Excessive Postoperative Bleeding Research Articles

Association of preoperative retinal microcirculation and perioperative outcomes in patients undergoing congenital cardiac surgery

BackgroundMicrocirculatory dysfunction is associated with increased morbidity and mortality in cardiac surgery patients. This study aimed to investigate the association between preoperative retinal microcirculation evaluated using optical coherence tomography angiography (OCTA) and perioperative outcomes in patients with congenital heart disease (CHD).MethodsThis prospective, observational study was performed from May 2017 to January 2021. OCTA was used to automatically quantify the vessel density (VD) of the superficial capillary plexus, deep capillary plexus (DCP), and radial peripapillary capillary (RPC) preoperatively. The primary outcome was excessive postoperative bleeding, defined as bleeding volume > 75th percentile for 24-hour postoperative chest tube output. The secondary outcome was composite adverse outcomes, including one or more operative mortalities, early postoperative complications, and prolonged length of stay. The association between retinal VD and outcomes was assessed using Poisson regression.ResultsIn total, 173 CHD patients who underwent cardiac surgery were included (mean age, 26 years). Among them, 43 (24.9%) and 46 (26.6%) developed excessive postoperative bleeding and composite adverse outcomes, respectively. A lower VD of DCP (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.08–1.43; P = 0.003) was independently associated with excessive postoperative bleeding, and a lower VD of RPC (OR, 1.97; 95% CI, 1.08–3.57; P = 0.027), and DCP (OR, 2.17; 95% CI, 1.08–4.37; P = 0.029) were independently associated with the postoperative composite adverse outcomes.ConclusionPreoperative retinal hypoperfusion was independently associated with an increased risk of perioperative adverse outcomes in patients with CHD, suggesting that retinal microcirculation evaluation could provide valuable information about the outcomes of cardiac surgery, thereby aiding physicians in tailoring individualized treatment.

Excessive Postoperative Nasal Bleeding Following Septoplasty Caused by a Branch of the Middle Meningeal Artery.

Septoplasty is a widely performed procedure globally to correct a deviated nasal septum and improve nasal breathing. Life-threatening nasal bleeding as a complication of septoplasty has been reported in a few cases in the literature. In cases of massive postoperative nasal bleeding, transarterial embolization using angiography was performed for the treatment. This article documents 1 case of excessive postoperative nasal bleeding following an uneventful septoplasty, which was successfully treated with embolization of the frontal branch of the middle meningeal artery. This case represents an extremely rare occurrence, and we present it in conjunction with a literature review.

Risk Factors for Hypocoagulability After Cardiac Surgery: A Retrospective Study.

Hemostatic disturbances after cardiac surgery can lead to excessive postoperative bleeding. Thromboelastography (TEG) was employed to evaluate perioperative coagulative alterations in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB), investigating the correlation between factors concomitant with cardiac surgery and modifications in coagulation. Coagulation index as determined by TEG correlated significantly with postoperative bleeding at 24-72 h after cardiac surgery (P < .001). Among patients with a normal preoperative coagulation index, those with postoperative hypocoagulability showed significantly lower nadir temperature (P = .003), larger infused fluid volume (P = .003), and longer CPB duration (P = .033) than those with normal coagulation index. Multivariate logistic regression showed that nadir intraoperative temperature was an independent predictor of postoperative hypocoagulability (adjusted OR: 0.772, 95% CI: 0.624-0.954, P = .017). Multivariate linear regression demonstrated linear associations of nadir intraoperative temperature (P = .017) and infused fluid volume (P = .005) with change in coagulation index as a result of cardiac surgery. Patients are susceptible to hypocoagulability after cardiac surgery, which can lead to increased postoperative bleeding. Ensuring appropriate temperature and fluid volume during cardiac surgery involving CPB may reduce risk of postoperative hypocoagulability and bleeding.

Is the disability of elderly patients related to increased blood transfusions after cardiac surgery?

