Measurement of Blood Loss in Cardiac Surgery: Still Too Much

Nelson, Mark; Green, Jeffrey; Spiess, Bruce D.; Kasirajan, Vigneshwar; Nicolato, Patricia; Liu, Hangcheng; Meshkin, Ryan S.

doi:10.1016/j.athoracsur.2017.11.023

Cited by 21 publications

(14 citation statements)

References 33 publications

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“…Excessive blood loss during cardiac surgery is associated with an increased incidence of blood transfusion, reoperation, prolonged hospital stay and death. [1][2][3][4] Excessive blood loss may be due to surgical factors alone, but may be compounded by impaired coagulation if plasma coagulation factors fall below critical levels. 4 This is more likely if cardiopulmonary bypass (CPB) is used, due to the associated haemodilution.…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4] Excessive blood loss may be due to surgical factors alone, but may be compounded by impaired coagulation if plasma coagulation factors fall below critical levels. 4 This is more likely if cardiopulmonary bypass (CPB) is used, due to the associated haemodilution. [4][5][6][7] Ongoing blood loss may exacerbate the haemodilution resulting in a vicious cycle of coagulopathy and further bleeding.…”

Section: Introductionmentioning

confidence: 99%

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Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review

Gibbs

Weightman

2020

Anaesth Intensive Care

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Hypofibrinogenaemia during cardiac surgery may increase blood loss and bleeding complications. Viscoelastic point-of-care tests provide more rapid diagnosis than laboratory measurement, allowing earlier treatment. However, their diagnostic test accuracy for hypofibrinogenaemia has never been reviewed systematically. We aimed to systematically review their diagnostic test accuracy for the identification of hypofibrinogenaemia during cardiac surgery. Two reviewers assessed relevant articles from seven electronic databases, extracted data from eligible articles and assessed quality. The primary outcomes were sensitivity, specificity and positive and negative predictive values. A total of 576 articles were screened and 81 full texts were assessed, most of which were clinical agreement or outcome studies. Only 10 diagnostic test accuracy studies were identified and only nine were eligible (ROTEM delta 7; TEG5000 1; TEG6S 1, n = 1820 patients) (ROTEM, TEM International GmbH, Munich, Germany; TEG, Haemonetics, Braintree, MA, USA). None had a low risk of bias. Four ROTEM studies with a fibrinogen threshold less than 1.5–1.6 g/l and FIBTEM threshold A10 less than 7.5–8 mm had point estimates for sensitivity of 0.61–0.88; specificity 0.54–0.94; positive predictive value 0.42–0.70; and negative predictive value 0.74–0.98 (i.e. false positive rate 30%–58%; false negative rate 2%–26%). Two ROTEM studies with higher thresholds for both fibrinogen (<2 g/l) and FIBTEM A10 (<9.5 mm) had similar false positive rates (25%–46%), as did the two TEG studies (15%–48%). This review demonstrates that there have been few diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients. The studies performed so far report false positive rates of up to 58%, but low false negative rates. Further diagnostic test accuracy studies of viscoelastic point-of-care identification of hypofibrinogenaemia are required to guide their better use during cardiac surgery.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review

Gibbs

Weightman

2020

Anaesth Intensive Care

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“…6 Patient circulating red cell mass has been shown to be one of the most important factors associated with reducing transfusion risk, with factors that are directed at mitigating its influence especially attractive for intervention. 20,21 Dedicated clinics for reducing preoperative anemia have been shown to be effective through the use of multiple modalities including the use of iron and erythropoietin. 22 However, these are often not conducive for cardiac surgery patients due to the timing of interventions that are related to the urgency often seen with heart lesions.…”

Section: Discussionmentioning

confidence: 99%

The effect of various blood management strategies on intraoperative red blood cell transfusion in first-time coronary artery bypass graft patients

