RESUMEN
OBJECTIVES: Antiplatelet therapy commonly is used for the prevention of cardiovascular complications but increases the risk of perioperative bleeding. Multiple-electrode aggregometry (MEA) was investigated for monitoring platelet inhibition by acetylsalicylic acid (ASA) and clopidogrel in patients undergoing elective coronary artery bypass graft (CABG) surgery with regard to clinical outcome as measured by postoperative blood loss and transfusion requirements. DESIGN: A prospective observational study. SETTING: A teaching hospital. PARTICIPANTS: One hundred fifty patients scheduled for elective CABG surgery were included: without antiplatelet therapy (group A, n = 50), single ASA exposure (group B, n = 50), and combined therapy with ASA and clopidogrel (group C, n = 50). MEASUREMENTS AND MAIN RESULTS: MEA was assessed preoperatively using either collagen (COL-MEA) or ADP (ADP-MEA). Postoperative blood loss and transfusion requirements were recorded for 24 hours after surgery. Postoperative blood loss significantly increased only from combined antiplatelet therapy (group A: 572 ± 297 mL, group B: 721 ± 356 mL, group C: 865 ± 346, p < 0.01) and correlated with ADP (r(p) = -0.35, p < 0.01) and COL-MEA (r(p) = -0.23, p > 0.01). COL-MEA and ADP-MEA discriminated between preoperative ASA and clopidogrel intake (ASA: sensitivity = 86.3%, and specificity = 89.3%; clopidogrel: sensitivity = 87.5%, and specificity = 95.1%). The postoperative transfusion risk was increased in patients diagnosed for clopidogrel treatment by ADP-MEA (odds ratio = 2.92; confidence interval: 1.44-5.92; p = 0.005). CONCLUSIONS: MEA is a suitable method for the detection of platelet inhibition by ASA and clopidogrel in patients undergoing CABG surgery. In these patients, preoperative ADP MEA seems to indicate patients at risk for postoperative transfusion requirements.
Asunto(s)
Puente de Arteria Coronaria , Monitoreo Intraoperatorio/métodos , Agregación Plaquetaria/fisiología , Pruebas de Función Plaquetaria/instrumentación , Anciano , Anestesia General , Aspirina/uso terapéutico , Transfusión Sanguínea/estadística & datos numéricos , Volumen Sanguíneo , Clopidogrel , Transfusión de Eritrocitos/estadística & datos numéricos , Femenino , Humanos , Derivados de Hidroxietil Almidón/uso terapéutico , Masculino , Persona de Mediana Edad , Sustitutos del Plasma/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Sistemas de Atención de Punto , Cuidados Posoperatorios , Hemorragia Posoperatoria/inducido químicamente , Hemorragia Posoperatoria/tratamiento farmacológico , Hemorragia Posoperatoria/epidemiología , Medicación Preanestésica , Estudios Prospectivos , Curva ROC , Ticlopidina/análogos & derivados , Ticlopidina/uso terapéutico , Resultado del TratamientoRESUMEN
OBJECTIVE: Balanced fluids appear to be have advantages over unbalanced fluids for correcting hypovolemia. The effects of a new balanced hydroxyethyl starch (HES) were studied in cardiac surgery patients. DESIGN: Prospective, randomized, unblinded study. SETTING: Clinical study in a single cardiac surgery institution. PARTICIPANTS: Sixty patients undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTION: Patients received either a balanced 6% HES 130/0.4 plus a balanced crystalloid (n = 30) or an unbalanced HES-in-saline plus saline (n = 30) to keep cardiac index >2.5 L/min/m(2). MEASUREMENTS AND MAIN RESULTS: Base excess (BE), kidney function, inflammatory response (interleukins-6, -10), endothelial activation (intercellular adhesion molecule-1 [ICAM]), and coagulation (thromboelastometry, whole blood aggregation) were measured after induction of anesthesia, after surgery and 5 hours later, and at the 1st and 2nd postoperative days; 2,950 +/- 530 mL of balanced and 3,050 +/- 560 mL of unbalanced HES were given. BE was reduced significantly in the unbalanced group (from 1.11 +/- 0.71 mmol/L to -5.11 +/- 0.48 mmol/L after surgery) and remained unchanged in the balanced group. Balanced volume replacement resulted in significantly lower IL-6, IL-10, and ICAM plasma concentrations and lower urine concentrations of kidney-specific proteins than in the unbalanced group. After surgery, thromboelastometry data and platelet function were changed significantly in both groups; 5 hours thereafter they were significantly changed only in the unbalanced group. CONCLUSION: A plasma-adapted HES preparation in addition to a balanced crystalloid resulted in significantly less decline in BE, less increase in concentrations of kidney-specific proteins, less inflammatory response and endothelial damage, and fewer changes in hemostasis compared with an unbalanced fluid strategy.
