Safety and efficacy of preoperative autologous apheresis platelet donation in coronary artery bypass grafting patients

Background

Demand for platelets is a concern for Coronary Artery Bypass Grafting (CABG) patients. Transfusion of platelet concentrates, in form of apheresis platelets or random donor platelets are used to achieve hemostasis after Coronary Pulmonary Bypass (CPB) but also expose the recipient to the risks of transfusion reactions, allo-immunisation and transmission of infectious agents. This study was designed to compare the efficacy and safety of apheresis platelet concentrate (autologous and homologous) and Random Donor Platelets (RDP).

Materials and methods

This study was conducted in Department of Cardiovascular and Thoracic Surgery and Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh over 1?year. Thirty consecutive patients with coronary artery disease were recruited in the study and divided into three groups??group 1-autologous apheresis, group 2-random donor platelets, group 3-homologous apheresis platelets. Each group had 10 patients. Levels of platelet activation marker??human soluble-P-selectin was estimated in platelet products (apheresis and random donor platelets), in patient??s sample (pre and postoperatively) and posttransfusion at 1?h and 24?h.

Results

There was significantly lower 24?h blood loss postoperatively in patients receiving apheresis platelets as compared to random donor platelets (p?<?0.05). There was decreased post operative transfusion requirements of both red cells and Fresh Frozen Plasma (FFP)/platelet concentrates in the apheresis group (p?<?0.05) as compared to Random donor platelet group. Apheresis platelets had better quality control parameters than random donor platelets i.e., pH ?7.0 Vs 6.5 and White Blood Cells (WBC) count ?10⁶ Vs 10⁷ respectively. There was decreased in vitro/in vivo activation of platelets as evidenced by lower P-selectin levels in samples from platelet units and patients. None of the patient had any serious adverse reaction during or after the autologous apheresis donation.

Conclusions

Harvesting of platelets by apheresis preoperatively before CPB is one of the good means of providing safe and good quality platelets in adequate dose.     

Neonatal onset atypical hemolytic uremic syndrome successfully treated with eculizumab

Background

Atypical hemolytic uremic syndrome (aHUS) is characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and renal impairment. Neonatal cases are extremely uncommon. Plasma therapy is the first choice therapy in patients with aHUS based on the belief of an underlying complement dysregulation. Alternatively, eculizumab, which targets complement 5, is used to block complement activation.

Case-diagnosis/treatment

Sudden onset macroscopic hematuria, hypertension, and bruises over the entire body were noted in a 5 day-old newborn. Investigations revealed hemolytic anemia, thrombocytopenia, renal impairment, and a low serum C3, leading to the diagnosis of aHUS. Fresh frozen plasma (FFP) infusions and peritoneal dialysis for acute kidney injury were initiated. This approach yielded full renal and hematological remission. The patient was discharged with FFP infusions, but subsequently developed three life-threatening disease recurrences at 1, 3, and 6 months of age. The last relapse presented with uncontrolled hypertension and impaired renal function while the patient was receiving FFP infusions. After the first dose of eculizumab, his renal and hematological parameters returned to normal and his blood pressure normalized. Genetic screening of the CFH gene revealed a novel homozygous p. Tyr1177Cys mutation.

Conclusion

Eculizumab can be considered as an alternative to plasma therapy in the treatment of specific patients with aHUS, even in infants.     

Adult cardiac surgery blood/blood product utilization in the post aprotinin era: an 855 patient,community hospital,retrospective experience

Background and objectives

Prior to 2008, when it was withdrawn, aprotinin use in cardiac surgery patients was associated with reduced bleeding and blood utilization, but studies linked its administration to increased patient mortality. We investigated (a) blood/blood product utilization between 2008 and 2013 at our community hospital heart center according to the type of surgery performed following the withdrawal of aprotinin and (b) clinical variables associated with increased patient blood utilization.

