Preoperative haemostasis testing does not predict requirement of blood products in cardiac surgery.

OBJECTIVE: Standard haemostasis screening tests are performed to reveal unknown congenital or acquired disturbances of plasma and/or platelet haemostasis. Since their diagnostic efficacy is often low, routinely performed haemostasis testing has been questioned. We investigated whether preoperatively assessed haemostasis testing can be used to predict the requirement of blood products. METHODS: We retrospectively assessed haemostasis parameters including platelet function testing by PFA 100 as well as the numbers of red blood cell (RBC) concentrates, fresh frozen plasmas (FFPs), and platelet concentrates (PCs) that were given peri-operatively and during the first two postoperative days in 2,831 cardiac surgery patients. Logistic regression analyses were used to select those parameters, which could predict blood product requirement. RESULTS: Of our study cohort, 56.5% needed RBCs, 15% FFPs, and 5% PCs. The need for RBCs was associated with significantly altered pre-operative values of most haemostasis parameters. However, by the use of logistic regression analysis fibrinogen was the only haemostasis parameter that was independently associated with the use of RBCs (odds ratio 1.56; 95% CI: 1.27-1.91; P <0.001). The predictive value of other parameters such as age, body weight, haemoglobin, and haematocrit was however much higher in comparison to fibrinogen (odds ratios: 1.92-3.50; P <0.001). It was not possible to develop a score based on haemostasis parameters to accurately identify patients at risk for RBC use. Moreover, we were unable to estimate the need for FFPs and PCs using preoperative haemostasis testing. CONCLUSIONS: Our data demonstrate that preoperatively performed haemostasis testing is not predictive in estimating the need for blood products in cardiac surgery patients.

[The Anaesthesiological Questionnaire for patients in cardiac anaesthesia. Results of a multicenter survey by the scientific working group for cardiac anaesthesia of the German Society for Anaesthesiology and Intensive Care Medicine]. / Der Anästhesiologische Nachbefragungsbogen für Patienten in der Herzanästhesie. Ergebnisse einer Multizentererhebung des wissenschaftlichen Arbeitskreises Kardioanästhesie der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin.

OBJECTIVE: The Anaesthesiological Questionnaire (ANP) is a self-rating method for the assessment of postoperative complaints and patient satisfaction. The questionnaire was adapted for use in cardiac anaesthesia (ANP-KA). The study was conducted to show the value of ANP-KA as a practicable means of assessing the patient's state after cardiac anaesthesia and for its use in quality assurance. METHODS: A total of 1,688 patients from 19 clinics were included who had exclusively received heart valve surgery, CABG surgery or both operations. They completed the ANP-KA between days 1 and 8 postoperatively. RESULTS: The ANP-KA was completed by 79.1% of the patients without any assistance. The highest incidence rates were reported for a dry mouth/thirst (85.1%) and for pain in the area of surgery (60.2%). Plausible and significant differences in patients' symptoms between the grading for the immediate postoperative period and the current state at filling in the questionnaire were found. Women reported more postoperative complaints than men but no differences were found between male and female patients with regard to satisfaction with anaesthesiological care and convalescence. More complaints were reported after heart valve surgery than after CABG and satisfaction with convalescence was significantly lower after heart valve surgery. The clinics differed with respect to the reported somatic complaints and satisfaction scales. CONCLUSION: The results demonstrate the practicability and validity of the ANP-KA for the assessment of postoperative complaints and patient satisfaction after cardiac surgery.

[Intraoperative blood requirements and allogeneic blood transfusion in cardioanesthesia. Data analysis of 7729 patients in 12 cardiac surgical clinics]. / Intraoperativer Fremdblutverbrauch und Eigenbluttransfusion in der Kardioanästhesie. Datenanalyse von 7729 Patienten aus 12 herzchirurgischen Kliniken.

UNLABELLED: Allogeneic blood requirements in cardiac surgery shows a wide variation even for comparable procedures. The aim of the present study was to compare the intraoperative allogeneic blood requirement in defined cardiac operations among 12 cardiac centers in Germany. METHOD: A data set with 25 variables concerning the intraoperative course in adult cardiac patients with myocardial revascularization, valve replacement (aortic or/and mitral valve) or combined procedures was distributed to the participating centers. The data of all patients between January 1th 1998 and June 30th 1998 were included. Besides demographic data, the intraoperative transfusion of allogeneic and autologous blood, fresh frozen plasma and the concomitant hematocrit values were registered. Data were analyzed for all centers and separated for each center. RESULTS: The data of 7,729 patients were analyzed. The intraoperative allogeneic blood requirement was 0.6 +/- 1.3 units for all patients. It varied among the centers from 0.25 +/- 0.6 units to 0.97 +/- 1.6 units (P < 0.05). The percentage of patients receiving allogeneic blood was 27% and differed among the centers from 17% to 35%. Female patients were transfused in 53% (36-39%) compared to male patients with 16% (9-20%) (P < 0.05). The rate of autologous blood predonation varied from 0.5% to 23%. Patients without autologous predonation were transfused in 28% compared to 4% in patients with predonation (P < 0.05). In patients with autologous predonation the intraoperative transfusion of allogeneic blood was significantly reduced (0.1 +/- 0.39 vs 0.6 +/- 1.4 units, P < 0.05). However, some centers with a high percentage of autologous predonation also demonstrated a high rate of perioperative allogeneic transfusion. CONCLUSION: The incidence of allogeneic blood transfusion in cardiac surgery depends on the institution and not on the surgical procedure. A common threshold value of hemoglobin for the transfusion of blood trigger even for comparable procedures could not be detected among the centers. Especially in female patients, there was a wide variation in allogeneic blood transfusion. Autologous blood predonation reduces blood requirement significantly, however, it is practiced with variing intensity. The data set did not include information about transfusion regimen in the postoperative period, thus, these data do not allow to draw conclusions for the whole perioperative period.

