Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers

Aronson, Solomon; Nisbet, Paul; Bunke, Martin

doi:10.1186/s13741-017-0071-6

Cited by 29 publications

(43 citation statements)

References 32 publications

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“…11 Finally, a recently published survey of cardiothoracic surgeons, anesthesiologists, and perfusionists found that in the cardiothoracic surgery setting, albumin is most commonly prescribed for volume expansion according to volume status indicators like blood pressure, urine output, cardiac output, and central venous pressure, but significant variability exists among prescribers. 12 These studies demonstrate a widespread problem in terms of inappropriate prescribing of albumin therapy and significant variability in prescribing practices.…”

Section: Discussionmentioning

confidence: 96%

“…7 The CVICU most commonly ordered albumin 25% as single 25 g doses following cardiac surgery, in which although most indications for use were undocumented, they are likely in line with the cardiothoracic surgery practices at other institutions for volume expansion. 12 Given that 73% of patients were receiving vasopressors and 49% of patients were receiving crystalloid therapy within 2 hours of albumin administration suggests that many of the undocumented indications for albumin use was likely fluid resuscitation and hypotension. This evaluation helped to identify our varying prescribing practices across our ICUs and allows for better focused efforts for cost-containment including implementation of restriction criteria and provider education.…”

Section: Discussionmentioning

confidence: 99%

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Evaluation of Albumin 25% Use in Critically Ill Patients at a Tertiary Care Medical Center

et al. 2019

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Background: Albumin 25% has been studied and has demonstrated benefit in a limited number of patient populations. The use of albumin 25% is associated with higher costs compared with crystalloid therapy. The aim of this study was to describe the prescribing practices of albumin 25% at a tertiary-care medical center and identify opportunities for restriction criteria related to its use to help generate cost savings. Methods: This evaluation was a retrospective, noninterventional, descriptive study of albumin 25% use between June 2015 and February 2016. Inclusion criteria consisted of patients ≥18 years old and who received at least one dose of albumin 25% while admitted to a Cleveland Clinic main campus intensive care unit (ICU). Inclusion was restricted to 150 randomly selected patients. Results: A total of 539 albumin 25% orders were placed for the 150 included patients. The cardiovascular ICU more frequently prescribed albumin 25% compared with the medical, surgical, neurosciences, and coronary ICUs (51% vs 23% vs 11% vs 9% vs 6%, respectively). Although the cardiovascular surgery ICU most frequently prescribed albumin 25% compared with other ICUs, the medical ICU prescribed a larger total quantity of albumin 25% compared with the cardiovascular, surgical, neurosciences, and coronary ICUs (8705 g vs 7275 g vs 3205 g vs 2162 g vs 625 g, respectively). The majority of patients (61%) did not have an indication listed for albumin 25% use and only 9% of patients were prescribed for indications supported by primary literature. Of the patients prescribed albumin for other indications not supported by primary literature (30%), the most common reasons for albumin 25% were hypotension, acute kidney injury, and volume resuscitation. The median cost per patient of albumin 25% was $417 with a total cost of $122 164 for the cohort. Only 19% of the total cost aligned with dosing regimens evaluated in primary literature. Conclusion: Prescribing patterns of albumin 25% at a tertiary academic medical center do not align with indications supported by primary literature. These findings identified a major opportunity for prescriber education and implementation of restriction criteria to target cost savings.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Evaluation of Albumin 25% Use in Critically Ill Patients at a Tertiary Care Medical Center

et al. 2019

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“…In Austria crystalloids are the first choice for volume expansion for all centers. Recent surveys on fluid resuscitation in cardiac surgery in the USA [ 15 ] and Europe [ 6 ] showed a more diverse picture. For colloids the Austrian results are in line with the European results naming gelatine as the preferred colloid in the majority of the centers [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

