Recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery.

Intractable bleeding unresponsive to conventional haemostatic measures is an uncommon but potentially life threatening surgical complication. Several studies have suggested that recombinant factor VIIa (rVIIa), a genetically engineered substitute for endogenous factor VIIa may have therapeutic application in patients with uncontrollable haemorrhage not previously diagnosed with coagulopathy. We report our experience of rVIIa use in eight such vascular surgery patients who developed life-threatening non-surgical haemorrhage either intra-operative or post-operatively. In all but one patient a marked clinical improvement was noted following treatment with rVIIa with significantly less transfusion, and obvious haemostasis associated with haemodynamic stability without adverse thrombotic complications.     

Increased recombinant activated factor VII use and need for surgical reexploration following a switch from aprotinin to epsilon-aminocaproic acid in infant cardiac surgery

Study ObjectiveTo evaluate whether conversion from aprotinin to epsilon-aminocaproic acid (EACA) during infant cardiac surgery was associated with increased perioperative bleeding.DesignStructured retrospective chart review.SettingUniversity-affiliated large congenital cardiac surgery program.MeasurementsRecords from 145 infants (age < 1 yr) receiving aprotinin as antifibrinolytic therapy for cardiac surgery between 6/1/2006 and 12/31/2006 were compared with a cohort of infants receiving EACA for cardiac surgery between 6/1/2008 and 12/31/2008. Sixty-eight infants received aprotinin and 77 infants received EACA. Measured indicators of perioperative bleeding included transfusion volumes, recombinant activated clotting factor VIIa (rFVIIa) administration, need for reexploration, and perioperative chest tube output.Main ResultsEACA treated patients received significantly more rFVIIa for uncontrolled bleeding (19/77 [25%] vs 3/68 [4%]; P < 0.001) and required surgical reexploration more frequently (21/77 [27%] vs 7/68 [10%]; P = 0.01]. Median (25th-75th percentiles) intraoperative platelet transfusion requirements were also increased after the switch to EACA (28 mL [0-58 mL] vs 0 mL [0 mL - 34.5 mL]), but this difference did not reach statistical significance (P = 0.06).ConclusionsBleeding in infant cardiac surgery increased following the change in antifibrinolytic therapy from aprotinin to EACA. Given the potential for major harm, especially thrombotic complications, from rFVIIa use, prospective studies examining the safety of postcardiopulmonary bypass rFVIIa administration in infants are necessary before the routine off-label use may be recommended.     

体外膜式氧合在冠心病外科治疗中的临床应用

目的 探讨冠状动脉粥样硬化性心脏病(冠心病)心脏手术后应用体外膜式氧合(ECMO)进行支持治疗的效果.方法 2004年6月至2006年11月,对16例冠心病心脏手术后需要心肺支持的患者进行ECMO辅助治疗.全组患者男14例,女2例,平均年龄(58±11)岁.体外循环下手术13例,非体外循环手术3例.记录术后ECMO辅助时间、监护室停留时间、并发症及转归等.结果 ECMO平均辅助时间51 h.监护室平均停留时间5 d.13例患者顺利撤除ECMO,脱机率为81.3%;10例生存出院,出院生存率为62.5%.主要并发症有出血(18.8%)、感染(37.5%)、肾功能不全(25%)及下肢缺血(18.8%)等.结论 ECMO辅助能有效治疗冠心病心脏手术后发生的心功能障碍.     

Open abdomen during extracorporeal membrane oxygenation is a safe and effective treatment for abdominal compartment syndrome

