Clinical and biological factors associated with red blood cell transfusion during severe postpartum haemorrhage - A single-center retrospective cohort study.

INTRODUCTION: Red blood cell (RBC) transfusions are of utmost importance in the management of severe post-partum haemorrhage. Although the recommendations for blood transfusion protocols are regularly issued, there are significant differences in management depending on the context and the medical teams involved. OBJECTIVE: To determine during the first 24 h, the clinical and biological factors associated with the decision for RBC transfusion during severe PPH (≥1000 mL) for vaginal and caesarean deliveries. STUDY DESIGN: Monocentric retrospective study conducted in a tertiary care university maternity unit (CHI-Creteil) including all parturients from November 23th 2018 to 31th December 2020 with severe PPH (≥1000 mL). RESULTS: Over the study period, we reported 7103 deliveries, out of which 682 were complicated by PPH (9.6 %) with 200 cases of PPH ≥1000 mL (2.8 %). In our study, 40 % of patients (80/200) required a RBC transfusion". After multivariate analysis, severe PPH caused by placental abruption, uterine rupture or placental implantation disorders (aOR = 3.48 IC95 [1.27-9.52], p < 0.001), estimated blood loss ≥1500 mL (aOR = 9.60 IC95 [3.69-24.95], p < 0. 001), invasive measures such as uterine balloon tamponade, arterial ligation and uterine packing (aOR = 4.15 IC95 [1.80-9.61], p < 0.001), pre-labor hemoglobin <10 g/dL (aOR =4.88 IC95 [1.57-15.15], p < 0.001) or abnormal biological results in the acute phase (including hemoglobin <7.0 g/dL and/or fibrinogen <2 g/L and/or platelets <100 G/L) (aOR =356 IC95 [1,05-12,10], p < 0.001) were significantly and independently associated with the decision to initiate RBC transfusions. CONCLUSIONS: In a monocentric retrospective study including 200 consecutive cases of severe PPH (≥1000 mL) we identified groups of clinical and biological factors directly accessible to clinicians, significantly and independently associated with RBC transfusion in the first 24 h of management.

Noninvasive investigation of autonomic activity after carotid stenting or carotid endarterectomy.

OBJECTIVE: Carotid artery stenting (CAS) has been introduced as an alternative to carotid endarterectomy (CEA) for the treatment of carotid artery stenosis. Both techniques seem to be associated with postoperative hemodynamic lability. Both may induce baroreceptor dysfunction, possibly leading to transient impairment of cardiovascular autonomic activity and resulting in hemodynamic instability. This instability might contribute to postoperative morbidity. To elucidate these phenomena, we studied the cardiac baroreflex and autonomic cardiovascular control after CAS and CEA. METHOD: In 20 patients scheduled for CAS (n = 10) or CEA (n = 10), intra-arterial pressures and electrocardiograms were recorded during 10 minutes before and 8 and 24 hours after the procedure. Spontaneous cardiac baroreflex sensitivity was assessed using the sequence method and cross-spectral analysis. In addition, cardiovascular autonomic activity was investigated using spectral analysis of heart rate variability and systolic arterial pressure variability. RESULTS: After CAS, we demonstrated an increase of the spontaneous baroreflex sensitivity median (interquartile range) from 5.6 (5.1 to 6.2) ms/mm Hg before the procedure to 8.8 (6.8 to 10.5) ms/mm Hg and 7.7 (3.9 to 8.6) ms/mm Hg (P < .001), 8 and 24 hours after the procedure. This was consistent with the increase of the high frequency component of heart rate variability reflecting cardiac parasympathetic activity and a decrease of the low frequency of systolic arterial pressure variability reflecting sympathetic vascular activity. The postoperative period was also associated with decreased systolic arterial pressure from 173 (162 to 190) mm Hg at baseline to 122 (109 to 143) mm Hg and 136 (121 to 143) mm Hg at 8 and 24 hours after CAS (P < .001). No changes in baroreflex sensitivity or in autonomic activity were observed after CEA. CONCLUSIONS: These preliminary data suggest that CAS is associated with parasympathetic predominance postoperatively and may probably explain the lower systolic arterial pressure observed after CAS.

Cardiac troponin I assessment and late cardiac complications after carotid stenting or endarterectomy.

PURPOSE: When compared with carotid endarterectomy (CEA), percutaneous carotid angioplasty with stent replacement (CAS) is a less invasive technique in the treatment of carotid stenosis. However, periprocedural hemodynamic instability still remains a challenge. This instability might lead to myocardial damage, which is now measured accurately by using cardiac troponin I (CTnI). METHODS: This study was designed to compare the periprocedural variation of CTnI in 150 consecutive patients scheduled to undergo CEA (n = 75) or CAS (n = 75). The levels of CTnI were measured until the third postoperative day in all patients. Short-term (1 month) and long-term (up to 5 years) postoperative cardiac outcome were assessed by means of chart review, regular follow-ups, and telephone calls. RESULTS: There was not any statistically significant difference between the 2 groups regarding the demographic characteristics and preprocedural medical status. The incidence of increase of CTnI (>0.5 ng/mL) was significantly higher in the CEA group (13%) compared with that in the CAS group (1%; P = .001). During the acute postprocedural period, the CAS group was significantly more prone to hypotension, requiring vasopressor therapy, whereas the CEA group had more hypertension, necessitating hypotensive medications (P < .001). At 5 years, the overall incidence of major cardiac complications (nonfatal myocardial infarction and death related to cardiac origin) was significantly more frequent in the CEA group (20% vs 5%, P < .01). CONCLUSION: The results of our study suggest that CAS yielded less myocardial damage in the short and long term when compared with CEA. Larger randomized multicenter trials with long-term outcomes are necessary to confirm our findings.