Materials and methods

Seven hundred nine patients were retrospectively investigated for blood/blood product utilization. Variables examined were patient age, body surface area (BSA), gender, preoperative creatinine level, hematocrit level, total cell saved blood (CSB) administered, cardiopulmonary bypass (CPB) time, type of surgical procedure performed, and preoperative clopidogrel usage. Variables (categorical and continuous) were placed into a forward stepwise regression model for the continuous outcome, packed red blood cell (PRBC) utilization. The stepwise function utilized a P value threshold of 0.25 for entering the model and 0.1 for leaving the model.

Results

For coronary artery bypass graft (CABG) surgery, use of PRBC was 29.26 % (0.75/1.44), of platelets was 14.18 % (0.24/0.72), of fresh frozen plasma (FFP) was 7.34 % (0.19/0.78), and of cryoprecipitate was 10.63 % (0.23/0.97) among our patient sample. [Data expressed as percent patient utilization, mean/S.D. in units transfused]. Increased age, smaller BSA, higher preoperative creatinine level, lower preoperative hematocrit level, longer CPB time, and increased CSB administration was associated with increased PRBC administration (P?<?0.0001).

Conclusion

At our community heart surgery center, with a multidisciplinary blood conservation program in place, expected increase in blood/blood product utilization following aprotinin withdrawal was not experienced.

     

The Initial Trauma Center Fluid Management of Penetrating Injury: A Systematic Review

Background

Damage-control resuscitation is the prevailing trauma resuscitation technique that emphasizes early and aggressive transfusion with balanced ratios of red blood cells (RBCs), plasma (FFP), and platelets (Plt) while minimizing crystalloid resuscitation, which is a departure from Advanced Trauma Life Support (ATLS) guidelines. It is unclear whether the newer approach is superior to the approach recommended by ATLS.

Questions/purposes

With these recent changes pervading resuscitation protocols, we performed a systematic review to determine if the shift in trauma resuscitation from ATLS guidelines to damage control resuscitation has improved mortality in patients with penetrating injuries.

Methods

A systematic search of PubMed, the Cochrane Library, and the Current Controlled Trials Register was performed for studies comparing mortality in massively transfused penetrating trauma patients receiving either balanced ratios of blood transfusion per damage control resuscitation tenets or undergoing an alternate blood volume resuscitation strategy. Studies were deemed appropriate for inclusion if they had a Newcastle-Ottawa Scale score of 6 or greater as well as at least 30% penetrating trauma. Twenty studies that reported on a total of 12,154 patients were included.

Results

Transfusion ratios varied widely, with 1:1 and 1:2 ratios of FFP:RBC most often defined as high ratios for purposes of comparison with other low ratio groups. Fourteen of 20 studies found significantly lower 30-day mortality when higher transfusion ratios of FFP, RBC, and/or Plt were used; six of 20 studies found mortality to be similar between higher and lower transfusion ratios.

Conclusions

Patients with penetrating injuries who require massive transfusion should be transfused early using balanced ratios of RBC, FFP, and Plt. Randomized, controlled trials are needed to determine optimal ratios for transfusion.     

Postoperative peripheral blood monocyte count correlates with postoperative bile leakage in patients with colorectal liver metastases after hepatic resection

Purpose

Postoperative bile leakage is one of the most common complications after hepatic surgery. The relationship between the inflammatory response and postoperative bile leakage has not been fully investigated. Therefore, we retrospectively investigated the relation between postoperative peripheral blood monocyte count and bile leakage in patients with colorectal liver metastases (CRLM) after elective hepatic resection.

Methods

The study comprised 105 patients who had undergone hepatic resection for CRLM between January 2000 and March 2012. Perioperative risk factors pertinent to development of bile leakage were investigated using univariate and multivariate analyses.

Results

Bile leakage developed in 9 (8.6 %) of 105 patients. In multivariate analysis, intraoperative fresh frozen plasma (FFP) transfusion (p?=?0.009) and lower monocyte count of the peripheral blood on postoperative day 1 (p?=?0.038) were found as independent risk factors of bile leakage.

