Coagulopathic Bleeding Research Articles

Perioperative point of care platelet function testing and postoperative blood loss in high-risk cardiac surgery patients

Postoperative coagulopathic bleeding is common in cardiac surgery and associated with increased morbidity and mortality. Platelet function is affected by multiple factors, including patient and procedural characteristics. Point-of-care (POC) multiple electrode aggregometry (MEA) can rapidly detect and quantify platelet dysfunction and could contribute to optimal patient blood management.In patients undergoing CABG and heart valve surgery platelet function was assessed using POC MEA at four different perioperative timepoints in response to stimulation with four specific receptor agonists (ADP, AA, COL, TRAP). Postoperative bleeding was recorded during 24 h after surgery. Regression analyses were performed to establish associations between perioperative platelet function and postoperative blood loss.Ninety-nine patients were included in the study. Fifty-nine patients (60%) were on antiplatelet therapy (APT) at time of surgery. ADP- and AA-induced platelet aggregation declined during CPB and after decannulation from CPB, with a maximum decrease of 55% for ADP (35 vs. 77 AU at baseline; P < 0.001) and 78% for ASPI (14 vs. 64 AU at baseline; P < 0.001). A linear relationship was present between ADP-induced platelet aggregometry at baseline and postoperative blood loss (r = −0.249; P = 0.015). In aspirin users, the maximum decline in platelet function between baseline and CPB decannulation was related to postoperative blood loss (r = 0.308; P = 0.037). In multivariate analysis, a reduced ADP platelet function prior to surgery remained associated with postoperative blood loss (r = −0.239; P = 0.012).Reduced ADP-induced platelet aggregation at baseline is associated with increased postoperative blood loss in high-risk cardiac surgery patients.

Massive Hemorrhages in Pregnant Women with Placenta Previa and Accreta: a Transfusiologist’s View

Abstract The aim of this study was to estimate volumes of blood loss and infusion and transfusion therapy during Cesarean section in pregnant women with placenta previa and accreta.Material and methods Тhe study group consisted of 15 patients with placenta previa and accreta. The delivery period was 32–36 weeks. We used clinical and laboratory techniques and special methods of investigation. The analysis of pregnancy course, bleeding volumes, infusion and transfusion therapy, hemostasis system parameters and hemogram was carried out.Results Тhe mean age of pregnant women was 33.8±4.3 years. All pregnant women underwent fundal Cesarean section. In 80% of women, we performed Cesarean section and metroplasty. In 20% of women, Cesarean section and hysterectomy were performed. The volume of intraoperative blood loss ranged from 750 ml to 6,000 ml and averaged 2,471.4±1,528.5 ml. The volumes of crystalloid solutions were 1,361.53±1,052.40 of Sterofundin, and 688.4±123.5 ml of other solutions. In 80% of patients, Gelofusine was administered (969.66±351.86 ml on the average), as well as Geloplasma (620.8±124.8 ml on the average). The volume of HES solutions 6% 130/04 was 744.4±120.45 ml on the average. FFP in the amount of 1,526.7±762.83 ml was transfused to 60% of women. The mean dose of tranexamic acid was 2.6±0.84 g. The factor rFVIIa was administered in three patients in the dose of 90 mcg/kg. Prothrombin complex concentrate 1200 IU was administered in three patients. The volume of reinfused autoerythrocytes was 793.7±424.17 ml on the average. The volume of donor red blood cells during the operation amounted to 775.12±120.2 ml.Conclusion Pregnant patients with placenta previa and accrete represent a high-risk group for the development of massive coagulopathic bleeding and postoperative complications. These patients should deliver on a routine basis at the high-tech institutions of obstetric care. The adequate, timely infusion and transfusion maintenance of surgical intervention with this pathology, using modern blood-saving technologies, transfusion of sufficient volumes of blood components, inhibitors of fibrinolysis, coagulation factors, modern balanced crystalloid and colloidal solutions plays a important role in implementation of organpreserving tactics.

Retrospective characterization of canine coagulopathies using the turbidimetric ACL-TOP 300 analyzer (2014-2015): Forty-seven dogs.

