Rotational Thromboelastometry Rapidly Predicts Thrombocytopenia and Hypofibrinogenemia During Neonatal Cardiopulmonary Bypass

Background: Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute to bleeding and morbidity. Rotational thromboelastometry (ROTEM) is a viscoelastic assay with a rapid turnaround time. Data validating ROTEM during neonatal cardiac surgery remain limited. This study examined perioperative hemostatic trends in neonates treated with standardized platelet and cryoprecipitate transfusion during CPB. We hypothesized that ROTEM would predict thrombocytopenia, hypofibrinogenemia, and the correction thereof. Methods: Forty-four neonates undergoing CPB were included in this prospective observational study. Blood samples were obtained at Baseline, On CPB, Post-CPB, and Postoperative. The ROTEM analysis included extrinsically activated (Extem) and fibrinogen-specific (Fibtem) assays. Platelet-specific thromboelastometry (Pltem) values were calculated. Platelet and cryoprecipitate transfusion was initiated prior to termination of CPB. Results: Platelet count and Extem amplitude decreased significantly On CPB ( P < .0001), increased significantly Post-CPB ( P < .0001), and Postoperative values were not significantly different from Baseline. Extem amplitude at 10 minutes (A10) > 46.5 mm (AUC = 0.941) and Pltem A10 > 37.5 mm [area under curve (AUC) = 0.960] predicted platelet count > 100 × 103/μL, and they highly correlated with platelet count ( R = 0.89 and R = 0.90, respectively). Fibrinogen concentration and Fibtem amplitude decreased significantly On CPB ( P ≤ .0001) and normalized after cryoprecipitate transfusion. Fibtem A10 > 9.5 mm predicted fibrinogen >200 mg/dL (AUC = 0.817), but it correlated less well with fibrinogen concentration ( R = 0.65). Conclusions: ROTEM analysis during neonatal cardiac surgery is sensitive and specific for thrombocytopenia and hypofibrinogenemia, identifying deficits within 10 minutes. Platelet and cryoprecipitate transfusion during neonatal CPB normalizes platelet count, fibrinogen level, and ROTEM amplitudes.

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Macroaggregation of Platelets in Plasma, as Distinct from Microaggregation in Whole Blood (and Plasma), as Determined Using Optical Aggregometry and Platelet Counting respectively, is Specifically Impaired following Cardiopulmonary Bypass in Man

Thrombosis and Haemostasis ◽

10.1055/s-0038-1648905 ◽

1994 ◽

Vol 72 (04) ◽

pp. 511-518 ◽

Cited By ~ 30

Author(s):

Valentine C Menys ◽

Philip R Belcher ◽

Mark I M Noble ◽

Rhys D Evans ◽

George E Drossos ◽

...

Keyword(s):

Cardiac Surgery ◽

Platelet Count ◽

Cardiopulmonary Bypass ◽

Whole Blood ◽

Platelet Rich Plasma ◽

Interquartile Range ◽

Contributory Factor ◽

Platelet Aggregability ◽

Aggregate Growth

SummaryWe determined changes in platelet aggregability following cardiopulmonary bypass, using optical aggregometry to assess macroaggregation in platelet-rich plasma (PRP), and platelet counting to assess microaggregation both in whole blood and PRP. Hirudin was used as the anticoagulant to maintain normocalcaemia.Microaggregation (%, median and interquartile range) in blood stirred with collagen (0.6 µg/ml) was only marginally impaired following bypass (91 [88, 93] at 10 min postbypass v 95 (92, 96] prebypass; n = 22), whereas macroaggregation (amplitude of response; cm) in PRP stirred with collagen (1.0µg/ml) was markedly impaired (9.5 [8.0, 10.8], n = 41 v 13.4 [12.7,14.3], n = 10; p <0.0001). However, in PRP, despite impairment of macroaggregation (9.1 [8.5, 10.1], n = 12), microaggregation was near-maximal (93 [91, 94]), as in whole blood stirred with collagen. In contrast, in aspirin-treated patients (n = 14), both collagen-induced microaggregation in whole blood (49 [47, 52]) and macroaggregation in PRP (5.1 [3.8, 6.6]) were more markedly impaired, compared with control (both p <0.001).Similarly, in PRP, macroaggregation with ristocetin (1.5 mg/ml) was also impaired following bypass (9.4 [7.2, 10.7], n = 38 v 12.4 [10.0, 13.4]; p <0.0002, n = 20), but as found with collagen, despite impairment of macroaggregation (7.2 [3.5,10.9], n = 12), microaggregation was again near-maximal (96 [93,97]). The response to ristocetin was more markedly impared after bypass in succinylated gelatin (Gelo-fusine) treated patients (5.6 [2.8, 8.6], n = 17; p <0.005 v control), whereas the response to collagen was little different (9.3 v 9.5). In contrast to findings with collagen in aspirin-treated patients, the response to ristocetin was little different to that in controls (8.0 v 8.3). Impairment of macroaggregation with collagen or ristocetin did not correlate with the duration of bypass or the platelet count, indicating that haemodilution is not a contributory factor.In conclusion: (1) Macroaggregation in PRP, as determined using optical aggregometry, is specifically impaired following bypass, and this probably reflects impairment of the build-up of small aggregates into larger aggregates. (2) Impairment of aggregate growth and consolidation could contribute to the haemostatic defect following cardiac surgery.