Abstract Funding Acknowledgements Type of funding sources: None. Intorduction. Perioperative bleeding occurs in 2 to 15% of patients. Cardiac surgeries are associated with perioperative blood loss due to the invasive nature of the procedures, the need for high doses of anticoagulation and the need for extracorporeal circulation. Both transfusions and reoperations due to excessive postoperative bleeding are associated with adverse clinical outcomes and increased costs of care. In 2017, the common position of the European Association of Cardiac Cancer Surgeons (EACTS) and the European Association of Cardiac Cancer Surgical Anesthesiologists (EACTA) regarding the management of patient blood in order to maintain adequate perioperative homeostasis and minimizing bleeding, and thus reducing the amount of blood transfusions. Advanced age is one of the factors associated with an increased risk of perioperative bleeding, including the need for transfusion and reoperation. Purpose. Assessment of the relationship between preoperative disability and the amount of blood transfused in elderly patients after cardiac surgeries. Methods. The study included 100 patients ≥ 65 years of age (40 women and 60 men, mean age M ± SD =71.69 ± 4). A sociodemographic questionnaire and the Nagi scale for disability assessment were used to collect the research material. The Nagi scale assesses the limitations of the patient in seven activities. A significant disability is considered to be ≥ 3 points. The number of blood transfusions was assessed based on the analysis of medical records. The number of blood units transfused during hospitalization was taken into account. Statistically significant was assumed to be p &amp;lt; 0.05. Results. In the study group the mean score on the Nagi scale was M ± SD = 3.41 ± 1.83 points. Blood transfusions were required by 66% of the study participants. The number of transfused blood units ranged from 1 to 11. The mean number of transfused blood units was 1.41 ± 1.83 points: M ± SD = 1.56 ± 1.93. 28 patients required 1 blood unit, 11 blood units required 1 patient. There was a significant positive correlation between the values of the Nagi scale and the number of blood units transfused (r = 0.233, p = 0.019) . Moreover, the number of blood units transfused to patients with values of the Nagi scale ≥3 points turned out to be significantly higher than in patients with values of this scale &amp;lt;3 points (p = 0.015). Conclusions. 1) Patients with disability are qualified for cardiac surgeries. 2) Patients with disabilities require more blood units to be transfused.

Effect of albumin administration on post-operation mortality, duration on ventilator, and hospital stay on patients in cardiac intensive care: An observational study

Purpose: To justify the use of albumin infusion in patients in post-surgery cardiac intensive care unit.&#x0D; Methods: All patients who were hemodynamically stable before the operation and admitted into the surgical intensive care unit following coronary artery bypass, cardiopulmonary bypass, or aortic surgery, had no excessive postoperative bleeding and not on diuretic treatment, were included in the analysis. A total of 1998 patients were divided into two cohorts, viz, the first group was placed on albumin infusion (n = 999) while the second group received normal saline infusion (n = 999). Data were obtained from DICOM files of patients and records of pharmacy. Wilcoxon test or two-tailed paired t-test followed by Tukey post-hoc tests were performed for statistical analysis at 95 % of confidence level.&#x0D; Results: Albumin and normal saline administration did not decrease the duration of mechanical ventilation, incidence of mechanical ventilation, need for blood transfusion, and length of hospital stay (p &gt; 0.05). Albumin infusion decreased the need for fresh frozen plasma transfusion from 85 to 67, reduced mortality (p = 0.0005, q = 3.959), lowered serum lactate level (p &lt; 0.0001, q = 43.853), but increased cardiac index (p &lt; 0.0001, q = 12.192) as well as financial burden (p &lt; 0.0001, q = 95.158) for the patients, compared to normal saline group.&#x0D; Conclusion: In view of the foregoing, it is recommended that the use of restriction of albumin resuscitation in surgical intensive care unit should be restricted in this subset of patients evluated in this study.

