How I manage major hemorrhage.

Acute hemorrhage can be a life-threatening emergency that is complex in its management and affects many patient populations. The last 15 years has seen the introduction of comprehensive massive hemorrhage protocols, wider use of viscoelastic testing, new coagulation factor products, and the publication of robust randomized controlled trials in diverse bleeding patient populations. Although gaps continue to exist in the evidence-base for several aspects of patient care, there is now sufficient evidence to allow for an individualized hemostatic response based on the type of bleeding and specific hemostatic defects. We present three clinical cases that highlight some of the challenges in acute hemorrhage management, focusing on the importance of inter-professional communication, rapid provision of hemostatic resuscitation, repeated measures of coagulation, immediate administration of tranexamic acid, and prioritization of surgical or radiologic control of hemorrhage. This article provides a framework for the clear and collaborative conversation between the bedside clinical team and the consulting hematologist to achieve prompt and targeted hemostatic resuscitation. In addition to providing consultations on the hemostatic management of individual patients, the hematology service must be involved in setting hospital policies for the prevention and management of patients with major hemorrhage.

Postoperative anemia in cardiac surgery patients: a narrative review.

PURPOSE: Anemia reduces the blood's ability to carry and deliver oxygen. Following cardiac surgery, anemia is very common and affects up to 90% of patients. Nevertheless, there is a paucity of data examining the prognostic value of postoperative anemia. In this narrative review, we present findings from the relevant literature on postoperative anemia in cardiac surgery patients, focusing on the incidence, risk factors, and prognostic value of postoperative anemia. We also explore the potential utility of postoperative anemia as a therapeutic target to improve clinical outcomes. SOURCE: We conducted a targeted search of MEDLINE, Embase, and the Cochrane Database of Systematic Reviews up to September 2022, using a combination of search terms including postoperative (post-operative), perioperative (peri-operative), anemia (anaemia), and cardiac surgery. PRINCIPAL FINDINGS: The reported incidence of postoperative anemia varied from 29% to 94% across the studies, likely because of variations in patient inclusion criteria and classification of postoperative anemia. Nonetheless, the weight of the evidence suggests that postoperative anemia is common and is an independent risk factor for adverse postoperative outcomes such as acute kidney injury, stroke, mortality, and functional outcomes. CONCLUSIONS: In cardiac surgery patients, postoperative anemia is a common and prognostically important risk factor for postoperative morbidity and mortality. Nevertheless, there is a lack of data on whether active management of postoperative anemia is feasible or effective in improving patient outcomes.

RéSUMé: OBJECTIF: L'anémie réduit la capacité du sang à transporter et à fournir de l'oxygène. Suite à une chirurgie cardiaque, l'anémie est très fréquente et touche jusqu'à 90 % des patient·es. Néanmoins, il existe peu de données examinant la valeur pronostique de l'anémie postopératoire. Dans ce compte rendu narratif, nous présentons les résultats de la littérature pertinente sur l'anémie postopératoire chez les patient·es ayant bénéficié d'une chirurgie cardiaque, en mettant l'accent sur l'incidence, les facteurs de risque et la valeur pronostique de l'anémie postopératoire chez les personnes ayant bénéficié d'une chirurgie cardiaque. Nous explorons également l'utilité potentielle de l'anémie postopératoire en tant que cible thérapeutique pour améliorer les devenirs cliniques. SOURCES: Nous avons réalisé une recherche ciblée dans MEDLINE, Embase et la base de données des revues systématiques Cochrane jusqu'en septembre 2022, en utilisant une combinaison de termes de recherche, notamment postopératoire (postoperative/post-operative), périopératoire (perioperative/peri-operative), anémie (anemia/anaemia) et chirurgie cardiaque (cardiac surgery). CONSTATATIONS PRINCIPALES: L'incidence rapportée de l'anémie postopératoire variait de 29 % à 94 % d'une étude à l'autre, probablement en raison des variations dans les critères d'inclusion des patient·es et la classification de l'anémie postopératoire. Néanmoins, le poids de la preuve suggère que l'anémie postopératoire est courante et constitue un facteur de risque indépendant pour les devenirs postopératoires indésirables tels que l'insuffisance rénale aiguë, les accidents vasculaires cérébraux, la mortalité et les devenirs fonctionnels. CONCLUSION: Chez la patientèle en chirurgie cardiaque, l'anémie postopératoire est un facteur de risque commun et pronostiquement important de morbidité et de mortalité postopératoires. Néanmoins, il y a un manque de données sur la faisabilité ou l'efficacité de la prise en charge active de l'anémie postopératoire pour améliorer les devenirs des patient·es.

What can ex vivo experiments contribute to clinical haemostasis management?

A recent ex vivo study found that post-cardiopulmonary bypass platelet defects can be restored with supplemental fibrinogen, but the clinical significance of this finding will require further study. We propose that the best management strategy for achieving haemostasis in bleeding surgical patients is to identify individualised coagulation defects and then use a targeted therapeutic approach that addresses each identified defect systematically.

Impact of COVID-19 on electroconvulsive therapy practice across Canadian provinces during the first wave of the pandemic.

