Thromboelastometric evaluation of coagulation profiles of cold-stored autologous whole blood: A prospective observational study.

Preoperative autologous blood donation is a well-established procedure to reduce the need for allogeneic blood transfusion. We hypothesized that coagulation activity is maintained in cold-stored whole blood, because the fundamental polymerization properties of fibrin are preserved.Fifty adult patients who underwent elective cardiothoracic surgery were enrolled.Autologous whole blood collected 2 to 4 times at almost 1-week intervals before surgery was stored at approximately 4°C until reinfusion at the time of surgery. Blood samples were drawn just before reinfusion, and rotational thromboelastometry variables and fibrinogen levels were measured.A total of 158 samples were analyzed. The mean duration of cold storage was 16.7 ±â€Š7.4 days (range: 6-33 days). Platelet counts were very low due to collection through a leukoreduction filter. The mean fibrinogen level was 2.3 ±â€Š0.6 g/L. Amplitude at 10 minutes after CT (A10), amplitude at 20 minutes after CT (A20), and maximum clot firmness (MCF) values as determined by FIBTEM analysis were 10.8 ±â€Š3.8, 12.2 ±â€Š4.2, and 13.1 ±â€Š4.7 mm, respectively. Fibrinogen levels were strongly correlated with A10, A20, and FIBTEM-MCF values (ρ = 0.83, P < .0001, ρ = 0.84, P < .0001, ρ = 0.85, P < .0001, respectively). Fibrinogen levels were not correlated with the duration of cold storage (ρ = 0.06, P = .43).The results of the present study demonstrate that fibrin polymerization occurs in cold-stored autologous whole blood, and that such activity is strongly correlated with fibrinogen levels. Furthermore, our data suggest that cold-stored leukoreduced autologous whole blood retains fibrin polymerization properties throughout 33 days.

Heart Anatomy of Rhincodon typus: Three-Dimensional X-Ray Computed Tomography of Plastinated Specimens.

In this study, we examined the structure of the heart of the whale shark, Rhincodon typus, using a plastination technique and three-dimensional X-ray computer tomography (3DCT). Inspection of the atrium revealed a symmetric distribution of the pectinate muscles attached to the commissures of the sino-atrial valve, suggesting some functional advantages. The majority of the ventricular wall comprised spongiosa, and compacta accounted for only ~3% of the entire thickness. There were three major fiber orientations in the spongiosa: the fibers on the endocardial side formed trabeculae that were aligned with the blood flow tract, whereas those on the epicardial side formed a circular pattern around the flow tract. Transmural myofibers connected the inner and outer layers in the spongiosa, which may serve as an intraventricular conduction pathway. Plastination and 3DCT is a powerful combination that allowed for multifaceted visualization of the internal structure of rare heart specimens in a nondestructive manner. Anat Rec, 301:1801-1808, 2018. © 2018 Wiley Periodicals, Inc.

Perioperative Management of Patients With End-Stage Renal Disease.

End-stage renal disease (ESRD) is associated with significant alterations in cardiovascular function; homeostasis of body fluid, electrolytes, and acid-base equilibrium; bone metabolism, erythropoiesis; and blood coagulation. The prevalence of ESRD is increasing rapidly worldwide, as is the number of patients requiring surgery under general anesthesia. Patients with ESRD have significantly higher risks of perioperative morbidity and mortality due to multiple comorbidities. The perioperative management of patients with ESRD under general anesthesia therefore requires special considerations and a careful multidisciplinary approach. In this review, the authors summarize the available literature to address common issues related to patients with ESRD and discuss the best perioperative approach for this patient subgroup.

Effect of fluid loading on left ventricular volume and stroke volume variability in patients with end-stage renal disease: a pilot study.

PURPOSE: The aim of this study was to investigate fluid loading-induced changes in left ventricular end-diastolic volume (LVEDV) and stroke volume variability (SVV) in patients with end-stage renal disease (ESRD) using real-time three-dimensional transesophageal echocardiography and the Vigileo-FloTrac system. PATIENTS AND METHODS: After obtaining ethics committee approval and informed consent, 28 patients undergoing peripheral vascular procedures were studied. Fourteen patients with ESRD on hemodialysis (HD) were assigned to the HD group and 14 patients without ESRD were assigned to the control group. Institutional standardized general anesthesia was provided in both groups. SVV was measured using the Vigileo-FloTrac system. Simultaneously, a full-volume three-dimensional transesophageal echocardiography dataset was acquired to measure LVEDV, left ventricular end-systolic volume, and left ventricular ejection fraction. Measurements were obtained before and after loading 500 mL hydroxyethyl starch over 30 minutes in both groups. RESULTS: In the control group, intravenous colloid infusion was associated with a significant decrease in SVV (13.8%±2.6% to 6.5%±2.6%, P<0.001) and a significant increase in LVEDV (83.6±23.4 mL to 96.1±28.8 mL, P<0.001). While SVV significantly decreased after infusion in the HD group (16.2%±6.0% to 6.2%±2.8%, P<0.001), there was no significant change in LVEDV. CONCLUSION: Our preliminary data suggest that fluid responsiveness can be assessed not by LVEDV but also by SVV due to underlying cardiovascular pathophysiology in patients with ESRD.

Effect of fluid loading with normal saline and 6% hydroxyethyl starch on stroke volume variability and left ventricular volume.