Background/PurposeDecompressive laparotomy and open abdomen for abdominal compartment syndrome have been historically avoided during Extracorporeal Membrane Oxygenation (ECMO) due to seemingly elevated risks of bleeding and infection. Our goal was to evaluate a cohort of pediatric respiratory ECMO patients who underwent decompressive laparotomy with open abdomen at a single institution and to compare these patients to ECMO patients without open abdomen.MethodsWe reviewed all pediatric respiratory ECMO (30 days-18 years) patients treated with decompressive laparotomy with open abdomen at Riley Hospital for Children (1/2000–12/2019) and compared these patients to concurrent respiratory ECMO patients with closed abdomen. We excluded patients with surgical cardiac disease. We assessed demographics, ECMO data, and outcomes and defined significance as p = 0.05.Results6 of 81 ECMO patients were treated with decompressive laparotomy and open abdomen. Open and closed abdomen groups had similar age (p = 0.223) and weight (0.286) at cannulation, but the open abdomen group had a higher reliance on vasoactive medications (Vasoactive Inotropic Score, p = 0.040). Open abdomen group survival was similar to closed abdomen patients (66.7%, vs 62.7%, p = 1). Open abdomen patients had lower incidence of ECMO complications (33.3% vs 83.6%, p = 0.014), but the groups had similar bleeding complications (p = 0.412) and PRBC transfusion volume (p = 0.941).Conclusion/ImpactPediatric ECMO patients with open abdomen after decompressive laparotomy had similar survival, blood products administered, and complications as those with a closed abdomen. An open abdomen is not a contra-indication to ECMO support in pediatric respiratory patients and should be considered in select patients.     

Extracorporeal membrane oxygenation after cardiac surgery in 12 patients with cardiogenic shock

ObjectivesMortality is high when cardiogenic shock develops after cardiotomy, making it impossible to discontinue extracorporeal circulation and/or leading to low postoperative cardiac output that is refractory to treatment with vasoactive drugs or implantation of an intra-aortic balloon pump. Extracorporeal membrane oxygenation (ECMO) provides temporary assisted circulation, lending hemodynamic and respiratory support to the patient with cardiogenic shock in order to prevent multiple organ failure and death.Material and methodsFor this retrospective study of cases in which ECMO was applied in our hospital’s assisted circulation unit, we analyzed demographic data, indication, score on the European system for cardiac operative risk evaluation (Euroscore), duration of assistance, complications, and survival.ResultsIn the first 3 years after the assisted circulation unit was established, during which 1375 cardiac interventions took place, ECMO was used postoperatively in 12 patients (0.87%). In 8 of the patients, assistance was provided during cardiac surgery following cardiotomy and in 4 transplant patients it was used following primary graft failure. The mean (SD) patient age was 56.8 (9.1) years. The Euroscore predicted 37.3% (16.7%) of the deaths. ECMO was used for a mean of 5.4 (2.5) days. The most frequent complications were bleeding in the surgical area, cardiac tamponade, and acute renal insufficiency. Overall in-hospital mortality was 50%, lower than rates reported in the literature.ConclusionsECMO provided viable temporary support, maintaining adequate cardiac output while the patient’s condition could be observed and heart function evaluated. Mortality was reduced.     

Predictors of Acute Renal Failure During Extracorporeal Membrane Oxygenation in Pediatric Patients After Cardiac Surgery

Acute renal failure (ARF) is associated with increased mortality in pediatric extracorporeal membrane oxygenation (ECMO). The aim of this study was to identify predictors of ARF during ECMO in pediatric patients after cardiac surgery. A retrospective study analyzed 42 children (≤15 years) after cardiac surgery requiring venous‐arterial ECMO between December 2008 and December 2014 at Fuwai Hospital. ARF was defined as ≥300% rise in serum creatinine (SCr) concentration from baseline or application of dialysis. Multivariate logistic regression was performed to identify the predictors of ARF during ECMO. A total of 42 children (age, interquartile range [IQR], 13.0 [7.2–29.8] months; weight, IQR, 8.5 [6.7–11.0] kg) after cardiac surgery requiring ECMO were included in this study. The total survival rate was 52.4%, and the incidence of ARF was 40.5%. As the result of univariate analysis, ECMO duration, cardiopulmonary resuscitation, maximum free hemoglobin (FHB) during ECMO, lactate level, and mean blood pressure before initiation of ECMO were entered in multiple logistic regression analysis. In multiple logistic regression analysis, FHB during ECMO (OR 1.136, 95% CI 1.023–1.261) and lactate level before initiation of ECMO (OR 1.602, 95% CI 1.025–2.502) were risk factors for ARF during ECMO after pediatric cardiac surgery. There was a linear correlation between maximum SCr and maximum FHB (Pearson's r = 0.535, P = 0.001). Maximum SCr during ECMO has also a linear correlation with lactate level before initiation of ECMO (Pearson's r = 0.342, P = 0.044). Increased FHB during ECMO and high lactate level before initiation of ECMO were risk factors for ARF during ECMO in pediatric patients after cardiac surgery.     