To characterize disseminated intravascular coagulation (DIC), liver failure (LF), post-hepatic cholestasis (PHC), and anticoagulant rodenticide intoxication (ROD) in dogs using an immunoturbidimetric coagulation analyzer and to characterize the relationship between clinical bleeding and bleeding parameters. Retrospective study (August 2014-July 2015). University teaching hospital. Forty-seven client-owned dogs diagnosed with DIC (n= 24), LF (n= 9), PHC (n= 5), or ROD (n= 9) based on history, clinical pathology, cytology, histopathology. or exploratory surgery. None. Median prothrombin time (PT), activated partial thromboplastin time (aPTT), and quantitative fribrinogen assay (QFA) were above the reference interval for DIC, LF, PHC and ROD with the exception of a normal QFA for LF. Clot curve analysis for DIC was characterized by elevated PT Delta, PT first derivative, and aPTT Delta, and normal for aPTT second derivative; all LF parameters were within the RI; all PHC parameters were above the RI; and ROD had elevated aPTT delta, but low aPTT second derivative. Coagulopathic bleeding recognized within the DIC group was characterized by median PT delta in mABS (milliabsorbance), first derivative and aPTT delta values in mABS within the RI at 35.0, 55.5 and 38, respectively. The nonbleeding DIC group median values of these same parameters were 189.5, 586.5 and 288, respectively. The classically utilized indicators of secondary hemostasis, PT and aPTT, were prolonged within all 4 groups; DIC, LF, PHC and ROD as expected. Fibrinogen concentration was increased in both PHC and ROD, decreased in LF and increased but with a bimodal distribution in DIC that correlated with clinical bleeding. The degree of PT and aPTT prolongation did not correlate with clinical bleeding in the DIC group, however clot curve analysis, did reveal an association.

Factor VIIa administration in orthotopic heart transplant recipients and its impact on thromboembolic events and post-transplant outcomes

Recombinant, activated factor VIIa (rFVIIa) is used during cardiac surgeries to mitigate refractory coagulopathic bleeding. The purpose of this study was to examine whether rFVIIa use in orthotopic heart transplant (OHT) recipients was associated with a higher incidence of thromboembolic (TE) events compared to patients who did not. A single-center, retrospective, cohort study was performed on OHT recipients who received rFVIIa for refractory coagulopathic bleeding from January 2013 to December 2015. Patients were evaluated for up to 6months after transplantation and assessed for TE events, rejection, readmissions, graft survival, and patient survival. Categorical variables were analyzed using the Chi square test while student's t or ANOVA testing was utilized for continuous variables. Of the 62 patients who met inclusion criteria, 27 patients received rFVIIa, and 35 patients were selected for the control group. The overall incidence of TE events was not significantly different between patients who received rFVIIa compared to patients in the control group (14.8% vs 11.4%) (p = 0.69). Within 14days, 14.81% of rFVIIa patients suffered a TE event compared to 5.7% of the control group (p = 0.23). Rejection, readmissions, graft survival, and patient survival were not significantly different at any time points. Use of rFVIIa in heart transplantation showed no difference in the overall rate of TE events, however, there was a nonsignificant trend toward higher risk of early TE development in the rFVIIa group compared to the control group.

Assessing relative cost of complications following orthotopic liver transplant.

Perioperative complications impose both a clinical and financial burden on patients and the healthcare system. This study sought to identify the frequency and economic impact of complications following orthotopic liver transplantation (OLT). The Premier Perspective® Hospital Database was queried for patients undergoing OLT between 2008 and 2015. Complications were identified by ICD-9 code and grouped by complication type. Complication frequency as well as impact on clinical and economic outcomes was calculated. Complication frequency and effect on cost were combined to determine the annual impact of each complication type on perioperative OLT cost. Among 2747 OLT patients, the most common groups of complications following OLT were pulmonary, bleeding, and infectious. The complications with the greatest average effect on treatment-related costs were infectious, neurologic, deep vein thrombosis/pulmonary embolus, and hepatic arterial thrombosis. Infectious, pulmonary, and bleeding complications had the greatest annual effect on perioperative OLT cost. Efforts focused on preventing coagulopathic bleeding, improving post-operative pulmonary toilet, and minimizing sources of infection can help improve the cost-effectiveness of OLT. Additionally, the combination of these cost data and systematized protocols can help insurers construct bundled payments for OLT that more accurately reflect the cost of perioperative transplant care.