Asunto(s)
Volumen Sanguíneo/efectos de los fármacos , Procedimientos Quirúrgicos Cardíacos , Fluidoterapia/métodos , Derivados de Hidroxietil Almidón/uso terapéutico , Sustitutos del Plasma/uso terapéutico , Anciano , Anciano de 80 o más Años , Anestesia , Pérdida de Sangre Quirúrgica , Procedimientos Quirúrgicos Cardíacos/mortalidad , Puente Cardiopulmonar , Catecolaminas/uso terapéutico , Cuidados Críticos , Diuréticos/uso terapéutico , Femenino , Hemodinámica/efectos de los fármacos , Hemostasis/efectos de los fármacos , Humanos , Derivados de Hidroxietil Almidón/química , Inflamación/epidemiología , Inflamación/etiología , Riñón/efectos de los fármacos , Riñón/fisiología , Masculino , Persona de Mediana Edad , Sustitutos del Plasma/química , Pruebas de Función Plaquetaria , Terapia de Reemplazo Renal , Tromboelastografía , Equilibrio Hidroelectrolítico/efectos de los fármacosRESUMEN
INTRODUCTION: Several studies have shown that goal-directed hemodynamic and fluid optimization may result in improved outcome. However, the methods used were either invasive or had other limitations. The aim of this study was to perform intraoperative goal-directed therapy with a minimally invasive, easy to use device (FloTrac/Vigileo), and to evaluate possible improvements in patient outcome determined by the duration of hospital stay and the incidence of complications compared to a standard management protocol. METHODS: In this randomized, controlled trial 60 high-risk patients scheduled for major abdominal surgery were included. Patients were allocated into either an enhanced hemodynamic monitoring group using a cardiac index based intraoperative optimization protocol (FloTrac/Vigileo device, GDT-group, n = 30) or a standard management group (Control-group, n = 30), based on standard monitoring data. RESULTS: The median duration of hospital stay was significantly reduced in the GDT-group with 15 (12 - 17.75) days versus 19 (14 - 23.5) days (P = 0.006) and fewer patients developed complications than in the Control-group [6 patients (20%) versus 15 patients (50%), P = 0.03]. The total number of complications was reduced in the GDT-group (17 versus 49 complications, P = 0.001). CONCLUSIONS: In high-risk patients undergoing major abdominal surgery, implementation of an intraoperative goal-directed hemodynamic optimization protocol using the FloTrac/Vigileo device was associated with a reduced length of hospital stay and a lower incidence of complications compared to a standard management protocol. CLINICAL TRIAL REGISTRATION INFORMATION: Unique identifier: NCT00549419.
Asunto(s)
Presión Sanguínea , Periodo Intraoperatorio , Tiempo de Internación , Monitoreo Fisiológico/instrumentación , Anciano , Calibración , Femenino , Humanos , Masculino , Monitoreo Fisiológico/métodos , Factores de Riesgo , Procedimientos Quirúrgicos OperativosRESUMEN
OBJECTIVE: Preparing hydroxyethyl starch (HES) in a plasma-adapted solution is supposed to improve safety with regard to coagulation. The influence of a new plasma-adapted HES preparation on coagulation was studied. DESIGN: Operator-blinded, randomized study. SETTING: Laboratory in vitro study. PARTICIPANTS: Fifteen healthy young men scheduled for blood donation. INTERVENTIONS: Blood was diluted by 10%, 30%, and 50% using either a plasma-adapted or nonplasma-adapted (prepared in saline solution) potato-derived 6% HES 130/0.42. Only the composition of the solvent of the 2 HES preparations was different. MEASUREMENTS AND MAIN RESULTS: Rotation thromboelastometry (ROTEM; Pentapharm, Munich, Germany) was used to assess changes in coagulation; whole blood aggregometry with 3 inducers was used to assess effects of dilution with HES on platelet function. Clotting time (CT) and clot formation time were significantly prolonged by 30% and 50% dilution, showing significantly longer times in the non-plasma-adapted than in the plasma-adapted HES group (eg, intrinsic CT at the 30% dilution level: plasma-adapted HES 228 +/- 26 seconds [within normal range] v 269 +/- 29 seconds in the nonplasma-adapted HES group). Clot strengthening and clot firmness were significantly reduced by the non-plasma-adapted HES at the 30% dilution level. Platelet aggregation was significantly more reduced by the non-plasma-adapted HES at the 30% and 50% dilution levels. CONCLUSIONS: Dilution with the nonplasma-adapted HES 130/0.42 was associated with more negative effects on thromboelastometry and platelet aggregation than the same HES 130/0.4 dissolved in a plasma-adapted solution. The benefits of using a plasma-adapted modern HES preparation on blood loss and use of blood/blood products in cardiac surgery need to be studied.