Use of thromboelastography in children on extracorporeal membrane oxygenation

IntroductionExtracorporeal membrane oxygenation (ECMO) profoundly impacts inflammatory and coagulation pathways, and strict monitoring is essential to guide therapeutic anticoagulation. Thromboelastography (TEG) offers a global evaluation of whole blood hemostatic system components and may be a valuable measurement of hemostatic function in these patients. There is a paucity of data correlating TEG parameters with standard measures of coagulation in heparinized pediatric patients.MethodsChildren on ECMO during a 10-year period were retrospectively reviewed. Standard measures of coagulation were matched to TEGs drawn within 30 min of each other.ResultsOut of 296 unique patients with 331 ECMO runs, 74.3% (n = 246) had at least one set of matched laboratory samples for a total of 2502 matched samples. The aPTT correlated with R-time (p<0.001). Platelets and fibrinogen correlated with α-angle (p<0.001). Fibrinogen (p<0.001) and platelets (p<0.001) were each associated with maximum amplitude (MA). 158 (47.7%) patients had at least one bleeding complication, and 100 (30.2%) had at least one thrombotic complication. Interestingly, a decreasing MA was associated with increased thrombotic complications (p<0.001).DiscussionTEG correlated well with traditional measures of hemostasis in pediatric ECMO patients. However, there was not a clear benefit of the TEG over these other measuresLevel of evidenceIII.     

Five-year results of 121 consecutive patients treated with extracorporeal membrane oxygenation at Fu Wai Hospital

Since 2004, our institution has adopted venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for patients who otherwise could not be weaned from cardiopulmonary bypass and patients experiencing cardiogenic shock and/or pulmonary dysfunction unresponsive to conventional treatments. In this study, we reviewed our experience with ECMO support and tried to identify predictors of in-hospital mortality. We retrospectively analyzed the clinical records of 121 consecutive patients receiving ECMO. Patients were divided into adult and pediatric groups and analyzed separately. Demographics, clinical characteristics at the time of ECMO implantation, ECMO-related complications, and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A P value ≤ 0.05 was accepted as significant. Sixty-eight adult patients and 53 pediatric patients were included in this study. In adult patients, 52 were weaned from ECMO and 43 survived upon discharge. After univariate analysis, ECMO setup location, receiving cardiopulmonary resuscitation before ECMO, leg ischemia, hemolysis, acute renal failure (ARF), neurological dysfunction, and multiple organ dysfunction syndrome were associated with in-hospital death. In multiple logistic regression analyses, leg ischemia (OR 14.68, 95% CI 1.67-129.1), ARF (OR 12.14, 95% CI 2.5-58.8), and neurological dysfunction (OR 49.0, 95% CI 2.28-1051.96) were risk factors associated with in-hospital mortality. Patients put on ECMO in the operating room had a better chance of survival (OR 0.078, 95% CI 0.013-0.417). In pediatric patients, 30 were weaned from ECMO and 26 survived upon discharge. After univariate analysis, age, weight, and eight ECMO complications were associated with in-hospital death. In multiple logistic regression analyses, ARF (OR 24.0, 95% CI 4.2-137.3) was a risk factor associated with in-hospital mortality. A P value of 0.921 and >0.99 was obtained by the Hosmer-Lemeshow test, and the area under the curve was 0.863 and 0.867 for adult and pediatric patients, respectively. The overall survival rate was 57%. ECMO is a justifiable alternative treatment for refractory cardiac and/or pulmonary dysfunction which could rescue more than 50% of carefully selected patients. Higher survival rates could be achieved by preventing ECMO complications.     

rFVIIa in the treatment of persistent hemorrhage in pediatric patients on ECMO following surgery for congenital heart disease