Возможности органосохранения при тяжелой отслойке плаценты с коагулопатическим кровотечением

Возможности органосохранения при тяжелой отслойке плаценты с коагулопатическим кровотечением

Abnormalities of laboratory coagulation tests versus clinically evident coagulopathic bleeding: results from the prehospital resuscitation on helicopters study (PROHS)

BackgroundLaboratory-based evidence of coagulopathy (LC) is observed in 25-35% of trauma patients, but clinically-evident coagulopathy (CC) is not well described. MethodsProspective observational study of adult trauma patients transported by helicopter from the scene to nine Level 1 trauma centers in 2015. Patients meeting predefined highest-risk criteria were divided into CC+ (predefined as surgeon-confirmed bleeding from uninjured sites or injured sites not controllable by sutures) or CC-. We used a mixed-effects, Poisson regression with robust error variance to test the hypothesis that abnormalities on rapid thrombelastography (r-TEG) and international normalized ratio (INR) were independently associated with CC+. ResultsOf 1,019 highest-risk patients, CC+ (n=41, 4%) were more severely injured (median ISS 32 vs 17), had evidence of LC on r-TEG and INR, received more transfused blood products at 4 hours (37 vs 0 units), and had greater 30-day mortality (59% vs 12%) than CC- (n=978, 96%). The overall incidence of LC was 39%. 30-day mortality was 22% vs 9% in those with and without LC. In two separate models, r-TEG K-time >2.5 min (RR 1.3, 95% CI 1.1-1.7), r-TEG mA <55 mm (RR 2.5, 95% CI 2.0-3.2), platelet count <150 x 109/L (RR 1.2, 95% CI 1.1-1.3), and INR >1.5 (RR 5.4, 95% CI 1.8-16.3) were independently associated with CC+. A combined regression model was not generated because too few patients underwent both r-TEG and INR. ConclusionCC was rare compared to LC. CC was associated with poor outcomes and impairment of both clotting factor and platelet-mediated coagulation components.

Viscoelastic Monitoring to Guide Hemostatic Resuscitation in Liver Transplantation Surgery.

Coagulopathic bleeding must be anticipated during liver transplantation (LT) surgery. Patients with end-stage liver disease (ESLD) often present with disease-related hematologic disturbances, including the loss of hepatic procoagulant and anticoagulant clotting factors and thrombocytopenia. Transplantation surgery itself presents additional hemostatic changes, including hyperfibrinolysis. Viscoelastic monitoring (VEM) is often used to provide targeted, personalized hemostatic therapies for complex bleeding states including cardiac surgery and major trauma. The use in these coagulopathic conditions led to its application to LT, although the mechanisms of coagulopathy in these patients are quite different. While VEM is often used during transplant surgeries in Europe and North America, evidence supporting its use is limited to a few small clinical studies. The theoretical and clinical applications of the standard and specialized VEM assays are discussed in the setting of LT and ESLD.

Preclinical evaluation of point‐of‐care prothrombin time as a biomarker test to guide prothrombin replacement therapy in coagulopathic bleeding

