Perioperative Period Of Cardiac Surgery Research Articles

Real-world safety and effectiveness of inhaled nitric oxide therapy for pulmonary hypertension during the perioperative period of cardiac surgery: a post-marketing study of 2817 patients in Japan

ObjectiveTo evaluate the real-world safety and effectiveness of inhaled nitric oxide (INOflo® for Inhalation 800 ppm) for perioperative pulmonary hypertension associated with cardiac surgery in Japan.MethodsThis was a prospective, non-interventional, all-case, post-marketing study of pediatric and adult patients who received perioperative INOflo with cardiac surgery from November 2015–December 2020. Safety and effectiveness were monitored from INOflo initiation to 48 h after treatment completion or withdrawal. Safety outcomes included adverse drug reactions, blood methemoglobin concentrations, and inspired nitrogen dioxide concentrations over time. Effectiveness outcomes included changes in central venous pressure among pediatrics, mean pulmonary arterial pressure among adults, and the partial pressure of arterial oxygen/fraction of inspired oxygen ratio (PaO2/FiO2) in both populations.ResultsThe safety analysis population included 2,817 Japanese patients registered from 253 clinical sites (pediatrics, n = 1375; adults, n = 1442). INOflo was generally well tolerated; 15 and 20 adverse drug reactions were reported in 14 pediatrics (1.0%) and 18 adults (1.2%), respectively. No clinically significant elevations in blood methemoglobin and inspired nitrogen dioxide concentrations were observed. INOflo treatment was associated with significant reductions in both central venous pressure among pediatrics and mean pulmonary arterial pressure among adults, and significant improvements in PaO2/FiO2 among pediatrics and adults with PaO2/FiO2 ≤ 200 at baseline.ConclusionsPerioperative INOflo treatment was a safe and effective strategy to improve hemodynamics and oxygenation in patients with pulmonary hypertension during cardiac surgery. These data support the use of INOflo for this indication in Japanese clinical practice.

Физиологические основы целенаправленной инфузионной терапии в кардиохирургии (обзор)

Goal-directed fluid therapy is a paradigm in perioperative medicine, which includes haemodynamic monitoring and individualized haemodynamic management in high-risk patients by means of fluid therapy. This approach has certain benefits compared with the traditional model of fluid therapy during the perioperative period of cardiac surgery. The required fluid volume can be hard to determine. Traditionally, fluid therapy was guided by static preload parameters, such as central venous pressure and pulmonary artery occlusion pressure, which failed to provide adequate precision. In opposition to static parameters, a number of dynamic indices and tests were developed to assess fluid responsiveness. The cornerstone of dynamic indices are cyclic preload changes due to intrathoracic pressure variations during mechanical ventilation. Dynamic tests are circulatory stress tests involving preload changes. The most frequently used tests are passive leg raise, fluid challenge test, and some others. However, in spite of their satisfactory predictive value, dynamic indices and tests have certain limitations, which must be taken into consideration. For instance, mechanical ventilation, sinus rhythm, intact thorax, and normal respiratory mechanics are obligatory conditions for applying dynamic indices. Thus, using dynamic indices can be difficult in cardiac surgery, making the search for new methods to overcome their limitations highly important.

Use of Impella Devices for Acute Cardiogenic Shock in the Perioperative Period of Cardiac Surgery.

The Impella ventricular support system is a device that can be inserted percutaneously or directly across the aortic valve to unload the left ventricle. The purpose of this study is to determine the role of Impella devices in patients with acute cardiogenic shock in the perioperative period of cardiac surgery. A retrospective single-surgeon review of 11 consecutive patients who underwent placement of Impella devices in the perioperative period of cardiac surgery was performed. Patient records were evaluated for demographics, indications for placement, and postoperative outcomes. Impella devices were placed for refractory cardiogenic shock preoperatively in 6 patients, intraoperatively in 4 patients, and postoperatively as a rescue in 1 patient. Seven patients received Impella CP, 1 Impella RP, 1 Impella CP and RP, and 2 Impella 5.0. Additionally, 3 patients required preoperative venovenous extracorporeal membrane oxygenation (VV-ECMO), and 1 patient required intraoperative venoarterial extracorporeal membrane oxygenation (VA-ECMO). All Impella devices were removed 1 to 28 days after implantation. Length of stay in the intensive care unit stay ranged from 2 to 53 days (average 23.9±14.6). The 30-day and 1-year mortality were 0%. Ten of 11 patients were alive at 2 years. Also, 1 patient died 18 months after surgery from complications of coronavirus disease (Covid-19). Device-related complications included varying degrees> of hemolysis in 8 patients (73%) and device malfunction in 1 patient (9%). The Impella ventricular support system can be combined with other mechanical support devices for additional hemodynamic support. All patients demonstrated myocardial recovery with no deaths in the perioperative period and in 1-year of follow-up. Larger studies are necessary to validate these findings.