Asunto(s)
Coagulación Sanguínea/efectos de los fármacos , Derivados de Hidroxietil Almidón/farmacología , Sustitutos del Plasma/farmacología , Adenosina Difosfato/farmacología , Adulto , Pruebas de Coagulación Sanguínea , Plaquetas/efectos de los fármacos , Retracción del Coagulo/efectos de los fármacos , Colágeno/farmacología , Fibrinógeno/química , Hemoglobinas/análisis , Humanos , Derivados de Hidroxietil Almidón/química , Masculino , Soluciones Farmacéuticas , Sustitutos del Plasma/química , Agregación Plaquetaria/efectos de los fármacos , Pruebas de Función Plaquetaria , Tromboelastografía , Tiempo de Coagulación de la Sangre TotalRESUMEN
BACKGROUND: The optimal priming solution for cardiopulmonary bypass (CPB) is unclear. In this study, we evaluated the influence of high-volume priming with a modern balanced hydroxyethyl starch (HES) preparation on coagulation, inflammation, and organ function compared with an albumin-based CPB priming regimen. METHODS: In 50 patients undergoing coronary artery bypass grafting, the CPB circuit was prospectively and randomly primed with either 1500 mL of 6% HES 130/0.42 in a balanced electrolyte solution (Na(+) 140 mmol/L, Cl(-) 118 mmol/L, K(+) 4 mmol/L, Ca(2+) 2.5 mmol/L, Mg(++) 1 mmol/L, acetate(-) 24 mmol/L, malate(-) 5 mmol/L) (n = 25) or with 500 mL of 5% human albumin plus 1000 mL 0.9% saline solution (n = 25). Inflammation (interleukins [IL]-6, -10), endothelial damage (soluble intercellular adhesion molecule-1), kidney function (kidney-specific proteins alpha-glutathione S-transferase, neutrophil gelatinase-associated lipocalin), coagulation (measured by thrombelastometry [ROTEM, Pentapharm, Munich, Germany]), and platelet function (measured by whole blood aggregometry [Multiplate analyzer, Dynabyte Medical, Munich, Germany]) were assessed after induction of anesthesia, immediately after surgery, 5 h after surgery, and on the morning of first and second postoperative days. RESULTS: Total volume given during and after CPB was 3090 +/- 540 mL of balanced HES and 3110 +/- 450 mL of albumin. Base excess after surgery was lower in the albumin-based priming group than in the balanced HES priming group (-5.9 +/- 1.2 mmol/L vs +0.2 +/- 0.2 mmol/L, P = 0.0003). Plasma levels of IL-6, IL-10, and intercellular adhesion molecule-1 were higher after CPB in the albumin-based priming group compared with the HES priming group at all time periods (P = 0.0002). Urinary concentrations of alpha-glutathione S-transferase and neutrophil gelatinase-associated lipocalin were higher after CPB through the end of the study in the albumin group compared with the balanced HES group (P = 0.00004). After surgery through the first postoperative day, thrombelastometry data (clotting time and clot formation time) revealed more impaired coagulation in the albumin-based priming group compared with the HES priming group (P = 0.004). Compared with baseline, platelet function was unchanged in the high-dose balanced HES priming group after CPB and 5 h after surgery, but it was significantly reduced in the albumin-based priming group. CONCLUSION: High-volume priming of the CPB circuit with a modern balanced HES solution resulted in reduced inflammation, less endothelial damage, and fewer alterations in renal tubular integrity compared with an albumin-based priming. Coagulation including platelet function was better preserved with high-dose balanced HES CPB priming compared with albumin-based CPB priming.