Summary Essentials Prediction of bleeding risk in trauma patients is difficult.We evaluated a test which measures prothrombin time/ability of blood to clot.We showed the prothrombin time test reflected prothrombin concentration in blood.The test could be used in trauma patients to identify those in need of prothrombin replacement. BackgroundHemorrhage is still a common cause of death in trauma. Central lab measured prothrombin time (lab PT) is predictive of low prothrombin concentration and clinical outcome in trauma patients, however, treatment guidance is limited by slow turnaround times. Here, we have preclinically evaluated the potential of a point‐of‐care prothrombin time test (POC PT) as a faster alternative to identify patients with low prothrombin concentration.MethodsHuman whole blood was serially diluted and prothrombin time measured by POC PT (CoaguChek XS Pro, Roche) and lab PT. Recombinant human prothrombin (MEDI8111) was added to human whole blood with or without depletion of prothrombin by pretreatment with prothrombin neutralizing antibodies.ResultsThere was no observable difference in the sensitivity of either test to dilution at blood volumes of 60‐100%. At blood volumes of ≤55% (equivalent to 47 mg/L prothrombin), PT sharply increased, with greater dilutional sensitivity observed in the POC test. Both tests were insensitive to prothrombin up to 194 mg/L added MEDI8111 (equivalent to 328 mg/L prothrombin versus endogenous concentration of 129 mg/L). Depletion of endogenous prothrombin inversely correlated with an increase in PT which returned to baseline following addition of 97 mg/L MEDI8111 or above. Both assays correlated well above 48.5 mg/L added MEDI8111 (65.9 mg/L prothrombin).ConclusionsOur data supports that POC PT tests, such as the CoaguChek XS Pro, are fit for purpose to confirm a coagulopathic threshold for prothrombin and provide a fast, simple, and mobile method to guide MEDI8111 therapy in bleeding trauma patients.

Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials

BackgroundAnaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.ObjectiveTo evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.Methods and resultsWorkstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.LimitationsExisting studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.ConclusionsA systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.Study registrationCurrent Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.

The current understanding of trauma-induced coagulopathy (TIC): a focused review on pathophysiology.

The emergency management of acute severe bleeding in trauma patients has changed significantly in recent years. In particular, greater attention is now being devoted to a prompt assessment of coagulation alterations, which allows for immediate haemostatic resuscitation procedures when necessary. The importance of an early trauma-induced coagulopathy (TIC) diagnosis has led physicians to increase the efforts to better understand the pathophysiological alterations observed in the haemostatic system after traumatic injuries. As yet, the knowledge of TIC is not exhaustive, and further studies are needed. The aim of this review is to gather all the currently available data and information in an attempt to gain a better understanding of TIC. A comprehensive literature search was performed using MEDLINE database. The bibliographies of relevant articles were screened for additional publications. In major traumas, coagulopathic bleeding stems from a complex interplay among haemostatic and inflammatory systems, and is characterized by a multifactorial dysfunction. In the abundance of biochemical and pathophysiological changes occurring after trauma, it is possible to discern endogenously induced primary predisposing conditions and exogenously induced secondary predisposing conditions. TIC remains one of the most diagnostically and therapeutically challenging condition.

Предупреждение повышенной кровопотери и коагулопатического кровотечения при абдоминальном родоразрешении

The purpose of the study - to assess the effectiveness of intraoperative application of complex drugs calcium gluconate (10 ml of 10% solution) and tranexamic acid (1.0 g) for abdominal delivery of patients with disorders in the fibrinolytic links of blood coagulation. Material and methods. We observed 160 patients, delivery by caesarean section, which carried out by one and the same surgical team. All pregnant women are at risk for the development of coagulopathic bleeding. The average age of patients was 28.3±1.7 years. Observed were divided into equal groups and the number of subgroups (40 persons in each). According to the developed method, a specified author invention priority reference from 18.07.2016, Application №2016129336(045647), one group of patients at the time of abdominal wall incision sequentially intravenously injected into a peripheral vein with 10 ml of 10% solution of calcium gluconate and tranexamic acid. The patients in the other groups these drugs are either not used or used individually. The results. A decrease in the 2.5-1.5 times the total blood loss in patients who have a caesarean section at the complex were used calcium preparations and tranexamic acid, compared with women who did not receive these drugs, or treated them separately. In addition to clinical observation and gravimetric method of counting blood loss, a positive impact has a tranexam on perioperative volume so reduction and it has been proven by laboratory tests. Conclusion. To prevent the coagulopathic bleeding and reduce the total perioperative blood loss, highly effective and safe is the combined use of drugs calcium gluconate and tranexamic acid for the above scheme with operative delivery of patients with disorders of fibrinolytic level in the blood coagulation system.