Effect of mechanical ventilation during cardiopulmonary bypass on end-expiratory lung volume in the perioperative period of cardiac surgery: an observational study

BackgroundMany studies explored the impact of ventilation during cardiopulmonary bypass (CPB) period with conflicting results. Functional residual capacity or End Expiratory Lung Volume (EELV) may be disturbed after cardiac surgery but the specific effects of CPB have not been studied. Our objective was to compare the effect of two ventilation strategies during CPB on EELV.MethodsObservational single center study in a tertiary teaching hospital. Adult patients undergoing on-pump cardiac surgery by sternotomy were included. Maintenance of ventilation during CPB was left to the discretion of the medical team, with division between "ventilated" and "non-ventilated" groups afterwards. Iterative intra and postoperative measurements of EELV were carried out by nitrogen washin-washout technique. Main endpoint was EELV at the end of surgery. Secondary endpoints were EELV one hour after ICU admission, PaO2/FiO2 ratio, driving pressure, duration of mechanical ventilation and post-operative pulmonary complications.ResultsForty consecutive patients were included, 20 in each group. EELV was not significantly different between the ventilated versus non-ventilated groups at the end of surgery (1796 ± 586 mL vs. 1844 ± 524 mL, p = 1) and one hour after ICU admission (2095 ± 562 vs. 2045 ± 476 mL, p = 1). No significant difference between the two groups was observed on PaO2/FiO2 ratio (end of surgery: 339 ± 149 vs. 304 ± 131, p = 0.8; one hour after ICU: 324 ± 115 vs. 329 ± 124, p = 1), driving pressure (end of surgery: 7 ± 1 vs. 8 ± 1 cmH2O, p = 0.3; one hour after ICU: 9 ± 3 vs. 9 ± 3 cmH2O), duration of mechanical ventilation (5.5 ± 4.8 vs 8.2 ± 10.0 h, p = 0.5), need postoperative respiratory support (2 vs. 1, p = 1), occurrence of pneumopathy (2 vs. 0, p = 0.5) and radiographic atelectasis (7 vs. 8, p = 1).ConclusionNo significant difference was observed in EELV after cardiac surgery between not ventilated and ventilated patients during CPB.

Clinical analysis of hospital acquired mycoplasma pneumoniae infection after cardiac surgery: a case series.

Mycoplasma pneumoniae (MP) is a common pathogen of community-acquired respiratory infections. The clinical characteristics hospital-acquired MP infections are rarely reported in the literature. Our ward is mainly responsible for the management of patients during the perioperative period of cardiac surgery. Several patients had fever during the improvement of their condition after cardiac surgery, and the effect of upgrading antibiotics and increasing the antibacterial spectrum was not good. Using inpatient data of Guangdong Provincial People's Hospital, we conducted a retrospective case series study of hospital-acquired MP infection after cardiac surgery from January 2015 to December 2020 to investigate the clinical characteristics. Clinical data was extracted from patients with a confirmed diagnosis of MP infection after >48 hours of hospitalization. All analyses for this study were descriptive. Data were expressed as mean ± standard deviation (SD), median with range or number with percentage as appropriate. We totally included 22 patients. The time of onset of hospital-acquired MP infection after surgery was 23.32±12.57 days, and the duration of antibiotic use before the onset of infection was 4-40 days. Both fever and sore throat were the main symptoms of nosocomial MP infection, and the rash was the most common physical sign. Laboratory tests were normal for peripheral blood leukocyte count and procalcitonin in most patients (17 cases), while the lymphocyte count was decreased in 10 cases. A single serum anti-MP antibody titer ≥1:160 combined with clinical manifestations and imaging helped confirm nosocomial MP infection, although a double serum anti-MP antibody (four-fold change in titer) wasn't seen. With quinolone therapy, such as levofloxacin, all the patients' temperature gradually returned to normal and were discharged uneventfully. Patients after cardiac surgery should be aware of the presence of hospital-acquired MP infection when they develop new fever accompanied by atypical bacterial infection signs such as sore throat and rash during treatment. In such cases, changes in MP antibody titers need to be monitored and anti-MP therapy is required.