BACKGROUND: Electroconvulsive therapy (ECT) is a procedural treatment that is potentially life-saving for some patients with severe psychiatric illness. At the start of the global coronavirus disease 2019 (COVID-19) pandemic, ECT practice was remarkably disrupted, putting vulnerable individuals at increased risk of symptom exacerbation and death by suicide. This study aimed to capture the self-reported experiences of psychiatrists based at healthcare facilities across Canadian provinces who were delivering ECT treatments during the first phase of the COVID-19 pandemic (i.e., from mid-March 2020 to mid-May 2020). METHODS: A multidisciplinary team of experts developed a survey focusing on five domains: ECT unit operations, decision-making, hospital resources, ECT procedure, and mitigating patient impact. Responses were collected from psychiatrists providing ECT at 67 ECT centres in Canada, grouped by four geographical regions (Ontario, Quebec, Atlantic Canada, and Western Canada). RESULTS: Clinical operations of ECT programs were disrupted across all four regions - however, centres in Atlantic Canada were able to best preserve outpatient and maintenance care, while centres in Western Canada were able to best preserve inpatient and acute care. Similarly, Atlantic and Western Canada demonstrated the best decision-making practices of involving the ECT team and clinical ethicists in the development of pandemic-related guidelines. Across all four regions, ECT practice was affected by the redeployment of professionals, the shortage of personal protective equipment, and the need to enforce social distancing. Attempts to introduce modifications to the ECT delivery room and minimize bag-valve-mask ventilation were consistently reported. All four regions developed a new patient prioritization framework, and Western Canada, notably, aimed to provide ECT to only the most severe cases. CONCLUSIONS: The results suggest that ECT provision was disproportionately affected across different parts of Canada. Possible factors that could explain these interregional differences include population, distribution of urban vs. rural areas, pre-pandemic barriers in access to ECT, number of cases, ability to control the spread of infection, and the general reduction in physicians' activities across different areas of health care. Studying these factors in the future will inform how medical centres should respond to public health emergencies and pandemic-related circumstances in the context of procedural treatments.

Cold-stored platelets for acute bleeding in cardiac surgical patients: a narrative review.

PURPOSE: Cold-stored platelets (CSP) are an increasingly active topic of international research. They are maintained at 1-6 °C, in contrast to standard room-temperature platelets (RTP) kept at 20-24 °C. Recent evidence suggests that CSP have superior hemostatic properties compared with RTP. This narrative review explores the application of CSP in adult cardiac surgery, summarizes the preclinical and clinical evidence for their use, and highlights recent research. SOURCE: A targeted search of MEDLINE and other databases up to 24 February 2022 was conducted. Search terms combined concepts such as cardiac surgery, blood, platelet, and cold-stored. Searches of trial registries ClinicalTrials.gov and WHO International Clinical Trials Registry Platform were included. Articles were included if they described adult surgical patients as their population of interest and an association between CSP and clinical outcomes. References of included articles were hand searched. PRINCIPAL FINDINGS: When platelets are stored at 1-6 °C, their metabolic rate is slowed, preserving hemostatic function for increased storage duration. Cold-stored platelets have superior adhesion characteristics under physiologic shear conditions, and similar or superior aggregation responses to physiologic agonists. Cold-stored platelets undergo structural, metabolic, and molecular changes which appear to "prime" them for hemostatic activity. While preliminary, clinical evidence supports the conduct of trials comparing CSP with RTP for patients with platelet-related bleeding, such as those undergoing cardiac surgery. CONCLUSION: Cold-stored platelets may have several advantages over RTP, including increased hemostatic capacity, extended shelf-life, and reduced risk of bacterial contamination. Large clinical trials are needed to establish their potential role in the treatment of acutely bleeding patients.

RéSUMé: OBJECTIF: Les plaquettes conservées au froid (PCF) sont un sujet de recherche internationale de plus en plus populaire. Ces plaquettes sont maintenues à une température de 1-6 °C, contrairement aux plaquettes standard conservées à température ambiante (PTA), maintenues à 20­24 °C. Des données probantes récentes suggèrent que les PCF ont des propriétés hémostatiques supérieures aux PTA. Ce compte rendu narratif explore l'application de PCF en chirurgie cardiaque chez l'adulte, résume les données probantes précliniques et cliniques de leur utilisation, et met en évidence les recherches récentes. SOURCES: Une recherche ciblée dans MEDLINE et d'autres bases de données jusqu'au 24 février 2022 a été effectuée. Les termes de recherche combinaient des concepts en anglais tels que cardiac surgery, blood, platelet et cold-stored (soit chirurgie cardiaque, plaquette, et entreposage frigorifique). Des recherches dans les registres d'études ClinicalTrials.gov et le système d'enregistrement international des essais cliniques (ICTRP) de l'OMS ont été incluses. Les articles ont été inclus s'ils décrivaient des patient·es adultes de chirurgie en tant que population d'intérêt et une association entre les PCF et les issues cliniques. Les références des articles inclus ont fait l'objet d'une recherche manuelle. CONSTATATIONS PRINCIPALES: Lorsque les plaquettes sont conservées entre 1 et 6 °C, leur taux métabolique est ralenti, préservant la fonction hémostatique pour une durée d'entreposage accrue. Les plaquettes conservées au froid ont des caractéristiques d'adhésion supérieures dans des conditions de cisaillement physiologique et des réponses d'agrégation similaires ou supérieures aux agonistes physiologiques. Les plaquettes conservées au froid subissent des changements structurels, métaboliques et moléculaires qui semblent les « amorcer ¼ pour une activité hémostatique. Bien que préliminaires, les données probantes cliniques appuient la réalisation d'études comparant les PCF aux PTA chez la patientèle présentant des saignements liés aux plaquettes, tels que les personnes bénéficiant d'une chirurgie cardiaque. CONCLUSION: Les plaquettes conservées au froid peuvent présenter plusieurs avantages par rapport aux PTA, notamment une capacité hémostatique accrue, une durée de conservation prolongée et un risque réduit de contamination bactérienne. De grands essais cliniques sont nécessaires pour établir leur rôle potentiel dans le traitement de la patientèle en hémorragie aiguë.

Platelet preservation in cardiac surgery using minimally invasive extracorporeal circulation versus optimized cardiopulmonary bypass.

BACKGROUND: Minimally invasive extracorporeal circulation (MiECC) is employed as a strategy to attenuate the physiologic disturbance caused by cardiopulmonary bypass. The aim of this study was to compare the coagulation profile of MiECC to an optimized conventional extracorporeal circuit (OpECC) with regards to platelet function, rotational thromboelastometry and blood product usage. METHODS: A retrospective analysis of coronary artery bypass grafting operations using either MiECC or OpECC was performed at a single institution. RESULTS: A total of 112 patients were included, with 61 receiving MiECC and 51 OpECC patients. OpECC patients had a significantly larger BSA (1.95+/- 0.22m2 vs 1.88 +/- 0.18m2, p = 0.034), than those who received MiECC. No difference between groups was observed regarding red blood cell, plasma, and platelet transfusions. Functional platelet count during the warming phase of cardiopulmonary bypass was found to be higher in the MiECC group ((136 (102-171) x109/L vs 109 (94-136) x109/L), p = 0.027), as were functional platelets as a percent of total platelet count ((86 (77-91)% vs 76 (63-82)%), p = 0.003). There were no significant differences between other outcomes such as operative mortality, incidence of stroke, and intensive care unit length of stay. CONCLUSION: While we did not see a difference in blood transfusions, MiECC resulted in a statistically significant advantage over OpECC with regards to preservation of functional platelets.

