Intraoperative Blood Product Use Research Articles

Comparison of Intraoperative Blood Product Use During Heart Transplantation in Patients Bridged with Impella 5.5 versus Durable Left Ventricular Assist Devices

To determine if the intraoperative transfusion requirements differ based on the mechanical circulatory device used as a bridge to heart transplantation. A single-center retrospective analysis of intraoperative transfusion requirements in all patients undergoing heart or heart/kidney transplantation between November 2018 and July 2021 who were bridged with a temporary (Impella 5.5) or durable left ventricular assist device (LVAD). A tertiary care hospital. Forty-three adult patients bridged to heart or heart/kidney transplantation with a temporary or durable LVAD between 2018 and 2021 INTERVENTIONS: Recording of baseline characteristics and intraoperative transfusion requirements, including packed red blood cells, fresh frozen plasma, cryoprecipitate, autologous blood salvage, and platelets. The difference in cardiopulmonary bypass times, intensive care unit length of stay, and the vasoactive inotrope score following transplantation were also recorded. The primary outcome was the volume of blood products transfused intraoperatively. Patients who underwent bridge to transplantation using the Impella 5.5 had statistically significant lower median transfusions of cryoprecipitate (155 mL versus 200 mL, p = 0.015), autologous blood salvage (675 mL versus 1,125 mL, p ≤ 0.01), and platelets (412 mL versus 675 mL, p ≤ 0.01). Additionally, there was a trend toward lower transfusion of intraoperative packed red blood cells (4.5 units versus 6.5 units, p = 0.29) and fresh frozen plasma (675 mL versus 800 mL, p = 0.11), but these were not statistically significant. The results suggest a reduction in certain intraoperative transfusion requirements in patients undergoing heart transplantation bridged with the Impella 5.5 versus durable left ventricular assist device.

Novel method for direct retransfusion reduces blood transfusions in descending and thoracoabdominal aneurysm repair.

Allogenic blood product usage is associated with worse outcomes in open repair of descending and thoracoabdominal aortic aneurysms. This pilot study evaluated the safety and efficacy of a novel modification of the left heart bypass (LHB) circuit to reduce intraoperative blood transfusions. In modified LHB, pump suckers collected shed blood that was directly retransfused through a femoral vein cannula. In standard LHB, cellsavers were used to collect, wash, and retransfuse shed blood. Consecutive patients undergoing elective surgical descending or thoracoabdominal aneurysm repair using modified (N.=12) or standard (N.=21) LHB were compared. Intraoperative blood product use was the primary outcome. Hypotensive episodes, lactate levels, and adverse events (early mortality, spinal cord injury, renal and respiratory insufficiency) were secondary outcomes. Groups were comparable regarding pre- and intraoperative variables. No perfusion-related adverse events occurred. With modified LHB, intraoperative blood product use was significantly reduced: packed red blood cells by 60% from 10 to 4 units (P=0.002), fresh frozen plasma by 70% from 17 to 5 units (P<0.001) as well as retransfused cellsaver volume by 75%, from 4500 mL to 1110 mL (P<0.001). Hemodynamic instability occurred in 1 (8.3%) vs. 6 (29%), P=0.22 and overall lactate levels were significantly reduced (P=0.045) with modified LHB. Adverse events combined occurred in 1/12 vs. (P=0.022). The novel modified LHB with direct retransfusion was safe and associated with significantly reduced intraoperative blood product use, reduced lactate production and improved clinical outcomes as compared to standard LHB and could represent an important clinical improvement.

Evaluation of factors affecting the development of re-operation due to hemorrhage after lung resection

In our study, preoperative factors affecting the development of re-operation after lung resection were examined.413 patients who underwent lung resection between 2018-2020 were included in our study. The preoperative data of 25 (6.1%) patients who underwent re-operation and 388 (93.9%) patients who did not undergo re-operation were compared. Preoperative hemoglobin level (p=0.009), neoadjuvant therapy (p&lt;0.001), pneumonectomy (p&lt;0.001), thoracotomy (p=0.005), amount of intraoperative blood loss (p&lt;0.001), need for intraoperative blood product use (p). =0.005), intraoperative mean arterial pressure (p=0.01), pulse rate (p=0.001), postoperative hemoglobulin amount (p&lt;0.001) were found to affect and increase the probability of re-operation. It was statistically significant that the need for postoperative blood product usage was higher (p&lt;0.001), postoperative complications (100% vs. 22.8%, p&lt;0.001) and mortality (0.6% vs. 4%, p=0.01) in reoperated patients. It was found that the hospitalization day in the ICU was longer in those who underwent reoperation than in those who did not (3.2 days vs. 1.5, p&lt;0.001). Independent risk factors affecting re-operation according to multiple logistic regression analysis; neoadjuvant treatment (p&lt;0.001), operation time (p=0.04), intraoperative pulse rate (p=0.01) and postoperative hemoglobin (p&lt;0.001) were found. Low preoperative hemoglobin level, on the other hand, independently affected the development of re-operation at a level close to significance (p=0.06). Re-operation due to bleeding after lung resection increases the rate of cardiopulmonary complications in the postoperative period. Careful follow-up and approach of surgery and anesthesia in the intraoperative period will contribute to the decrease in the incidence of re-operation.