Application and evaluation of sacubitril/valsartan in patients with cardiac insufficiency during perioperative period of cardiac surgery

Sacubitril/valsartan is the first angiotensin II receptor blocker neprilysin inhibitor, which inhibits both angiotensin II receptor and neprilysin. In recent years, a series of clinical studies have shown that sacubitril/valsartan has a good therapeutic effect on heart failure. The present study was conducted to investigate the therapeutic effect and safety of sacubitril/valsartan in patients with cardiac insufficiency during the perioperative period of cardiac surgery. A total of 59 patients were divided into two groups: Heart failure with reduced ejection fraction (HFrEF) group and heart failure with preserved ejection fraction (HFpEF) group. The therapeutic effect on patients with sacubitril/valsartan was assessed by the values of left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVED). The renal safety of patients was assessed by serum creatinine (Cr) and blood urea nitrogen (BUN). Sacubitril/valsartan decreased LVED in HFrEF group and HFpEF group. And it showed a significant increase of LVEF in the HFrEF group. There was no significant change in Cr and BUN. Sacubitril/valsartan showed a good therapeutic effect on cardiac function for the perioperative period of cardiac surgery.

Neurosurgical Treatment of Patients with Posterior Fossa Acute Subdural Hematoma Right after Cardiac Surgery.

As posterior fossa acute subdural hematoma (ASDH) right after cardiac surgery is extremely rare, the clinical course and optimal treatment strategy remain undetermined. We performed a retrospective analysis of patients with posterior fossa ASDH right after cardiac surgery requiring neurosurgical treatment at our institution over a 7-year period and, in this study, discussed the neurosurgical strategy and clinical course. Collected data included clinical history, laboratory results, time course, symptoms, neurosurgical treatment, outcome at discharge, and imaging studies. All six patients were women who had no history of head trauma and had received antithrombotic therapy during the perioperative period of cardiac surgery. All patients showed lower platelets count and were diagnosed with ASDH within 3 days (longest time 64 h) right after cardiac surgery. After discontinuation of anticoagulation therapy and administration of reversal agents, they underwent emergency hematoma evacuation craniotomy (n = 5) or burr hole drainage surgery (n = 1), which were performed in the prone (n = 4) or lateral (n = 2) positions. Four of these patients showed favorable outcomes, and two showed poor outcomes. One of the poor-outcome patients received three antithrombotic therapies, and another developed rapidly progressive ASDH. Posterior fossa ASDH associated with antithrombotic therapy right after cardiac surgery is frequently found in women, and emergent neurosurgical treatment with anticoagulation discontinuation and reversal agent administration can be performed safely. Burr hole drainage surgery might be acceptable in nonsevere cases. By contrast, we must pay attention to cases receiving both anticoagulant and antiplatelet drugs and rapid progression cases.

Application of Metagenomic Next-Generation Sequencing in the Etiological Diagnosis of Infective Endocarditis During the Perioperative Period of Cardiac Surgery: A Prospective Cohort Study

ObjectiveThe present study aimed to prospectively evaluate the role of metagenomic next-generation sequencing (mNGS) in the etiological diagnosis of patients with perioperative infective endocarditis (IE).MethodsFrom May 1st, 2019 to December 31st, 2020, a total of 99 patients with IE were enrolled in the present study according to the modified Duke criteria, etiological, and pathological results. 11 non-IE patients undergoing heart valve surgery in the same period were selected as the control group. A blood culture test was performed immediately after admission, and the valves harvested operatively were examined by blood culture and mNGS.ResultsIn the IE group, there were 29 cases (29.3%) with positive blood culture, 16 cases (16.2%) with positive valve culture, and 85 cases (85.9%) with positive valve mNGS. Compared to culture-based detection, mNGS achieved better performance with a sensitivity, specificity, area under the curve (AUC) of 0.859, 0.727, and 0.793, respectively. The combined approach using culture and mNGS further improved the diagnostic accuracy (sensitivity 89.9%, specificity 72.7%, AUC 0.813). Preoperative white blood cell (P = 0.029) and neutrophils (P = 0.046) were identified as independent factors affecting the detection rate of mNGS. In the mNGS-positive group, 95 strains of pathogens were found and 10 cases were identified with mixed infection. There were 72 gram-positive bacteria and 14 gram-negative bacteria. mNGS positive group displayed higher species richness than mNGS negative group with enrichment of Streptococcus sanguis, Streptococcus buccalis, and Streptococcus griseus. Proteobacteria and Actinomycetes were enriched in mNGS negative group. Notably, six patients showed disconcordant results between culture and mNGS. Rothia aeria was identified in the blood culture, valve culture, and valve mNGS in one patient. Bartonella Quintana and Coxiella burnetii, which were fastidious intracellular bacteria, were found in two blood and valve culture-negative cases.ConclusionsmNGS outperformed the conventional culture method and displayed high accuracy in detecting pathogens in IE patients. This study provided support for the use of mNGS in the etiological diagnosis of IE.