PURPOSE: The aim of this clinical trial was to investigate changes in stroke volume variability (SVV) and left ventricular end-diastolic volume (LVEDV) after a fluid bolus of crystalloid or colloid using real-time three-dimensional transesophageal echocardiography (3D-TEE) and the Vigileo-FloTrac™ system. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, and informed consent from the research participants, 22 patients undergoing scheduled peripheral vascular bypass surgery were enrolled in the study. The patients were randomly assigned to receive 500 mL of hydroxyethyl starch (HES; HES group, n=11) or normal saline (Saline group, n=11) for fluid replacement therapy. SVV was measured using the Vigileo-FloTrac system. LVEDV, stroke volume, and cardiac output were measured by 3D-TEE. The measurements were performed over 30 minutes before and after the fluid bolus in both groups. RESULTS: SVV significantly decreased after fluid bolus in both groups (HES group, 14.7%±2.6% to 6.9%±2.7%, P<0.001; Saline group, 14.3%±3.9% to 8.8%±3.1%, P<0.001). LVEDV significantly increased after fluid loading in the HES group (87.1±24.0 mL to 99.9±27.2 mL, P<0.001), whereas no significant change was detected in the Saline group (88.8±17.3 mL to 91.4±17.6 mL, P>0.05). Stroke volume significantly increased after infusion in the HES group (50.6±12.5 mL to 61.6±19.1 mL, P<0.01) but not in the Saline group (51.6±13.4 mL to 54.1±12.8 mL, P>0.05). Cardiac output measured by 3D-TEE significantly increased in the HES group (3.5±1.1 L/min to 3.9±1.3 L/min, P<0.05), whereas no significant change was seen in the Saline group (3.4±1.1 L/min to 3.3±1.0 L/min, P>0.05). CONCLUSION: Administration of colloid and crystalloid induced similar responses in SVV. A higher plasma-expanding effect of HES compared to normal saline was demonstrated by the significant increase in LVEDV.

Reappearance of circulating heparin in whole blood heparin concentration-based management does not correlate with postoperative bleeding after cardiac surgery.

OBJECTIVE: The Hepcon Heparin Management System (HMS) facilitates administration of higher heparin and lower protamine doses, which may affect bleeding potential due to heparin rebound. The present study evaluated heparin rebound in patients for whom the Hepcon HMS was used to determine whether point-of-care tests detect residual heparin and residual heparin is associated with postoperative blood loss. DESIGN: Prospective study. SETTING: Tertiary care center affiliated with a university hospital. PARTICIPANTS: Adults undergoing elective cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS: In blood samples obtained at baseline, at 2 minutes, and at 1, 2, 4, 6, and 24 hours after heparin neutralization, heparin concentrations were measured using an automated chromogenic assay. Activated coagulation time (ACT), activated partial thromboplastin time (APTT), and thromboelastometry 2 hours after heparin neutralization also were examined in the last 22 study patients enrolled. MEASUREMENTS AND MAIN RESULTS: All 31 patients had measurable heparin levels 2 hours after protamine administration; 22 patients exhibited a primary failure to reverse heparin after protamine administration, and 9 patients had measureable heparin levels 2 hours after complete heparin reversal (ie, heparin rebound). The thromboelastometric variable, INTEM-CT:HEPTEM-CT ratio, correlated with heparin concentration (r=0.72), but ACT (r=-0.12), APTT (r=0.36), and whole blood heparin concentration, determined using the Hepcon HMS, did not. Peak heparin concentration (0.18±0.07 U/mL) at 4 hours was not correlated with mediastinal blood loss. CONCLUSION: Circulating heparin detected by the chromogenic assay was too low to be clinically significant based on postoperative bleeding, although all 31 patients had residual heparin or heparin rebound at 2 hours after protamine administration with use of the Hepcon HMS.

Cardiac axis-oriented full-volume data acquisition in real-time three-dimensional transesophageal echocardiography to facilitate on-cart analysis.

We propose a useful method to acquire a full-volume dataset that allows for efficient assessment of cardiac structures by real-time 3-dimensional transesophageal echocardiography (3DTEE). In our method, bicommissural full-volume acquisition, the dataset is acquired with the X-Y-Z axes aligned along the lines connecting the mitral commissures, the mitral annular center to the left ventricular apex, and the mitral anterior-posterior ends, respectively. The image dataset obtained using this method not only allows for visualization of en face images of the cardiac structures, but box cropping of the dataset also provides useful sectional images that are the analogues of the standard 2DTEE views. Our method can potentially standardize 3D image orientation of the cardiac structures and facilitate intraoperative on-cart analysis in real-time 3DTEE.

[Case of severe hypokalemia during emergency surgery caused by long-term administration of Shakuyaku-kanzo-to].

An 82-year-old female underwent emergency surgery for right femoral incarcerated hernia under general anesthesia. Anesthesia was induced and maintained with remifentanil and propofol. Her laboratory data showed severe hypokalemia (1.83 mEq x l(-1)) and metabolic alkalosis (HCO3 36.9 mmol x l(-1)). We suspected that the causes of such abnormalities were due to an endocrinological abnormality, but we could not ascertain the actual cause. Drip infusion of sodium chloride and saline solution infusion, to avoid supplying lactate or acetate, the source of bicarbonate ions, were chosen for palliative treatment. No adverse event occurred during surgery. After surgery, endocrinological functions were examined. Primary aldosteronism was ruled out because serum aldosterone and rennin activity were within normal ranges. The patient had been taking a Kampo preparation, Shakuyaku-kanzo-to, for two years. Glycyrrhizin, the main component of Shakuyaku-kanzo-to, has been reported to be a cause of pseudoaldosteronism by inhibiting the enzyme converting cortisol to cortisone. With these findings we confirmed that severe hypokalemia was induced by pseudoaldosteronism by long-term administration of Shakuyaku-kanzo-to.