Post Operative Complications Associated with Preoperative use of Clopidogrel in Patients Undergoning Coronary Artery Bypass Surgery

Background: Majority of the patients presenting for coronary artery bypass surgery are preoperatively on clopidogrel and aspirin i.e., Dual antiplatelets therapy (DAPT) because of high incidence of left main stem disease, acute coronary syndrome and diffuse coronary artery disease. Preceding coronary stenting and coming from far flung areas even from other countries with poor socioeconomic status contributes to continuation of DAPT till surgery. The main objective of the study was to evaluate hospital complications like chest tube output, re-explorations, blood, and blood product administration and in-hospital mortality in patients who continued DAPT till 48 hours prior to surgery versus those who continued DAPT until 48 to 120 hours before surgery. Methods: Preoperative history, perioperative and postoperative data of patients was gathered retrospectively from 1st July to 31st December 2019 in a tertiary care hospital of Peshawar. Total patients undergoing CABG Surgery were 223. From those 223 patients 192 patients were on DAPT. We than divided the 192 patients into two groups, Group A and Group B. 102 patients (Group A) received clopidogrel plus aspirin until 48 hours before surgery, and 89 patients (Group B) continued clopidogrel 48 to 120 hours prior to surgery. Chest tube output, need for exploration, in-hospital mortality, and blood or products transfusions among both groups were compared. Results: In terms of bleeding complications no significant difference between the both groups with similar chest drainage in the first 24 hours (602 ml and 609ml). In group A 33 patients received blood transfusion compared to 25 patients from group B. There was no significant difference in the amount of platelets given to group A (0.63 L) and to group B was (0.60 L). On the other hand, Group, A received 1.08 L fresh frozen plasma (FFPs) transfusion and group B 1.10 L respectively. Re-exploration was observed in Group A and B as (3 vs 2). Mortality was observed in 7 patients from group A and 2 from Group B. Conclusions: Usage of Dual antiplatelets therapy (DAPT) before surgery was an effective treatment method for postoperative complication of bleeding. It was suggested that with proper management with DAPT before surgery was planned is an effective and safe treatment method.. Keywords: Cardiopulmonary surgery, Coronary bypass grafting, hemoglobin, platelets, bleeding.

Blunt Chest Trauma in Polytraumatized Patients: Predictive Factors for Urgent Thoracotomy

Purpose: Current guidelines on urgent thoracotomy of polytraumatized patients are based on data from perforating chest injuries. We aimed to identify predictive factors for urgent thoracotomy after chest-tube placement for blunt chest trauma in a civilian setting. Methods: Polytraumatized patients (Injury Severity Score ≥16) with blunt chest trauma, submitted to a level I trauma centre during a period of 12 years that received at least one chest tube were included. Trauma mechanism, chest-tube output, haemoglobin values, need for cellular blood products, coagulopathies, rib fracture pattern, thoracotomy, and mortality were retrospectively analysed. Results: 235 polytraumatized patients were included. Patients that received urgent thoracotomy (UT, n = 10) showed a higher mean chest-tube output within 24 h with a median (Mdn) of 3865 (IQR 2423–5156) mL compared to the group with no additional thoracic surgery (NT, n = 225) with Mdn 185 (IQR 50–463) mL (p < 0.001). The cut-off 24-h chest-tube output value for recommended thoracotomy was 1270 mL (ROC-Curve). UT showed an initial haemoglobin of Mdn 11.7 (IQR 9.2–14.3) g/dL and an INR value of Mdn 1.27 (IQR 1.11–1.69) as opposed to Mdn 12.3 (IQR 10–13.9) g/dL and Mdn 1.13 (IQR 1.05–1.34) in NT (haemoglobin: p = 0.786; INR: p = 0.215). There was an average number of 7.1(±3.4) rib fractures in UT and 6.7(±4.8) in NT (p = 0.649). Conclusions: Chest-tube output remains the single most important predictive factor for urgent thoracotomy also after blunt chest trauma. Patients with a chest-tube output of more than 1300 mL within 24 h after trauma should be considered for transfer to a level I trauma centre with standby thoracic surgery.