Routine Use of Viscoelastic Blood Tests for Diagnosis and Treatment of Coagulopathic Bleeding in Cardiac Surgery

Abstract Viscoelastic point-of-care tests are commonly used to provide prompt diagnosis of coagulopathy and allow targeted treatments in bleeding patients. We updated existing meta-analyses that have evaluated the clinical effectiveness of viscoelastic point-of-care tests vs the current standard of care for the management of cardiac surgery patients at risk of coagulopathic bleeding. Randomized controlled trials comparing viscoelastic point-of-care diagnostic testing with standard care in cardiac surgery patients were sought. All-cause mortality, blood loss, reoperation, blood transfusion, major morbidity, and intensive care unit and hospital length of stay were analysed using random-effects modelling. Fifteen trials that randomized a total of 8737 participants were included for the analysis. None of the trials was classified as low risk of bias. The use of thromboelastography- (TEG®) or thromboelastometry (ROTEM®)-guided algorithms did not reduce mortality [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.28–1.10] without heterogeneity (I2=1%), reoperation for bleeding, stroke, ventilation time, or hospital length of stay compared with standard care. Use of TEG® or ROTEM® resulted in reductions in the frequency of red blood cell (Risk Ratio 0.88, 95% Confidence Interval 0.79-0.97; I2=43%) and platelet transfusion (Risk Ratio 0.78, 95% Confidence Interval 0.66-0.93; I2=0%). Group Reading Assessment and Diagnostic Evaluation (GRADE) assessment demonstrated that the quality of the evidence was low or very low for all estimated outcomes. Routine use of viscoelastic point-of-care tests did not improve important clinical outcomes beyond transfusion in adults undergoing cardiac surgery.

Coagulation Profile of Children on Extracorporeal Membrane Oxygenation (ECMO) - Is FXIII the Missing Link?

BackgroundPublished data about bleeding management on extracorporeal membrane oxygenation (ECMO) in children is sparse and to date no global transfusion algorithm has been established. Viscoelastic testing can be effective for determining the etiology and management of coagulopathic bleeding during cardiothoracic procedures, but data regarding its usefulness in ECMO patients are scarce. Recently, low factor XIII levels were determined to be a frequent finding in adult ECMO patients(Kalbhenn et al; Perfusion 2015;30:675-82).MethodsThis is a retrospective analysis of thromboelastometry (ROTEM®) and factor XIII data obtained in children (ages 0 to 18 years) undergoing ECMO since 2013 in a single center children’s hospital. Acute bleeding treatment was based on daily ROTEM testing, complete blood count and routine plasmatic coagulation testing. The transfusion algorithm targeted a hemoglobin level >13g dL-1, a Quick’s value >50%, a plasma fibrinogen level >1.5g L-1, and a platelet count of >100,000 µL-1. Red blood cells (RBC), solvent detergent (S/D) plasma and platelet apheresis concentrates were exclusively used to maintain hemostasis. Measurement of FXIII levels is not part of routine testing, but was assessed when unexplained bleeding was observed.ResultsLaboratory and transfusion data from sixteen patients, age 4 (1-15) months [median(IQR)] with a body weight of 6 (3-8) kg were included. Median time on ECMO was 7 (4-9) days. Large volumes of allogeneic blood were transfused to all children, meeting criteria for massive transfusion each individual day on ECMO (Tab.1). Overall, median daily ROTEM measurements were within reference ranges (Tab.2), while median levels of FXIII were decreased despite massive transfusion [FXIII levels 42% (28-51%)].ConclusionPediatric ECMO was almost always combined with daily massive transfusion, which led to correction of overall ROTEM values. Notably, despite transfusion of large amounts of plasma, decreased FXIII levels were noted. This finding is supported by results of a study in adult ECMO patients, where FXIII levels <50% were observed in 88% of all patients. Although inherited homozygous FXIII deficiency is usually defined by levels <5%, even mildly to moderately reduced FXIII levels have been reported to contribute to increased bleeding after cardiac surgery(Ternström et al; Thromb Res 2010;126:e128-33). Further studies should be performed to assess the impact of FXIII substitution in pediatric ECMO patients and to investigate whether substitution of FXIII may decrease bleeding without increasing thrombotic complications. [Display omitted] [Display omitted] DisclosuresHaas:CSL Behring: Speakers Bureau; TEM International: Speakers Bureau; Octapharma: Consultancy.