Expert consensus on the use of human serum albumin in critically ill patients.

Expert consensus on the use of human serum albumin in critically ill patients.

Analysis of the effect of multimedia-assisted psychological nursing in perioperative period of cardiac surgery with cardiopulmonary bypass.

article: Analysis of the effect of multimedia-assisted psychological nursing in perioperative period of cardiac surgery with cardiopulmonary bypass - Panminerva Medica 2022 June;64(2):308-9 - Minerva Medica - Journals

Expanding enhanced recovery protocols for cardiac surgery to include the patient voice: a scoping review protocol

BackgroundCardiac surgery is becoming increasingly common in older, more vulnerable adults. A focus on timely and complete medical and functional recovery has led to the development of enhanced recovery protocols (ERPs) for a number of surgical procedures and subspecialties, including cardiac surgery (ERAS® Cardiac). An element that is often overlooked in the development and implementation of ERPs is the involvement of key stakeholder groups, including surgery patients and caregivers (e.g., family and/or friends). The aim of this study is to describe a protocol for a scoping review of cardiac patient and caregiver preferences and outcomes relevant to cardiac surgery ERPs.MethodsUsing Arksey and O’Malley’s et al six-stage framework for scoping review methodologies with adaptions from Levac et al. (Represent Interv: 1–18, 2012), a scoping review of existing literature describing patient- and caregiver-identified preferences and outcomes as they relate to care received in the perioperative period of cardiac surgery will be undertaken. The search for relevant articles will be conducted using electronic databases (i.e., the Cochrane Library, Medline, PsycINFO, Scopus, and Embase), as well as through a search of the grey literature (e.g., CPG Infobase, Heart and Stroke Foundation, ProQuest Theses and Dissertations, Google Advanced, and Prospero). Published and unpublished full-text articles written in English, published after the year 2000, and that relate to the research question will be included. Central to the design of this scoping review is our collaboration with two patient partners who possess lived experience as cardiac surgery patients.DiscussionThis review will identify strategies that can be integrated into ERPs for cardiac surgery which align with patient- and caregiver-defined values. Broadly, it is our goal to demonstrate the added value of patient engagement in research to aid in the success of system change processes.

Chinese consensus guideline for cerebral protection in the perioperative period of cardiac surgery (2019)

Cerebral complication in the postoperative period of cardiac surgery is one of the most important elements for the prognosis and rehabilitation. It is significant for the clinicians to recognize, comprehend, prevent and ameliorate the complications of cerebral nervous system. For the purpose of down-regulating brain injury and cerebral complications after cardiac surgery, promoting nosocomial rehabilitation, Cerebral Protection in Cardiac Intensive Care Group, Neural Regeneration and Repair Committee, Chinese Research Hospital Association organizes Chinese medical experts who specialize in cardiac surgery, critical care medicine, extracorporeal circulation, anesthesiology and emergency medicine cooperatively draft Chinese consensus guideline for cerebral protection in the perioperative period of cardiac surgery (2019). Its content includes brain injury classifying risk factors recognizing, treatment protocols formulating, intra-operative cerebral function monitoring, brain protection in intensive care unit (ICU) and drug administration in order to guide the clinical practice.