Asunto(s)
Albúminas/administración & dosificación , Puente Cardiopulmonar/métodos , Coloides/administración & dosificación , Puente de Arteria Coronaria , Derivados de Hidroxietil Almidón/administración & dosificación , Sustitutos del Plasma/administración & dosificación , Proteínas de Fase Aguda , Anciano , Albúminas/efectos adversos , Biomarcadores/sangre , Coagulación Sanguínea/efectos de los fármacos , Transfusión Sanguínea , Puente Cardiopulmonar/efectos adversos , Coloides/efectos adversos , Creatinina/sangre , Endotelio Vascular/efectos de los fármacos , Endotelio Vascular/inmunología , Femenino , Glutatión Transferasa/sangre , Humanos , Derivados de Hidroxietil Almidón/efectos adversos , Inflamación/etiología , Inflamación/inmunología , Mediadores de Inflamación/sangre , Molécula 1 de Adhesión Intercelular/sangre , Interleucina-10/sangre , Interleucina-6/sangre , Isoenzimas/sangre , Riñón/efectos de los fármacos , Riñón/metabolismo , Lipocalina 2 , Lipocalinas/sangre , Masculino , Sustitutos del Plasma/efectos adversos , Agregación Plaquetaria/efectos de los fármacos , Estudios Prospectivos , Proteínas Proto-Oncogénicas/sangre , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: Haemostasis appears to be less altered with balanced than with unbalanced hydroxyethylstarch (HES) preparations. In a blinded in-vitro coagulation study, the effects of two HESs dissolved in different balanced solutions were measured. METHODS: Blood from 12 healthy young male volunteers was diluted by 10, 30 and 50% by using either a balanced 6% HES 130/0.42 or a balanced 6% HES 130/0.4. Composition of the solvent of the two HES preparations differed. An unbalanced gelatin solution was used as a control. Rotation thrombelastometry was used to assess changes in coagulation, and whole blood aggregometry using three different inductors was used to assess the effects of dilution on platelet function. RESULTS: Dilutions of 10 and 30% showed no significant changes in thrombelastometry data and platelet aggregation in all three groups. Fifty per cent haemodilution was associated with significantly more pronounced deterioration in clotting time, clot formation time and clot firmness, with the balanced HES 130/0.42 containing calcium than with the balanced HES without calcium. Platelet function was also more impaired by HES not containing calcium than by HES containing calcium. Extreme dilution with gelatin showed similar results to those of balanced HES 130/0.4. CONCLUSION: Our in-vitro studies showed that extreme haemodilution with HES 130/0.42 dissolved in a balanced solution containing calcium was associated with less negative effects on thrombelastometry and platelet aggregation than HES 130/0.4 prepared in a balanced solution without calcium. Gelatin prepared in a nonbalanced solution showed similar effects on coagulation to balanced HES without calcium.