Novel autologous, high concentrated fibrin as advanced hemostatic agent for coronary surgery

BackgroundVariability in transfusion outcomes and excessive postoperative bleeding represents a significant problem in cardiac surgery. The effort to reduce bleeding complications and transfusion outcomes is desirable. Our study investigated the feasibility of reducing bleeding complications and transfusion requirements by applying perioperatively prepared autologous bio-regenerative fibrin sealant. MethodsA prospective, case-control study enrolled 74 patients undergoing coronary artery bypass grafting by a single surgeon. Patients in the control group (N = 43), received traditional methods of hemostasis, while patients in the experimental group (N = 31) were treated additionally with autologous bio-regenerative fibrin. ResultsPatients were well-matched with regard to basic demographic, laboratory and procedural data. Allogeneic blood transfusion requirement in control group was 39.5 % (17 of 43 patients), compared to 6.5 % (2 of 31 patients) in treated group (p < 0,001). The lower infection rate in the experimental group was also noted. No safety issues were identified during the preparation and application process. ConclusionAutologous bio-regenerative fibrin can be safely prepared, with no time consuming, and was demonstrated to be a useful tool to decrease allogeneic blood transfusion requirements following elective coronary artery bypass grafting surgery. A prospective randomized trial is needed to confirm these findings.

Changing of haemostatic system in a pig model during different types of hypothermic circulatory arrest.

Hypothermic circulatory arrest is usually used in aortic surgery, congenital heart defect repairs and other complex surgeries. It is frequently associated with excessive postoperative bleeding and the transfusion of allogeneic blood products. The physiopathology of hypothermic circulatory arrest-induced coagulopathy has never been systematically studied. The aim of the study was to investigate this phenomenon in a pig model. Ten pigs were randomly assigned to 30min of hypothermic circulatory arrest at either 15°C (n=5) or 25°C (n=5). Detection of apoptosis and haemostatic system assays were performed in this experiment. Enzyme-linked immunosorbent assays were performed at ten time points in each group to study the changes in the coagulation system in hypothermic circulatory arrest. All of the statistical analyses were performed in SPSS software, version 18.0, and as bilateral tests, and p<0.05 was considered statistically significant. There was no significant difference in the effect of different types of hypothermic circulatory arrest on routine laboratory tests and tissue sample analysis (p>0.05, for all). Our results demonstrated that more severe systemic activation of the coagulation system (TAT and F1+2) was applied in the deep hypothermic circulatory arrest group but not in the moderate hypothermic circulatory arrest group (TAT/p=0.01, F1+2/p=0.03). However, this activation of the coagulation system (AT III and PC) was not associated with changes in the anticoagulation pathway (AT III/p=0.24, PC/p=0.33). In addition, analysis of biomarkers of the haemostatic system revealed that the consumption of coagulation is more concentrated on extrinsic coagulation factors (FVII/p=0.01). Moderate hypothermic circulatory arrest is more suitable for patients with coagulation dysfunction. We believe the application of deep hypothermic circulatory arrest should pay more attention to changes in coagulation rather than the anticoagulation pathway. Extrinsic coagulation factor supplementation is more effective after deep hypothermic circulatory arrest.

EFFECT OF TOPICAL USE OF TRANEXAMIC ACID IN PATIENTS WITH THORACOLUMBAR FRACTURE UNDERGOING POSTERIOR SPINAL FIXATION AND FUSION

Thoracic and lumbar spine trauma (TLST) is frequently associated with chest and abdominal injuries. Multilevel spinal fusions require a longer operative time, with significant soft tissue stripping as well as blood loss, which frequently leads to allogenic blood transfusion. Topical TXA might enhance patient safety, reducing excessive postoperative bleeding. To evaluate effect of topically applied 1 g TXA on postoperative whole blood transfusion and blood loss in neurologically intact patients with thoracolumbar spine fracture. A clinical prospective randomized study is done on 30 patients with thoracolumbar fracture, undergoing primary posterior instrumented fixation and fusion. Patients were randomized to 2 groups, first group (15 patients) was injected with saline only and second group (15 patients) was injected with mixture of tranexamic acid and saline. Patients were operated under general anesthesia, using a standard midline incision. Wounds are closed in layers over a 16 gauge suction drain; injection cocktail was delivered retrograde into the drain which was then closed for 2 hours. There was a highly significant decrease in blood loss in Group 2. The decrease in Hb level is less in the 2nd group than in the 1st group, indicating less postoperative anemia in the blood count (highly significant). Use of topically administered 1 g of TXA (20 mL) in thoracic and lumbar spinal trauma cases undergoing posterior instrumented fixation and fusion effectively decreased postoperative transfusion requirements. Treatment also reduced total drainage volume, time until drain removal, and length of postoperative hospital stay.

