Smith, Mark M

AbstractCoagulopathy is common during left ventricular assist device (LVAD) implantation, treatment of which can be challenging given the often‐limited ability for the right ventricle to accommodate volume transfusion after device initiation with 20% to 40% of patients developing right ventricular failure (RVF). Transfusion of plasma late on cardiopulmonary bypass (CPB) combined with ultrafiltration may replace clotting factors while reducing volume administration. We compared outcomes in patients undergoing LVAD implantation receiving plasma on CPB and ultrafiltration with traditional transfusion practices. Co‐primary outcomes needed for blood product transfusion in the first 6 and 24 hours after CPB. Secondary outcomes included metrics of morbidity and mortality. 396 patients were analyzed (59 plasma on CPB). Patients receiving plasma on CPB had a greater volume of blood products transfused (3764 vs. 2741 mL first 6 hours; 6059 vs. 4305 mL first 24 hours) in unadjusted analysis. In adjusted analysis, plasma transfusion on CPB with ultrafiltration had no significant effect on the primary outcomes of blood products given in the first 6 hours (estimated effect size 982 [−428, 2392] mL, P = .17) and 24 hours (estimated effect size 1076 [−904, 3057] mL, P = .29). Patients receiving plasma on CPB were more likely on either vasopressors or inotropes at 24 hours after ICU admission (P = .01), however, indices of coagulopathy and RVF were similar between groups. While prospective studies would be necessary to definitively evaluate the clinical utility of this strategy, no signal for benefit was observed suggesting plasma should not be used for this purpose.

Abstract Prothrombin complex concentrate (PCC) administration has increased among cardiac surgery patients in recent years; however, use in LVAD implantation/exchange is not widespread due to the fear of thrombotic complications. The purpose of this study was to compare the clinical outcomes of patients undergoing LVAD implantation/exchange with intraoperative PCC administration versus traditional transfusion practices alone. Adult LVAD implants/exchanges at our institution between 2015 and 2018 were included. Patients were categorized as receiving intraoperative PCC or no‐PCC (traditional). The primary outcome was the need for allogenic transfusion and transfusion volume at 48 hours after initial intensive care unit (ICU) admission. Secondary outcomes included metrics of morbidity and mortality. A total of 160 patients (39 PCC, 121 traditional) were analyzed. In unadjusted analysis, patients in the PCC group received lower intraoperative transfusion volumes compared to the traditional group although not statistically significant (1464 mL [IQR 796, 4876] vs. 2568 mL [IQR 1292, 3606]; P value .37). In the fully adjusted analysis, patients in the PCC group had increased odds of transfusion within 48 hours of ICU admission (OR 4.06, 95% CI: 1.35‐12.20; P < .01); however, there was no significant difference in transfusion volumes ( P = .09). Patients receiving PCCs had higher incidence of deep vein thrombosis (10.3% vs. 0%; P < .01) and 30‐day mortality (17.9% vs. 4.1%; P < .01). LVAD pump thrombosis occurred in 2.6% versus 0.8% in the PCC and traditional groups, respectively; P = .98. Patients undergoing LVAD implantation and exchange represent a complex surgical cohort. The results of this study suggest that the intraoperative PCC use during LVAD implant/exchange was associated with reduced intraoperative transfusions. Intraoperative PCC use was, however, associated with higher odds of postoperative transfusion, although transfusion volumes were not significantly different. While the deep vein thrombosis and 30‐day mortality rates were higher in the PCC group, these results are likely related to the degree of surgical and patient complexity rather than PCC use itself. Further studies are needed to assess PCC use in this surgical cohort.