Conclusions

Postoperative lower monocyte count and intraoperative FFP transfusion were associated with the development of postoperative bile leakage after elective hepatic resection in patients with CRLM.     

Pedicle versus free frozen autograft for reconstruction in malignant bone and soft tissue tumors of the lower extremities

Background

Of the biological reconstruction methods for malignant bone and soft tissue tumors, reconstruction with liquid nitrogen has the advantage of maintaining continuity on the distal side of the tumor bone site (pedicle freezing procedure; PFP). This method is expected to result in early blood flow recovery, with early union and low complication rate. The purpose of this study was to compare the outcomes of the PFP and free freezing procedure (FFP) in the lower extremities.

Methods

The study included 20 patients (12 men and 8 women) with frozen autografts (FFP, 13 cases; PFP, 7 cases). The mean age of the subjects was 36.3 years (range 11–79 years), and the mean follow-up period was 56.4 months (range 12–142 months).

Results

Final bone union occurred in 11 patients in the FFP group (84.6 %) and in 7 patients in the PFP group (100 %). The mean union period in patients who did not need additional surgery was 9.8 months (range 4–21 months) in the FFP group and 4.8 months (range 2–7 months) in the PFP group. Postoperative complications occurred in 8 cases: infection in 3 cases, fracture in 3 cases, and joint destruction in 2 cases. Six FFP patients, and 2 PFP patients (two cases of fracture), developed postoperative complications.

Conclusions

The union period was shorter and the rate of postoperative complications was lower with the PFP than with the FFP. We considered that early blood flow recovery might have led to the above results in the PFP.     

Efficacy of a high FFP:PRBC transfusion ratio on the survival of severely injured patients: a retrospective study in a single tertiary emergency center in Japan

Purpose

Recent studies have shown increased survival benefits when a high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio is used during trauma resuscitation. However, some reports have raised questions about the effect of higher FFP:PRBC transfusion ratios. The aim of this study was to examine the efficacy of high FFP:PRBC ratios in injured patients with regard to survival and morbidity in a single tertiary emergency center in Japan.

Methods

This study examined severe trauma patients who received 10 or more PRBC units during the first 24 h of admission. We examined the relationship between the FFP:PRBC ratios during the first 6 h and the patient outcome.

Results

The severity was similar among all groups. The mortality rate was 44.4 % in the high (>1:1.5), 16.7 % in the middle (1:1.5–1:2) and 33.3 % in the low (<1:2) F:P ratio groups. Only one patient in the high group developed sepsis, and none of the patients developed ARDS.

Conclusions

The current results indicate that the FFP:PRBC ratios during the first 6 h after admission might not affect the mortality or morbidity. However, differences between trauma care systems in Japan and other countries, along with other study limitations, necessitate that a subsequent prospective multicenter study be undertaken before any definitive conclusions can be made.     

The effect of celiac plexus block on heart rate variability

Background

Celiac plexus block (CPB) can be used for treating intra-abdominal visceral pain syndromes. The celiac plexus is the largest plexus of the sympathetic nervous system. Several nerve blocks have a marked effect on autonomic nervous activity. Furthermore, stellate ganglion block changes cardiac autonomic nervous activity. Thus, CPB could influence the sympathetic activity of the cardiac plexus. The aim of the present study was to see whether CPB modulated heart rate variability (HRV) in patients with pancreatic cancer.

Methods

Twelve patients received neurolytic CPB using 14 ml absolute alcohol. Data recorded in a palm-sized electrocardiographic unit were analyzed for HRV.

Results

CPB using a neurolytic solution did not induce any significant changes in the low-frequency (LF)/high-frequency (HF) ratio of HRV (LF/HF, P = 0.4642). Furthermore, the procedure did not induce any significant changes in blood pressure (systolic, P = 0.5051; diastolic, P = 0.5180).