Risk factors for neurological dysfunctions after surgical repair of acute aortic dissection type A.

IntroductionTechnical improvement and new operative strategies significantly influence survival and outcomes after the treatment of acute aortic dissection type A (AADA). However, postoperative complications and particularly neurological dysfunctions (ND) are still very common.AimTo identify preoperative and intraoperative factors as well as immediate postoperative conditions with an influence on the occurrence of neurological complications of surgical treatment of AADA and accordingly take action to reduce them.Material and methodsBetween January 2013 and December 2018, 240 patients with AADA were emergently surgically treated. All patients were divided into two groups: group I – patients with postoperative ND (subgroup Ia – patients with mild, transient ND and Ib – patients with severe ND) and group II – patients without ND.ResultsNeurological damage after the operation was registered in 87 (39.5%) patients. Thirty (13.6%) patients had mild ND and 57 (25.9%) severe. Presence of preoperative neurological deficit, reduced level of consciousness, supra-aortic vessel dissection, hemodynamic instability, and excessive postoperative bleeding with hypotension are factors with a highly statistically significant association with the occurrence of severe ND. Neurological complications were not identified in 66.7% of patients who were axillary cannulated versus 55.9% of patients cannulated in the other way but the difference did not reach statistical significance (p = 0.1099).ConclusionsAdvanced neuroprotective strategies during surgical treatment of AADA are associated with favorable neurological outcomes, especially in a group of patients with identified risk factors for ND.

Acquired Hemophilia and Plasma Cell Neoplasms, a Rare Association

Acquired hemophilia A (AHA) is a rare autoimmune disease caused by circulating autoantibodies inhibiting coagulation factor VIII (FVIII), leading to a clinically significant bleeding diathesis. While in half of AHA cases, no underlying cause is identified, in the other half an association with autoimmune diseases, cancer, the use of certain drugs, pregnancy or the post-partum period is found. We present a case with severe bleeding in which AHA was diagnosed and subsequently a smoldering myeloma was found as underlying disease (case 16, Table 1). We conducted a systematic review of the literature in PubMed looking for the association of AHA and plasma cell neoplasm (PCN) (key words used: hemophilia, inhibitor, factor VIII, myeloma, plasma cell disorder or neoplasms, smoldering myeloma, MGUS, monoclonal gammopathy, paraprotein) and identified 15 additional cases. Description of the cases, sequence of occurrence of both diseases, their treatment, evolution and outcome are here analyzed (Table 1). We found that patients having AHA and PCN were more often males (9/16, 56%), had a median age of 61.5 (range 43-87) years at AHA diagnosis. The most common pattern of bleeding was a soft tissue bleeding. In two cases, AHA was diagnosed after excessive post-operative bleeding, in one patient following a life threatening pericardial bleeding and a hemarthrosis. AHA with active bleeding was the presenting sign in 6 cases (38%) (Table 1, cases 4, 5, 6, 10, 13, 16), in search for an underlying diseases, a PCN was diagnosed subsequently. In the other 10 cases, AHA was diagnosed after PCN. In 3 of them, the occurrence of AHA was interpreted to be secondary to multiple myeloma treatment; the implicated drugs were interferon alpha in one and lenalidomide in two cases. Information about the type of monoclonal gammopathy was available in 11 cases; no particular type of paraprotein or clonal light-chain was discernable. Factor concentrates were used in 12 cases to treat relevant bleedings. Further treatment of AHA consisted of immunosuppression with steroids (N=4), steroids in combination with cyclophosphamide (N=5), or cyclophosphamide alone (N=1). Rituximab was used in 3 cases. Plasma exchange to remove FVIII antibodies was performed in 2 cases, and immunoadsorption was done in our patient. Different therapy regimens were used to treat the underlying PCN over the years (Table 1). At the time of reporting 13 patients were alive, while 2 of 3 patients who died, died of bleeding complications. Information on outcome of AHA and/or PCN was available for 9 of 13 survivors: 6 had normal coagulation tests, while FVIII activity was mildly reduced in two. PCN was in complete and partial remission in 7 and 2 cases, respectively (table 1). Management of AHA is based on four pillars: avoidance of procedures that may have induced bleedings, control of bleeding, inhibitor eradication and treatment of the underlying disease. Our case, together with those described in the literature, emphasizes the possibility of PCN as an underlying cause of AHA. Accordingly, diagnostics including protein-electrophoresis, immune-fixation and free light chains should be considered in patients with AHA. In our experience, early intervention with immunoadsorption can be lifesaving in cases with high FVIII inhibitor titers. The occurrence of excessive unexplained bleeding in PCN should raise the suspicion of secondary AHA and trigger the investigation of coagulations tests. Whether PCN treatment alone can control AHA in these cases remains open, 11/16 (69%) of the reported cases received treatment for both diseases. Disclosures Jalowiec: Amgen: Other: Travel grant; Pfizer: Other: Travel grant; Novartis: Other: Travel grant. Andres:AbbVie: Membership on an entity's Board of Directors or advisory committees; Janssen-Cilag: Membership on an entity's Board of Directors or advisory committees; Roche: Other: Travel support ; Gilead: Other: Travel support ; Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Other: Travel support ; Mundipharma: Other: Travel support ; AbbVie: Other: Travel support; Celgene: Other: Travel support . Kremer Hovinga:CSL-Behring: Honoraria, Other: Honoraria go to employer (Insel Gruppe AG, Department of Hematology); Ablynx/Sanofi: Consultancy, Honoraria, Other: Honoraria go to employer (Insel Gruppe AG, Department of Hematology); Roche: Honoraria, Other: Honoraria go to employer (Insel Gruppe AG, Department of Hematology); Shire: Consultancy, Other: Honoraria go to employer (Insel Gruppe AG, Department of Hematology), Research Funding; Siemens: Honoraria, Other: Honoraria go to employer (Insel Gruppe AG, Department of Hematology).