Stammers¹,

Tesdahl²,

Mongero³

et al. 2019

Perfusion

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Effective blood management during cardiac surgery requires a multifactorial effort to limit exposure to allogeneic blood products. The present study evaluated the distribution of intraoperative interventions in patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass. Records from patients undergoing non-reoperative surgery at 120 hospitals between January 2017 and December 2017 were reviewed, and red blood cell transfusion quartiles established. The 31 hospitals with the lowest transfusion rates fell into the first quartile (low transfusion group, n = 3,186 patients), while 29 hospitals with the highest transfusion were in the fourth quartile (high transfusion group, n = 2,561). A survey was sent to assess the blood management techniques: acute normovolemic hemodilution, autologous prime, fluid management, intraoperative autotransfusion, ultrafiltration, and transfusion triggers. All data are presented as mean (standard deviation). Patients in the low transfusion group had red blood cell transfusion rate of 5.5%, while the high transfusion group was 28.3%. There was no difference in gender or age. Fluid management was reduced in the low transfusion group with smaller prime volumes and anesthesia volumes, but higher crystalloid use during cardiopulmonary bypass. The low transfusion group did not use acute normovolemic hemodilution as often and had lower sequestered volumes when used. When ultrafiltration was used, the low transfusion quartile group removed more volume (1,555.9 ± 955.2 vs. 1,326.1 ± 918.9 mL, p ⩽ 0.001). In the low transfusion group, nadir hematocrit on–cardiopulmonary bypass averaged 1.6% lower and 3.0% lower for transfusion post–cardiopulmonary bypass. Intraoperative red blood cell units averaged 0.11 ± 0.50 U in low transfusion group compared to 0.63 ± 1.14 U in the high transfusion group. Mixed-effects logistic regression identified first in operating room and first on cardiopulmonary bypass hematocrit, estimated blood volume and nadir hematocrit transfusion trigger as the strongest predictors for red blood cell transfusion. Significant variation exists in the transfusion of red blood cell in coronary artery bypass graft patients undergoing cardiopulmonary bypass which may be related to the application of intraoperative blood management techniques.

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“…It is not a coincidence that every cardiac surgery unit has an intensive care unit dedicated for the early postoperative monitoring. The most of the cardiac surgery procedures have long operative timing characterized by many sutures in vascular and cardiac tissues and need often the extracorporeal circulation, with inevitable consequences of loss in hematocrit values both in the surgical time and in the following postoperative period [1]. For these reasons, the percentage of blood transfusions in cardiac surgery is still high, easily overcoming the 50% of the operations.…”

Section: Editorialmentioning

confidence: 99%

“…Collected scientific literature [1][2][3] and patients' ideals, we discussed with Anesthesiologists of our Cardiac Anesthesia Department and hence we wrote a protocol to treat the patients that refuse blood products transfusions in the most of cardiac surgery procedures except in some complex operative technique as heart transplantation or aortic arch surgery or debranching surgery in deep hypothermia. We drafted the protocol, that was approved by the hospital and warmly accepted and appreciated by the Jehovah's health exponents, and we started to treat the patients who refused blood products transfusion respecting their wills.…”

Section: Editorialmentioning

confidence: 99%

Cardiac Surgery in Jehovah's Witnesses: Another Frontier Overcoming

2018

ARC Journal of Cardiology

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Measurement of Blood Loss in Cardiac Surgery: Still Too Much

Abstract: Decreases in hematocrit observed in cardiac surgery patients are due to significant red blood cell losses and not to hemodilution. Red blood cell losses averaged 38%. Plasma volume also decreased.

Cited by 21 publications

References 33 publications

Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review

Diagnostic accuracy of viscoelastic point-of-care identification of hypofibrinogenaemia in cardiac surgical patients: A systematic review

The effect of various blood management strategies on intraoperative red blood cell transfusion in first-time coronary artery bypass graft patients

Cardiac Surgery in Jehovah's Witnesses: Another Frontier Overcoming

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