Clinical impact of rotational thromboelastometry in cardiac surgery.

Patients undergoing cardiac surgery are at high risk of postoperative bleeding, which is related to worse prognosis and survival. The use of ROTEM®, together with the implementation of a specific treatment algorithm, to reduce the risk of postoperative bleeding. An observational, comparative, cross-case study with historical controls. A total of 1772 consecutive patients admitted to intensive care unit after having undergone cardiac surgery, was divided into 3 groups: Group 1: Coagulation was only monitored by the classical coagulation test (control group). Group 2: Monitorization was done by ROTEM®, according to a protocol designed in our center. Group 3: VerifyNow® was added to ROTEM®, implementing a specific treatment algorithm. We observed a decreased of red blood cell transfusion (Group 1 55.5%, Group 2 52.7%, Group 3 46.6%, P<0.01). Postoperative results include a significant reduction in complications with a marked improvement in overall survival in the ROTEM® - guided groups. Conclusions: Monitoring of hemostasis by POCT'S (ROTEM® and VerifyNow®) in patients undergoing cardiac surgery and cardiac transplantation was associated with a decreased incidence of blood transfusion, postoperative clinical complications, and mortality.

Point-of-care haemostasis monitoring during liver transplantation reduces transfusion requirements and improves patient outcome.

BACKGROUND: Optimal haemostasis management can improve patient outcomes and reduce blood loss and transfusion volume in orthotopic-liver-transplant (OLT). METHODS: We performed a prospective study including 200 consecutive OLTs. The first 100 patients were treated according to the clinic's standards and the next 100 patients were treated using the new point-of-care (POC)-based haemostasis management strategy. Transfusion parameters and other outcomes were compared between groups. RESULTS: Transfusion requirements were reduced in the POC group. The median and IQR of red-blood-cells (RBC) transfusion units were reduced from 5 [2-8] to 3 [0-5] (p < 0.001), plasma from 2 [0-4] to 0 (p < 0.001), and platelets from 1 [0-4] to 0 [0-1] (p < 0.001), into the POC group only four patients received tranexamic acid and fibrinogen transfusion rate was 1.13 ± 1.44 g (p = 0.001). We also improved the incidence of transfusion avoidance, 5% vs. 24% (p < 0.001) and reduced the incidence of massive transfusion (defined as the transfusion of more than 10 RBC units), 13% vs. 2% (p = 0.005). We also observed a relationship between RBC transfusion requirements and preoperative haemoglobin, and between platelet transfusion and preoperative fibrinogen levels. The incidence of postoperative complications, such as, reoperation for bleeding, acute-kidney-failure or haemodynamic instability was significantly lower (13.0% vs. 5%, p = 0.048, 17% vs. 2%, p < 0.001, and 29% vs. 16%, p = 0.028). Overall, blood product transfusion was associated with increased risk of postoperative complications. CONCLUSIONS: A haemostatic therapy algorithm based on POC monitoring reduced transfusion and improved outcome in OLT.

Mobile Laboratory Unit: a disruptor solution for hemostasis management during major surgery. Usage in the context of face transplantation.

BACKGROUND: The management of surgical bleeding during a face transplant in a patient diagnosed with bilateral neurofibromatosis is quite complex. With the actual methods and technology for hemostasis management, it may not always be possible to give the clinician the support needed to manage operative associated bleeding. Bedside hemostasis monitors are needed urgently to assist clinicians in making the correct diagnosis in a timely manner. METHODS: Our Mobile Laboratory Unit is a disruptive solution for hemostasis management during major surgery as it allows real-time monitoring, the predominant mechanism of bleeding and goal-direct coagulation therapy. The unit is an autonomous mobile platform that can be moved immediately to anywhere its service is needed and offers a complete flexible laboratory test which includes biochemistry, hematology and coagulation studies as standard equipment. RESULTS: In our case the test performed by the unit allowed us to identify the reason for our patient's bleeding at the bedside. Severely decreased clot firmness of the fibrin-based clot and a less impaired firmness of the whole blood clot, suggested an acceptable contribution of platelets to the clot quality, but decreased polymerization of fibrinogen into fibrin. CONCLUSIONS: In our opinion new insights into the pathophysiology of coagulopathy, the availability of technology such as our Mobile Laboratory Unit, and awareness of side effects of intravenous fluids should encourage the idea that perhaps it is time to change hemostasis management in operation-related bleeding.

Mantenimiento del donante de órganos / Maintenance of the organ donor

No disponible

The influence of the preoperative immune response on blood transfusion requirements in patients undergoing cardiac surgery.

OBJECTIVE: The purpose of this study was to evaluate the influence of preoperative type I and II immune responses on blood transfusion requirements. DESIGN: A prospective and observational trial. SETTING: A postcardiac surgery unit of a university hospital. PARTICIPANTS: Seventy-one consecutive patients undergoing elective cardiac surgery. INTERVENTIONS: Blood samples drawn for laboratory analysis and immunologic study. MEASUREMENTS AND MAIN RESULTS: Patients were divided into 2 groups according to blood transfusion requirements: < or = 2 units (n = 35) and >2 units of red blood cells (n = 36). The preoperative immune response was assessed by flow cytometry, measuring the proportion of CD4+ T helper cells producing cytokines, including Th1 response (interferon-gamma and tumor necrosis factor-alpha [TNF-alpha]) and Th2 response (interleukin 4 and 10). Two logistic regression analyses (including and not including immunologic variables) were used to select and weight perioperative variables associated with an increased risk of transfusion. Three variables were found to be independent predictors of transfusion requirements when immunologic variables were not included: preoperative platelet count, preoperative hemoglobin, and hypertension. When all the variables were included, preoperative hemoglobin, cardiopulmonary bypass time, and the preoperative proportion of CD4+ T cells producing TNF-alpha were associated with an increased risk of transfusion (Hosmer-Lemeshow, 0.33; c-index, 0.93), but preoperative platelet count and hypertension were not. CONCLUSIONS: A low preoperative Th1 immune response, as assessed by the proportion of CD4+ T-helper-producing TNF-alpha, was associated with a higher blood transfusion rate.

Thymic function-related markers within the thymus and peripheral blood: Are they comparable?

The thymus involutes with age and its functionality has traditionally been assumed to be limited early in life. However, some studies have demonstrated that thymic function persists in adults. In humans, since it is difficult to obtain thymic samples from healthy individuals, indirect parameters have been used to study the thymic function. The aim of this study was to compare thymic function parameters within both the thymus and peripheral blood mononuclear cells from thirty-three patients who underwent cardiac surgery, as well as to relate these parameters with aging. The proportion of peripheral naïve T cells and intrathymic T cell differentiation stages, as well as peripheral and intrathymic TREC levels were analysed. We demonstrated that thymopoyesis persists in the healthy elderly since all T cell differentiation stages were found within the thymus. Among the studied parameters, peripheral TREC levels are found to be a good thymic function marker since they correlated with age. In healthy individuals, peripheral TREC levels are a good reflect of thymic function as demonstrated by their correlation with intrathymic TREC values.