Cost Analysis of Transfusion Therapy in Coronary Artery Surgery.

In patients undergoing coronary artery bypass grafting (CABG), wide variability in transfusion rate (7.8% to 92.8%) raises the question of the amount of unnecessary transfusions. The aim of the study was (1) to identify CABG patients at low risk of bleeding to whom transfusion treatment should be avoided and (2) to calculate the amount of possible cost savings that would be achieved by avoiding transfusion in low bleeding risk patients. This retrospective observational study enrolled patients undergoing isolated elective CABG from January 2010 to January 2018. Patients were divided with respect to the presence of excessive bleeding and transfusion costs were compared between the two groups. Predictors for postoperative excessive bleeding were defined and multivariable logistic regression analysis and risk modeling were performed. The use of a model to predict patients at low risk of bleeding allowed for the estimation of transfusion cost savings assuming the patients who were found to be at low risk of bleeding should not be transfused. A total of 1,426 patients were enrolled in the analysis. Of those, 28.3% had excessive postoperative bleeding. The multivariate logistic regression analysis model was developed to identify/predict patients without excessive bleeding (receiver operating characteristic curve analysis, area under the curve 72.3%, p < 0.001). When applied to the existing database, the use of the developed model identifying patients at low risk of bleeding may result in a 39.1% reduction of transfusions. Specifically, cost savings would be 48.2% for packed red blood cells, 38.9% for fresh frozen plasma, 10.9% for platelets concentrate, and 17.9% for fibrinogen concentrate. The clinical and economic burdens associated with unnecessary transfusions are significant. Avoiding transfusion in CABG patients found to be at low risk of bleeding may result in significant reduction of transfusion rate and transfusion-associated costs.

Association among Clopidogrel Cessation, Platelet Function, and Bleeding in Coronary Bypass Surgery: An Observational Trial.