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Fibrinogen measurement in cardiac surgery with cardiopulmonary bypass: Analysis of repeatability and agreement of Clauss method within and between six different laboratories

Thrombosis and Haemostasis ◽

10.1160/th13-12-0997 ◽

2014 ◽

Vol 112 (07) ◽

pp. 109-117 ◽

Cited By ~ 30

Author(s):

Ekaterina Baryshnikova ◽

Armando Tripodi ◽

Christoph J. Schlimp ◽

Herbert Schöchl ◽

Janne Cadamuro ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Plasma Fibrinogen ◽

Detection Methods ◽

Fibrinogen Concentration ◽

Plasma Samples ◽

Limits Of Agreement ◽

Study Objective ◽

Standard Operating ◽

Mean Differences

SummaryPlasma fibrinogen concentration is important for coagulopathy assessment, and is most commonly measured using the Clauss method. Several factors, including device type and reagent, have been shown to affect results. The study objective was to evaluate performance and repeatability of the Clauss method and to assess differences between measurements performed during and after cardiopulmonary bypass (CPB), by testing plasma samples from patients undergoing cardiac surgery with CPB. Samples were collected from 30 patients before surgery, approximately 20 minutes before weaning from CPB, and 5 minutes after CPB and protamine. Fibrinogen concentration was determined using the Clauss method at six quality-controlled specialised laboratories, according to accredited standard operating procedures. Regarding within-centre agreement for Clauss measurement, mean differences between duplicate measurements were between 0.00 g/l and 0.15 g/l, with intervals for 95% limits of agreement for mean Bland-Altman differences up to 1.3 g/l. Regarding between-centre agreement, some mean differences between pairs of centres were above 0.5 g/l. Differences of up to ∼2 g/l were observed with individual samples. Increased variability was observed between centres, with inter-class correlation values below 0.5 suggesting only fair agreement. There were no significant differences in fibrinogen concentration before weaning from CPB and after CPB for most centres and methods. In conclusion, considerable differences exist between Clauss-based plasma fibrinogen measured using different detection methods. Nevertheless, the similarity between measurements shortly before weaning from CPB and after CPB within centres suggests that on-pump measurements could provide an early estimation of fibrinogen deficit after CPB and thus guidance for haemostatic therapy.

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Vasoresponsiveness in patients with heart failure (VASOR): protocol for a prospective observational study

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-019-1014-8 ◽

2019 ◽

Vol 14 (1) ◽

Author(s):

Marieke E. van Vessem ◽

Saskia L. M. A. Beeres ◽

Rob B. P. de Wilde ◽

René de Vries ◽

Remco R. Berendsen ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Observational Study ◽

