Hematologic evaluation of intraoperative autologous blood collection and allogeneic transfusion in cardiac surgery

Henderson, Reney; Judd, Miranda; Strauss, Erik; Gammie, James S.; Mazzeffi, Michael; Taylor, Bradley S.; Tanaka, Kenichi A.

doi:10.1111/trf.16259

Cited by 20 publications

(25 citation statements)

References 40 publications

(96 reference statements)

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“…The TG pattern at T3 showed numerically greater peak levels in both PNP and FVIII inhibitor mixture with the patient's plasma. This is consistent with slower FXa and thrombin inhibition due to lower antithrombin activity due to hemodilution on CPB 33,34 …”

Section: Discussionsupporting

confidence: 68%

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In vitro effects of emicizumab on activated clotting time in blood samples from cardiac surgical patients

et al. 2021

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Background Heparin management in hemophilia A (HA) patients with a factor VIII (FVIII) inhibitor can be challenging due to severe activated clotting time (ACT) prolongations. It is important to better understand the impact of emicizumab, a FVIII mimetic on ACT, and tissue factor (TF)‐based coagulation assays. Methods Whole blood from 18 patients undergoing cardiopulmonary bypass (CPB) were mixed in vitro with pooled normal plasma, FVIII‐deficient or FVIII‐inhibitor plasma to affect functional FVIII levels. ACTs and heparin concentration by protamine titration were measured in whole blood mixture with/without emicizumab (50‐100 μg/ml). Thrombin generation and plasmin generation were measured in the patient's plasma mixed with normal plasma or FVIII‐inhibitor plasma to assess the impact of emicizumab under low TF activation. Results FVIII inhibitors prolonged ACTs by 2.2‐fold compared to those in normal plasma mixture at baseline. During CPB, ACTs in normal plasma mixture, and FVIII‐deficient mixture were in 400s, but ACTs reached 900s in FVIII‐inhibitor mixture. Emicizumab shortened ACTs by up to 100s in normal plasma mixture, and FVIII‐deficient mixtures. ACTs remained over 600s in FVIII‐inhibitor mixture, despite adding emicizumab at 100 μg/ml. Heparin concentration measured by TF‐based protamine titration was unaffected. Emicizumab enhanced thrombin peak in the presence of FVIII inhibitors, whereas plasmin generation was mainly affected by thrombin generation, and systemic use of ɛ‐aminocaproic acid. Conclusions FVIII inhibitors extensively prolong ACTs in heparinized whole blood, and clinical levels of emicizumab partially reverse ACT values. Protamine titration should be considered for optimal heparin monitoring in emicizumab‐treated patients with FVIII inhibitors.

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Section: Discussionsupporting

confidence: 68%

“…This is consistent with slower FXa and thrombin inhibition due to lower antithrombin activity due to hemodilution on CPB. 33,34 The PG patterns showed distinctive changes in relation to TG, and in vivo use of EACA. While FVIII inhibitors strongly inhibited TG at baseline (T1), they minimally affected the baseline PG patterns.…”

Section: Discussionmentioning

confidence: 99%

In vitro effects of emicizumab on activated clotting time in blood samples from cardiac surgical patients

et al. 2021

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“…Those findings are consistent with previously published results. 21,22,24 As fibrinogen in both groups was over 200 mg/dl, it is unclear if the statistical difference also translates into significant biological difference, and particularly so in absence of significant clinical bleeding. Importantly, we found no significant difference in the 12-hour chest tube output or rate of reoperation for bleeding in the studied cohorts.…”

Section: Discussionmentioning

confidence: 99%

Hemodilution in high‐risk cardiac surgery: Laboratory values, physiological parameters, and outcomes

et al. 2022

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Background: Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability, and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. Study design and methods:This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N = 66) and non-ANH controls (N = 103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass.Results: Intraoperatively, the ANH group received more albumin (p = .04) and vasopressor medications (p = .01), while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO 2 ) values were similar before and after hemodilution. During bypass, rSO 2 were discretely lower in the ANH versus control group (right rSO 2 p = .03, left rSO 2 p = .05).No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, intensive care unit length of stay, kidney injury, stroke, or infection were demonstrated.Discussion: This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better

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“…Although authors believe that point of care coagulation tests (TEG ® ) do have a role in assessing coagulopathy, those tests have not been consistently used in our institutional practice and we were unable to include them in the analysis due to the level of missing data. 22 23 24 Interpretation of coagulopathy and laboratory values in cardiac surgery remains challenging, and particularly so in our study group, as one of the frequently used indicators of coagulopathy is number of transfused blood products. Secondly, by excluding patients who received allogeneic transfusion, we likely selected for patients with milder coagulopathy and uncomplicated procedures (i.e., shorter CPB runs).…”

Section: Limitationsmentioning

confidence: 92%

Hemodilution in High Risk Cardiac Surgery: Laboratory Values, Physiological Parameters and Outcomes

Mladinov

Padilla

Leahy

et al. 2021

Preprint

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Background: Acute normovolemic hemodilution (ANH) is a blood conservation strategy in cardiac surgery, predominantly used in coronary artery bypass graft (CABG) and/or valve procedures. Although higher complexity cardiac procedures may benefit from ANH, concerns for hemodynamic instability and organ injury during hemodilution hinder its wider acceptance. Laboratory and physiological parameters during hemodilution in complex cardiac surgeries have not been described. Study Design and Methods: This observational cohort (2019-2021) study included 169 patients who underwent thoracic aortic repair, multiple valve procedure, concomitant CABG with the aforementioned procedure, and/or redo sternotomies. Patients who received allogeneic blood were excluded. Statistical comparisons were performed between ANH (N=66) and non ANH controls (N=103). ANH consisted of removal of blood at the beginning of surgery and its return after cardiopulmonary bypass (CPB). Results: Intraoperatively, the ANH group received more albumin (p=0.04) and vasopressor medications (p=0.01); while urine output was no different between ANH and controls. Bilateral cerebral oximetry (rSO2) values were similar before and after hemodilution. During bypass rSO2 were discretely lower in the ANH vs. control group (right rSO2 p=0.03, left rSO2 (p=0.05). No differences in lactic acid values were detected across the procedural continuum. Postoperatively, no differences in extubation times, ICU length of stay, kidney injury, stroke or infection were demonstrated. Discussion: This study suggests hemodilution to be a safe and comparable blood conservation technique, even without accounting for potential benefits of reduced allogenic blood administration. The study may contribute to better understanding and wider acceptance of ANH protocols in high risk cardiac surgeries.

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Hematologic evaluation of intraoperative autologous blood collection and allogeneic transfusion in cardiac surgery

Cited by 20 publications

References 40 publications

In vitro effects of emicizumab on activated clotting time in blood samples from cardiac surgical patients

In vitro effects of emicizumab on activated clotting time in blood samples from cardiac surgical patients

Hemodilution in high‐risk cardiac surgery: Laboratory values, physiological parameters, and outcomes

Hemodilution in High Risk Cardiac Surgery: Laboratory Values, Physiological Parameters and Outcomes

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