This study sought to determine (1) the association between the length of preoperative clopidogrel discontinuation, blood loss, and transfusion requirements and (2) whether preoperative platelet function testing predicts excessive postoperative bleeding in patients undergoing coronary artery bypass grafting (CABG) surgery. In this retrospective analysis, patients undergoing CABG were divided into three groups with regard to the period between preoperative clopidogrel cessation and surgery: group 1 (n = 94, ≤3 days), group 2 (n = 100, 4-5 days), and group 3 (n = 83, 6-7 days), respectively. Impedance aggregometry (Multiplate) with arachidonic acid (ASPI) test assay (used for platelets stimulation) and adenosine diphosphate (ADP) test (used for platelets stimulation) was performed before the surgery. Primary outcome was 24 hours chest tube output (CTO) and transfusion requirements (red blood cell concentrate [RBCC], platelet concentrate [PC], fibrinogen concentrate [FC], and fresh-frozen plasma [FFP]) were considered as secondary outcomes. CTO during 24 hours was significantly higher in group 1 as compared with groups 2 and 3, respectively (p = 0.003). Considering secondary outcomes, RBCC (p = 0.043), PC (p = 0.001), FC (p = 0.003), and FFP (p = 0.010) were more frequently transfused in group 1 as compared with groups 2 and 3, respectively. Multiple electrode aggregometry ASPI and ADP tests were significantly correlated with the 24-hour CTO (ASPI test-rho = -0.258, p < 0.001; ADP test-rho = -0.164, p = 0.007). A significant correlation was observed between clopidogrel-free interval and 24-hour CTO (rho = -0.200, p < 0.001). Receiver-operating characteristics (ROC) curve analysis revealed cutoff values to delineate bleeding tendency (ASPI test ≤ 25 area under the aggregation curve [AUC], ADP test ≤63 AUC, and clopidogrel-free interval ≤3 days). Excessive postoperative bleeding occurred less frequently if the period between clopidogrel discontinuation and surgery was longer than 3 days, as compared with shorter waiting time. Inadequate recovery of the platelets function following clopidogrel cessation in preoperative period was associated with increased bleeding risk. Platelet function testing was found to be a useful tool for postoperative bleeding management in our hands.

Heparin–protamine balance after neonatal cardiopulmonary bypass surgery

Background Neonates undergoing cardiopulmonary bypass (CPB) are at risk of excessive bleeding. Blood is anticoagulated with heparin during CPB. Heparin activity is reversed with protamine at the end of CPB. Paradoxically, protamine also inhibits blood coagulation when it is dosed in excess of heparin. Objectives To evaluate heparin-protamine balance in neonates undergoing CPB by using research and clinical assays, and to determine its association with postoperative bleeding. Patients/Methods Neonates undergoing CPB in the first 30 days of life were studied. Blood samples were obtained during and after surgery. Heparin-protamine balance was assessed with calibrated automated thrombography, thrombin-initiated fibrin clot kinetic assay (TFCK), activated partial thromboplastin time (APTT), anti-FXa activity, and thromboelastometry. Excessive postoperative bleeding was determined by measurement of chest tube output or the development of cardiac tamponade. Results and Conclusions Of 44 neonates enrolled, 16 (36%) had excessive postoperative bleeding. The TFCK value was increased. By heparin in neonatal blood samples, but was only minimally altered by excess protamine. Therefore, it reliably measured heparin in samples containing a wide range of heparin and protamine concentrations. The APTT most closely correlated with TFCK results, whereas anti-FXa and thromboelastometry assays were less correlative. The TFCK and APTT assay also consistently detected postoperative heparin rebound, providing an important continued role for these long-established coagulation tests in the management of postoperative bleeding in neonates requiring cardiac surgical repair. None of the coagulation tests predicted the neonates who experienced postoperative bleeding, reflecting the multifactorial causes of bleeding in this population.