Determining the Optimal Tranexamic Acid Dose for Cardiac Surgery With Cardiopulmonary Bypass: A Randomized Controlled Trial

Background: Tranexamic acid (TXA) has been widely used to reduce the risk of bleeding in patients undergoing cardiac surgery. However, the clinical TXA dose that best reduces postoperative bleeding has not been determined. We evaluated the efficacy of two different doses of TXA using Thromboelastography (TEG) in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).Methods: One hundred and eleven patients who underwent primary cardiac valve replacement with CPB were enrolled in this study. Patients were randomly divided into three groups: T1, T2, and the control group. Patients in the TXA group would receive different TXA doses: 15 mg/kg loading dose followed by an infusion of 5 mg/kg/h until the completion of surgery (T1 group) or 6 mg/kg loading dose followed by an infusion of 3 mg/kg/h until the completion of surgery (T2 group). Pre-operative patient characteristics, intraoperative data, transfusions between and after surgery, chest tube output after surgery within two days, and outcome data were recorded.Results: Transfusion of blood products, blood loss, and chest tube output were significantly reduced in the T1 group compared with the control group (P< 0.05). Compared to the control group, the T2 group had similar results. Surgical time and length of intensive care unit (ICU) stay were significantly lower in the T1 and T2 groups compared to the control group (P< 0.05). No postoperative seizures occurred in all three patient groups.Conclusions: The use ofTranexamic acid was associated with a lower risk of bleeding compared to the control group. Both doses of tranexamic acid were effective to reduce blood loss as well as transfusions compared to the control group.

A Comparison of Prothrombin Complex Concentrate and Recombinant Activated Factor VII for the Management of Bleeding With Cardiac Surgery

Bleeding following cardiac surgery that warrants transfusion of blood products is associated with significant complications, including increased mortality at 1 year following surgery. Factor concentrates, such as prothrombin complex concentrate (PCC), or recombinant activated factor VII (rFVIIa) have been used off-label for bleeding in cardiac surgery that is refractory to conventional therapy. The objective of this retrospective study is to assess the hemostatic effectiveness of 4-factor PCC or rFVIIa for bleeding after a broad range of cardiac surgeries. Patients were included if they were at least 18 years of age and had undergone cardiac surgery with bleeding requiring intervention with 4-factor PCC or rFVIIa. There were no differences observed in the number of packed red blood cells (4-factor PCC: 2 units vs. rFVIIa: 2 units), fresh frozen plasma (0 units vs. 1 unit) or platelet (2 units vs. 2 units) transfusions following the administration of 4-factor PCC or rFVIIa. The patients in the rFVIIa group, required more cryoprecipitate than those in the 4-factor PCC group (4-factor PCC: 2 units (range 0-6) vs. rFVIIa: 2 units (range 0-8), p = 0.03). There were no differences in secondary outcomes of chest tube output at 2, 6, 12 and 24 hours, nor was there a difference in reexploration rates or the median length of stay in the intensive care unit. Thromboembolic complications at 30 days were similar between the two groups (4-factor PCC: 13% vs. rFVIIa 26%, p = 0.08). The total median dose requirement for 4-factor PCC was 1000 units (15 units/kg) and 2 mg (20 mcg/kg) for rFVIIa. The results demonstrate feasibility of utilizing the minimum amount of drug in order to achieve a desired effect. Both 4-factor PCC and rFVIIa appear to be safe and effective options for the management of bleeding associated with cardiac surgery.