Vascular Reactivity ◽

Prospective Observational Study ◽

Ex Vivo ◽

Phase 1 ◽

Resistance Arteries ◽

Patients With Heart Failure

Abstract Background Vasoplegia is a severe complication which may occur after cardiac surgery, particularly in patients with heart failure. It is a result of activation of vasodilator pathways, inactivation of vasoconstrictor pathways and the resistance to vasopressors. However, the precise etiology remains unclear. The aim of the Vasoresponsiveness in patients with heart failure (VASOR) study is to objectify and characterize the altered vasoresponsiveness in patients with heart failure, before, during and after heart failure surgery and to identify the etiological factors involved. Methods This is a prospective, observational study conducted at Leiden University Medical Center. Patients with and patients without heart failure undergoing cardiac surgery on cardiopulmonary bypass are enrolled. The study is divided in two inclusion phases. During phase 1, 18 patients with and 18 patients without heart failure are enrolled. The vascular reactivity in response to a vasoconstrictor (phenylephrine) and a vasodilator (nitroglycerin) is assessed in vivo on different timepoints. The response to phenylephrine is assessed on t1 (before induction), t2 (before induction, after start of cardiotropic drugs and/or vasopressors), t3 (after induction), t4 (15 min after cessation of cardiopulmonary bypass) and t5 (1 day post-operatively). The response to nitroglycerin is assessed on t1 and t5. Furthermore, a sample of pre-pericardial fat tissue, containing resistance arteries, is collected intraoperatively. The ex vivo vascular reactivity is assessed by constructing concentrations response curves to various vasoactive substances using isolated resistance arteries. Next, expression of signaling proteins and receptors is assessed using immunohistochemistry and mRNA analysis. Furthermore, the groups are compared with respect to levels of organic compounds that can influence the cardiovascular system (e.g. copeptin, (nor)epinephrine, ANP, BNP, NTproBNP, angiotensin II, cortisol, aldosterone, renin and VMA levels). During inclusion phase 2, only the ex vivo vascular reactivity test is performed in patients with (N = 12) and without heart failure (N = 12). Discussion Understanding the difference in vascular responsiveness between patients with and without heart failure in detail, might yield therapeutic options or development of preventive strategies for vasoplegia, leading to safer surgical interventions and improvement in outcome. Trial registration The Netherlands Trial Register (NTR), NTR5647. Registered 26 January 2016.

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Trillium™ Biopassive Surface: A New Biocompatible Treatment for Extracorporeal Circulation Circuits

The International Journal of Artificial Organs ◽

10.1177/039139880002300506 ◽

2000 ◽

Vol 23 (5) ◽

pp. 319-324 ◽

Cited By ~ 8

Author(s):

A. Cazzaniga ◽

M. Ranucci ◽

G. Isgrò ◽

G. Soro ◽

D. De Benedetti ◽

...

Keyword(s):

Cardiac Surgery ◽

Platelet Count ◽

Cardiopulmonary Bypass ◽

Blood Cell ◽

Control Group ◽

Biochemical Profile ◽

Leukocyte Activation ◽

Blood Cell Count ◽

To Receive ◽

Protamine Administration

139 patients undergoing cardiac surgery were included in a prospective, randomized trial. Patients were randomly allocated to receive cardiopulmonary bypass (CPB) with Trillium™ Biopassive Surface (TBS Group) coated oxygenators or conventional circuits (control group). 112 patients were studied with respect to postoperative biochemical profile; a subgroup of 27 patients was studied with respect to perioperative complement (C3a) activation. Patients in the TBS group demonstrated a significantly lower white blood cell count at the end of the operation (p=0.036) and a significantly higher platelet count the day after the operation (p=0.023) when compared to the control group. C3a was significantly higher (p=0.02) in the TBS group after 30 minutes of CPB, but the C3a increase after protamine administration was significantly less pronounced in the TBS group vs. the control group. Further studies involving platelet and leukocyte activation are required to better elucidate the action of this new coating in the setting of routine CPB.

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Combined Use of Rotational Thromboelastometry (Rotem) and Platelet Impedance Aggregometry (Multiplate Analyzer) in Cyanotic and Acyanotic Infants and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass: Subgroup Analysis of a Randomized Clinical Trial

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2020.09.133 ◽

2020 ◽

Author(s):

Audrey Dieu ◽

Victoria Van Regemorter ◽

Thierry Detaille ◽

Laurent Houtekie ◽

Stéphane Eeckhoudt ◽

...

Keyword(s):

Clinical Trial ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Randomized Clinical Trial ◽

Subgroup Analysis ◽

Infants And Children ◽

Rotational Thromboelastometry ◽

Combined Use ◽

Impedance Aggregometry ◽

Multiplate Analyzer

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Analysis of online gas monitoring CDI 500® and SYSTEM M-M4®. Are they comparable tools for clinical perfusion practice?