Efficacy and Safety of Prothrombin Complex Concentrate in Patients Undergoing Major Cardiac Surgery

IntroductionAdministration of coagulation factors after major cardiac surgery, with or without cardiopulmonary bypass, may be a strategy for reducing risk of bleeding and requirement for allogeneic blood transfusions. However, transfusion of large volumes of fresh frozen plasma (FFP) is restricted by the competing problem of heart failure, a common complication following cardiac surgery in patients with existing cardiac decompensation. Prothrombin complex concentrate (PCC) has a smaller volume of administration than FFP for a similar amount of coagulation factors, making it an attractive option in this situation. However, patients undergoing complex cardiac surgery may also have prothrombotic conditions and have a high risk of both venous and arterial thrombosis including ischemic neurological complications. We performed a retrospective analysis to investigate whether the use of PCC is safe and effective compared with FFP to treat coagulopathy in patients undergoing isolated coronary artery bypass graft (CABG), valve surgery (with or without concomitant CABG) and major aortic procedures. If the patient was on warfarin, this was stopped at least 5 days before the surgery and appropriate bridging was followed. For patients on dual antiplatelet therapy, P2Y12 receptor inhibitors such as Clopidogrel and Prasugrel were stopped 5-7days before the surgery and Aspirin was allowed to continue. The decision to use PPC or FFP was based on individual patient characteristics such as complexity of the surgery and previous history of increased bleeding during surgery and also ability to tolerate volume.MethodsOne hundred and seventy consecutive adult patients who underwent major cardiac surgery between January 2015 and December 2015 were studied. Among them, 87 received PCC (male/female = 55/32, mean age= 56 years) and 83 received FFP (male/female = 56/27, mean age = 58 years) to control coagulopathy. The decision on need for coagulation factor treatment and the choice of treatment was made by the treating team of the patient. Those who received both PCC and FFP were excluded. Blood loss within first 12 hours and 24hours from the end of operation, total use of allogeneic blood and platelet transfusion and patient outcomes in terms of thrombotic complications both venous and arterial, incidence of acute kidney injury and 30 day mortality were compared in the two groups. Antiplatelet drug effect on bleeding was also assessed.ResultsThere was no significant difference in the amount of bleeding at the first 12 hours from the end of the operation in the two groups (p=0.25) :median and 95% confidence interval [CI] were 825mL [926-1317] and 787mL [804-1067] patients received PPC or FFP respectively. However, total blood loss within 24hours was significantly higher in patients who received PPC (median [CI] (1575mL [1658-2263]) compared to FFP (median [CI] (1213mL [1244-1641]), P=0.0034. There was no difference in the mean blood loss between patients continued Aspirin at the time of surgery and those who were not on Aspirin in either groups. The use of allogeneic blood (P=.001) and platelets (P=0.03) was significantly higher in patients receiving FFP compared to PPC. A significantly higher number of patients treated with FFP (9.6% vs 3.5%, p=0.002) developed cardiac failure related to circulatory overload. There was no difference in thrombotic events in the two groups: one patient from each group (1.1%) developed venous and arterial thrombosis respectively following surgery. Thirty day mortality rate was similar in the patients receiving FFP or PPC (4%) and none were directly related to surgery. There was no difference in the acute kidney injury in the two groups.ConclusionsThis retrospective analysis suggests that PCC may be an alternative to FFP in patients undergoing major cardiac surgery. Although there was a higher amount of bleeding within 24hours of surgery in patients treated with PCC, this may reflect the complexity, duration and the individual patient risk of bleeding due to selection bias. The use of PPC may reduce the number of allogeneic blood and platelet transfusion in these patients and reduce risk of circulatory overload. There was no increased risk of thrombosis with use of PCC. However, randomized controlled studies powered to evaluate efficacy and safety in patients receiving PCC versus FFP for coagulopathic bleeding after major cardiac surgery are warranted. DisclosuresLaffan:CSL: Other: Travel support; Octapharma: Speakers Bureau.