Postoperative management of patients undergoing cardiac surgery in Austria

Menger

Edlinger-Stanger

Dworschak

et al. 2018

Wien Klin Wochenschr

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SummaryBackgroundNo data are currently available regarding the current clinical practice in postoperative care of cardiac surgical patients in Austria.ObjectiveThe study investigated the current intensive care management concerning hemodynamic monitoring and strategies to treat common perioperative disorders of patients after cardiac surgery in Austria.MethodsA survey consisting of 31 questions was sent to intensivists at all 9 hospitals offering cardiac surgery in Austria.ResultsThe response rate was 100%. The mean number of procedures on cardiopulmonary bypass per centre was 722 ± 223. In the majority of cases postoperative critical care is performed by anesthesiologists. Blood gas analysis, pulse oximetry, electrocardiogram, temperature, central venous pressure, arterial pressure and hourly urine output are de facto standard monitoring in all centers. Transesophageal echocardiography is available in all centers and is frequently used. Crystalloids are the first choice for volume replacement, whereas levosimendan and adrenaline are employed for the treatment of low cardiac output syndrome.ConclusionsThis study provides insights into the current state of postoperative management of cardiac surgical patients in Austria. Standard monitoring as proposed by international guidelines is well established in Austrian intensive care units. Echocardiography is widely seen as a very important tool in the postoperative care of cardiac surgical patients. Knowledge about the status quo of postoperative intensive care management of cardiac surgical patients enables further development of patient care.Electronic supplementary materialThe online version of this article (10.1007/s00508-018-1403-3) contains supplementary material, which is available to authorized users.

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“…At the onset of CPB, the patient's blood is diluted due to priming of the bypass circuit with crystalloids and/or colloids. 29,30 Subsequently, nonphysiological flow patterns within the bypass circuit (e.g., shear effects) can affect plasmatic and cellular components of hemostasis. 28 Interactions between the blood and the circuit include activation and binding of coagulation factors and platelets, leading to reductions in plasma levels and/or function of these constituents.…”

Section: Cardiopulmonary Bypass and Cardiac Surgerymentioning

confidence: 99%

Fibrinogen Supplementation and Its Indications

Grottke

Mallaiah

Karkouti

et al. 2019

Semin Thromb Hemost

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Adequate plasma levels of fibrinogen are essential for clot formation, and in severe bleeding, fibrinogen reaches a critically low plasma concentration earlier than other coagulation factors. Although the critical minimum concentration of fibrinogen to maintain hemostasis is a matter of debate, many patients with coagulopathic bleeding require fibrinogen supplementation. Among the treatment options for fibrinogen supplementation, fibrinogen concentrate may be viewed by some as preferable to fresh frozen plasma or cryoprecipitate. The authors review major studies that have assessed fibrinogen treatment in trauma, cardiac surgery, end-stage liver disease, postpartum hemorrhage, and pediatric patients. Some but not all randomized controlled trials have shown that fibrinogen concentrate can be beneficial in these settings. The use of fibrinogen as part of coagulation factor concentrate based therapy guided by point-of-care viscoelastic coagulation monitoring (ROTEM [rotational thromboelastometry] or TEG [thromboelastography]) appears promising. In addition to reducing patients' exposure to allogeneic blood products, this strategy may reduce the risk of complications such as transfusion-associated circulatory overload, transfusion-related acute lung injury, and thromboembolic adverse events. Randomized controlled trials are challenging to perform in patients with critical bleeding, and more evidence is needed in this setting. However, current scientific rationale and clinical data support fibrinogen repletion in patients with ongoing bleeding and confirmed fibrinogen deficiency.

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Fluid resuscitation practices in cardiac surgery patients in the USA: a survey of health care providers

Cited by 29 publications

References 32 publications

Evaluation of Albumin 25% Use in Critically Ill Patients at a Tertiary Care Medical Center

Evaluation of Albumin 25% Use in Critically Ill Patients at a Tertiary Care Medical Center

Postoperative management of patients undergoing cardiac surgery in Austria

Fibrinogen Supplementation and Its Indications

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