Incidence and risk factors of perioperative cerebral complications. Heart transplantation compared to coronary artery bypass grafting and valve surgery.

OBJECTIVE: The aim of this study was to define the neurologic risk of heart transplantation compared to coronary artery bypass grafting (CABG) and valve surgery. DESIGN: A retrospective study. SETTING: A university hospital. PATIENTS: 8001 patients undergoing heart transplantation, CABG and valve surgery. MEASURES: The incidences of perioperative central nervous system (CNS) complications were compared between different procedures. Risk factors were analysed using univariate and multivariate methods. RESULTS: The overall incidence of CNS complications was 19.8% (78/393) in heart transplantation, 3.1% (176/5734) in elective CABG, 9.5% (161/1689) in elective valve surgery, 10.3% (15/146) in emergency CABG and 51.3% (20/39) in emergency valve surgery. Most powerful predictors of CNS complications were preoperative intra-aortic counterpulsation (IABP) in the heart transplantation group, age >65 years in the CABG group and preoperative use of catecholamine in the valve group. CONCLUSIONS: CNS complications occur much more frequently after heart transplantation than elective CABG and valve surgery. The high incidence of CNS complications after emergency operations as well as preoperative catecholamine and IABP as powerful contributing factors suggest that preoperative cerebral hypoperfusion due to a compromised hemodynamic state facilitates postoperative CNS complications and this may partly explain the high incidence of CNS complications after heart transplantation.

Left ventricular function in heart valve surgery: a multidisciplinary challenge.

Between January 1988 and December 1994, 4,097 patients underwent heart valve replacement at the Heart Center North Rhine-Westfalia, Bad Oeynhausen, 1,388 (33.8%) of them suffered from impaired left ventricular (LV) function. Overall hospital mortality was 2.3% (n = 95). In the poor LV function group it was 1.8% (n = 25). There was a significant increase of mortality from 1.5% in patients younger than 60 years to 4.9% in patients 80 years of age and older. Reoperations and emergency operations showed an additional increase of mortality each: 6.2% and 18.2%, respectively. Medium term survival (maximum 48 months) was assessed in a group of 2,006 patients operated between January 1991 and December 1993. The cumulative mortality for patients with poor LV function (n = 148) was 12.8%, whereas for those with normal LV function it was 6.1%. Our data suggest that left ventricular function is of minor importance as far as primary operative results are concerned. In long term follow up patients with valve replacement and poor LV function show an increased mortality mainly due to cardiac causes.

Aortic valve replacement in octogenarians.

In a consecutive series of 1109 patients undergoing aortic valve replacement (AVR) between January 1988 and December 1990, there were 48 patients (33 female, 15 male) over 80 years of age (mean age 83.5 years, median 82.9 years). Of those, 33 had aortic stenosis and 15 combined aortic valve disease, with additional coronary artery disease being present in 36. Isolated AVR was performed in 25 patients, and it was combined with coronary venous bypass grafting, with 1-4 (mean 1.8) peripheral anastomoses in 23. Two patients died within 30 days (early mortality 4.2%). Non-fatal complications included one hemiparesis, four transient cerebral disorders, two cases of pneumonia which led to ventilatory assistance, three rethoracotomies because of postoperative bleeding, 15 tachycardias and one transient AV block. Late results were obtained after a median follow up time of 22 months. There were eight late deaths (four cardiac related, four not related) and a low incidence of non-fatal complications (two episodes of gastrointestinal bleeding while on oral anticoagulation, one cerebral transient ischemic attack and one acute left ventricular failure). Nine patients are in NYHA Class I, 12 in Class I-II, 11 in Class II, three in Class II-III and three in Class III. Of the surviving 38 patients, four are currently living in a home for the aged or a nursing home, while all the others are living in their own homes and are able to sustain a relatively independent life-style. We conclude that in very old patients with aortic valve disease, AVR can be performed with low mortality and few non-fatal complications.