Conclusion

CPB did not induce any significant changes in HRV or hemodynamics.     

Prothrombin Complex Concentrate Versus Fresh-Frozen Plasma for Reversal of Coagulopathy of Trauma: Is There a Difference?

Introduction

The development of coagulopathy of trauma is multifactorial associated with hypoperfusion and consumption of coagulation factors. Previous studies have compared the role of factor replacement versus FPP for reversal of trauma coagulopathy. The purpose of our study was to determine the time to correction of coagulopathy and blood product requirement in patients who received PCC+FFP compared with patients who received FFP alone.

Methods

We performed a retrospective analysis of a prospectively maintained database of all coagulopathic (INR ≥ 1.5) trauma patients presenting to our level I trauma center during a 2-years period (2011–2012). Patients were stratified into two groups: patients who received PCC+FFP and patients who received FFP alone. Patients in the two groups were matched in a 1:3 (PCC+FFP:FFP) ratio using propensity score matching for demographics, injury severity, vital parameters, and initial INR. The two groups were then compared for: correction of INR, time to correction of INR, thromboembolic complications, mortality, and cost of therapy.

Results

A total of 252 were included in the analysis [PCC+FFP:63; FFP:189]. The mean age was 44 ± 20 years; 70 % were male, with a median ISS score of 27 [16–38]. PCC use was associated with an accelerated correction of INR (394 vs. 1,050 min; p 0.001), reduction in requirement of pack red blood cell (6.6 vs. 10 units; p 0.001) and FFP (2.8 vs. 3.9 units; p 0.01), and decline in mortality (23 vs. 28 %; p 0.04). PCC+FFP use was associated with a higher cost of therapy ($1,470 ± 845 vs. 1,171 ± 949; p 0.01) but lower overall cost of transfusion ($7,110 ± 1,068 vs. 9,571 ± 1,524; p 0.01) compared with FFP therapy alone.

Conclusions

PCC in conjunction with FFP rapidly corrects INR in a matched cohort of trauma patients not on warfarin therapy compared with FFP therapy alone. The use of PCC as an adjunct to FFP therapy is associated with reduction of blood product requirement and also lowers overall cost.     

STT arthrodesis versus proximal row carpectomy for Lichtman stage IIIB Kienb?ck’s disease: first results of an ongoing observational study

Introduction

Scapho-trapezial-trapezoidal (STT) arthrodesis and proximal row carpectomy (PRC) are used for the treatment of Lichtman stage IIIB Kienb?ck’s disease. This study prospectively compares 1-year results of STT arthrodesis and PRC in Lichtman stage IIIB Kienb?ck’s disease.

Materials and methods

Nineteen patients were operated: eight with STT arthrodesis and 11 with PRC. Preoperatively and 1-year postoperatively, mobility and grip strength were examined. Both DASH and Mayo Wrist Scores were obtained from the patients.

Results

In the STT arthrodesis group, mean extension/flexion worsened from 54 to 39?% of the opposite hand. Grip strength improved from 52.9 to 62.1?%. The DASH Score improved from 32.6 to 21.4, and the Mayo Wrist Score from 50.6 to 57.9. In the PRC group, extension/flexion decreased from 62.5 to 57.0?% of the opposite hand. Grip strength improved from 38.6 to 69.0?%, the DASH Score from 36.7 to 18.9, and the Mayo Wrist Score from 54.6 to 66.0.

Conclusion

One year after operation, slightly better results were observed in patients with PRC compared to STT arthrodesis.     

Exakte Messung des Volumeneffektes von 6%iger Hydroxyethylstärke 130/0,4 (Voluven®) während präoperativer akuter normovolämer Hämodilution

Background

What is the effect of preoperative acute normovolemic hemodilution (ANH) with 6% hydroxyethyl starch (HES) 130/0.4 (Voluven^®) on blood volume?