BACKGROUND: Patients who require extracorporeal membrane oxygenation (ECMO) postsurgery for congenital heart disease (CHD) frequently experience severe bleeding episodes. Whereas recombinant-activated factor VII (rFVIIa) has proven efficacy in counteracting intractable hemorrhage in various scenarios, its use in patients on ECMO is limited by the increased risk for thrombotic events. METHODS: Between December 2004 and January 2006, ECMO was used in 10 pediatric patients following cardiac surgery, of whom seven were treated with rFVIIa because of intractable hemorrhage. Their medical records were reviewed with respect to variations in chest tube output and transfusion requirements, occlusion of or thrombus formation in the ECMO circuit and the occurrence of thromboembolic events. Outcome and rate of ECMO circuit occlusion were compared with historic controls. RESULTS: Three patients died, and four survived (none of the deaths was attributable to thrombus formation or bleeding). All patients were treated with aprotinin prior to and during rFVIIa therapy. Two patients developed an occlusion of the oxygenator, one after receiving co-medication with a FXIII concentrate, another after RBC transfusion in the ECMO system. In two patients, thrombus formation was observed in the ECMO system on inspection after discontinuation. Thromboembolic events were not observed. CONCLUSIONS: Recombinant-activated factor VII in a median dosage of 90 microg.kg(-1) was used in seven pediatric patients on ECMO. Rates of ECMO system occlusions and mortality did not differ from historic controls. Neither the reduction of chest tube output nor the blood product transfusion requirements did reach statistical significance.     

Utilisation du facteur VIIa en cas d’hémorragie réfractaire sous ECMO centrale veino-artérielle

Objective

The purpose of our study is to describe the use of recombinant factor VIIa (rFVIIa) in patients on central veno-arterial ECMO with a particular attention on associated thrombotic complications.

Study design

Monocentric retrospective study.

Patients and methods

We examined 91 files of patients on ECMO between 2005 and 2010. During this period, eight patients presented refractory bleeding and benefited from rFVIIa treatment.

Results

In six of the eight patients, the bleeding stopped. A decrease of the bleeding was noticed after the treatment of rFVIIa (before rFVIIa: 40.1 ± 33.1 mL/kg per 3 hours after rFVIIa: 5.4 ± 3.2 mL/kg per 3 hours (P = 0.01). The transfusional needs were decreased after administration of rFVIIa. No thrombotic event was detected. Fibrinogen, d-dimers, platelet count and lactate were not modified by the treatment. Two patients were weaned from ECMO. One patient died 17 days after the weaning. The other patient survived without neurological damages.

Conclusion

The rFVIIa is a treatment of exception for patients on central veno-arterial ECMO and could be a last-resort treatment in the presence of a not curable massive bleeding.     

Heparin-free management of intra-aortic balloon pump after cardiac surgery

Abstract Background : Anticoagulation with heparin is recommended in patients with an intra‐aortic balloon pump (IABP) to prevent thrombosis and embolization. However, anticoagulation increases the risk of bleeding, particularly in the early postoperative period after cardiac surgery. We investigated the safety of heparin‐free management after IABP insertion in patients who underwent cardiac surgery. Methods : We studied 203 consecutive patients who received perioperative IABP support between August 2004 and December 2011. All patients were managed without heparin and were followed for thrombotic and/or hemorrhagic complications. Results : Patients were divided into two groups, according to time of IABP treatment following surgery. Group I, 81 patients (39.9%) were treated less than 24 hours following surgery and Group II, 122 patients (60.1%) were treated more than 24 hours following surgery. Vascular complications developed in seven patients (3.4%), two in Group I and five in Group II. Three patients had major and four had minor limb ischemia. There were no major bleeding complications, but minor bleeding complications were observed in eight patients (4.2%). Conclusion : In patients undergoing cardiac surgery with IABP support, the rate of thromboembolic complications was relatively low compared to historical controls. Heparin‐free management may reduce the risk of hemorrhagic complications, with a low risk of thrombotic complications. Heparin should not be routinely used in patients requiring IABP after cardiac surgery. (J Card Surg 2012;27:434‐437)     

Extracorporeal membrane oxygenation in pediatric cardiac transplantation

Background

We reviewed a single institution experience with extracorporeal membrane oxygenation (ECMO) in the perioperative management of cardiac transplantation.