Pleth Variability Index Guided Volume Optimisation in Major Gynaecologic Surgery.

To compare conventional fluid management (CFM) with pleth variability index (PVI) guided goal-directed fluid management (GDFM) during elective total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO) operations. Randomised controlled trial. Department of Anaesthesiology and Reanimation, Faculty of Medicine, Health Sciences University, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, from February to July 2021. This trial included 78 patients aged 18-65 years with ASA I-III who would undergo elective TAH-BSO under general anaesthesia. Following randomisation with the closed envelope method, standard monitoring, and 250 ml crystalloid infusion during anaesthesia induction, maintenance fluid therapy was administered at 8-10 ml/Kg/hour to the control group and 2-3 ml/Kg/hour to the PVI group. If the mean arterial pressure (MAP) was ≤65 mmHg and/or the MAP was decreased by more than 20%, and the PVI was >13%, a 250 ml colloid bolus was given. When there was no response, a vasoactive agent was administered. Vital signs, laboratory findings, and postoperative complications were evaluated. Age, weight, BMI, urine output, bleeding, hospital stay, comorbidities, intraoperative use of blood products, and complication rates were not significantly different between the PVI and CFM groups (p>0.05). The PVI group had shorter operational times and used less crystalloid than the control group (p=0.033 and p<0.001, respectively). The PVI group's postoperative base excess (BE) levels changed significantly less than the control group's (p<0.001). In both pre- and postoperative haemoglobin, haematocrit, urea, creatinine, electrolytes, and lactate measurements, there were no statistically significant differences between the groups (p>0.05). PVI-GDFM is equally safe as CFM for intraoperative fluid management during elective complete abdominal hysterectomy and bilateral salpingo-oophorectomy procedures. Pleth variability index, Fluid management, Base excess.

Evaluation of Risk Factors for Cardiac Complications After Lung Resection

Aim: The aim of this study is to evaluate cardiac complications (CC) and risk factors associated with these complications in patients after lung resection. Methods: Cardiac complications were observed in 136 (11.4%) of 1186 patients who underwent lung resection in a single center between 2017 and 2020. 136 patients who developed complications in the same period and 215 patients who had consecutive operations and did not develop complications were included in the study Results: 287 (81.7%) of the patients were male and the mean age was 58.9 years. There is a statistically significant relationship between cardiac complications after lung resection with geriatric age, male gender, presence of hypertension (HT), presence of lung cancer, neoadjuvant therapy, high SOFA score, chronic obstructive pulmonary disease (COPD), and cerebrovascular accident (CVA). In addition, CVA, EF&lt;60%, neoadjuvant therapy, pneumonectomy, high Sequential Organ Failure Assessment score (SOFA) and intraoperative blood transfusion were found to be independent risk factors for the development of complications. Among the intraoperative factors, pneumonectomy (p&lt;0.001), thoracotomy (p=0.002), intraoperative blood product use (p&lt;0.001) and inotropic use (p&lt;0.001) were correlated with CC. In multiple logistic regression analysis, preoperative thyroid disease (p=0.04), CVA (p=0.001), neoadjuvant therapy (p=0.002), EF&lt;60% (p=0.01), pneumonectomy (p=0.003), intraoperative blood transfusion (p&lt;0.0001) and high SOFA score (p&lt;0.0001) emerged as independent risk factors affecting the development of cardiac complications. Conclusions: There is significant relationship between cardiac complications after lung resection with geriatric age, male sex, HT, lung cancer presence, neoadjuvant therapy, high SOFA score, COPD, CVA presence. In addition, CVA, EF&lt; 60%, neoadjuvant therapy, pneumonectomy and high SOFA score and intraoperative blood transfusion were identified as independent risk factors in the development of complications.