Creative Optimization and Industrial Research of Freeze Drying Process of the Cardiomyopeptidin for Injection

Cardiomyopeptidin is a kind of biological drug used in the perioperative period of cardiac surgery, and the main ingredient of it can help to repair myocardial damage. In the production of cardiomyopeptidin for injection, vacuum freeze drying is a key technology. However, it has to face many difficulties such as the long cycle of freeze drying process (78 h) and large deviation of quality in group which reduce the efficiency of product. Currently, the study of freeze drying process of cardiomyopeptidin for injection is rare. The experiments in this paper were conducted by a miniature freeze dryer, cutting down the cycle of freeze drying process to an ideal value (45 h) and diminishing the deviation of quality in group. At present, many key factors of freeze drying process of the cardiomyopeptidin have been investigated, the optimized freeze drying program successfully cuts down the cycle to 36 h in the pilot freeze dryer. Luckily, the research also found a new auxiliary material which could greatly improve the efficiency of freeze drying. This paper provides a new way for the research of freeze drying process of biological drugs.

Volatile anaesthetics added to cardiopulmonary bypass are associated with reduced cardiac troponin.

Every year, over 1 million cardiac surgical procedures are performed all over the world. Reducing myocardial necrosis could have strong implications in postoperative clinical outcomes. Volatile anaesthetics have cardiac protective properties in the perioperative period of cardiac surgery. However, little data exists on the administration of volatile agents during cardiopulmonary bypass. The aim of this study was to assess if volatile anaesthetics administration during cardiopulmonary bypass reduces cardiac troponin release after cardiac surgery. We retrospectively analysed data from 942 patients who underwent cardiac surgery in a teaching hospital. The only difference between the groups was the management of anaesthesia during CPB. The volatile group received sevoflurane or desflurane while the control group received a combination of propofol infusion and fentanyl boluses. Patients who received volatile anaesthetics during cardiopulmonary bypass (n=314) were propensity-matched 1:2 with patients who did not receive volatile anaesthetics during CPB (n=628). We found a reduction in peak postoperative troponin I, from 7.8 ng/ml (4.8-13.1) in the non-volatile group to 6.8 ng/ml (3.7-11.8) in the volatile group (p=0.013), with no differences in mortality [2 (0.6%) in the volatile group and 2 (0.3%) in the non-volatile group (p=0.6)]. Adding volatile anaesthetics during cardiopulmonary bypass was associated with reduced peak postoperative troponin levels. Larger studies are required to confirm our data and to assess the effect of volatile agents on survival.

Clinical application of intra-aortic balloon pump in patients with cardiogenic shock during the perioperative period of cardiac surgery.

Intra-aortic balloon pumps (IABP) have saved many patients with cardiogenic shock during the perioperative period of cardiac surgery. However, the ideal insertion timing is controversial. In the present study, we aimed to optimize the insertion timing, in order to increase the survival rate of the patients. A total of 197 patients with cardiogenic shock during the perioperative period of cardiac surgery and implemented IABP from January 2011 to October 2015 were selected for the study. Patients were divided into five groups on the basis of application timing of IABP: 0–60, 61–120, 121–180, 181–240 and >240 min. The 30-day mortality, application rate of continuous renal replacement therapy (CRRT), duration of mechanical ventilation, duration of hospital stay and hospitalization charges were analyzed in the above groups. The risk factors related to mortality and the occurrence of IABP complications were also analyzed. The mortality in the 0–60, 61–120, 121–180, 181–240 and >240 min groups were 42.17, 36.6, 77.3, 72.7 and 79.3%, respectively. Earlier IABP insertion resulted in less patients receiving CRRT from acute renal failure and less daily hospitalization charges. However, the IABP application timing had no effect on indexes such as hospitalization duration, duration of mechanical ventilation and total hospitalization charges. Multifactor logistic regression analysis indicated that the independent risk factors of death in patients with cardiogenic shock during cardiac surgery were related to IABP support timing and vasoactive-inotropic score (VIS) before balloon insertion. In the first 120 min of cardiogenic shock during the perioperative period of cardiac surgery, IABP application decreased 30-day mortality. Mortality was related with VIS score of patients, which can be used to predict the prognosis of patients with cardiogenic shock.

Neurocognitive and Psychiatric Issues Post Cardiac Surgery.