Evaluation of the Safety and Efficacy of a Novel Thrombin Containing Combination Hemostatic Powder Using a Historical Control

This clinical study compares 2 hemostatic agents, a novel combination powder (CP) (HEMOBLAST™ Bellows) and an established polysaccharide starch powder (PP) (Arista™ AH) to assess the usefulness of CP. Retrospective comparative analysis of CP (July 2018 to July 2019, 68 patients) to PP (January 2011 to January 2013, 94 patients) in cardiothoracic patients was performed using linear regression models adjusting for age, sex, and procedure type for the endpoints: blood loss; protamine to skin closure time (hemostasis time); chest tube output and blood products required 48 hours postoperatively; ICU stay; postoperative comorbidities; and 30 day mortality. 162 patients (108 M: 54 F) underwent 162 cardiothoracic surgical procedures including: transplantation (n = 44), placement of ventricular assist device (n = 87), and others (n = 31). Use of CP compared to PP (Estimated Mean Difference [95% CI], P-value) produced significant reductions: blood loss (mL) (−886.51 [−1457.76, −312.26], P = 0.003); protamine to skin closure time (min) (−16.81 [−28.03, −5.59], P = 0.004); chest tube output (48 hrs, mL) (−445.76 [−669.38, −222.14], P < 0.001); packed red blood cell transfusions (units) (−0.98 [−1.56, −0.4], P = 0.001); and postoperative comorbidities (−0.31 [−0.55, −0.07], P = 0.012). There were no differences in the ICU stay (4.07 [−2.01, 10.15], P = 0.188) or 30-day mortality (0.57 [0.20, 1.63], P = 0.291). The use of CP in complex cardiothoracic operations resulted in improved hemostasis and significant clinical benefits in blood loss, transfusion requirements, morbidity, and time in operating room.

Transfusion requirements in cardiac Surgery III (TRICS III), Ticagrelor Substudy

Background Ticagrelor, in addition to aspirin, has been demonstrated to reduce morbidity and mortality in patients with acute coronary syndrome compared to clopidogrel with aspirin. The treatment effect appeared to be maintained in the subgroup of patients who underwent urgent surgical revascularization. However, the risk of postoperative bleeding in these patients has not been well described. Research question We aimed to establish the effect of ticagrelor exposure within 7 days before surgery on blood loss as measured by postoperative chest tube output and blood product use. Method In a nested cohort study of patients enrolled in the Transfusion Requirements in Cardiac Surgery III (TRICS III) trial, we compared chest tube output and blood product use in patients based on their preoperative exposure to ticagrelor ≤3 days versus &gt;3 days before surgery. Results Of the 5243 patients in TRICS III, 87 patients were exposed to ticagrelor within 7 days with a mean age of 78 years (SD 6) and 74% were male. Patients exposed to ticagrelor 3 days or less before surgery bled a median of 730 ml (IQR 295, 2195) postoperatively in the first 24 hours postoperatively, compared to 518 ml (IQR 350, 1000) for those for whom ticagrelor was held for more than 3 days. We log-transformed the data and found that recent ticagrelor exposure (≤3 days) was associated with significantly more blood loss compared to no exposure for more than 3 days (P-value: 0.01). 69.6% of patients in the recent exposure group received at least one red blood cell transfusion versus 54.7% in patients exposed to ticagrelor more than 3 days pre-operatively (p-value: 0.214). Platelet and fresh frozen plasma transfusion were 52.2% vs 15.6% (p-value 0.001), and 39.1% vs 9.4% (p-value 0.003), respectively, for ticagrelor exposure ≤3 days compared to &gt;3 days. Cryoprecipitate use was 17.4% in the ≤3 days group and 3.1% in the &gt;3 days group (p-value 0.04). Only 1 patient in each group received prothrombin complex concentrate (PCC) transfusion. And 1 patient with exposure ≤3 days received Factor VII. Conclusion Exposure to ticagrelor within 3 days of surgery is associated with an increased risk of postoperative bleeding as assessed by greater chest tube output at 24 hours and more patients requiring blood product transfusion. A ticagrelor-reversing agent may improve the outcomes of patients who have been recently exposed to ticagrelor and require urgent cardiac surgery. Funding Acknowledgement Type of funding source: None