Risk scoring for prediction of postoperative bleeding in cardiac surgery

BackgroundMorbidity and mortality after cardiac surgery can be caused by excessive bleeding which is a common and preventable cause. Excessive bleeding after cardiac operations can be classified to surgical or medical causes. The Papworth Bleeding Risk Score can be helpful in predicting the high risk patients for excessive bleeding.The objective of this study was the evaluation of the ability of Papworth Bleeding Risk Score for prediction of excessive early bleeding after cardiac surgery in Egypt. MethodsIn this prospective single-center observational study carried out from September 2017 till December 2017, at National Heart Institute of Egypt enrolled 100 consecutive patients.Adult patients who were plnned to undergo cardiac surgery with cardiopulmonary bypass were included. Exclusion criteria were Off pump surgeries, congenital heart diseases and known bleeding disorders. The aim was to identify patients with expected risk of an adverse excessive postoperative bleeding according to Papworth bleeding risk score. Postoperative bleeding, reopening and death were calculated. ResultsTotal number of the bleeders were 17 cases, (4 high risk, 11 medium risk and 2 low risk). Three patients were reopened with only one patient because of surgical cause. ConclusionsWe consider this bleeding score as a simple, effective and discriminative modality to stratify cases into three risk groups to take the prophylactic measures with high risk patients and to avoid side effects of these measures in low risk patients.

Association Between Platelet Count and Postoperative Blood Loss in Patients Undergoing Cardiac Surgery With Cardiopulmonary Bypass and Fresh Frozen Plasma Administration Guided by Thromboelastometry.

Coagulopathy after cardiopulmonary bypass (CPB) is caused by multiple factors, including reduced coagulation factors and a low platelet count.Methods and Results:In this study, we undertook a post hoc analysis to identify factors associated with increased postoperative blood loss in 97 patients undergoing cardiac surgery with CPB, with fresh frozen plasma administered according to a ROTEM-guided algorithm. We identified 24 patients for the top quartile of postoperative blood loss, >528 mL and defined as having excessive blood loss. Using Spearman's rank correlation test and multivariable linear regression, we reanalyzed the participants' demographic, surgical and anesthetic variables, laboratory test results, blood loss, and transfusion data. Univariate analysis indicated that patients who experienced higher postoperative blood loss received a significantly higher heparin dose, had a higher requirement for fresh frozen plasma transfusion during surgery, and had a significantly lower hematocrit and platelet count at the end of surgery compared with patients without excessive blood loss. Multivariate analysis showed that platelet count at the end of surgery (odds ratio 0.780, 95% confidence interval 0.629-0.967; P=0.024) was an independent factor for excessive blood loss. Low platelet count at the end of surgery was associated with excessive postoperative bleeding during cardiac surgery with CPB.

Validation of a definition of excessive postoperative bleeding in infants undergoing cardiac surgery with cardiopulmonary bypass

ObjectiveTo derive and validate an objective definition of postoperative bleeding in neonates and infants undergoing cardiac surgery with cardiopulmonary bypass. MethodsUsing a retrospective cohort of 124 infants and neonates, we included published bleeding definitions and cumulative chest tube output over different postoperative periods (eg, 2, 12, or 24 hours after intensive care unit admission) in a classification and regression tree model to determine chest tube output volumes that were associated with red blood cell transfusions and surgical re-exploration for bleeding in the first 24 hours after intensive care unit admission. After the definition of excessive bleeding was determined, it was validated via a prospective cohort of 77 infants and neonates. ResultsExcessive bleeding was defined as ≥7 mL/kg/h for ≥2 consecutive hours in the first 12 postoperative hours and/or ≥84 mL/kg total for the first 24 postoperative hours and/or surgical re-exploration for bleeding or cardiac tamponade physiology in the first 24 postoperative hours. Excessive bleeding was associated with longer length of hospital stay, increased 30-day readmission rate, and increased transfusions in the postoperative period. ConclusionsThe proposed standard definition of excessive bleeding is based on readily obtained objective data and relates to important early clinical outcomes. Application and validation by other institutions will help determine the extent to which our specialty should consider this definition for both clinical investigation and quality improvement initiatives.

The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis.

