (adjusted hazards ratio, 3.7; 95% CI, 2.1 to 6.5) as well as a higher 1-yr mortality rate (adjusted hazards ratio, 2.5; 95% CI, 1.8 to 3.5) compared with nonreceivers. Among propensity-matched, the following absolute events rates were observed: myocardial infarction 2.4%, stroke 2.8%, arrhythmia 35%, and renal replacement therapy 23.9%. Inotropic therapy was independently associated with postoperative myocardial infarction (adjusted odds ratio, 2.1; 95% CI, 1.4 to 3.0), stroke (adjusted odds ratio, 2.4; 95% CI, 1.4 to 4.3), and renal replacement therapy (adjusted odds ratio, 7.9; 95% CI, 3.8 to 16.4). Conclusion: Use of intra- and postoperative inotropes was associated with increased mortality and major postoperative morbidity.

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The Effect of Platelet Transfusion on Death in the Intensive Care Unit

Blood ◽

10.1182/blood.v128.22.3850.3850 ◽

2016 ◽

Vol 128 (22) ◽

pp. 3850-3850 ◽

Cited By ~ 1

Author(s):

Donald M. Arnold ◽

Shuoyan Ning ◽

Rebecca Barty ◽

Yang Liu ◽

Richard Cook ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Research Funding ◽

Platelet Transfusion ◽

Oncology Patients ◽

Risk Of Death ◽

Platelet Transfusions

Abstract Background: Thrombocytopenia is a common complication of critical illness and an independent risk factor for death in the intensive care unit (ICU). Whether platelet transfusions modify the risk of death in critically ill patients is unknown. Methods: Adult patients admitted to ICU who received one or more platelet transfusion over a 10-year period (2006 - 2015) from 3 academic hospitals in Canada were analyzed from a blood transfusion registry. Oncology patients were excluded. Contemporaneous non-transfused ICU patients were used as controls. Data from the registry were validated by integrity checks with medical records and laboratory information systems. We estimated the effect of platelet transfusion on mortality in ICU adjusted for baseline and time-varying covariates including multi-organ dysfunction score (MODS) and severity of thrombocytopenia using a stratified cox proportional hazards model. Significance was set at p<0.05 for all analyses. Results: Of 43,234 non-oncology patients admitted to ICU, 5,621 (13.0%) received one or more platelet transfusion. Compared with non-transfused controls, transfused patients had lower platelet counts (median, 82 x109/L vs. 163 x109/L); were more often admitted after surgery (90.7% vs. 46.9%) especially cardiac surgery (86.8% of surgeries vs. 60.6%); and had higher unadjusted mortality (10.7% vs. 6.5%). Using regression analysis adjusted for covariates (nadir platelet count, red blood cell transfusion, need for hemodialysis) and stratified by age, baseline MODS score (available for 66.2% of patients) and need for invasive mechanical ventilation, platelet transfusions were associated with a lower risk of death in ICU [hazard ratio (HR)= 0.66; 95% confidence interval (CI), 0.46 - 0.96; p= 0.028; n= 26,404 with all available data]. A similar effect was observed in the subgroup of cardiac surgery patients (HR= 0.50; 95% CI, 0.26 - 0.98; p=0.044; n= 10,676) but not all surgical patients (HR = 0.73; 95% CI, 0.46 - 1.17; p= 0.188; n= 14,461). Conclusion:After adjusting for illness severity, thrombocytopenia and other confounders common among critically ill patients, platelet transfusions were associated with improved survival in the population of mostly cardiac surgery patients. This potential protective effect of platelet transfusions requires further evaluation in prospective studies. Disclosures Arnold: Novartis: Consultancy, Research Funding; Bristol Myers Squibb: Consultancy; UCB: Consultancy; Amgen: Consultancy, Research Funding.

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