Asunto(s)
Coagulación Sanguínea/efectos de los fármacos , Derivados de Hidroxietil Almidón/farmacología , Agregación Plaquetaria/efectos de los fármacos , Tromboelastografía/métodos , Adulto , Relación Dosis-Respuesta a Droga , Gelatina/farmacología , Humanos , Derivados de Hidroxietil Almidón/administración & dosificación , Técnicas In Vitro , Masculino , Peso Molecular , Pruebas de Función Plaquetaria/métodos , Resultado del Tratamiento , Tiempo de Coagulación de la Sangre TotalRESUMEN
BACKGROUND: Increased inorganic fluoride levels after methoxyflurane exposure in the 1970s and prolonged intraoperative sevoflurane use have been suggested to be potentially nephrotoxic. In the intensive care unit we evaluated the effect on renal integrity of short-term inhaled postoperative sedation with sevoflurane using the Anesthetic Conserving Device (ACD) compared with propofol. METHODS: In this prospective, randomized, single-blinded study, after major abdominal, vascular or thoracic surgery 125 patients were allocated to receive either sevoflurane (n = 64) via the ACD (end-tidal 0.5-1 vol%) or i.v. propofol (n = 61) for postoperative sedation up to 24 h. Urinary alpha-glutathione-s-transferase as primary outcome variable, urinary N-acetyl-glucosaminidase, serum creatinine, and inorganic fluoride concentrations, urine output and fluid management were measured preoperatively, at the end of surgery, and at 24 and 48 h postoperatively. RESULTS: The sedation time in the intensive care unit was comparable between the sevoflurane (9.2 +/- 4.3 h) and the propofol (9.3 +/- 4.7 h) group. Alpha-glutathione-s-transferase levels were significantly increased at 24 and 48 h postoperatively compared with preoperative values in both groups, without significant differences between the groups. N-acetyl-glucosaminidase and serum creatinine remained unchanged in both study groups, and urine output and creatinine clearance were comparable between the groups throughout the study period. Inorganic fluoride levels increased significantly (P < 0.001) at 24 h after sevoflurane exposure (39 +/- 25 micromol/L) compared with propofol (3 +/- 6 micromol/L) and remained elevated 48 h later (33 +/- 26 vs 3 +/- 5 micromol/L). One patient in each group suffered from renal insufficiency, requiring intensive diuretic therapy, but not dialysis, during hospital stay. CONCLUSIONS: Short-term sedation with either sevoflurane using ACD or propofol did not negatively affect renal function postoperatively. Although inorganic fluoride levels were elevated after sevoflurane exposure, glomerular and tubular renal integrity were preserved throughout the hospital stay.
Asunto(s)
Anestésicos por Inhalación , Sedación Consciente , Hipnóticos y Sedantes , Enfermedades Renales/inducido químicamente , Enfermedades Renales/diagnóstico , Éteres Metílicos , Complicaciones Posoperatorias/inducido químicamente , Complicaciones Posoperatorias/epidemiología , Propofol , Anciano , Anciano de 80 o más Años , Pérdida de Sangre Quirúrgica , Cuidados Críticos , Femenino , Fluidoterapia , Fluoruros/sangre , Glutatión Transferasa/sangre , Humanos , Hipnóticos y Sedantes/administración & dosificación , Inyecciones Intravenosas , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Propofol/administración & dosificación , Sevoflurano , Método Simple CiegoRESUMEN
PURPOSE: A balanced fluid replacement strategy appears to be promising for correcting hypovolemia. The benefits of a balanced fluid replacement regimen were studied in elderly cardiac surgery patients. METHODS: In a randomized clinical trial, 50 patients aged >75 years undergoing cardiac surgery received a balanced 6% HES 130/0.42 plus a balanced crystalloid solution (n = 25) or a non-balanced HES in saline plus saline solution (n = 25) to keep pulmonary capillary wedge pressure/central venous pressure between 12-14 mmHg. Acid-base status, inflammation, endothelial activation (soluble intercellular adhesion molecule-1, kidney integrity (kidney-specific proteins glutathione transferase-alpha; neutrophil gelatinase-associated lipocalin) were studied after induction of anesthesia, 5 h after surgery, 1 and 2 days thereafter. Serum creatinine (sCr) was measured approximately 60 days after discharge. RESULTS: A total of 2,750 +/- 640 mL of balanced and 2,820 +/- 550 mL of unbalanced HES were given until the second POD. Base excess (BE) was significantly reduced in the unbalanced (from +1.21 +/- 0.3 to -4.39 +/- 1.0 mmol L(-1) 5 h after surgery; P < 0.001) and remained unchanged in the balanced group (from 1.04 +/- 0.3 to -0.81 +/- 0.3 mmol L(-1) 5 h after surgery). Evolution of the BE was significantly different. Inflammatory response and endothelial activation were significantly less pronounced in the balanced than the unbalanced group. Concentrations of kidney-specific proteins after surgery indicated less alterations of kidney integrity in the balanced than in the unbalanced group. CONCLUSIONS: A total balanced volume replacement strategy including a balanced HES and a balanced crystalloid solution resulted in moderate beneficial effects on acid-base status, inflammation, endothelial activation, and kidney integrity compared to a conventional unbalanced volume replacement regimen.