Predictors of Primary Graft Dysfunction Following Bilateral Lung Transplantation

<h3>Purpose</h3> Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality following lung transplantation, affecting up to 30% of recipients within 72 hours of transplantation¹. Published perioperative risk factors include a history of donor smoking^2,3 or heavy donor alcohol use⁴, longer graft ischemic times², volume of intraoperative fluid administered⁵, and higher recipient BMI^2,3,6. Our aim was to identify additional intraoperative risk factors for PGD after lung transplantation. <h3>Methods</h3> In this single center, retrospective cohort study evaluating all primary, double lung transplants (DLT) performed at our institution between January 1, 2016 and December 31, 2018, data was collected from several hospital registries as well as our electronic medical record and UNOS data to evaluate donor and recipient demographics as well as intraoperative management strategies that may be associated with PGD. The primary outcome was grade 3 PGD, based on the ISHLT definition. Continuous variables are expressed as medians with range, and categorical variables as n (%). A multivariate regression model was built from our univariate analysis. <h3>Results</h3> 105 patients underwent primary DLT during the study period; 6 refused research participation. Data from 99 patients was collected and analyzed. Eighteen patients (18%) met criteria for the primary outcome of PGD. Recipient etiology of respiratory failure, intraoperative requirement for inhaled pulmonary vasodilator (IPV), degree of HLA mismatching, and the use of intraoperative blood products were associated with PGD (Table 1). The use of an inhaled pulmonary vasodilator, degree of HLA mismatch and increased red cell transfusion were independently associated with PGD. <h3>Conclusion</h3> In this retrospective analysis, we identify additional independent perioperative risk factors associated with PGD following double lung transplant. Future efforts will focus on identifying risk factors for massive intraoperative red blood cell transfusion and the need for IPV.

HeartMate III™ Implantation: A Novel Technique to Reduce the Incidence of Perioperative Bleeding and the Use of Intraoperative Blood Products

<h3>Purpose</h3> We describe a method for implanting the Abbot HeartMate 3™ (HM3) Left Ventricular Assist Device (LVAD) that may reduce perioperative bleeding and the use of blood products. <h3>Methods</h3> First a median sternotomy is performed and the HM3 prepared. The driveline is tunneled through the subcutaneous tissue and the patient is placed on cardiopulmonary bypass (CPB). The HM3 is implanted via the "cut then sew" method. A ring is made from Teflon™ felt and placed over the cuff of the HM3 sewing ring (Figure 1A-C). After coring the LV apex, a second donut shaped felt ring (1D) is placed (1E). Sutures are placed through the felt and LV wall and passed through the sewing cuff. The cuff is lowered, sutures tightened (1F-G), and more sutures are placed through the cuff and passed through the myocardium and felt strip (1H). The inflow and outflow cannula are attached, and patient removed from CPB. To determine the effect of this method on perioperative bleeding, we reviewed the charts of 114 patients that underwent HM3 placement in our institution between October 2015 and June 2019 by 4 surgeons, 1 of whom used this method. <h3>Results</h3> Table 1 shows our results and suggests that the novel method results in less perioperative bleeding, as indicated by both comparison of pre and postoperative hemoglobin and hematocrit and the amount of blood products given intraoperatively. The novel method also resulted in a shorter procedure time, possibly due to improved hemostasis. <h3>Conclusion</h3> Our addition of Teflon™ felt strips around the sewing cuff of the HM3 may reduce perioperative bleeding and the use of perioperative blood products.

A clinical calculator for predicting intraoperative blood loss and transfusion risk in spine tumor patients

BACKGROUND CONTEXTSurgery for vertebral column tumors is commonly associated with intraoperative blood loss (IOBL) exceeding 2 liters and the need for transfusion of allogeneic blood products. Transfusion of allogeneic blood, while necessary, is not benign, and has been associated with increased rates of wound complication, venous thromboembolism, delirium, and death. PURPOSETo develop a prediction tool capable of predicting IOBL and risk of requiring allogeneic transfusion in patients undergoing surgery for vertebral column tumors. STUDY DESIGN/SETTINGRetrospective, single-center study. PATIENT SAMPLEConsecutive series of 274 patients undergoing 350 unique operations for primary or metastatic spinal column tumors over a 46-month period at a comprehensive cancer center OUTCOME MEASURESIOBL (in mL), use of intraoperative blood products, and intraoperative blood products transfused. METHODSWe identified IOBL and transfusions, along with demographic data, preoperative laboratory data, and surgical procedures performed. Independent predictors of IOBL and transfusion risk were identified using multivariable regression. RESULTSMean age at surgery was 57.0±13.6 years, 53.1% were male, and 67.1% were treated for metastatic lesions. Independent predictors of IOBL included en bloc resection (p<.001), surgical invasiveness (β=25.43 per point; p<0.001), and preoperative albumin (β=−244.86 per g/dL; p=0.011). Predictors of transfusion risk included preoperative hematocrit (odds ratio [OR]=0.88 per %; 95% confidence interval [CI, 0.84, 0.93]; p<0.001), preoperative MCHgb (OR=0.88 per pg; 95% CI [0.78, 1.00]; p=0.048), preoperative red cell distribution width (OR=1.32 per %; 95% CI [1.13, 1.55]; p<0.001), en bloc resection (OR=3.17; 95%CI [1.33, 7.54]; p=0.009), and surgical invasiveness (OR=1.08 per point; [1.06; 1.11]; p<0.001). The transfusion model showed a good fit of the data with an optimism-corrected area under the curve of 0.819. A freely available, web-based calculator was developed for the transfusion risk model (https://jhuspine3.shinyapps.io/TRUST/). CONCLUSIONSHere we present the first clinical calculator for intraoperative blood loss and transfusion risk in patients being treated for primary or metastatic vertebral column tumors. Surgical invasiveness and preoperative microcytic anemia most strongly predict transfusion risk. The resultant calculators may prove clinically useful for surgeons counseling patients about their individual risk of requiring allogeneic transfusion.