Practice patterns of ABO-matching for cryoprecipitate and patient outcomes after ABO-compatible versus incompatible cryoprecipitate.

BACKGROUND AND OBJECTIVES: This sub-study of the FIBRES trial sought to examine the patterns of ABO-compatible cryoprecipitate administration and to identify adverse consequences of ABO-incompatible cryoprecipitate. MATERIALS AND METHODS: This was a post hoc analysis of data collected from the FIBRES randomized clinical trial comparing fibrinogen concentrate with cryoprecipitate in the treatment of bleeding related to hypofibrinogenemia after cardiac surgery. The primary outcome was the percentage of administered cryoprecipitate that was ABO-compatible. Secondary outcomes were adverse events at 28 days. A follow-up survey was distributed to the FIBRES participating sites to examine the rationale behind the identified cryoprecipitate ABO-matching practice patterns. RESULTS: A total of 363 patients were included: 53 (15%) received ABO-incompatible cryoprecipitate and 310 (85%) received ABO-compatible cryoprecipitate. There was an increased incidence of post-operative anaemia in the ABO-incompatible group (15; 28.3%) in comparison to the ABO-compatible (44; 14.2%) group (p = 0.01) at 28 days, which was unrelated to haemolysis, without a significant difference in transfusion requirement. In the multivariable logistic regression models accounting for clustering by site, there was no observed statistically significant association between the administration of ABO-incompatible cryoprecipitate and any other adverse outcomes. Nine out of 11 sites did not have a policy requiring ABO-matched cryoprecipitate. CONCLUSION: This sub-study demonstrated that most cryoprecipitate administered in practice is ABO-compatible, despite the absence of guidelines or blood bank policies to support this practice. A signal towards increased risk of post-operative anaemia may be explained by higher rates of urgent surgery (vs. elective) in the ABO-incompatible group. Future studies should prospectively examine the impact of ABO-compatible versus incompatible cryoprecipitate to conclusively establish if there is a meaningful clinical impact associated with the administration of ABO-incompatible cryoprecipitate.

Impact of cardiopulmonary bypass duration on efficacy of fibrinogen replacement with cryoprecipitate compared with fibrinogen concentrate: a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) randomised controlled trial.

BACKGROUND: Coagulopathy in cardiac surgery is frequently associated with acquired hypofibrinogenaemia, which can be treated with either purified fibrinogen concentrate (FC) or cryoprecipitate. Because the latter is not purified and therefore contains additional coagulation factors, it is thought to be more effective for treatment of coagulopathy that occurs after prolonged cardiopulmonary bypass (CPB). We examined the impact of CPB duration on the efficacy of the two therapies in cardiac surgery. METHODS: This was a post hoc analysis of the Fibrinogen Replenishment in Surgery (FIBRES) RCT comparing FC (4 g) to cryoprecipitate (10 U) in adult patients undergoing cardiac surgery and experiencing bleeding with acquired hypofibrinogenaemia (n=735). The primary outcome was allogeneic blood products transfused within 24 h after CPB. Subjects were stratified by CPB duration (≤120, 121-180, and >180 min). The interaction of treatment assignment with CPB duration was tested. RESULTS: Subjects with longer CPB duration experienced more bleeding and transfusion. With CPB time ≤120 min (FC, n=134; cryoprecipitate, n=146), the ratio of least-squares means between the FC and cryoprecipitate groups for total allogeneic blood products at 24 h was 0.90 (one-sided 97.5% confidence interval [CI]: 0.00-1.12); P=0.004. For subjects with CPB time 121-180 min, it was 1.00 ([one-sided 97.5% CI: 0.00-1.22]; P=0.03], and for CPB time >180 min it was 0.91 ([one-sided 97.5% CI: 0.00-1.12]; P=0.005). Results were similar for all secondary outcomes, with no interaction between treatment and CPB duration for all outcomes. CONCLUSIONS: The haemostatic efficacy of FC was non-inferior to cryoprecipitate irrespective of CPB duration in cardiac surgery. CLINICAL TRIAL REGISTRATION: NCT03037424.

A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Preoperative Antithrombin Supplementation in Patients at Risk for Antithrombin Deficiency After Cardiac Surgery.

BACKGROUND: Antithrombin (AT) activity is reduced during cardiac operations with cardiopulmonary bypass (CPB), which is associated with adverse outcomes. Preoperative AT supplementation, to achieve >58% and <100% AT activity, may potentially reduce postoperative morbidity and mortality in cardiac operations with CPB. This prospective, multicenter, randomized, double-blind, placebo-controlled study was designed to evaluate the safety and efficacy of preoperative treatment with AT supplementation in patients at risk for low AT activity after undergoing cardiac surgery with CPB. METHODS: A total of 425 adult patients were randomized (1:1) to receive either a single dose of AT (n = 213) to achieve an absolute increase of 20% above pretreatment AT activity or placebo (n = 212) before surgery. The study duration was approximately 7 weeks. The primary efficacy end point was the percentage of patients with any component of a major morbidity composite (postoperative mortality, stroke, acute kidney injury [AKI], surgical reexploration, arterial or venous thromboembolic events, prolonged mechanical ventilation, and infection) in the 2 groups. Secondary end points included AT activity, blood loss, transfusion requirements, duration of intensive care unit (ICU), and hospital stays. Safety was also assessed. RESULTS: Overall, 399 patients (men, n = 300, 75.2%) with a mean (standard deviation [SD]) age of 66.1 (11.7) years, with the majority undergoing complex surgical procedures (n = 266, 67.9%), were analyzed. No differences in the percentage of patients experiencing morbidity composite outcomes between groups were observed (AT-treated 68/198 [34.3%] versus placebo 58/194 [29.9%]; P = .332; relative risk, 1.15). After AT infusion, AT activity was significantly higher in the AT group (108% [42-143]) versus placebo group (76% [40-110]), and lasted up to postoperative day 2. At ICU, the frequency of patients with AT activity ≥58% in the AT group (81.5%) was significantly higher ( P < .001) versus placebo group (43.2%). Secondary end point analysis did not show any advantage of AT over placebo group. There were significantly more patients with AKI ( P < .001) in the AT group (23/198; 11.6%) than in the placebo group (5/194, 2.6%). Safety results showed no differences in treatment-emergent adverse events nor bleeding events between groups. CONCLUSIONS: AT supplementation did not attenuate adverse postoperative outcomes in our cohort of patients undergoing cardiac surgery with CPB.