BackgroundPlatelet (PLT) transfusions are an important component of hemostatic resuscitation. The AABB has published several guidelines recommending that PLT units should not be infused through blood warming devices.Study Design and MethodsThirty‐one units of hospital blood bank apheresis PLTs were obtained. PLT‐rich plasma (PRP) aggregometry and thromboelastography (TEG) were performed on the unit samples before and after the units were infused through a Ranger blood/fluid warming device.ResultsThere were no differences in any of the aggregometry results before and after infusion of the PLTs through the blood warmer (all P > .32). There was a significant reduction in the TEG maximum amplitude (MA) of 69.8 ± 7.9 mm before and 66.0 ± 8.8 mm after (P < .001) infusion of the PLTs through the blood warmer and α angle 61.8 ± 9.4° before and 59.3 ± 8.2° after (P = .044) infusion of the PLTs through the blood warmer, although both mean values were within normal range for the TEG and not clinically significant. There were very good correlations of aggregometry and TEG results before and after infusion of the PLTs through the blood warmer device.ConclusionThis study did not demonstrate significant deleterious effect on PLT function from infusing apheresis PLT units through a blood warming device by PRP aggregometry. We did detect a statistically significant—but not clinically significant—reduction in TEG MA and α angle. The prohibition of transfusing PLT units though the Ranger blood warming device is not indicated.

AbstractBackgroundTransesophageal echocardiography (TEE) is a specialized form of cardiac ultrasound and has been associated with rare but serious complications. In patients with prior esophageal surgery, the risk of esophageal damage or the inability to perform a comprehensive and successful TEE warrants further evaluation.MethodsRetrospective study of patients with prior esophageal surgery who underwent TEE between June 21, 2002 and October 15, 2019. Medical and echocardiographic records were reviewed for image quality and procedural complications. Post‐procedure complications and 30‐day all‐cause mortality were collected. Evaluation by gastroenterology (GI), otolaryngology/ear, nose, throat (ENT), or thoracic surgery (TS) within 30 days of TEE was reviewed in detail.ResultsNinety‐five patients with prior esophageal surgery underwent 145 TEEs. The most commonly performed esophageal procedures were anti‐reflux operations (89%). TEE image quality was degraded in 16% while transgastric imaging was not completed in 37% of cases. A comprehensive TEE was completed in 57% of patients with diagnostic study goals achieved in 96% of cases. Comments describing procedural difficulty were reported in 6% while comments on procedural complications occurred in 1% of cases. Post‐procedure complications occurred in 1% of patients including hypotension and unplanned hospital/ICU admission.ConclusionsConcern for esophageal damage and the inability to perform a comprehensive and diagnostic TEE may limit the usefulness of TEE in patients with prior esophageal surgery. While TEE‐associated complications were rare in this series, a conservative approach with a thorough pre‐procedure assessment, including multi‐disciplinary evaluation when appropriate, is prudent in this complex cohort of patients.

SummaryBackgroundBardet–Biedl syndrome (BBS) is a rare genetic condition with manifestations that can impact anesthetic and perioperative care. There is a void of literature describing the perioperative anesthetic management in this complex patient population.ObjectivesThe purpose of this retrospective series was to describe the perioperative care of patients diagnosed with BBS at a large academic tertiary referral center with experience in caring for these patients.MethodsAll patients receiving anesthesia during the time between July 10, 1997 and Jan 1, 2015 were identified. Anesthetic and perioperative records were reviewed in detail for demographic, echocardiographic, preoperative, intraoperative, and postoperative data.ResultsWe identified 12 patients with BBS undergoing 40 anesthetics at our institution. The study identified a high risk for difficult airway with need for advanced airway techniques (67% of patient's ≥18 years of age required either awake fiberoptic or video laryngoscopy techniques), cardiac abnormalities, renal impairment, morbid obesity, and intellectual disability as the main syndrome manifestations of interest to the anesthesiologist. No patient had perioperative complications directly related to BBS; however, each underwent thorough perioperative evaluation with emphasis on the systemic comorbidities associated with the syndrome. This report illustrates that patients with BBS can safely undergo anesthesia, but a detailed and often multidisciplinary preoperative evaluation is prudent.