Predictors of Primary Graft Dysfunction Following Bilateral Lung Transplantation

Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality following lung transplantation, affecting up to 30% of recipients within 72 hours of transplantation1. Published perioperative risk factors include a history of donor smoking2,3 or heavy donor alcohol use4, longer graft ischemic times2, volume of intraoperative fluid administered5, and higher recipient BMI2,3,6. Our aim was to identify additional intraoperative risk factors for PGD after lung transplantation. In this single center, retrospective cohort study evaluating all primary, double lung transplants (DLT) performed at our institution between January 1, 2016 and December 31, 2018, data was collected from several hospital registries as well as our electronic medical record and UNOS data to evaluate donor and recipient demographics as well as intraoperative management strategies that may be associated with PGD. The primary outcome was grade 3 PGD, based on the ISHLT definition. Continuous variables are expressed as medians with range, and categorical variables as n (%). A multivariate regression model was built from our univariate analysis. 105 patients underwent primary DLT during the study period; 6 refused research participation. Data from 99 patients was collected and analyzed. Eighteen patients (18%) met criteria for the primary outcome of PGD. Recipient etiology of respiratory failure, intraoperative requirement for inhaled pulmonary vasodilator (IPV), degree of HLA mismatching, and the use of intraoperative blood products were associated with PGD (Table 1). The use of an inhaled pulmonary vasodilator, degree of HLA mismatch and increased red cell transfusion were independently associated with PGD. In this retrospective analysis, we identify additional independent perioperative risk factors associated with PGD following double lung transplant. Future efforts will focus on identifying risk factors for massive intraoperative red blood cell transfusion and the need for IPV.

Heartmate III™ Implantation: A Novel Technique to Reduce the Incidence of Perioperative Bleeding and the Use of Intraoperative Blood Products

We describe a method for implanting the Abbot HeartMate 3™ (HM3) Left Ventricular Assist Device (LVAD) that may reduce perioperative bleeding and the use of blood products. First a median sternotomy is performed and the HM3 prepared. The driveline is tunneled through the subcutaneous tissue and the patient is placed on cardiopulmonary bypass (CPB). The HM3 is implanted via the "cut then sew" method. A ring is made from Teflon™ felt and placed over the cuff of the HM3 sewing ring (Figure 1A-C). After coring the LV apex, a second donut shaped felt ring (1D) is placed (1E). Sutures are placed through the felt and LV wall and passed through the sewing cuff. The cuff is lowered, sutures tightened (1F-G), and more sutures are placed through the cuff and passed through the myocardium and felt strip (1H). The inflow and outflow cannula are attached, and patient removed from CPB. To determine the effect of this method on perioperative bleeding, we reviewed the charts of 114 patients that underwent HM3 placement in our institution between October 2015 and June 2019 by 4 surgeons, 1 of whom used this method. Table 1 shows our results and suggests that the novel method results in less perioperative bleeding, as indicated by both comparison of pre and postoperative hemoglobin and hematocrit and the amount of blood products given intraoperatively. The novel method also resulted in a shorter procedure time, possibly due to improved hemostasis. Our addition of Teflon™ felt strips around the sewing cuff of the HM3 may reduce perioperative bleeding and the use of perioperative blood products.