Titrated versus conventional anticoagulation management for thrombin generation in cardiac surgery: a randomized controlled trial.

PURPOSE: Optimal heparin titration during cardiopulmonary bypass (CPB) may reduce coagulation system activation and preserve hemostatic function post-CPB. Our objective was to assess if the Heparin Management System (HMS) Plus improves heparin titration, thereby leading to higher thrombin generation post-CPB compared with activated clotting time (ACT)-guided management. METHODS: We conducted a randomized controlled trial of 100 patients undergoing cardiac surgery with CPB at a single center. A total of 50 patients were randomized to conventional ACT-guided management, and 50 to the HMS Plus system. The primary outcome was change in thrombin generation post-CPB compared with baseline, as assessed by calibrated automated thrombography. Secondary outcomes included intraoperative blood loss, chest drain output up to 72 hr, and transfusions. In an exploratory analysis, we compared the quintile of patients with the highest average heparin concentration on CPB (≥ 4.0 mg⋅kg-1) with the rest of the cohort. RESULTS: A total of 100 patients were included in an intent-to-treat analysis. We observed no difference in post-CPB thrombin generation or secondary outcomes. However, patients in the HMS Plus group had higher average heparin concentrations while on CPB than patients in the conventional management group did (mean difference, -0.21; 95% confidence interval, -0.42 to -0.01). The quintile of patients with the highest average heparin concentration (4.0 mg⋅kg-1) had higher thrombin generation post-CPB than the rest of the cohort did. CONCLUSIONS: The HMS Plus system did not show significant benefits in thrombin generation, bleeding outcomes, or transfusion in patients undergoing cardiac surgery with CPB. Higher average heparin concentrations on CPB were associated with higher post-CPB thrombin generation. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT03347201); first submitted 12 October 2017.

RéSUMé: OBJECTIF: Un titrage optimal de l'héparine pendant la circulation extracorporelle (CEC) peut réduire l'activation du système de coagulation et préserver la fonction hémostatique après la CEC. Notre objectif était d'évaluer si le système de gestion de l'héparine HMS Plus améliorait le titrage de l'héparine, entraînant ainsi une génération de thrombine plus élevée après la CEC par rapport à la gestion guidée par le temps de coagulation activé (ACT). MéTHODE: Nous avons réalisé une étude randomisée contrôlée de 100 patients bénéficiant d'une chirurgie cardiaque sous CEC dans un seul établissement. Au total, 50 patients ont été randomisés à une gestion conventionnelle guidée par l'ACT et 50 à une gestion guidée par le système HMS Plus. Le critère d'évaluation principal était la variation de la génération de thrombine post-CEC par rapport aux valeurs de base, telles qu'évaluées par thrombographie calibrée automatisée. Les critères secondaires comprenaient les pertes sanguines peropératoires, le drainage thoracique jusqu'à 72 heures et les transfusions. Dans une analyze exploratoire, nous avons comparé le quintile de patients ayant la concentration moyenne d'héparine la plus élevée sous CEC (≥ 4,0 mg⋅kg-1) au reste de la cohorte. RéSULTATS: Au total, 100 patients ont été inclus dans une analyze en intention de traiter. Nous n'avons observé aucune différence dans la génération de thrombine post-CEC ou dans nos critères d'évaluation secondaires. Cependant, les patients du groupe HMS Plus présentaient des concentrations moyennes d'héparine plus élevées sous CEC que les patients du groupe de gestion conventionnelle (différence moyenne, -0,21; intervalle de confiance à 95 %, -0,42 à -0,01). Le quintile de patients ayant la concentration moyenne d'héparine la plus élevée (4,0 mg⋅kg-1) avaient une génération de thrombine post-CEC plus élevée que le reste de la cohorte. CONCLUSION: Le système HMS Plus n'a pas montré d'avantages significatifs dans la génération de thrombine, les issues hémorragiques ou la transfusion chez les patients bénéficiant d'une chirurgie cardiaque sous CEC. Des concentrations moyennes d'héparine plus élevées sous CEC ont été associées à une génération de thrombine post-CEC plus élevée. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03347201); soumis pour la première fois le 12 octobre 2017.

The association of thrombin generation with bleeding outcomes in cardiac surgery: a prospective observational study.

BACKGROUND: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with coagulopathic bleeding. Impaired thrombin generation may be an important cause of coagulopathic bleeding but is poorly measured by existing hemostatic assays. We examined thrombin generation during cardiac surgery, using calibrated automated thrombography, and its association with bleeding outcomes. METHODS: We conducted a prospective observational study in 100 patients undergoing cardiac surgery with CPB. Calibrated automated thrombography parameters were expressed as a ratio of post-CPB values divided by pre-CPB values. The association of thrombin generation parameters for bleeding outcomes was compared with conventional tests of hemostasis, and the outcomes of patients with the most severe post-CPB impairment in thrombin generation (≥ 80% drop from baseline) were compared with the rest of the cohort. RESULTS: All 100 patients were included in the final analysis, with a mean age of 63 (12) yr, 31 (31%) female, and 94 (94%) undergoing bypass and/or valve surgery. Post-CPB, peak thrombin decreased by a median of 73% (interquartile range [IQR], 49-91%) (P < 0.001) and total thrombin generation, expressed as the endogenous thrombin potential (ETP), decreased 56% [IQR, 30-83%] (P < 0.001). In patients with ≥ 80% decrease in ETP, 21% required re-exploration for bleeding compared with 7% in the rest of the cohort (P = 0.04), and 48% required medical or surgical treatment for hemostasis compared with 27% in the rest of the cohort (P = 0.04). CONCLUSIONS: Thrombin generation is significantly impaired by CPB and associated with higher bleeding severity. Clinical studies aimed at the identification and treatment of patients with impaired thrombin generation are warranted.