Methods

Of all pediatric cardiac transplant candidates (1984-2003), patients requiring ECMO pretransplantation/posttransplantation were identified, with particular attention to use of ECMO as a bridge to transplantation. Parameters reviewed included proportionate survival, incidence of pre-ECMO cardiac arrest, ECMO duration, and United Network for Organ Sharing list time.

Results

Three hundred patients were listed for transplantation. Twenty-nine required ECMO: 18 pretransplant, 3 pretransplant and posttransplant, 6 posttransplant, and 2 for delayed acute rejection. There were 21 bridge-to-transplant candidates, of which 10 eventually transplanted with 60% survival; 11 not transplanted had no survivors (P = .004). Thirteen of 21 had cardiac arrest pre-ECMO with 1 (8%) survivor; 8 of 21 had no arrest with 5 (63%) survivors (P = .014). Mean ECMO duration and United Network for Organ Sharing list times between transplanted and not transplanted were not significant. Nine received ECMO posttransplantation for cardiopulmonary support; 5 (56%) of 9 survived. Two patients supported with ECMO for rejection-related cardiovascular collapse survived.

Conclusion

ECMO can bridge children to cardiac transplantation. Survival is significantly impaired in bridge-to-transplant candidates stratified by pre-ECMO cardiac arrest. ECMO can also help transition from cardiopulmonary bypass after transplantation and provide effective support during acute rejection.     

Extracorporeal Life Support After Cardiac Surgery in Children: Outcomes From a Single Institution

Extracorporeal life support (ECLS) is used after congenital heart surgery for several indications, including failure to separate from cardiopulmonary bypass, postoperative low cardiac output syndrome, and extracorporeal cardiopulmonary resuscitation. Here, we assessed the outcomes of ECLS in children after cardiac surgery at our institution. Medical records of all children who required postoperative ECLS at our institution were reviewed. Between 2003 and 2011, 36 (1.4%) of 2541 pediatric cardiac surgical cases required postoperative ECLS. Median age of patients was 64 days (range: 0 days–4.1 years). ECLS was in the form of either extracorporeal membrane oxygenation (ECMO; n = 24) or ventricular assist system (VAS; n = 12). Mean duration of ECLS was 4.9 ± 4.2 days. Overall, 21 patients (58%) were weaned off ECLS, and 17 patients (47%) were successfully discharged from the hospital. Patients with biventricular heart (BVH) had higher survival‐to‐hospital discharge rates compared with those with univentricular heart (UVH) (P = 0.019). Regarding ECLS type, UVH patients who received VAS showed higher rates of device discontinuation than UVH patients who received ECMO (P = 0.012). However, rates of hospital discharge were not significantly different between UVH patients who received VAS or ECMO. Surgical interventions, such as banding of Blalock–Taussig shunt to reduce pulmonary blood flow or placing bidirectional cavopulmonary shunt to minimize ventricular volume overload, were effective for weaning off ECLS in patients with UVH. ECLS is beneficial to children with low cardiac output after cardiac surgery. Rates of survival‐to‐hospital discharge were higher in BVH patients than UVH patients. Additional interventions to reduce ventricular volume load may be effective for discontinuing ECLS in patients with UVH.     

Is recombinant activated factor VII useful for intractable bleeding after cardiac surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether use of Recombinant Activated Factor VII could help haemostasis for intractable bleeding, and decrease blood or blood product requirements in patients undergoing cardiac surgery without excessive risk from thrombosis. Altogether 129 papers were identified using the reported search strategy of which 13 represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that Factor VIIa has proven efficacy and safety in over 400,000 uses worldwide outside the cardiothoracic surgical arena, mostly in haemophiliacs. Results from this experience show a 1% risk of serious thrombotic complications. In the cardiothoracic literature, there have been more than 160 reports of its use for intractable bleeding and the serious complication rate is again around 1-2%. In addition, it has been found to be highly efficacious in 80-90% of cases with a single dose of 60-90 mug/kg, which can be repeated after 2-4 h. Thus, for patients with intractable bleeding post cardiac surgery refractory to conventional haemostatic interventions, Factor VIIa is recommended and its complication rates are low.     