Anesthetic Management for Left Ventricular Assist Device Implantation Through Left Thoracotomy: Evaluation of On-Pump Versus Off-Pump

BackgroundVentricular assist devices (VADs) are alternative approaches to medical treatment in patients with acute or chronic heart failure. The goal of this study was to compare an anesthetic approach in patients undergoing implantation of a VAD with (on-pump) or without (off-pump) cardiopulmonary bypass (CPB) through left thoracotomy. MethodsA total of 32 patients were divided into 2 groups: on-pump (group 1) and off-pump (group 2). A standard anesthesia protocol was used in all patients. Baseline characteristics of the patients, intraoperative hemodynamic and respiratory variables, anesthetic agents and vasoactive drugs administered, the amount of blood products, extubation, length of hospital stay and intensive care unit stay, and postoperative complications were recorded. ResultsPatients' mean age was 54.7 ± 13.3 years (range, 18–74 years). Eighteen patients underwent surgery with CPB. Demographic data of the patients, preoperative characteristics, intraoperative use of blood products, intraoperative complications, and anesthetic drugs used were similar between groups (P > .05). The duration of surgery (219 ± 23 vs 273 ± 56 minutes) and anesthesia (274 ± 38 vs 323 ± 57 minutes) were shorter in group 2; there was no difference between the 2 groups in terms of mechanical ventilation time, length of stay in the intensive care unit, and length of hospital stay. There was no decrease in postoperative oxygen parameters and an increase in patient lactate levels with the use of CPB. The use of fresh frozen plasma and platelet suspension in the postoperative period was significantly higher in group 1 (P < .05). The rate of complications and mortality rate were comparable between the 2 groups (P > .05). ConclusionsOur study results show that the use of CPB during VAD implantation via left thoracotomy increases operation time and use of blood products, while causing no change in the rate of complications.

Lung Transplantation and the Routine Use of Cardiopulmonary Bypass and Median Sternotomy: Experience at the Ochsner Multi-Organ Transplant Institute.

From 1990-2005 at Ochsner Medical Center in New Orleans, LA, cardiopulmonary bypass (CPB) was used only when necessary during lung transplantation surgeries. Ochsner's lung transplant program was closed for more than 4 years after Hurricane Katrina, and since the program's reestablishment in 2010, the majority of lung transplantation surgeries have been performed with the patient on CPB and with a median sternotomy incision. The purpose of this study was to compare the outcomes of the CPB and non-CPB groups. After institutional review board approval, we conducted a retrospective review of the entire program using the Ochsner lung transplant database to identify patients in the non-CPB group from 1990-2005 and in the CPB group from 2010-2014. We calculated 1- and 3-year survival rates for each patient and reviewed medical records for evidence of stroke, the need for operative reexploration, and venous stenosis. We also performed a subgroup analysis of the first 20 consecutive patients undergoing lung transplantation on CPB with median sternotomy from February 2010 through April 2011 to examine intraoperative blood product use, the quantity of blood products administered, CPB cannulation and pump complications, ischemic time, and primary graft dysfunction. Of the 208 patients in the non-CPB group, 74% had 1-year graft survival and 55% had 3-year survival following transplantation. After February 2010, 79 patients underwent lung transplantation on CPB with median sternotomy, and 90% of those patients had 1-year graft survival. Of the 46 patients available for 3-year follow-up, 59% were alive with functional grafts. The difference in 1-year survival rates between the 2 cohorts was statistically significant. Two deaths, 3 strokes, and 5 reexplorations of the chest for bleeding occurred during the perioperative time period in the CPB group, but no mortality was associated with these perioperative events. One patient who had perioperative complications died within the first year; the death was attributable to gastric perforation. Patients' early outcomes appear to have improved with the use of CPB and median sternotomy; however, 3-year survival is similar to the non-CPB group. Technical benefits of CPB with median sternotomy include decreased warm ischemia time during graft implantation, controlled hemodynamics and reperfusion, avoidance of single-lung ventilation of a freshly implanted graft, and the option to open the left atrium for implantation of a venous cuff without using a clamp. The surgical exposure facilitated by CPB with median sternotomy for lung transplantation appears to be a safe and feasible approach for lung transplantations.

Delayed Sternal Closure After Continuous Flow Left Ventricle Assist Device Implantation: Analysis of Risk Factors and Impact on Outcomes and Costs.