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Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Endotelio Vascular/efectos de los fármacos , Hipovolemia/terapia , Inflamación/terapia , Soluciones Isotónicas/uso terapéutico , Insuficiencia Renal/prevención & control , Cloruro de Sodio/uso terapéutico , Equilibrio Ácido-Base , Anciano , Anciano de 80 o más Años , Gasto Cardíaco/fisiología , Soluciones Cristaloides , Femenino , Frecuencia Cardíaca/fisiología , Humanos , Molécula 1 de Adhesión Intercelular/metabolismo , Masculino , Periodo Posoperatorio , Presión Esfenoidal PulmonarRESUMEN
BACKGROUND: Along with postoperative nausea and vomiting (PONV), postanesthetic shivering (PAS) is one of the leading causes of distress postoperatively. Previous studies report on a decrease in incidence of PAS due to ketamine administration; however, the S(+) isomer of ketamine has not been evaluated before. Additionally the administration of ketamine minimizes the use of opioids, one of the most important risk factor of PONV. The aim of the present study was to evaluate the efficacy of S(+)-ketamine in the prophylaxis of both PAS and PONV in patients undergoing cardiac surgery. MATERIAL/METHODS: After ethics committee approval and written informed consent from the patients, 54 patients scheduled for coronary artery bypass graft surgery (CABG) were studied for both postanesthetic shivering and PONV. The sedation on the ICU was maintained using continuous infusion of propofol (1-3 mg x kg(-1) x h(-1)) and if necessary boli of 3.75 mg piritramide. At arrival in the ICU patients supplementary received either S(+)-ketamine (2 mg x kg(-1) x h(-1); group A; n=27) or 0.9% saline as placebo (group B; n=27) in a double-blind fashion. The severity of PAS was assessed by using a five-point rating scale. Fifteen minutes after extubation and 24 hours postoperatively, patients were asked about occurrence of PONV. RESULTS: In group A 4 (14.8%) patients suffered from PAS compared to 12 (44.4%) in the control group (p<0.05). The severity of shivering was significantly lower in group A than in group B (p<0.05). In group A, patients showed a significant lower incidence of PONV (3.7% vs. 33.3%) and vomiting (3.7% vs. 22.2%) compared to patients of group B (p<0.05). CONCLUSIONS: S(+)-ketamine reduced both postanesthetic shivering and postoperative nausea and vomiting, when administered for postoperative analgosedation.
Asunto(s)
Anestesia/efectos adversos , Puente de Arteria Coronaria , Hipnóticos y Sedantes/administración & dosificación , Ketamina/administración & dosificación , Náusea/prevención & control , Enfermería Posanestésica , Complicaciones Posoperatorias , Vómitos/prevención & control , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Incidencia , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Náusea/inducido químicamente , Vómitos/inducido químicamenteRESUMEN
BACKGROUND: Antifibrinolytic drugs including aprotinin and tranexamic acid are currently used in cardiac surgery to reduce postoperative bleeding and transfusion requirements, and may have different effects on platelets. We therefore evaluated platelet function after cardiopulmonary bypass (CPB) and cardiac surgery to determine the effect of either aprotinin or tranexamic acid. METHODS: In a prospective, randomized study, 50 patients scheduled for elective cardiac surgery with CPB were evaluated. Patients received high-dose aprotinin (n = 25) or tranexamic acid (n = 25) as antifibrinolytic drugs. Coagulation and platelet function were assessed preoperatively, after CPB, 3 and 24 h after surgery using modified thrombelastography and whole blood aggregometry. RESULTS: Impaired coagulation after CPB occurred in both groups compared with preoperative data (P < 0.01). In contrast to modified thrombelastography, thrombin receptor-mediated aggregometry after CPB was significantly decreased only in those patients receiving tranexamic acid until the end of the study period in comparison to the aprotinin group (P < 0.05). Aprotinin-treated patients showed significantly less chest tube drainage (575 mL +/- 228 vs 1033 mL +/- 647, P < 0.05) and need for postoperative transfusion requirements (P < 0.01) compared with the tranexamic acid group. CONCLUSIONS: Platelet function measured by whole blood aggregometry is better preserved by aprotinin than tranexamic acid and may be responsible for producing less bleeding within the first 24 h after CPB.