Neurocognitive and psychiatric complications are common following cardiac surgery and impact on patient quality of life, recovery from surgery, participation in rehabilitation and long-term mortality. Postoperative cognitive decline, depressive disorders, post-traumatic stress disorder and neurocognitive impairment related to silent brain infarcts have all been linked to the perioperative period of cardiac surgery, and potentially have serious consequences. The accurate assessment of these conditions, particularly in determining the aetiology, and impact on patients is difficult due to the poorly recognised nature of these complications as well as similarities in presentation with postoperative delirium. This review aims to summarise current understanding surrounding psychiatric disturbances following cardiac surgery including the impact on patient quality of life and long-term outcomes.

Feasibility of measuring superior mesenteric artery blood flow during cardiac surgery under hypothermic cardiopulmonary bypass using transesophageal echocardiography: An observational study.

Background:Abdominal complications being rare but results in high mortality, commonly due to splanchnic organ hypoperfusion during the perioperative period of cardiac surgery. There are no feasible methods to monitor intraoperative superior mesenteric artery blood flow (SMABF). Hence, the aim of this study was to evaluate the feasibility and to measure SMABF using transesophageal echocardiography (TEE) during cardiac surgery under hypothermic cardiopulmonary bypass (CPB).Methodology:Thirty-five patients undergoing elective cardiac surgery under CPB were enrolled. Heart rate, mean arterial pressure (MAP), cardiac output (CO), SMABF, superior mesenteric artery (SMA) diameter, superior mesentric artery blood flow over cardiac output (SMA/CO) ratio and arterial blood lactates were recorded at three time intervals. T0: before sternotomy, T1: 30 min after initiation of CPB and T2: after sternal closure.Results:SMA was demonstrated in 32 patients. SMABF, SMA diameter, SMA/CO, MAP and CO decreased significantly (P < 0.0001) between T0 and T1, increased significantly (P ≤ 0.001) between T0 and T2. Lactates increased progressively from T0 to T2.Conclusion:Study shows that there is decrease in SMABF during CPB and returns to baseline after CPB. Hence, it is feasible to measure SMABF using TEE in patients undergoing cardiac surgery under hypothermic CPB. TEE can be a promising tool in detecting and preventing splanchnic hypoperfusion during perioperative period.

Nursing diagnoses in the perioperative period of cardiac surgery

The identification of nursing diagnoses most commonly reported in the literature in the perioperative period of cardiac surgery can assist nurses in this context of clinical practice to plan the nursing care towards the individual needs of each patient, contributing to the implementation of rapid and effective actions to solve identified problems. An integrative literature review aimed at identifying nursing diagnoses in the perioperative period of cardiac surgery was developed. The search was performed in the LILACS and SCIELO databases with the descriptors “nursing diagnosis”, “nursing care”, and “cardiac surgery” or “thoracic surgery”. Thirteen studies were included, which identified 17 main preoperative diagnoses, 10 main intraoperative diagnoses, and 28 main post-operative diagnoses. Different studies often found the same diagnosis in each period, which reinforces a profile with which nurses can expect to deal with, and on which they must intervene to obtain the best results. Additional studies on diagnostic accuracy and validity of such diagnoses are expected.

Dexmedetomidine: a review of applications for cardiac surgery during perioperative period.

Cardiac surgery is associated with a high incidence of cardiovascular and other complications during the perioperative period that translate into increased mortality and prolonged hospital stays. Safe comprehensive perioperative management is required to eliminate these adverse events. Dexmedetomidine is a selective α2-adrenoreceptor agonist that has been described as an ideal medication in the perioperative period of cardiac surgery. The major clinical effects of dexmedetomidine in this perioperative period can be summarized as attenuating the hemodynamic response, cardioprotective effects, antiarrhythmic effects, sedation in the ICU setting, treatment of delirium, and procedural sedation. Although there are some side effects of dexmedetomidine, it is emerging as an effective therapeutic agent in the management of a wide range of clinical conditions with an efficacious, safe profile. The present review serves as an overview update in the diverse applications of dexmedetomidine for cardiac surgery during the perioperative period.

Goal-Directed Coagulation Management in the Perioperative Period of Cardiac Surgery

COAGULOPATHY IS A CONCERN in cardiac surgery that involves cardiopulmonary bypass as it leads to an increased risk of perioperative bleeding and transfusion. Recent advances in coagulation monitoring using point-of-care (POC) devices, and new hemostatic agents have increased interest in using a goal-directed approach to treat coagulopathy. The availability of POC devices in the perioperative setting allows coagulopathy to be assessed using rapid bedside tests. This allows physicians to adopt a goal-directed approach to targeted therapy according to the underlying hemostatic pathology.