Methods

In 10 patients undergoing radical hysterectomy, ANH was performed to a hematocrit of 21% using 6% HES 130/0.4 (Voluven^®) whereby a replacement of blood with 115% of colloid was planned. Plasma volume (indocyanine green dilution technique) and hematocrit were determined before, 30 and 60 min after ANH. Red cell volume (labelling erythrocytes with fluorescein) was determined before and 30 min after ANH.

Results

After removal of 1,431±388 ml of blood and simultaneous replacement with 1,686±437 ml of colloid, blood volumes were 218±174 ml higher than before (at 105±4%). The volume effect was 98±12%, 30 min after ANH. Even 60 min after ANH, mean blood volumes were with 4,228±986 ml slightly higher than before ANH (102±5%). The hematocrit decreased disproportionally in relation to the residual intravascular volume. Consequently, estimating the volume effect from the changes in hematocrit led to an overestimation (about +30%).

Conclusion

Double label measurements of blood volume demonstrated that the volume effect of 6% HES 130/0.4 (Voluven^®) is about 100% in the course of ANH. The reason for the disproportionally large decrease in hematocrits could be the mobilization of a fraction of the plasma volume which was retained within the endothelial glycocalyx.     

Population pharmacokinetics of olprinone in patients undergoing cardiac surgery with cardiopulmonary bypass

Purpose

Olprinone, a phosphodiesterase type III inhibitor, is a strong inotrope and vasodilator that does not increase oxygen consumption and is often used during weaning from cardiopulmonary bypass (CPB). To control the pharmacological effects of olprinone, pharmacokinetic information is essential; however, there is little published information on the pharmacokinetics of olprinone in a large population. Therefore, the purpose of this study was to determine olprinone pharmacokinetic parameters in a large population undergoing cardiac surgery with CPB.

Methods

Olprinone was infused at a rate of 0.2 μg/kg/min when weaning from CPB was started. Whole blood samples were periodically obtained to determine the olprinone concentrations using high-performance liquid chromatography. Measured olprinone concentrations were analyzed with a one-compartment model via a population approach.

Results

A total of 86 blood samples from 26 patients were used for pharmacokinetic analysis. The calculated clearance, volume of distribution (V _d), and elimination half-life were 378 ml/min, 40.7 l, and 97.1 min, respectively. Olprinone clearance depended on weight and creatinine clearance, whereas V _d depended only on weight.

Conclusion

We investigated the pharmacokinetic parameters of olprinone in patients undergoing cardiac surgery with CPB. Olprinone clearance depended on weight and creatinine clearance, whereas V _d depended only on weight. When olprinone is infused according to the recommended dosing regimen, it takes more than 60 min to reach the target concentration (20 ng/ml). However, there is a possibility that a lower concentration is sufficient for weaning from CPB in combination with a continuous infusion of dopamine.     

Continuous haemodiafiltration during and after cardiopulmonary bypass in renal failure patients

Purpose

Continuous haemodiafiltration (CHDF) is a technique enhancing the efficiency of solute clearance of continuous haemofiltration by infusing dialysis fluid through the haemofilter. It has been reported to control water and electrolyte balance continuously without haemodynamic instability in critically ill patients with renal failure. Therefore, we used CHDF during and after cardiopulmonary bypass (CPB) in two renal failure patients, and discuss its efficacy.

Clinical features

The first patient undergoing aortic valve replacement had dialysis-dependent renal failure. Chronic renal failure in the second patient undergoing mitral valve replacement and coronary revasculanzation was controlled preoperatively with diuretics. In both cases, CHDF was performed not only during CPB but also in the post-CPB period. Serum concentrations of potassium, urea and creatmine were well-controlled in spite of large amount of blood transfused in the post-CPB penod (1000 ml fresh blood and 400 ml fresh frozen plasma in the fist patient, and 1400 ml fresh blood in the second patient). There was no difficulty in haemostasis dunng the use of nafamostat mesilate as an anticoagulant to keep activated clotting time at about 150 sec for CHDF in the post-CPB period.