Asunto(s)
Antifibrinolíticos/uso terapéutico , Aprotinina/uso terapéutico , Puente de Arteria Coronaria , Hemostáticos/uso terapéutico , Hemorragia Posoperatoria/prevención & control , Inhibidores de Serina Proteinasa/uso terapéutico , Ácido Tranexámico/uso terapéutico , Anciano , Coagulación Sanguínea/efectos de los fármacos , Transfusión Sanguínea , Puente Cardiopulmonar , Femenino , Humanos , Masculino , Sustitutos del Plasma/uso terapéutico , Agregación Plaquetaria/efectos de los fármacos , Pruebas de Función Plaquetaria , TromboelastografíaRESUMEN
OBJECTIVES: Impaired hemostasis of multiple etiologies are often present in patients undergoing cardiopulmonary bypass (CPB) surgery. Platelet dysfunction is considered to be important in the early postoperative period. Therefore, a new whole-blood platelet function analyzer was compared with thromboelastography in predicting postoperative hemostatic outcomes as measured by blood loss and blood product use. DESIGN: Prospective study. SETTING: Teaching hospital. PARTICIPANTS: The study enrolled 54 patients scheduled for coronary artery bypass surgery with CPB. INTERVENTIONS: Coagulation and platelet function were assessed preoperatively, after CPB, at 3 hours, and at 24 hours after surgery by using thromboelastography and impedance aggregometry. Patients were divided into a transfused and nontransfused group on the basis of postoperative transfusion requirements. Postoperative blood loss and requirements of blood transfusions were documented until 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Twenty-five patients (46%) received postoperative blood transfusions. Impaired hemostasis occurred after CPB detected by thromboelastography (p < 0.01) and impedance aggregometry (p < 0.01). In contrast to thromboelastography, preoperative adenosine diphosphate-mediated aggregometry correlated with postoperative requirements for blood transfusion (Spearman r = -0.302, p < 0.05) and was significantly lower in patients receiving allogeneic blood transfusion compared with nontransfused patients (p < 0.05). Neither aggregometry nor thromboelastography was correlated with postoperative blood loss. CONCLUSION: Impedance aggregometry as well as thromboelastography are able to detect impaired hemostasis after CPB. In contrast to thromboelastography, aggregometry using a new whole-blood aggregometer identified patients with a reduced risk for postoperative transfusion requirements.
Asunto(s)
Trastornos de la Coagulación Sanguínea/diagnóstico , Puente de Arteria Coronaria , Agregación Plaquetaria/fisiología , Pruebas de Función Plaquetaria/instrumentación , Anciano , Trastornos de la Coagulación Sanguínea/etiología , Pérdida de Sangre Quirúrgica , Transfusión Sanguínea , Diseño de Equipo , Femenino , Humanos , Masculino , Sistemas de Atención de Punto , Sensibilidad y Especificidad , TromboelastografíaRESUMEN
BACKGROUND: The lack of acceptance of hydroxyethylstarch (HES) for intravascular volume replacement is most likely due to reports of abnormal coagulation. In a blinded in vitro study, we compared the effects on hemostasis of a new HES, prepared in a balanced solution, with a conventional HES preparation and Ringer's lactate solution. METHODS: Blood was taken from 10 healthy young male volunteers. Blood was diluted by 10%, 30%, and 50% using either 6% HES 130/0.42 prepared in a balanced solution, a conventional nonbalanced 6% HES 130/0.4 or Ringer's lactate solution. Rotation thrombelastography, was performed after adding two activators (thromboplastin-phospholipid to monitor the intrinsic system; tissue factor to monitor the extrinsic system). Whole blood aggregometry adding adenosine diphosphate, collagen, and thrombin receptor-activating protein was used to assess changes of platelet function. RESULTS: Dilution of blood (30% and 50%) resulted in clot formation time that was significantly more prolonged in the nonbalanced than in the balanced HES group. In the 50% diluted sample using the unbalanced HES, maximum clot firmness was significantly more reduced than by 50% dilution using the balanced HES. In the 50% diluent using the nonbalanced HES, adenosine diphosphate-, collagen-, and thrombin receptor activating protein-induced aggregometry was more reduced than in the balanced HES group. CONCLUSIONS: A balanced HES preparation showed fewer negative effects on thrombelastographic data and platelet aggregation than a nonbalanced HES preparation, especially when using higher degrees of dilution. Future clinical studies may show a decreased influence of balanced HES solutions on coagulation.