RéSUMé: CONTEXTE: La chirurgie cardiaque avec circulation extracorporelle (CEC) est associée à des saignements sur coagulopathie. L'altération de la génération de thrombine peut constituer une cause importante de saignement sur coagulopathie, mais elle est mal mesurée par les tests d'hémostase existants. Nous avons examiné la génération de thrombine pendant la chirurgie cardiaque à l'aide d'une thrombographie automatisée calibrée ainsi que son association avec les issues hémorragiques. MéTHODE: Nous avons réalisé une étude observationnelle prospective portant sur 100 patients bénéficiant d'une chirurgie cardiaque sous CEC. Les paramètres de thrombographie automatisée calibrée ont été exprimés sous forme du rapport entre les valeurs post-CEC divisées par les valeurs pré-CEC. L'association des paramètres de génération de thrombine pour les issues hémorragiques a été comparée aux tests conventionnels de l'hémostase, et les issues des patients présentant l'altération post-CEC la plus prononcée dans la génération de thrombine (baisse ≥ 80 % par rapport aux valeurs de base) ont été comparées au reste de la cohorte. RéSULTATS: Les 100 patients ont tous été inclus dans l'analyse finale, avec un âge moyen de 63 (12) ans, 31 (31 %) femmes et 94 (94 %) subissant une chirurgie de pontage et / ou une chirurgie valvulaire. Après la CEC, le pic de thrombine a diminué d'une médiane de 73 % (écart interquartile [ÉIQ], 49 à 91 %) (P < 0,001) et la génération de thrombine totale, exprimée en potentiel de thrombine endogène (PTE), a diminué de 56 % [ÉIQ, 30­83 %] (P < 0,001). Chez les patients présentant une diminution ≥ 80 % du PTE, 21 % ont nécessité une nouvelle exploration pour dépister les saignements, comparativement à 7 % dans le reste de la cohorte (P = 0,04), et 48 % ont nécessité un traitement médical ou chirurgical pour l'hémostase, comparativement à 27 % dans le reste de la cohorte (P = 0,04). CONCLUSION: La génération de thrombine est significativement altérée par la CEC et associée à des saignements plus graves. Des études cliniques visant à identifier et à traiter les patients présentant une altération de la génération de thrombine sont recommandées.

Effect of intravenous acetaminophen on postoperative outcomes in hip fracture patients: a systematic review and narrative synthesis.

PURPOSE: Hip fractures are debilitating in older adults because of their impact on quality of life. Opioids are associated with adverse effects in this population, so oral acetaminophen is commonly prescribed to minimize opioid use. Intravenous (iv) acetaminophen has been reported to have superior efficacy and bioavailability than oral acetaminophen. Nevertheless, its effect on postoperative outcomes in emergency hip fractures is unclear. This systematic review assessed the effect of iv acetaminophen on postoperative outcomes in older hip fracture patients. SOURCE: We searched multiple databases from inception to June 2021 for studies on adults > 50 yr of age undergoing emergency hip fracture surgery who received iv acetaminophen (or paracetamol) and that reported postoperative outcomes. Relevant titles, abstracts, and full texts were screened based on the eligibility criteria. The Newcastle-Ottawa scale was used to assess the quality of the selected papers. PRINCIPAL FINDINGS: Of 3,510 initial studies, four met the inclusion criteria. One was a prospective cohort study and three were retrospective cohort studies. All four studies used historical control groups. Three studies reported a significantly lower mean opioid dose with iv acetaminophen than with oral acetaminophen. Three studies also reported a significantly shorter hospital stay. One study each reported a significant decrease in the number of missed physical therapy sessions, the need for one-to-one supervision, and episodes of delirium. CONCLUSION: There is very limited low-level evidence that iv acetaminophen improves preoperative and postoperative analgesia and shortens hospital stay in older hip fracture patients. Nevertheless, our results should be interpreted with caution since there are no prospective randomized trials investigating whether iv acetaminophen improves postoperative outcomes in this patient population. STUDY REGISTRATION: PROSPERO (CRD42021198174); registered 15 August 2021.