Conclusion

Our initial expenences of CHDF dunng and after CPB suggest that the technique provides excellent electrolyte, metabolite and fluid management for the cardiac patients with chronic renal failure. Combined with nafarnostat mesilate for anticoagulation, CHDF was simple and safe and did not increase the nsk of bleeding.     

Effect of low volume ventilation during cardiopulmonary bypass on oxygenation and postoperative pulmonary outcome

Objective

This study was carried out to evaluate effect of low volume normal frequency ventilation during Cardiopulmonary Bypass (CPB) on immediate postoperative respiratory outcome in patients undergoing elective open heart surgeries.

Background

Lung deflation during CPB is considered as major cause of postoperative pulmonary dysfunction. Various methods of ventilation had been tried during CPB to prevent postoperative lung dysfunction. As yet, little information is available comparing low volume normal frequency ventilation with no ventilation during CPB.

Patients and Methods

Thirty six patients aged 18 years to 65 years were included and randomized into two groups; Group V (n?=?18) or Group NV (n?=?18). Group V patients were ventilated with a tidal volume of 2 mL?kg^?1with 100 % oxygen during CPB after aortic clamp placement, and respiratory rate was continued as per pre CPB period. Ventilation was discontinued in NV group after aorta was cross clamped. Normal ventilation was restored in both groups after release of aortic clamp.

Results

Intraoperative PaO₂ and PaCO₂ were similar in both groups. The group V patients had improved inspiratory capacity (p?=?0.0) in both day 1 (after extubation) and day 2 (24 h after extubation). Extubation was significantly earlier in group V patients (p?<?0.05).

Conclusion

Low volume normal frequency ventilation during cardiopulmonary bypass improves lung mechanics during early postoperative period in patients undergoing open heart surgery.     

The effect of hemodilution by cardiopulmonary bypass on protein binding of olprinone

Purpose

Olprinone is a phosphodiesterase type III inhibitor that is often used to increase cardiac output after cardiopulmonary bypass (CPB). Hemodilution by CPB is likely to decrease total olprinone concentration, but it may also increase the free (unbound) concentration of olprinone due to reduced protein binding. The aim of this study was to investigate the effect of hemodilution on the protein binding of olprinone.

Methods

Eleven patients scheduled for elective cardiac surgery with CPB were enrolled in our study. Olprinone was continuously infused at a rate of 0.2 μg/kg/min from the time of the first surgical incision until the patient arrived at the recovery unit. Protein binding was evaluated twice, just before the start of CPB and at the beginning of withdrawal from CPB. Olprinone concentration and protein binding were determined with high-performance liquid chromatography and ultrafiltration methods, respectively. Olprinone protein binding was also evaluated in vitro.

Results

Olprinone protein binding to albumin was 63 % in vitro, but it did not bind to alpha-1 acid glycoprotein. Olprinone protein binding in patients before CPB was 81.5 ± 4.3 %, whereas protein binding at withdrawal from CPB was 63.3 ± 14.3 %.

Conclusions

Unbound olprinone concentration increased by 20 % during CPB, which suggests that the pharmacological effects of olprinone might be enhanced during and after CPB. Close hemodynamic monitoring is necessary to control the effects of olprinone after CPB, because CPB alters olprinone’s pharmacokinetics.     

Actions of osteoporosis treatments on bone histomorphometric remodeling: a two-fold principal component analysis

Summary

This was the first study to apply principal component analysis method to bone histomorphometric parameters. The results corroborated teriparatide’s distinct, yet different, mechanisms of action, which stimulate both bone formation and resorption.

Introduction

This study consolidated bone histomorphometric parameters and compared the effects of two osteoporosis treatments on bone remodeling by using a principal component analysis (PCA).