The HAT Score—A Simple Risk Stratification Score for Coagulopathic Bleeding During Adult Extracorporeal Membrane Oxygenation

The study objective was to create an adult extracorporeal membrane oxygenation (ECMO) coagulopathic bleeding risk score. Secondary analysis was performed on an existing retrospective cohort. Pre-ECMO variables were tested for association with coagulopathic bleeding, and those with the strongest association were included in a multivariable model. Using this model, a risk stratification score was created. The score's utility was validated by comparing bleeding and transfusion rates between score levels. Bleeding also was examined after stratifying by nadir platelet count and overanticoagulation. Predictive power of the score was compared against the risk score for major bleeding during anti-coagulation for atrial fibrillation (HAS-BLED). Tertiary care academic medical center. The study comprised patients who received venoarterial or venovenous ECMO over a 3-year period, excluding those with an identified source of surgical bleeding during exploration. None. Fifty-three (47.3%) of 112 patients experienced coagulopathic bleeding. A 3-variable score-hypertension, age greater than 65, and ECMO type (HAT)-had fair predictive value (area under the receiver operating characteristic curve [AUC] = 0.66) and was superior to HAS-BLED (AUC = 0.64). As the HAT score increased from 0 to 3, bleeding rates also increased as follows: 30.8%, 48.7%, 63.0%, and 71.4%, respectively. Platelet and fresh frozen plasma transfusion tended to increase with the HAT score, but red blood cell transfusion did not. Nadir platelet count less than 50×103/µL and overanticoagulation during ECMO increased the AUC for the model to 0.73, suggesting additive risk. The HAT score may allow for bleeding risk stratification in adult ECMO patients. Future studies in larger cohorts are necessary to confirm these findings.

Optimal temperature management in aortic arch operations.

Hypothermic circulatory arrest is a critical component of aortic arch procedures, without which these operations could not be safely performed. Despite the use of hypothermia as a protective adjunct for organ preservation, aortic arch surgery remains complex and is associated with numerous complications despite years of surgical advancement. Deep hypothermic circulatory arrest affords the surgeon a safe period of time to perform the arch reconstruction, but this interruption of perfusion comes at a high clinical cost: stroke, paraplegia, and organ dysfunction are all potential-associated complications. Retrograde cerebral perfusion was subsequently developed as a technique to improve upon the rates of neurologic dysfunction, but was done with only modest success. Selective antegrade cerebral perfusion, on the other hand, has consistently been shown to be an effective form of cerebral protection over deep hypothermia alone, even during extended periods of circulatory arrest. A primary disadvantage of using deep hypothermic circulatory arrest is the prolonged bypass times required for cooling and rewarming which adds significantly to the morbidity associated with these procedures, especially coagulopathic bleeding and organ dysfunction. In an effort to mitigate this problem, the degree of hypothermia at the time of the initial circulatory arrest has more recently been reduced in multiple centers across the globe. This technique of moderate hypothermic circulatory arrest in combination with adjunctive brain perfusion techniques has been shown to be safe when performing aortic arch operations. In this review, we will discuss the evolution of these protection strategies as well as their relative strengths and weaknesses.

Short- and long-term impact of reoperation for complications after major hepatectomy for hepatocellular carcinoma

The impact of reoperation for complications after major liver resection for hepatocellular carcinoma was evaluated. In this retrospective study covering 25years, patients with reoperation for complications after major liver resection for hepatocellular carcinoma were compared with patients without reoperation in terms of demographics, tumor characteristics, operative details, postoperative results, oncologic outcomes, and survival. Reasons for reoperation were also investigated. Forty-nine out of 1,092 patients underwent reoperation within a median of 0.2days (range, 0-6.9days) after hepatectomy. Patients with and without reoperation had similar baseline characteristics and liver function. Nonetheless, patients with reoperation had a higher indocyanine green retention rate at 15minutes (12.55% vs 10.5%, P=.015), more operative blood loss (1.4L vs 1L, P=.012), a higher blood transfusion rate (44.9% vs 29.2%, P=.029), longer hospital stay (21days vs 11days, P<.001), a higher hospital mortality (38.8% vs 3.0%, P<.001), and a higher 90-day mortality (38.8% vs 4.7%, P<.001). Hemorrhage was the most common cause for reoperation (26/49, 53.1%), mainly resulting from coagulopathic bleeding from raw areas (12/26, 46.2%) and bleeding from diaphragmatic veins (6/26, 23.1%). However, reoperation did not affect 5-year overall survival (50.2% vs 48.3%, P=.468). Postoperative hemorrhage was associated with a high mortality, signifying the importance ofmeticulous hemostasis and careful perioperative management. Oncologic outcomes, however, were not affected by reoperation.

Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting.

Prothrombin complex concentrates (PCCs) contain vitamin K-dependent clotting factors (II, VII, IX, and X) and are marketed as 3 or 4 factor-PCC formulations depending on the concentrations of factor VII. PCCs rapidly restore deficient coagulation factor concentrations to achieve hemostasis, but like with all procoagulants, the effect is balanced against thromboembolic risk. The latter is dependent on both the dose of PCCs and the individual patient prothrombotic predisposition. PCCs are approved by the US Food and Drug Administration for the reversal of vitamin K antagonists in the setting of coagulopathy or bleeding and, therefore, can be administered when urgent surgery is required in patients taking warfarin. However, there is growing experience with the off-label use of PCCs to treat patients with surgical coagulopathic bleeding. Despite their increasing use, there are limited prospective data related to the safety, efficacy, and dosing of PCCs for this indication. PCC administration in the perioperative setting may be tailored to the individual patient based on the laboratory and clinical variables, including point-of-care coagulation testing, to balance hemostatic benefits while minimizing the prothrombotic risk. Importantly, in patients with perioperative bleeding, other considerations should include treating additional sources of coagulopathy such as hypofibrinogenemia, thrombocytopenia, and platelet disorders or surgical sources of bleeding. Thromboembolic risk from excessive PCC dosing may be present well into the postoperative period after hemostasis is achieved owing to the relatively long half-life of prothrombin (factor II, 60-72 hours). The integration of PCCs into comprehensive perioperative coagulation treatment algorithms for refractory bleeding is increasingly reported, but further studies are needed to better evaluate the safe and effective administration of these factor concentrates.

Abstract 17197: The Value of Routine Near-patient Haemostasis Testing for Predicting Bleeding After Cardiac Surgery

Introduction: Near-patient haemostasis tests assist diagnosis and treatment of blood clotting abnormalities in bleeding patients after cardiac surgery. Aim: To quantify the predictive value of routine near-patient haemostasis tests for coagulopathic bleeding in a large clinical trial. Methods: We performed a prospective cohort study of the patient characteristics and the results of 23 near-patient platelet and viscoelastometry tests in adults undergoing a range of cardiac surgery procedures. The primary outcome was clinical concern about bleeding (CCB), defined as a composite of high blood loss or pro-haemostatic treatment or re-operation for bleeding. A multivariable predictive model for CCB was developed based on the pre-operative characteristics of 1833 patients at a single cardiac centre recruited between March 2010 and August 2012. This model was validated using data for 1611 patients recruited at 16 other UK cardiac surgery centres between July 2009 and February 2013. The additional predictive value of near-patient test results was estimated in the development cohort. Results: CCB occurred in 449 (24.5%) patients in the development cohort. Male sex, absence of diabetes, complex procedure, anti-platelet treatment, short interval since withdrawal of anti-platelet treatment, reduced BMI, reduced pre-operative haematocrit and reduced pre-operative platelet count were independently associated with increased risk of CCB (area under RoC curve (AUR)=0.72 (0.69 to 0.75)). At 75% sensitivity, the specificity of the model was 57%. In the validation cohort, the AUR of the patient characteristics model was 0.63 (0.60 to 0.66). Adding the results of the most predictive near-patient tests performed immediately after surgery improved prediction of CCB in the development cohort (AUR 0.74; 0.72 to 0.77), but at 75% sensitivity this increased the specificity by only 4%. Adding the results of near-patient platelet tests performed before surgery did not further improve prediction of CCB (AUR 0.75; 0.72 to 0.77). Conclusions: Routine near-patient haemostasis tests offer little improvement in the prediction of CCB after cardiac surgery compared to pre-operative patient characteristics alone.