Despite the fact that aspirin is of benefit to patients following coronary artery bypass grafting (CABG), continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the influence of preoperative aspirin administration on patients undergoing cardiac surgery. Medline database was searched using OVID SP interface. Similar searches were performed separately in EMBASE, PubMed, and Cochrane Central Registry of Controlled Trials. Twelve randomized controlled trials and 28 observational studies met our inclusion criteria and were included in the meta-analysis. The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury (AKI). Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI). Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. Despite this effect of preoperative aspirin, it did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC) when preoperative low-dose aspirin (≤160 mg/d) was administered. Preoperative aspirin increases the risk for postoperative bleeding. However, this did not result in an increased need for chest re-exploration and did not increase the rates of PRBC transfusion when preoperative low-dose (≤160 mg/d) aspirin was administered. Aspirin at any dose is associated with decreased mortality and AKI and low-dose aspirin (≤160 mg/d) decreases the incidence of perioperative MI.

Effect of Low-Dose Aspirin on Bleeding Following Exodontia: A Prospective Clinical Study

This research aims to study the effects of low-dose aspirin on bleeding after exodontia and to compare statistically and analyze perioperative blood loss during exodontia in patients on aspirin therapy and healthy patients and also to discuss the various measures if required necessary for controlling postoperative bleeding in simple and uncomplicated exodontia. The study included 100 patients, ranging in age from 30 to 60years. The patients were divided into two groups, a test group consisting of 50 patients who were on a daily dose of 75-150mg of aspirin and a control group consisting of 50 patients not on any antiplatelet therapy. All extraction procedures were performed on outpatient basis. Patients were operated under local anesthesia. Post-extraction sockets were checked for bleeding immediately (30min) and followed up at 24, 48, and 72h, and 1week, after the procedure. Amount of intraoperative blood loss was similar in both test and control groups, and there was no excessive postoperative bleeding in any case. Out of 100 patients, only three patients of test group and two patients of control group required level II hemostatic measures and two patients of test group needed level III measures. We could reach a conclusion and recommend that patients on long-term low-dose aspirin (75-150mg) need not to discontinue their aspirin dose prior to routine exodontia and can be carried out safely with enhanced local hemostatic measures, if required.

Haemophilia: a rare cause of bleeding after ear surgery

Introduction: Excessive bleeding during ear surgery is a troublesome problem which could be related to inadequate infiltration, active infection, trauma to the dura or jugular bulb or sudden hypertension. When the problem recurs in the postoperative period, despite intraoperative control of the field, a bleeding diathesis should be suspected.Case report: We present two adult patients in whom excessive intraoperative and postoperative bleeding associated with ear surgery led to the diagnosis of congenital mild haemophilia A.Conclusion: This case report highlights the fact that excessive perioperative bleeding for which no other cause can be found in an adult patient should suggest the presence of a bleeding diathesis like haemophilia A or B for which detailed coagulation workup is required. Any subsequent surgery would need to be performed with administration of specific perioperative medication to reduce the possibility of excessive bleeding.Bangladesh Journal of Medical Science Vol.15(1) 2016 p.135-138

Single center experience with wrapping of the dilated ascending aorta.

BackgroundExternal wrapping is a surgical technique performed in patients with a dilated ascending aorta. The aim of this study is to present the mid-term results of wrapping of the dilated ascending aorta.Methods34 patients (mean age: 64.4 ± 10.8 years, 21 males) with a dilated ascending aorta were operated on at a single cardiac surgery center using a wrapping technique. The aortas were wrapped with 32–36 mm straight Dacron vascular prostheses. The aortic wall was not excised in any of the patients. Wrapping was performed concomitant to other cardiac surgery procedures in 30 patients (88 %), which involved surgery on the aortic valve in 28 patients (82 %).ResultsThe mean follow-up time was 19.5 ± 8.3 months (median: 18 months, range: 12–36 months). None of the patients died or had aortic complications during the hospital stay and the follow-up period. A rethoracotomy had to be performed due to excessive postoperative bleeding in two patients. One patient was diagnosed with a transient ischemic attack on the 4th postoperative day, while another had respiratory failure requiring prolonged intubation. No redilatation of the ascending aorta or dislocation of the wrap was noticed in any of the patients.ConclusionsAccording to our study, external wrapping of the ascending aorta has good short-term results and may be regarded as a safe surgical option for patients with a moderately dilated ascending aorta.