Extracorporeal membrane oxygenation in children after repair of congenital cardiac lesions

Background. The purpose of this study was to review our experience in the early application of extracorporeal membrane oxygenation (ECMO) in patients requiring mechanical assistance after cardiac surgical procedures.

Methods. The hospital records of all children requiring ECMO after cardiac operation were retrospectively reviewed, and an analysis of variables affecting survival was performed.

Results. Fifty pediatric patients between May 1997 and October 2000 required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years (median age, 40 days). Forty-eight patients underwent repair of congenital cardiac lesions and 2 were included after receiving a heart transplant. Twenty-two children could not be weaned from cardiopulmonary bypass and were placed on ECMO in the operating room for circulatory support. Of the 28 children who required ECMO in the intensive care unit, 10 had ECMO instituted after cardiopulmonary arrest (mean cardiopulmonary resuscitation time, 42 minutes; range, 5 to 110 minutes). In infants with single-ventricle physiology, survival to discharge was 61% (11 of 18 patients) as compared with 43% (14 of 32 patients) in those with biventricular physiology. Thirty of the 50 patients (60%) were successfully weaned from ECMO, of which 25 (83%) were discharged home. Overall survival to discharge in the entire cohort was 50%. Extracorporeal membrane oxygenation support greater than 72 hours was a grave prognostic indicator. Overall survival in this group was 36% (9 of 25 patients) compared with 56% (14 of 25 patients) in those with ECMO support less than 72 hours (p < 0.05). Univariate analysis revealed the presence of renal failure, extended periods of circulatory support, and a prolonged period of cardiopulmonary resuscitation as risk factors for mortality. The presence of shunt-dependent flow, operative procedure, and institution of ECMO in the intensive care unit did not alter survival.

Conclusions. Extracorporeal membrane oxygenation provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients.     

Extracorporeal membrane oxygenation for cardiac support in pediatric patients

Extracorporeal membrane oxygenation (ECMO) has been used for pediatric cardiac support in settings of expected mortality due to severe myocardial dysfunction. We reviewed the records of 34 children (<18 years) placed on ECMO between March 1995 and May 1999. Demographic, cardiac, noncardiac, and outcome variables were recorded. Data were subjected to univariate analysis to define predictors of outcome. Eighteen patients were placed on ECMO after cardiac surgery (Group A); seven of 18 were weaned off ECMO, and four survived to discharge (22%). Thirteen patients were placed on ECMO as a bridge to cardiac transplantation (Group B), six of 13 received a heart transplant, one recovered spontaneously, and six survived to discharge (46%). Three patients were placed on ECMO for failed cardiac transplantation while awaiting a second transplant (Group C); one recovered graft function, two received a second heart transplant, and two of three survived (66%). The primary cause of death was multiorgan system failure (68%). Group A patients supported on ECMO for more than 6 days did not survive. Mediastinal bleeding complications and renal failure requiring dialysis were associated with nonsurvival. We conclude that ECMO as a bridge to cardiac transplant was more successful than ECMO support after cardiotomy. Mediastinal bleeding and renal failure were associated with poor outcome. Recovery of cardiac function occurred within the first week of ECMO support if at all. Longer support did not result in survival without transplantation.     

Factores implicados en el desarrollo de vasoplejía tras cirugía cardiaca con circulación extracorpórea. Estudio prospectivo observacional