RéSUMé: OBJECTIF: Les fractures de la hanche sont débilitantes chez les personnes âgées en raison de leur impact sur leur qualité de vie. Les opioïdes sont associés à des effets indésirables chez cette population, de sorte que l'acétaminophène par voie orale est couramment prescrit pour minimiser la consommation d'opioïdes. L'acétaminophène par voie intraveineuse (IV) a une efficacité et une biodisponibilité supérieures à celles de l'acétaminophène par voie orale. Néanmoins, son effet sur les devenirs postopératoires dans les fractures d'urgence de la hanche n'est pas clair. Cette revue systématique a évalué l'effet de l'acétaminophène IV sur les devenirs postopératoires chez les patients âgés avec une fracture de la hanche. SOURCES: Nous avons effectué des recherches dans plusieurs bases de données de leur création à juin 2021 pour en tirer les études portant sur des adultes > 50 ans bénéficiant d'une chirurgie d'urgence pour une fracture de la hanche et ayant reçu de l'acétaminophène IV (ou paracétamol), et qui rapportait les devenirs postopératoires. Les titres, résumés et textes intégraux pertinents ont été sélectionnés en fonction des critères d'admissibilité. L'échelle de Newcastle-Ottawa a été utilisée pour évaluer la qualité des articles sélectionnés. CONSTATATIONS PRINCIPALES: Sur les 3510 études initiales, quatre ont répondu aux critères d'inclusion. L'une était une étude de cohorte prospective et trois étaient des études de cohorte rétrospectives. Les quatre études ont utilisé des groupes témoins historiques. Trois études ont rapporté une dose moyenne d'opioïdes significativement plus faible avec l'acétaminophène IV qu'avec de l'acétaminophène par voie orale. Trois études ont également rapporté un séjour à l'hôpital significativement plus court. Une diminution significative du nombre de séances de physiothérapie manquées a été rapporté dans une étude, une autre a rapporté une diminution significative de la nécessité de supervision individuelle, et une troisième une réduction des épisodes d'état confusionnel aigu. CONCLUSION: : Il n'existe que très peu de données probantes qui sont de faible qualité et selon lesquelles l'acétaminophène IV améliore l'analgésie préopératoire et postopératoire et réduit la durée de séjour à l'hôpital chez les patients âgés atteints d'une fracture de hanche. Néanmoins, nos résultats doivent être interprétés avec prudence car il n'existe pas d'étude randomisée prospective évaluant si l'acétaminophène IV améliore les issues postopératoires dans cette population de patients. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021198174); enregistrée le 15 août 2021.

Albumin use for fluid resuscitation in cardiac surgical patients: a survey of Canadian perioperative care providers.

PURPOSE: To evaluate the perceptions and practices of Canadian cardiovascular anesthesiologists and intensivists towards intravenous albumin as a resuscitation fluid in patients undergoing cardiac surgery. METHODS: We conducted a cross-sectional survey of cardiac anesthesiologists and intensivists involved in the care of cardiac surgical patients. The 22-item survey included seven open-ended questions and assessed practice patterns and attitudes towards albumin. Descriptive statistics were analyzed using counts and proportions. Qualitative data were analyzed to identify themes describing albumin use patterns in Canada. RESULTS: A total of 133 respondents from seven provinces participated, with 83 (62%) using albumin perioperatively. The majority of respondents (77%) felt a low fluid balance in cardiac surgical patients was important, and that supplementing crystalloids with albumin was helpful for this objective (67%). There was poor agreement among survey respondents regarding the role of albumin for faster vasopressor weaning or intensive care discharge, and ≥ 90% did not feel albumin reduced mortality, renal injury, or coagulopathy. Nevertheless, cardiac surgical patients were identified as a distinct population where albumin may help to minimize fluid balance. There was an acknowledged paucity of formal evidence supporting possible benefits. Fewer than 10% of respondents could identify institutional or national guidelines for albumin use. A lack of evidence supporting albumin use in cardiac surgical patients, especially those at highest risk of complications, was a frequently identified concern. CONCLUSIONS: The majority of Canadian anesthesiologists and intensivists (62%) use albumin in cardiac surgical patients. There is clinical equipoise regarding its utility, and an acknowledged need for higher quality evidence to guide practice.

RéSUMé: OBJECTIF: Évaluer les perceptions et les pratiques des anesthésiologistes et intensivistes cardiovasculaires canadiens à l'égard de l'albumine intraveineuse comme liquide de réanimation pour les patients bénéficiant d'une chirurgie cardiaque. MéTHODE: Nous avons mené un sondage transversal auprès d'anesthésiologistes et d'intensivistes cardiaques impliqués dans les soins aux patients de chirurgie cardiaque. Le sondage en 22 éléments comprenait sept questions ouvertes et évaluait les habitudes de pratique et les attitudes des praticiens à l'égard de l'albumine. Les statistiques descriptives ont été analysées à l'aide de dénombrements et de proportions. Des données qualitatives ont été analysées pour identifier des thèmes décrivant les tendances d'utilisation de l'albumine au Canada. RéSULTATS: Au total, 133 répondants de sept provinces ont participé, et 83 (62 %) utilisent l'albumine en périopératoire. La majorité des répondants (77 %) estimaient qu'un bilan liquidien négatif était important chez les patients en chirurgie cardiaque et que la supplémentation en cristalloïdes par de l'albumine était utile pour atteindre cet objectif (67 %). Il y avait un faible accord parmi les répondants concernant le rôle de l'albumine pour accélérer le sevrage des vasopresseurs ou la sortie de soins intensifs, et ≥ 90 % ne pensaient pas que l'albumine réduisait la mortalité, les lésions rénales ou la coagulopathie. Néanmoins, les patients en chirurgie cardiaque ont été identifiés comme une population distincte pour laquelle l'albumine pourrait contribuer à minimiser le bilan liquidien. Il y avait un manque reconnu de données probantes formelles à l'appui des avantages possibles. Moins de 10 % des répondants ont pu trouver des lignes directrices institutionnelles ou nationales portant sur l'utilisation de l'albumine. Le manque de données probantes à l'appui de l'utilisation de l'albumine chez les patients en chirurgie cardiaque, en particulier chez ceux présentant le risque le plus élevé de complications, était une préoccupation fréquemment identifiée. CONCLUSION: La majorité des anesthésiologistes et intensivistes canadiens (62 %) utilisent l'albumine chez les patients en chirurgie cardiaque. Il existe un équilibre clinique quant à son utilité et un besoin reconnu de données probantes de meilleure qualité pour guider la pratique.

Electroconvulsive Therapy in Canada During the First Wave of COVID-19: Results of the "What Happened" National Survey.