Methods

Included in this analysis were postmenopausal women with osteoporosis who were treated with either teriparatide or alendronate and who completed transiliac bone biopsy at either 6 or 18 months in the randomized, double-blind Forteo Alendronate Comparator Trial. Eighteen histomorphometric parameters were grouped into formation and resorption categories. The first principal component of each category was estimated through the PCA. The summation of principal formation component (PFC) and principal resorption component (PRC) was calculated to represent the overall level of bone turnover. The difference between PFC and PRC was computed to determine the balance between formation and resorption.

Results

The PFC was significantly higher in the teriparatide group than in the alendronate group (P?<?0.0001), while the PRC was numerically lower in the alendronate group (P?=?0.18). The mean difference between the PFC and PRC was positive in the teriparatide group and negative in the alendronate group.

Conclusions

Our approach of consolidating bone histomorphometric remodeling parameters corroborated the idea that the distinct, yet different, mechanisms of action of teriparatide treatment stimulate both bone formation and resorption, and alendronate treatment suppresses both bone formation and resorption.     

Role of Factor VII in Correcting Dilutional Coagulopathy and Reducing Re-operations for Bleeding Following Non-traumatic Major Gastrointestinal and Abdominal Surgery

Objective

The objective of this study is to evaluate the effectiveness of rfVIIa in reducing blood product requirements and re-operation for postoperative bleeding after major abdominal surgery.

Background

Hemorrhage is a significant complication after major gastrointestinal and abdominal surgery. Clinically significant bleeding can lead to shock, transfusion of blood products, and re-operation. Recent reports suggest that activated rfVIIa may be effective in correcting coagulopathy and decreasing the need for re-operation.

Methods

This study was a retrospective review over a 4-year period of 17 consecutive bleeding postoperative patients who received rfVIIa to control hemorrhage and avoid re-operation. Outcome measures were blood and clotting factor transfusions, deaths, thromboembolic complications, and number of re-operations for bleeding.

Results

Seventeen patients with postoperative hemorrhage following major abdominal gastrointestinal surgery (nine pancreas, four sarcoma, two gastric, one carcinoid, and one fistula) were treated with rfVIIa. In these 17 patients, rfVIIa was administered for 18 episodes of bleeding (dose 2,400-9,600 mcg, 29.8-100.8 mcg/kg). Transfusion requirement of pRBC and FFP were each significantly less than pre-rfVIIa. Out of the 18 episodes, bleeding was controlled in 17 (94%) without surgery, and only one patient returned to the operating room for hemorrhage. There were no deaths and two thrombotic complications. Coagulopathy was corrected by rfVIIa from 1.37 to 0.96 (p?<?0.0001).

Conclusion

Use of rfVIIa in resuscitation for hemorrhage after non-traumatic major abdominal and gastrointestinal surgery can correct dilutional coagulopathy, reducing blood product requirements and need for re-operation.     

Results of cardiac surgery in advanced liver cirrhosis

Purpose

Cardiac surgery for the patients with advanced liver cirrhosis is still challenging. High mortality has been reported in the literature. We evaluate the clinical outcome of cardiac surgery in patients with advanced liver cirrhosis.

Methods

Patients with advanced liver cirrhosis who underwent cardiac surgery between October 1999 and April 2009 were reviewed. The severity of liver cirrhosis was assessed using Child-Pugh class, Child-Pugh score, and MELD score. Advanced liver cirrhosis was defined as Child-Pugh class B or C. Cardiopulmonary bypass (CPB) was carried out at higher flow rate (2.4–3.2 L/min/m²), and hematocrit (25–30 %). Moderate and more tricuspid regurgitation were aggressively treated. Dilutional ultrafiltration was performed at the termination of CPB.

