Optimizing Perioperative Blood and Coagulation Management During Cardiac Surgery

Meesters, Michaël I.; Heymann, Christian von

doi:10.1016/j.anclin.2019.08.006

Cited by 17 publications

(13 citation statements)

References 87 publications

(79 reference statements)

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“…This review will discuss the assessment, diagnosis, and management of coagulopathy associated with cardiac surgery focusing on the current evidence in adult patients. Interested readers may also refer to a number of excellent reviews relevant to this topic, including in pediatric patients 24‐26 …”

Section: The Impact Of Cardiopulmonary Bypass On Coagulationmentioning

confidence: 99%

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Managing the coagulopathy associated with cardiopulmonary bypass

Bartoszko

Karkouti

2021

Journal of Thrombosis and Haemostasis

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Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB‐associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre‐procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point‐of‐care viscoelastic and functional platelet testing. Common pitfalls in the management of post‐CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near‐normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB‐associated coagulopathy can significantly improve patient outcomes.

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Section: The Impact Of Cardiopulmonary Bypass On Coagulationmentioning

confidence: 99%

“…Interested readers may also refer to a number of excellent reviews relevant to this topic, including in pediatric patients. [24][25][26]…”

Section: Introductionmentioning

confidence: 99%

Managing the coagulopathy associated with cardiopulmonary bypass

Bartoszko

Karkouti

2021

Journal of Thrombosis and Haemostasis

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“…Bleeding after cardiac surgery is common and frequently due to haemostatic disturbances with a multifactorial origin 1 . To date, treatment of post‐operative coagulopathy remains highly variable among centres and physicians 3–5 .…”

Section: Discussionmentioning

confidence: 99%

“…Cardiac surgery is associated with major blood loss and the subsequent need for allogeneic blood transfusion. The origin of coagulopathy is multifactorial, owing to the invasiveness of the procedure, use of anticoagulants, and exposure to the extracorporeal bypass circuit 1 . This makes management of coagulopathy complex in this setting.…”

Section: Introductionmentioning

confidence: 99%

The effect of non‐point‐of‐care haemostasis management protocol implementation in cardiac surgery: A systematic review

Boxma

Garnier

Bulte

et al. 2021

Transfusion Medicine

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Objectives This systematic review aims to outline the evidence on the implementation of a non‐point‐of‐care (non‐point‐of‐care [POC]) haemostasis management protocol compared to experience‐based practice in adult cardiac surgery. Background Management of coagulopathy in cardiac surgery is complex and remains highly variable among centres and physicians. Although various guidelines recommend the implementation of a transfusion protocol, the literature on this topic has never been systematically reviewed. Methods PubMed, Embase, Cochrane Library, and Web of Science were searched from January 2000 till May 2020. Results A total of seven studies (one randomised controlled trial [RCT], one prospective cohort study, and five retrospective studies) met the inclusion criteria. Among the six non‐randomised, controlled studies, the risk of bias was determined to be serious to critical, and the one RCT was determined to have a high risk of bias. Five studies showed a significant reduction in red blood cells, fresh frozen plasma, and/or platelet transfusion after the implementation of a structural non‐POC algorithm, ranging from 2% to 28%, 2% to 19.5%, and 7% to17%, respectively. One study found that fewer patients required transfusion of any blood component in the protocol group. Another study had reported a significantly increased transfusion rate of platelet concentrate in the haemostasis algorithm group. Conclusion Owing to the high heterogeneity and a substantial risk of bias of the included studies, no conclusion can be drawn on the additive value of the implementation of a cardiac‐surgery‐specific non‐POC transfusion and haemostasis management algorithm compared to experience‐based practice. To define the exact impact of a transfusion protocol on blood product transfusion, bleeding, and adverse events, well‐designed prospective clinical trials are required.

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“…Approaches to protamine dosing vary widely [ 5 , 6 ]. A common recommendation is a fixed 1:1 (1-mg protamine to every 100 IU of heparin) ratio based on the initial dose of heparin required to establish therapeutic anticoagulation [ 1 , 7 ]. This method does not directly account for heparin clearance and may lead to excessive protamine dosage [ 8 ].…”

Section: Introductionmentioning

confidence: 99%

Optimal protamine dosing after cardiopulmonary bypass: The PRODOSE adaptive randomised controlled trial

et al. 2021

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Background The dose of protamine required following cardiopulmonary bypass (CPB) is often determined by the dose of heparin required pre-CPB, expressed as a fixed ratio. Dosing based on mathematical models of heparin clearance is postulated to improve protamine dosing precision and coagulation. We hypothesised that protamine dosing based on a 2-compartment model would improve thromboelastography (TEG) parameters and reduce the dose of protamine administered, relative to a fixed ratio. Methods and findings We undertook a 2-stage, adaptive randomised controlled trial, allocating 228 participants to receive protamine dosed according to a mathematical model of heparin clearance or a fixed ratio of 1 mg of protamine for every 100 IU of heparin required to establish anticoagulation pre-CPB. A planned, blinded interim analysis was undertaken after the recruitment of 50% of the study cohort. Following this, the randomisation ratio was adapted from 1:1 to 1:1.33 to increase recruitment to the superior arm while maintaining study power. At the conclusion of trial recruitment, we had randomised 121 patients to the intervention arm and 107 patients to the control arm. The primary endpoint was kaolin TEG r-time measured 3 minutes after protamine administration at the end of CPB. Secondary endpoints included ratio of kaolin TEG r-time pre-CPB to the same metric following protamine administration, requirement for allogeneic red cell transfusion, intercostal catheter drainage at 4 hours postoperatively, and the requirement for reoperation due to bleeding. The trial was listed on a clinical trial registry (ClinicalTrials.gov Identifier: NCT03532594). Participants were recruited between April 2018 and August 2019. Those in the intervention/model group had a shorter mean kaolin r-time (6.58 [SD 2.50] vs. 8.08 [SD 3.98] minutes; p = 0.0016) post-CPB. The post-protamine thromboelastogram of the model group was closer to pre-CPB parameters (median pre-CPB to post-protamine kaolin r-time ratio 0.96 [IQR 0.78–1.14] vs. 0.75 [IQR 0.57–0.99]; p < 0.001). We found no evidence of a difference in median mediastinal/pleural drainage at 4 hours postoperatively (140 [IQR 75–245] vs. 135 [IQR 94–222] mL; p = 0.85) or requirement (as a binary outcome) for packed red blood cell transfusion at 24 hours postoperatively (19 [15.8%] vs. 14 [13.1%] p = 0.69). Those in the model group had a lower median protamine dose (180 [IQR 160–210] vs. 280 [IQR 250–300] mg; p < 0.001). Important limitations of this study include an unblinded design and lack of generalisability to certain populations deliberately excluded from the study (specifically children, patients with a total body weight >120 kg, and patients requiring therapeutic hypothermia to <28°C). Conclusions Using a mathematical model to guide protamine dosing in patients following CPB improved TEG r-time and reduced the dose administered relative to a fixed ratio. No differences were detected in postoperative mediastinal/pleural drainage or red blood cell transfusion requirement in our cohort of low-risk patients. Trial registration ClinicalTrials.gov Unique identifier NCT03532594.

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Optimizing Perioperative Blood and Coagulation Management During Cardiac Surgery

Cited by 17 publications

References 87 publications

Managing the coagulopathy associated with cardiopulmonary bypass

Managing the coagulopathy associated with cardiopulmonary bypass

The effect of non‐point‐of‐care haemostasis management protocol implementation in cardiac surgery: A systematic review

Optimal protamine dosing after cardiopulmonary bypass: The PRODOSE adaptive randomised controlled trial

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