Patient and institutional factors predictive of delayed sternal closure (DSC) practice and its impact on clinical and cost outcomes when compared with primary sternal closure (PSC) following continuous-flow left ventricular assist device (CF-LVAD) implantation were examined. Statewide Society of Thoracic Surgeons and hospital cost data on CF-LVADs implanted were analyzed. Between January 2007 and December 2013, 558 CF-LVADs were implanted (PSC = 464, 83.2%; DSC = 94, 16.8%). Among the six institutions implanting CF-LVADs, DSC practice ranged from 3.1% to 37.8%. Compared with PSC, the DSC group had higher body mass index (BMI), renal failure, anemia, IIb/IIIa inhibitor use, emergency surgery, and extracorporeal membrane oxygenation (ECMO) support. Delayed sternal closure patients had significantly longer bypass time (139 ± 63 min vs. 107.6 ± 42 min) and higher use of intraoperative blood products (82% vs. 69%) and right ventricular assist device (RVAD) support (4.3% vs. 0.2%). Postoperative morbidities and mortality (23.4% vs. 6.5%; p ≤ 0.0001) were higher in the DSC group compared with PSC. Mean hospital costs for DSC were higher than PSC ($249,144 ± 123,273 vs. $155,915 ± 95,032; p ≤ 0.0001). Multivariate predictors of DSC include institution with higher DSC practice, preoperative ECMO support, use of IIb/IIIa inhibitors, tricuspid valve surgery, and intraoperative red blood cell transfusion. Delayed sternal closure was an independent risk factor for postoperative mortality, odds ratio 3.0 (1.2-7.2).

Prior Sternotomy Increases the Mortality and Morbidity of Adult Heart Transplantation

BackgroundThis study investigated the effect of prior sternotomy (PS) on the postoperative mortality and morbidity after orthotopic heart transplantation (HTx). MethodsOf 704 adults who underwent HTx from December 1988 to June 2012 at a single institution, 345 had no PS (NPS group) and 359 had ≥1 PS (PS group). Survival, intraoperative use of blood products, intensive care unit (ICU) and hospital stays, frequency of reoperation for bleeding, dialysis, and >48-hour ventilation were examined. ResultsThe NPS and PS groups had similar 60-day survival rates (97.1 ± 0.9% vs 95.3 ± 1.1%; P = .20). However, the 1-year survival was higher in the NPS group (94.7 ± 1.2% vs 89.7 ± 1.6%; hazard ratio [HR], 1.98; 95% CI, 1.12–3.49; P = .016). The PS group had longer pump time and more intraoperative blood use (P < .0001 for both). Postoperatively, the PS group had longer ICU and hospital stays, and higher frequencies of reoperation for bleeding and >48-hour ventilation (P < .05 for all comparisons). Patients with 1 PS (1PS group) had a higher 60-day survival rate than those with ≥2 PS (2+PS group; 96.7 ± 1.1% vs 91.1 ± 3.0%; HR, 2.70; 95% CI, 1.04–7.01; P = .033). The 2+PS group had longer pump time and higher frequency of postoperative dialysis (P < .05 for both). Patients with prior VAD had lower 60-day (91.1 ± 3.0% vs 97.1 ± 0.9%; P = .010) and 1-year (87.4 ± 3.6% vs 94.7 ± 1.2%; P = .012) survival rates than NPS group patients. Patients with prior CABG had a lower 1-year survival than NPS group patients (89.0 ± 2.3% vs 94.7 ± 1.2%; P = .018). ConclusionThe PS group had lower 1-year survival and higher intraoperative blood use, postoperative length of ICU and hospital stays, and frequency of reoperation for bleeding than the NPS group. Prior sternotomy increases morbidity and mortality after HTx.

Perioperative hyperglycemia is associated with postoperative neurocognitive disorders after cardiac surgery

ObjectiveNeurocognitive disorders commonly occur following cardiac surgery. However, the underlying etiology of these disorders is not well understood. The current study examined the association between perioperative glucose levels and other risk factors and the onset of neurocognitive disorders in adult patients following coronary artery bypass and/or valvular surgery.MethodsAdult patients who underwent their first cardiac surgery at a large tertiary care medical center were identified and those with neurocognitive disorders prior to surgery were excluded. Demographic, perioperative, and postoperative neurocognitive outcome data were extracted from the Society for Thoracic Surgery database, and from electronic medical records, between January 2004 and June 2009. Multiple clinical risk factors and measures associated with insulin resistance, such as hyperglycemia, were assessed. Multivariable Cox competing risk survival models were used to assess hyperglycemia and postoperative neurocognitive disorders at follow up, adjusting for other risk factors and confounding variables.ResultsOf the 855 patients included in the study, 271 (31.7%) had new onset neurocognitive disorders at follow-up. Age, sex, New York Heart Failure (NYHF) Class, length of postoperative intensive care unit stay, perioperative blood product transfusion, and other key factors were identified and assessed as potential risk factors (or confounders) for neurocognitive disorders at follow-up. Bivariate analyses suggested that new onset neurocognitive disorders were associated with NYHF Class, cardiopulmonary bypass, history of diabetes, intraoperative blood product use, and number of diseased coronary vessels, which are commonly-accepted risk factors in cardiac surgery. In addition, higher first glucose level (median =116 mg/dL) and higher peak glucose >169 mg/dL were identified as risk factors. Male sex and nonuse of intra-operative blood products appeared to be protective. Controlling for potential risk factors and confounders, multivariable Cox survival models suggested that increased perioperative first glucose measured in 20 unit increments, was significantly associated with the onset of postoperative neurocognitive disorders at follow-up (hazard ratio [HR] =1.16, P<0.001) and that women had an elevated risk for this outcome (HR =4.18, P=0.01).ConclusionOur study suggests that perioperative hyperglycemia was associated with new onset of postoperative neurocognitive disorders in adult patients after cardiac surgery, and that men tended to be protected from these outcomes. These findings may suggest a need for the revision of clinical protocols for perioperative insulin therapy to prevent long-term neurocognitive complications.

