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Thorac Cardiovasc Surg 2021; 69(08): 710-718
DOI: 10.1055/s-0040-1710582
Original Cardiovascular

Implementation of Perioperative Point-of-Care Platelet Function Analyses Reduces Transfusion Requirements in Cardiac Surgery: A Retrospective Cohort Study

Lihui Wang
1   Department of Clinical Perfusion, St George's Hospital, London, United Kingdom
,
Oswaldo Valencia
2   Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
,
Simon Phillips
1   Department of Clinical Perfusion, St George's Hospital, London, United Kingdom
,
Vivek Sharma
3   Department of Anaesthesia, St George's Hospital, London, United Kingdom
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Abstract

Background Platelet dysfunction is a common cause of bleeding, perioperative blood transfusion, and surgical re-exploration in cardiac surgical patients. We evaluated the effect of incorporating a platelet function analyzer utilizing impedance aggregometry (Multiplate, Roche, Munich, Germany) into our local transfusion algorithm on the rate of platelet transfusion and postoperative blood loss in patients undergoing coronary artery bypass grafting (CABG) surgery.

Methods Data were collected on patients undergoing CABG surgery from January 2015 to April 2017. Patients who underwent surgery before and after introduction of this algorithm were classified into prealgorithm and postalgorithm groups, respectively. The primary outcome was the rate of platelet transfusion before and after implementation of the Multiplate-based transfusion algorithm. Secondary outcomes included transfusion rate of packed red blood cells, postoperative blood loss at 12 and 24 hours, length of stay in the intensive care unit, and the hospital and mortality.

Results A total of 726 patients were included in this analysis with 360 and 366 patients in the pre- and postalgorithm groups, respectively. Transfusion rates of platelets (p = 0.01) and packed red blood cells (p = 0.0004) were significantly lower following introduction of the algorithm in patients (n = 257) who had insufficient time to withhold antiplatelet agents. Receiver operating characteristic curves defined optimal cutoff points of arachidonic acid and adenosine diphosphate assays on the Multiplate to predict future platelet transfusion were 23AU and 43AU, respectively.

Conclusions The introduction of a Multiplate-based platelet transfusion algorithm showed a statistically significant reduction in the administration of platelets to patients undergoing urgent CABG surgery.

Keywords

coronary artery bypass grafting surgery - CABG - blood transfusion - blood - coagulation/anticoagulation - outcomes