OBJECTIVES: The COVID-19 pandemic has disrupted the provision of essential and potentially life-saving procedural treatments such as electroconvulsive therapy (ECT). We surveyed ECT providers across Canada to understand how the first wave of the pandemic affected ECT delivery between mid-March 2020 and mid-May 2020. METHODS: The survey was administered to ECT team members and decision makers at 107 Canadian health care centers with a focus on 5 domains: operations, decision-making, hospital resources, ECT procedure, and patient impact. Responses were obtained from 72 institutions, and collected answers were used to derive representative responses reflecting the situation at each ECT center. For specific domains, responses were split into 2 databases representing the perspective of psychiatrists (n = 67 centers) and anesthesiologists (n = 24 centers). RESULTS: Provision of ECT decreased in 64% centers and was completely suspended in 27% of centers after the onset of the pandemic. Outpatient and maintenance ECT were more affected than inpatient and acute ECT. Programs reported a high level of collaboration between psychiatry and hospital leadership (59%) but a limited input from clinical ethicists (18%). Decisions were mostly made ad hoc leading to variability across institutions in adopted resource allocation, physical location of ECT delivery, and triaging frameworks. The majority of centers considered ECT to be aerosol-generating and incorporated changes to airway management. CONCLUSIONS: Electroconvulsive therapy services in Canada were markedly disrupted by the COVID-19 pandemic. The variability in decision-making across centers warrants the development of a rational approach toward offering ECT in pandemic contexts.

Rationale and design of the intravenous iron for treatment of anemia before cardiac surgery trial.

Background Approximately 20% to 30% of patients awaiting cardiac surgery are anemic. Anemia increases the likelihood of requiring a red cell transfusion and is associated with increased complications, intensive care, and hospital stay following surgery. Iron deficiency is the commonest cause of anemia and preoperative intravenous (IV) iron therapy thus may improve anemia and therefore patient outcome following cardiac surgery. We have initiated the intravenous iron for treatment of anemia before cardiac surgery (ITACS) Trial to test the hypothesis that in patients with anemia awaiting elective cardiac surgery, IV iron will reduce complications, and facilitate recovery after surgery. Methods ITACS is a 1,000 patient, international randomized trial in patients with anemia undergoing elective cardiac surgery. The patients, health care providers, data collectors, and statistician are blinded to whether patients receive IV iron 1,000 mg, or placebo, at 1-26 weeks before their planned date of surgery. The primary endpoint is the number of days alive and at home up to 90 days after surgery. Results To date, ITACS has enrolled 615 patients in 30 hospitals in 9 countries. Patient mean (SD) age is 66 (12) years, 63% are male, with a mean (SD) hemoglobin at baseline of 118 (12) g/L; 40% have evidence (ferritin <100 ng/mL and/or transferrin saturation <25%) suggestive of iron deficiency. Most (59%) patients have undergone coronary artery surgery with or without valve surgery. Conclusions The ITACS Trial will be the largest study yet conducted to ascertain the benefits and risks of IV iron administration in anemic patients awaiting cardiac surgery.

Albumin in adult cardiac surgery: a narrative review.

PURPOSE: Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE: We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS: Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS: In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.

RéSUMé: OBJECTIF: Les liquides intravasculaires sont une composante nécessaire et universelle des soins aux patients de chirurgie cardiaque. Les cristalloïdes et les colloïdes sont utilisés pour maintenir ou restaurer le volume plasmatique en circulation et assurer une perfusion adéquate des organes. Au Canada, les solutions d'albumine humaine (concentration de 5 % ou 25 %) constituent un colloïde couramment utilisé à cette fin. Dans ce compte rendu narratif, nous discutons de l'approvisionnement en albumine au Canada, explorons les avantages perçus de l'albumine et décrivons la littérature clinique soutenant ou réfutant l'utilisation de l'albumine par rapport à d'autres solutions pour la population chirurgicale cardiaque adulte. SOURCES: Nous avons effectué une recherche ciblée dans les bases de données PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, le Cochrane Central Register of Controlled trials et la Cochrane Database of Systematic Reviews. Les termes de recherche (en anglais) incluaient albumine, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, et cardiopulmonary bypass (soit albumine, colloïde, chirurgie cardiaque, saignement, hémorragie, transfusion et circulation extracorporelle). CONSTATATIONS PRINCIPALES: L'albumine est fabriquée à partir de plasma humain fractionné et importée au Canada à partir de fournisseurs internationaux au coût d'environ 21 millions CAD par année. Bien qu'elle soit largement utilisée chez les patients de chirurgie cardiaque à travers le pays, elle est environ 30 fois plus coûteuse que des doses équivalentes de solutions cristalloïdes équilibrées, avec une grande variabilité interinstitutionnelle quant à son utilisation et aucune association claire avec des devenirs améliorés. Il n'existe en général pas de données probantes de qualité élevée confirmant la supériorité de l'albumine par rapport aux cristalloïdes dans cette population de patients, et les données probantes quant à son innocuité sont contradictoires. CONCLUSION: Chez les patients de chirurgie cardiaque, l'albumine est largement utilisée en dépit d'un manque de données probantes de haute qualité soutenant son efficacité ou son innocuité. Une étude randomisée contrôlée bien conçue est nécessaire pour clarifier le rôle de l'albumine chez les patients de chirurgie cardiaque.

The association of prothrombin complex concentrates with postoperative outcomes in cardiac surgery: an observational substudy of the FIBRES randomized controlled trial.

PURPOSE: The mainstay of therapy for coagulation factor deficiency in cardiac surgical patients is frozen plasma (FP); however, prothrombin complex concentrates (PCCs) may offer logistical and safety advantages. As there is limited comparative evidence, we conducted this study to explore the association of comparable PCC or FP doses with transfusion and outcomes. METHODS: This was a post hoc analysis of a multicentre randomized trial comparing fibrinogen concentrate with cryoprecipitate (FIBRES trial) in bleeding cardiac surgical patients. This analysis included 415 patients who received only PCC (n = 72; 17%) or only FP (n = 343; 83%) for factor replacement. The main outcomes of interest were red blood cell (RBC) and platelet transfusion within 24 hr of cardiopulmonary bypass. Secondary outcomes included postoperative adverse events. Associations were examined by hierarchical generalized estimating equation models adjusted for demographic and surgical characteristics. RESULTS: The median [interquartile range (IQR)] PCC dose was 1,000 [1,000-2,000] units, while the median [IQR] FP dose was 4 [2-6] units. Each unit of FP was independently associated with increased adjusted odds of RBC (1.60; 95% confidence interval [CI], 1.36 to 1.87; P < 0.01) and platelet transfusion (1.40; 95% CI, 1.15 to 1.69; P < 0.01) while each 500 units of PCC was independently associated with reduced adjusted odds of RBC (0.67; 95% CI, 0.50 to 0.90; P < 0.01) and platelet transfusion (0.80; 95% CI, 0.70 to 0.92; P < 0.01). Adverse event rates were comparable. CONCLUSIONS: In cardiac surgical patients with post-cardiopulmonary bypass bleeding, PCC use was associated with lower RBC and platelet transfusion than FP use was. Prospective, randomized clinical trials comparing FP with PCC in this setting are warranted.