Intraoperative Risk Factors Associated With Postoperative Pressure Ulcers in Critically Ill Patients

The risk for pressure ulcers is rarely identified in the perioperative period, and the influence of this period on risk factors has not been as rigorously studied as the postoperative period. We hypothesized that intraoperative risk factors exist, which increase the likelihood of a postoperative new-onset pressure ulcer. A retrospective observational study. A large midwestern U.S. quaternary care institution. A total of 2,695 adult surgical patients underwent operative procedures and received care in one of three ICUs using an electronic documentation application. None. The primary outcome was hospital-acquired pressure ulcer categorized as stages II, III, and IV; deep tissue injury; or unstageable. Univariate analyses comparing patients with and without the outcome of pressure ulcers were conducted for each preoperative characteristic or comorbidity. Patients were matched using the logit of the propensity score based solely on their preoperative comorbidities. Adjusted associations between development of pressure ulcers and intraoperative characteristics were determined in the postmatch cohort. We identified seven independent preoperative patients' characteristics and comorbidities in our adult surgical patient sample: American Society of Anesthesiologists risk classification 4 or 5, underweight body mass index, noncardiac surgery, history of congestive heart failure, renal disease, existing airway present prior to arrival in the operating room, and age. The only significant association in the matched dataset accounting for patient preoperative variability is the use of intraoperative blood products. Postoperative pressure ulcers developed in 10.7% of critically ill patients in our study. Only intraoperative use of blood products, not operative case length, hypotension, or vasopressor use, was associated with postoperative pressure ulcer development on adjusted analysis.

Incidence of postoperative atrial fibrillation in patients undergoing minimally invasive versus median sternotomy valve surgery

Atrial fibrillation (AF) after cardiac surgery is associated with increased morbidity and hospital length of stay. Our objective was to determine whether a minimally invasive approach to isolated valve surgery reduced the incidence of postoperative AF. Patients without a history of arrhythmia, who underwent isolated aortic or mitral valve surgery between January 2005 and August 2011, were included. The incidence of postoperative AF in those who underwent a minimally invasive approach was compared with that of patients undergoing median sternotomy surgery. Resource utilization was approximated on the basis of intensive care unit and total hospital lengths of stay. A total of 571 patients were identified (413 minimally invasive and 158 median sternotomy). No significant differences in baseline characteristics existed between groups. The incidence of postoperative AF (25% vs 37%; P=.002), use of intraoperative blood products (52% vs 83%; P<.001), and prolonged intubation (≥24 hours) (12% vs 20%; P=.008) were significantly less in the minimally invasive group. The intensive care unit and hospital lengths of stay were 45 hours (interquartile range [IQR], 28-66 hours) versus 53 hours (IQR, 45-91 hours) (P<.001), and 5 days (IQR, 4-7 days) versus 8 days (IQR, 6-11 days) (P<.001) for the minimally invasive and median sternotomy groups, respectively. Multivariable analysis revealed a decreased risk of postoperative AF in patients undergoing minimally invasive surgery (odds ratio, 0.4; 95% confidence intervals, 0.24-0.66; P<.001). A minimally invasive approach for isolated valve surgery reduces postoperative AF and resource use when compared with median sternotomy.