Revista Española de Perfusión ◽

10.36579/rep.2019.66.3 ◽

2019 ◽

pp. 21-27 ◽

Cited By ~ 1

Author(s):

Maria Luz Recio ◽

Maria Carmen Santos ◽

Carlos Casado ◽

Juan Carlos Santos

Keyword(s):

Cardiac Surgery ◽

Clinical Practice ◽

Cardiopulmonary Bypass ◽

Prospective Observational Study ◽

Venous Blood ◽

Blood Gases ◽

Reliable Data ◽

Direct Evaluation ◽

Two Samples ◽

Evaluation Of Data

Objective: to compare the data obtained from the CDI500® and Spectrum M4® to assess the reliability of the results and their impact on cardiopulmonary bypass. Methods: a prospective observational study of patients undergoing cardiac surgery with CPB was conducted between January-2017 and February-2018. The data provided by CDI and M4 was collected. Arterial and venous blood gases taken from Radiometer ABL90 Flex® were used as control. With the first sample, the data of both analyzers were adjusted. A minimum of two samples and a maximum of four were made. Results: 100 patients and 292 samples (32% women) with a mean age of 65.2 ± 11.5 years were studied. The parameters of the CDI and M4 practically did not present significant differences after the first adjustment, and without affecting the clinical practice, except in the bicarbonate and the excess of base where CDI does not adjust to the values. The analysis was done with the Bland/Altman charts, the PCO2 and PO2 were better measured by the CDI while Hto, Hb and SvO2 by M4, which was corroborated comparing the error percentages less than ± 5% in both systems, the significant differences being in the five parameters. Conclusions: both systems provide reliable data, although they require a previous calibration. The M4 allows direct evaluation of data to help a goal directed perfusion.

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Abstract 19663: Failed Delayed Sternal Closure Following Neonatal Cardiac Surgery Predicted by High Mean Airway Pressure and Associated with Increased Post-operative Mortality

Circulation ◽

10.1161/circ.130.suppl_2.19663 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Dashiell Massey ◽

Kathryn A Williams ◽

Ravi R Thiagarajan ◽

Frank Pigula ◽

Catherine K Allan

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Cardiopulmonary Bypass ◽

Categorical Variables ◽

Sternal Closure ◽

Increased Risk ◽

Significant Difference ◽

Delayed Sternal Closure ◽

Neonatal Cardiac Surgery

Background: Myocardial edema, increased lung water, and anasarca are common following neonatal cardiac surgery with cardiopulmonary bypass and amplify the risk of hemodynamic instability and inadequate ventilation following sternal closure. Delayed sternal closure (DSC) in the intensive care unit one or more days following surgery is a common strategy to mitigate this risk, but has been associated with increased risk of infection. In addition, failed DSC has previously been identified as a risk factor for mortality. This study sought to identify predictor variables and determine impact of failed DSC. Methods: Records of all neonates undergoing DSC in the cardiac intensive care unit (CICU) following surgery with cardiopulmonary bypass between January 2008 and May 2013 were reviewed. Pre-operative, intra-operative and post-operative variables were compared for those patients who failed DSC versus those who did not. Continuous variables were compared utilizing Wilcoxon’s test and categorical variables using Fisher’s exact test. Results: Of 256 neonates undergoing DSC in the CICU, 22 failed first attempt at DSC. No significant difference between the two groups was appreciated in age, weight, or bypass (cross clamp, circulatory arrest, and total) times. Comparing DSC failures to successes, significantly more failures: followed Stage I palliation (63% vs. 31%); occurred later (post-operative day 4.7 vs. 2.8, p = 0.009); and were proceeded by higher mean airway pressures (9 vs. 8 cm H2O, p = 0.04), peak inspiratory pressure (27 vs. 24, p = 0.002), and inotrope score (12.1 vs. 9.6, p = 0.06). There was no association with systolic blood pressure or lactate prior to DSC. Failed DSC was associated with increased duration of mechanical ventilation (41.6 vs 7.4 days, p < 0.001), length of ICU stay (44.3 vs 12.0 days, p < 0.001), and mortality (38 vs 3%, p < 0.001). Conclusions: Mortality for patients who fail the first ICU attempt at delayed sternal closure is significantly higher than for those with successful sternal closure. Ventilatory pressures but not hemodynamic variables prior to DSC differed significantly between the two groups. First attempt at DSC was later in those who failed, suggesting that clinicians had a priori identified these patients as higher risk.

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