Results

Eighteen patients (mean age 70 years, male:female = 14:4) were identified. Twelve patients had hepatitis virus infection and 6 cases were alcohol-related. Fourteen patients were graded as Child-Pugh class B and 4 in class C. Seventeen patients underwent cardiac surgery with the use of cardiopulmonary bypass, and 1 patient underwent off-pump coronary artery bypass surgery. The overall mortality rate was 17 % (3 of 18). The cause of death was liver failure, esophageal variceal bleeding and bacteremia. The mortality of redo surgery was high (50 %). The incidence of postoperative liver failure was 11 % (2 of 18). Child-Pugh class or score was not correlated with hospital mortality. MELD score was significantly higher in hospital mortality (10.8 ± 4.0 vs. 17.3 ± 2.1, p = 0.001).

Conclusions

Although the mortality of redo surgery was high, cardiac surgery could be safely performed in selected patients with advanced liver cirrhosis.     

Morbidity and mortality after autotransfusion following open heart surgery

Background

The technique of ‘blood pooling’ before the onset of cardiopulmonary bypass (CPB) has been shown to be beneficial as a single technique in patients having elective open heart surgery. We sought to more clearly evaluate the role of intra-operative autologous donation also known as acute normovolemic haemodilution in open heart surgery.

Methods

The study was conducted in the Department of Cardiothoracic and Vascular Surgery, King George’s Medical University, Lucknow, India, in patients who underwent open heart surgery under cardiopulmonary bypass. Autologous blood transfusion was used in all the patients who underwent surgery on CPB since August 2009. Patients were divided into two groups: group I (study group)—patients operated between August 2009 and December 2011 and who received autologous blood and group II (control)—those operated before August 2009 and who did not receive autologous blood transfusion.

Results

The post-operative haemoglobin and coagulation profile measured on the first post-operative day differed significantly between the two groups. Intensive care unit (ICU) stay, hospital stay, inotropic support and ventilatory support were significantly less in group 1. Mediastinal drainage was found to be significantly higher in the control group compared to the study group. The mean volume of packed red blood cell, fresh frozen plasma and platelet units transfused per patient in the study group were significantly less than the control group.

Conclusion

The use of intra-operative autologous blood donation and transfusion improves haemostasis, decreases the post-operative blood loss and improves the post-operative outcome in terms of intensive care unit stay, hospital stay, morbidity and mortality.     

Plasma lipid concentrations correlate inversely with CPB-induced interleukin-6 release

Purpose

Cardiopulmonary bypass (CPB) is characterized by translocation of intestinal endotoxin and subsequent endogenous production of the pro-inflammatory cytokine interleukin-6 (IL-6). Plasma lipid fractions, especially high density lipoproteins, bind and neutralize endotoxin and, therefore, inhibit endotoxin-induced macrophage cytokine production, including IL-6. Increased IL-6 plasma levels have been implicated in adverse consequences associated with CPB. Previous studies demonstrated large interpatient variability in IL-6 plasma levels after CPB. The purpose of this study was to evaluate the relationship between plasma lipid concentrations and the concentrations of IL-6 following CPB in humans.

Methods

In a prospective study, a group of 15 patients selected to exclude variables known to influence post-CPB plasma levels of IL-6 (preoperative left ventricular ejection fraction > 45%, similar durations of aortic cross clamping and total CPB time, similar temperature control during CPB, and avoidance of platelet transfusion and shed mediastinal blood re-infusion), IL-6 was measured at baseline, one and 24 hr post-CPB.

Results

Interleukin-6 plasma concentrations (mean ± SD) increased at one (142 ± 89 pg·ml^?1,P < 0.05) and 24 (129 ± 82 pg·ml^?1,P < 0.05) hr post-CPB compared with baseline (1,5 ± 1 pg·ml^?1) concentrations. An inverse correlation was found between IL-6 plasma concentrations at one hour post-CPB and plasma cholesterol concentrations (r = -0.592,P = 0.02), high density lipoprotein (r = -0.595,P = 0.02), and low density lipoprotein (r = -0.656,P = 0.01).

Conclusions

These results suggest that plasma lipids attenuate the production of IL-6 during CPB and may partly explain the variability of interpatient levels of IL-6 reported post-CPB by others.