Role of streptokinase in management of retained hemothorax: a multicentric study

Background: Enzymatic debridement of the pleural cavity for retained haemothorax is a frequently overlooked option.Methods: A retrospective, multicentre study was carried out using intrapleural streptokinase was carried out in 15 patients with retained or clotted haemothorax.Results: Thirteen of fifteen patients (86%) with retained pleural collections underwent successful enzymatic debridement and tube drainage with streptokinase injections in our study. The average increase in chest tube output following streptokinase injections was 160%. No significant adverse reactions occurred. Two patients required thoracotomy when streptokinase therapy failed. No deaths were reported in the study.Conclusions: Intrapleural streptokinase is a safe, effective means of removing retained proteinaceous collections in the pleural space. It is a useful adjunct to chest tube drainage and may obviate the need for more invasive procedures.

Post-operative blood loss is higher among African American neonates undergoing open-heart surgery with cardiopulmonary bypass for CHD

Background:Neonates are at high risk of bleeding after open-heart surgery. We sought to determine pre-operative and intra-operative risk factors for increased bleeding after neonatal open-heart surgery with cardiopulmonary bypass.Methods:We conducted a retrospective cohort study of neonates (0–30 days old) who underwent open-heart surgery with cardiopulmonary bypass from January, 2009, to March, 2013. Cardiac diagnosis; demographic and surgical data; and blood products, haemostatic agents, and anti-thrombotic agents administered before, during, and within 24 hours after surgery were abstracted from the electronic health record and anaesthesia records. The outcome of interest was chest tube output (in ml/kg body weight) within 24 hours. Relationships between chest tube output and putative associated factors were evaluated by unadjusted and adjusted linear regression.Results:The cohort consisted of 107 neonates, of whom 79% had a Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Mortality Category of 4 or 5. Median chest tube output was 37 ml/kg (range 9–655 ml/kg). Age, African-American race, and longer durations of surgery and cardiopulmonary bypass each had statistically significant associations with increased chest tube output in unadjusted analyses. In multivariable analysis, African-American race retained an independent, statistically significant association with increased chest tube output; the geometric mean of chest tube output among African-American neonates was 71% higher than that of Caucasians (95% confidence interval, 29–125%; p = 0.001).Conclusion:Among neonates with CHD undergoing open-heart surgery with cardiopulmonary bypass, African-American race is independently associated with greater chest tube output over the first 24 hours post-operatively.

Post-operative non-steroidal anti-inflammatory drug use for pain in infant and paediatric cardiac surgery patients

Background:Pain control is an important element of care for patients after surgery, leading to better outcomes, quicker transitions to recovery, and improvement in quality of life. The purpose of this study was to evaluate the safety and efficacy of non-steroidal anti-inflammatory drugs in children after cardiac surgeryMaterials and Methods:Patients between the ages of 1 month and 18 years of age, who received intravenous or oral non-steroidal anti-inflammataory drugs after cardiac surgery, from November 2015 until September 2017 were included in this study. The primary endpoints were non-steroidal anti-inflammataory drug-associated renal dysfunction and post-operative bleeding. Secondary endpoints examined the effect of non-steroidal anti-inflammataory drug use on total daily dose of narcotics, number of intravenous PRN narcotic doses received, and pain assessment score. Data were analysed using descriptive statistics for frequencies and ranges. Multivariate analysis was performed to measure the association of all predictors and outcomes. Wilcoxon singed-rank test was performed for secondary outcomes.Results:There was no association between the incidence of renal dysfunction and the use of or duration of non-steroidal anti-inflammataory drugs; in addition no association was found with increased chest tube output. There was a statistically significant reduction of patients’ median Face, Legs, Activity, Cry, Consolability (FLACC) scores (2–0; p = 0.003), seen within first 24 hours after initiation of ketorolac, and a significant reduction of morphine requirements seen from day 1 to day 2 (0.3 mg/kg versus 0.1 mg/kg; p < 0.001) and number of as-needed doses.Conclusion:Non-steroidal anti-inflammataory drugs in paediatric cardiac surgery patients are safe and effective for post-operative pain management.