ObjectiveThe incidence and risk factors for vasoplegia in the early postoperative period and at 24 h are investigated in patients subjected to cardiopulmonary bypass surgery. Vasoplegia following cardiac surgery with cardiopulmonary bypass is associated with a high morbimortality. The risk factors described emerged from retrospective, non-controlled studies.MethodsObservational prospective study of 188 consecutive patients subjected to cardiac surgery with cardiopulmonary bypass in a single hospital between November 2011 and May 2012. Emergency surgery or complex procedures were excluded. Vasoplegia was assessed during the immediate postoperative period, and at 24 h after surgery, and was defined as a mean arterial pressure below 50 mmHg, and the need for a noradrenaline perfusion of more than 0.08 μg/kg/min, monitored by cardiac output and systemic vascular resistances. The anaesthetic and cardiopulmonary bypass protocols, as well as haemodynamic management, were the same in all patients.ResultsAlmost half (48%) of patients had vasoplegia in the immediate postoperative period, and 34% at 24 h. Risk factors for immediate vasoplegia development were preoperative use of angiotensin converting enzyme inhibitor drugs, a mean arterial pressure < 50 mmHg immediately after beginning cardiopulmonary bypass, duration of aortic clamping as well as the cardiopulmonary bypass, and minimum temperature in cardiopulmonary bypass. Vasoplegia at 24 h after surgery was correlated to preoperative angiotensin converting enzyme inhibitor drug treatment and cardiopulmonary bypass duration.ConclusionThe incidence of vasoplegia after cardiac surgery with cardiopulmonary bypass is high during the first 24 postoperative hours. Preoperative treatment with angiotensin converting enzyme inhibitor and the mean arterial pressure at the beginning of cardiopulmonary bypass are the more easily controllable risk factors. In patients arriving to surgery with those drugs, treatment or prevention of vasoplejia should be planned.     

Vascular injury and thrombotic potential: a note of caution about recombinant factor VIIa

Postoperative hemorrhage following cardiac surgery increases morbidity, mortality, and costs. Several case reports have described the successful use of recombinant factor VIIa to decrease or stop bleeding in patients undergoing cardiac surgery. The mechanism of action of recombinant factor VIIa is thought to be increased site-specific thrombin generation by tissue factor-mediated activation of coagulation or from activated platelets. However, there have also been many reports of thrombotic complications after recombinant factor VIIa administration. Randomized clinical trials and further laboratory studies should help better clarify the efficacy, safety, cost-effectiveness, and optimal dosing of recombinant factor VIIa in the cardiac surgical setting.     

Risk factors reducing blood transfusion requirements in pediatric open heart surgery after introduction of vacuum assisted circuits

OBJECTIVES: Open heart surgery without homologous blood transfusion remains difficult in children. The introduction of vacuum-assisted cardiopulmonary bypass circuits to reduce priming volume for pediatric patients has improved the percentage of transfusion-free operations. We retrospectively analyzed blood transfusion risk factors to further reduce blood transfusion requirements after vacuum-assisted circuit introduction. METHODS: From March 1995 to June 1996, 49 patients weighing between 5 and 20 kg underwent cardiac surgery with cardiopulmonary bypass at our institution, excluding hospital deaths. We retrospectively analyzed risk factors influencing blood use in 37 patients with no blood priming in cardiopulmonary bypass after introducing a vacuum-assisted system. Factors selected for univariate analysis were age, body weight, cyanosis, preoperative Hb, operation time, cardiopulmonary bypass time, aortic cross-clamping time, and intraoperative and postoperative bleeding volume. Correlation between total bleeding volume/body weight and cardiopulmonary bypass time was studied by regression analysis. RESULTS: As risk factors, univariate analysis identified cyanotic disease, longer operation time (> 210 minutes), longer cardiopulmonary bypass time (> 90 minutes), longer aortic cross-clamping time (> 45 minutes), greater intraoperative bleeding volume/body weight (> 4 ml/kg), and greater postoperative bleeding volume/body weight (> 15 ml/kg). Regression analysis showed a significant positive correlation between total bleeding volume/body weight and cardiopulmonary bypass time. CONCLUSIONS: Cyanotic disease and long bypass time are risk factors in reducing blood transfusion requirements in pediatric open heart surgery after introduction of vacuum-assisted circuits. Further efforts are needed, however, to reduce blood transfusion requirements, particularly in these children.     

Platelet inhibition and bleeding complications in cardiac surgery: A review

Abstract

Dual antiplatelet therapy (DAPT) with acetylsalicylic acid and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) reduces thrombotic events in patients with acute coronary syndrome (ACS), but it is also associated with an increased risk of bleeding complications. Excessive bleeding in cardiac surgery patients is associated with increased morbidity and mortality and high costs. In this review, different aspects of platelet inhibition in cardiac surgery patients will be discussed, including direct effects on bleeding and transfusion requirements, discontinuation and reinstitution of antiplatelet drugs before and after surgery, and the use of perioperative platelet function testing.