The intra-operative use of blood products in neurosurgical operations

The occasional publication of the odd article may serve a purpose to the community of readers that may transpire not only from the immediate contents or the purported message conveyed by it but also by indirect inference allowed. That is certainly the case with the current paper. The issue of how to handle blood products in neurosurgical procedures and, in a general manner, all aspects related to the best operating room (OR) performance are of extreme importance, and not only the technical aspects of the procedure itself. Positioning, monitoring, use of sterile techniques, circulation in the OR, intra-operative use of drugs akin to the surgical act, use of blood products, timing of the procedure, etc. are all aspects which need to be systematically assessed, audited and taught. A surgeon, or a surgical team, who for a typified type of operation consistently takes considerably longer time than normal to conclude the surgical act, is also exposing the patient to an unnecessary risk. In the same manner, inordinate use of blood products is a stigma of poor quality. This can be translated both into an overuse of transfused units or of an inadequate and unjustified cross-matching of blood units. Blood is scarce, expensive, and too precious to be handled around in a frivolous manner. For this reason, I think that the article serves the purpose of alerting us to this constant reality, and to the need for creating institutional policies based also on institutional evidence for the use of blood products, with a strong emphasis on the need to reduce the over-expenditure that many of our daily acts imply. Whether this should be based on a percentage obtained after a certain number of operations of each type is only an incomplete way of looking at the problem. The planning and anticipation of the average intraoperative need for blood products must take into account the type of operation, the type of patient, the type of anaesthesiologist and the type of surgeon. I do not believe this can be uniquely extrapolated from a percent figure out of a surgical series. It needs to be tempered by the individual appreciation of factors involved, which means that for each single case an honest estimation has to be reached by both the surgical and anaesthetic teams. It is interesting to note the high number of units routinely cross-matched for neurosurgical procedures in this institution in the recent past. How recent was it and how did the data drawn from this study change the authors’ practice?

Early Postoperative Outcomes and Blood Product Utilization in Adult Cardiac Surgery

Aprotinin was a commonly used pharmacological agent for homeostasis in cardiac surgery but was discontinued, resulting in the extensive use of lysine analogues. This study tested the hypothesis that early postoperative adverse events and blood product utilization would affected in this post-aprotinin era. Adult patients (n=781) undergoing coronary artery bypass, valve replacement, or both from November 1, 2005, to October 31, 2008, at a single institution were included. Multiple logistic regression modeling and propensity scoring were performed on 29 preoperative and intraoperative variables in patients receiving aprotinin (n=325) or lysine analogues (n=456). The propensity-adjusted relative risk (RR) for the intraoperative use of packed red blood cells (RR, 0.75; 95% confidence interval [CI], 0.57 to 0.99), fresh frozen plasma (RR, 0.37; 95% CI, 0.21 to 0.64), and cryoprecipitate (RR:0.06; 95% CI, 0.02 to 0.22) were lower in the aprotinin versus lysine analog group (all P<0.05). The risk for mortality (RR, 0.53; 95% CI, 0.16 to 1.79) and neurological events (RR, 0.87; 95% CI, 0.35 to 2.18) remained similar between groups, whereas a trend for reduced risk for renal dysfunction was observed in the aprotinin group. In the post-aprotinin era, with the exclusive use of lysine analogues, the relative risk of early postoperative outcomes such as mortality and renal dysfunction have not improved, but the risk for the intraoperative use of blood products has increased. Thus, improvements in early postoperative outcomes have not been realized with the discontinued use of aprotinin, but rather increased blood product use has occurred with the attendant costs and risks inherent with this strategy.

Preoperative Beta-Blocker Usage: Is It Really Worthy of Being a Quality Indicator?

Since 2007, the use of preoperative β-blockers has been used as a quality standard for patients undergoing coronary artery bypass graft surgery. Recent studies have called into question of the benefit of empiric preoperative β-blocker use. Data were extracted from our Society of Thoracic Surgeons certified database for patients undergoing isolated coronary artery bypass graft surgery from 2000 to 2008. We compared the outcomes for patients who received preoperative β-blockers with those of patients who did not. The study group had 12,855 patients, of whom 7,967 (62.0%) were treated preoperatively with β-blockers. Using propensity matching, we selected two matched groups of 4,474 patients with preoperative β-blocker use and 4,474 not using preoperative β-blockers. In the unmatched cohort, only deep sternal infection (0.3% versus 0.5% without β-blockers; p=0.032), pneumonia (1.9% versus 2.4% without β-blockers; p=0.039), and intraoperative blood usage (37.2% versus 34.1% without β-blockers; p<0.001) reached statistically significant difference. In the matched groups, there was no difference between adverse event rates in patients treated with β-blockers and those who were not. The number of patients requiring intraoperative blood product use was significantly higher among β-blocker-treated patients (p=0.004). Calculating the adjusted odds ratios showed that in the matched groups, the preoperative use of β-blockers was not an independent predictor of mortality. A rational for preoperative β-blockade exists. However, as with any medical intervention, its application should be tailored to specific clinical scenarios. With no differences in mortality or morbidity, our findings do not support preoperative β-blockade as a useful quality indicator for coronary artery bypass graft surgery.