Publication History

Received: 19 December 2019

Accepted: 23 March 2020

Article published online:
19 June 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Kolh P, Windecker S, Alfonso F. et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2014; 46: 517-592
    CrossrefPubMedSearch in Google Scholar
  • 2 Ferraris VA, Ferraris SP, Saha SP. et al. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83: S27-S86
    CrossrefPubMedSearch in Google Scholar
  • 3 Goodnough LT. Blood management: transfusion medicine comes of age. Lancet 2013; 381: 1791-1792
    CrossrefPubMedSearch in Google Scholar
  • 4 Despotis G, Eby C, Lublin DM. A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery. Transfusion 2008; 48 (01) 2S-30
    CrossrefPubMedSearch in Google Scholar
  • 5 Vamvakas EC, Blajchman MA. Blood still kills: six strategies to further reduce allogeneic blood transfusion-related mortality. Transfus Med Rev 2010; 24: 77-124
    CrossrefPubMedSearch in Google Scholar
  • 6 Rohde JM, Dimcheff DE, Blumberg N. et al. Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA 2014; 311: 1317-1326
    CrossrefPubMedSearch in Google Scholar
  • 7 Karkouti K, Wijeysundera DN, Yau TM. et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion 2004; 44: 1453-1462
    CrossrefPubMedSearch in Google Scholar
  • 8 Karkouti K, Stukel TA, Beattie WS. et al. Relationship of erythrocyte transfusion with short- and long-term mortality in a population-based surgical cohort. Anesthesiology 2012; 117: 1175-1183
    CrossrefPubMedSearch in Google Scholar
  • 9 Görlinger K, Shore-Lesserson L, Dirkmann D, Hanke AA, Rahe-Meyer N, Tanaka KA. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth 2013; 27 (04) S20-S34
    CrossrefPubMedSearch in Google Scholar
  • 10 Görlinger K, Dirkmann D, Hanke AA. Potential value of transfusion protocols in cardiac surgery. Curr Opin Anaesthesiol 2013; 26: 230-243
    CrossrefPubMedSearch in Google Scholar
  • 11 Schöchl H, Voelckel W, Grassetto A, Schlimp CJ. Practical application of point-of-care coagulation testing to guide treatment decisions in trauma. J Trauma Acute Care Surg 2013; 74: 1587-1598
    CrossrefPubMedSearch in Google Scholar
  • 12 Corredor C, Wasowicz M, Karkouti K, Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia 2015; 70: 715-731
    CrossrefPubMedSearch in Google Scholar
  • 13 Karkouti K, McCluskey SA, Callum J. et al. Evaluation of a novel transfusion algorithm employing point-of-care coagulation assays in cardiac surgery: a retrospective cohort study with interrupted time-series analysis. Anesthesiology 2015; 122: 560-570
    CrossrefPubMedSearch in Google Scholar
  • 14 Kuiper GJAJM, van Egmond LT, Henskens YMC. et al. Shifts of transfusion demand in cardiac surgery after implementation of rotational thromboelastometry-guided transfusion protocols: analysis of the HEROES-CS (HEmostasis Registry of patiEntS in Cardiac Surgery) observational, prospective open cohort database. J Cardiothorac Vasc Anesth 2019; 33: 307-317
    CrossrefPubMedSearch in Google Scholar
  • 15 Bolliger D, Tanaka KA. Point-of-care coagulation testing in cardiac surgery. Semin Thromb Hemost 2017; 43: 386-396
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Karkouti K, Callum J, Wijeysundera DN. et al. TACS investigators. Point-of-care hemostatic testing in cardiac surgery: a Stepped-Wedge clustered randomized controlled trial. Circulation 2016; 18 (134) 1152-1162
    CrossrefPubMedSearch in Google Scholar
  • 17 Ellis J, Valencia O, Crerar-Gilbert A, Phillips S, Meeran H, Sharma V. Point-of-care platelet function testing to predict blood loss after coronary artery bypass grafting surgery: a prospective observational pilot study. Perfusion 2016; 31: 676-682
    CrossrefPubMedSearch in Google Scholar
  • 18 Kong R, Trimmings A, Hutchinson N. et al. Consensus recommendations for using the Multiplate(®) for platelet function monitoring before cardiac surgery. Int J Lab Hematol 2015; 37: 143-147
    CrossrefPubMedSearch in Google Scholar
  • 19 Reece MJ, Klein AA, Slaviz EA. et al. Near-platelet function testing in patients undergoing coronary artery surgery: a pilot study. Anaesthesia 2011; 66: 97-103
    CrossrefPubMedSearch in Google Scholar
  • 20 Trevisan D, Zavatti L, Gabbieri D, Pedulli M, Giordano G, Meli M. Point-of-care-based protocol with first-line therapy with coagulation factor concentrates is associated with decrease allogenic blood transfusion and costs in cardiovascular surgery: an Italian single-center experience. Minerva Anestesiol 2016; 82: 1077-1088
    PubMedSearch in Google Scholar
  • 21 Della Corte A, Bancone C, Spadafora A. et al. Postoperative bleeding in coronary artery bypass patients on double antiplatelet therapy: predictive value of preoperative aggregometry. Eur J Cardiothorac Surg 2017; 52: 901-908
    CrossrefPubMedSearch in Google Scholar
  • 22 Rafiq S, Johansson PI, Kofoed KF, Olsen PS, Steinbrüchel DA. Preoperative hemostatic testing and the risk of postoperative bleeding in coronary artery bypass surgery patients. J Card Surg 2016; 31: 565-571
    CrossrefPubMedSearch in Google Scholar
  • 23 Woźniak S, Woźniak K, Hryniewiecki T, Kruk M, Różański J, Kuśmierczyk M. The predictive value of multiple electrode platelet aggregometry for postoperative bleeding complications in patients undergoing coronary artery bypass graft surgery. Kardiochir Torakochirurgia Pol 2016; 13: 3-9
    PubMedSearch in Google Scholar
  • 24 Mishra PK, Thekkudan J, Sahajanandan R. et al. The role of point-of-care assessment of platelet function in predicting postoperative bleeding and transfusion requirements after coronary artery bypass grafting. Ann Card Anaesth 2015; 18: 45-51
    CrossrefPubMedSearch in Google Scholar
  • 25 Schimmer C, Hamouda K, Sommer SP, Özkur M, Hain J, Leyh R. The predictive value of multiple electrode platelet aggregometry (multiplate) in adult cardiac surgery. Thorac Cardiovasc Surg 2013; 61: 733-743
    Thieme ConnectPubMedSearch in Google Scholar
  • 26 Dyke C, Aronson S, Dietrich W. et al. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg 2014; 147: 1458-1463
    CrossrefPubMedSearch in Google Scholar
  • 27 Ranucci M, Baryshnikova E, Soro G. et al. Multiple electrode whole-blood aggregometry and bleeding in cardiac surgery patients receiving thienopyridines. Ann Thorac Surg 2011; 91: 123-129
    CrossrefPubMedSearch in Google Scholar
  • 28 Kosiorowska K, Lukaszewski M, Jakubaszko J. et al. Platelets function assessment in patients qualified for cardiac surgery - clinical problems and a newer diagnostic possibilities. J Cardiothorac Surg 2018; 13: 131
    CrossrefPubMedSearch in Google Scholar
  • 29 Ferraris VA, Brown JR, Despotis GJ. et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91: 944-982
    CrossrefPubMedSearch in Google Scholar
  • 30 Sousa-Uva M, Neumann FJ, Ahlsson A. et al. 2018 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2019; 55: 4-90
    CrossrefPubMedSearch in Google Scholar
  • 31 Agarwal S, Johnson RI, Kirmani BH. Pre- and post-bypass platelet function testing with multiple electrode aggregometry and TEG platelet mapping in cardiac surgery. J Cardiothorac Vasc Anesth 2015; 29: 1272-1276
    CrossrefPubMedSearch in Google Scholar