RéSUMé: OBJECTIF: Le pilier du traitement du déficit en facteur de coagulation chez les patients de chirurgie cardiaque est le plasma congelé (PC); cependant, les concentrés de complexe prothrombinique (CCP) peuvent offrir des avantages en matière de logistique et de sécurité. Comme il existe peu de données probantes comparatives, nous avons réalisé cette étude pour explorer l'association de doses comparables de CCP ou de PC avec la transfusion et les issues postopératoires. MéTHODE: Il s'agit d'une analyse post-hoc d'une étude randomisée multicentrique comparant le concentré de fibrinogène au cryoprécipité (étude FIBRES) chez des patients avec hémorragies en chirurgie cardiaque. Cette analyse a inclus 415 patients qui n'ont reçu que du CCP (n = 72; 17 %) ou du PC (n = 343; 83 %) pour le remplacement des facteurs. Les principaux critères d'évaluation étaient la transfusion d'érythrocytes et de plaquettes dans les 24 heures suivant la circulation extracorporelle (CEC). Les critères d'évaluation secondaires comprenaient les événements indésirables postopératoires. Les associations ont été examinées par des modèles d'équation d'estimation généralisée hiérarchiques ajustés en fonction des caractéristiques démographiques et chirurgicales. RéSULTATS: La dose médiane de CCP [écart interquartile (ÉIQ)] était de 1000 [1000 à 2000] unités, tandis que la dose médiane [ÉIQ] de PC était de 4 [2-6] unités. Chaque unité de PC était indépendamment associée à une augmentation de la probabilité ajustée de transfusion d'érythrocytes (1,60; intervalle de confiance [IC] à 95 %, 1,36 à 1,87; P < 0,01) et de plaquettes (1,40; IC 95 %, 1,15 à 1,69; P < 0,01), alors que chaque 500 unités de CCP étaient indépendamment associées à une réduction de la probabilité ajustée de transfusion d'érythrocytes (0,67; IC 95 %, 0,50 à 0,90; P < 0,01) et de plaquettes (0,80; IC 95 %, 0,70 à 0,92; P < 0,01). Les taux d'événements indésirables étaient comparables. CONCLUSION: Chez les patients de chirurgie cardiaque présentant un saignement post-CEC, l'utilisation de CCP a été associée à un taux de transfusion plus faible d'érythrocytes et de plaquettes que lors de l'utilisation de PC. Des études cliniques randomisées prospectives comparant le PC au CCP dans ce type de contexte sont nécessaires.

Albumin use in bleeding cardiac surgical patients and associated patient outcomes.

PURPOSE: Albumin solution is a colloid used for resuscitation in cardiac surgical patients, but it is unclear if it offers advantages over crystalloids. We examined current clinical practice across 11 cardiac surgical centres and the association of albumin with outcomes in a cohort of bleeding cardiac surgical patients. METHODS: This was a post hoc analysis of data from the Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery (FIBRES) trial. Multivariable regression models adjusted for demographic and surgical characteristics were used to examine predictors of early albumin administration (within the initial 24 perioperative hours), late albumin administration (from 24 hr to seven days after cardiopulmonary bypass), and the association of albumin use with 28-day acute kidney injury, mortality, and length of hospital and intensive care unit (ICU) stay. RESULTS: Of the 735 patients included, 525 (71%) received albumin, ranging from 4.8% to 97.4% of patients across institutions, with 475 (64.6%) receiving albumin early (5% or 25% solution). In the adjusted models, female sex and preoperative hospital admission were associated with early use, while heart failure, female sex, bleeding severity, older age, and prior albumin use were predictors of later administration. Early albumin use was not associated with differences in acute kidney injury (adjusted odds ratio [aOR] 1.77; 95% confidence interval [CI], 0.96 to 3.27; P = 0.07), mortality (aOR 1.66; 95% CI, 0.99 to 2.78; P = 0.05), or length of ICU stay (P = 0.11) or hospital stay (P = 0.67). CONCLUSIONS: Albumin use is common but highly variable within and across sites. Albumin use was not associated with improved outcomes. High quality randomized controlled trials should clarify its role in cardiac surgical patients.

RéSUMé: OBJECTIF: La solution d'albumine est un colloïde utilisé pour la réanimation des patients chirurgicaux cardiaques, mais nous ne savons pas si elle est avantageuse par rapport aux cristalloïdes. Nous avons examiné la pratique clinique actuelle dans 11 centres de chirurgie cardiaque et l'association entre l'albumine et les devenirs dans une cohorte de patients chirurgicaux cardiaques en état d'hémorragie. MéTHODE: Il s'agissait d'une analyse post hoc des données de l'étude FIBRES (Effect of Fibrinogen Concentrate vs Cryoprecipitate on Blood Component Transfusion After Cardiac Surgery, soit 'Effet du concentré de fibrinogène vs cryoprécipité sur la transfusion de composants sanguins après une chirurgie cardiaque'). Des modèles de régression multivariée ajustés pour tenir compte des caractéristiques démographiques et chirurgicales ont été employés pour examiner les facteurs prédictifs d'une administration précoce d'albumine (dans les premières 24 heures périopératoires), d'une administration tardive d'albumine (entre 24 heures et sept jours après la circulation extracorporelle), et l'association entre l'utilisation d'albumine et l'insuffisance rénale aiguë à 28 jours, la mortalité, et la durée de séjour à l'hôpital et à l'unité de soins intensifs (USI). RéSULTATS: Parmi les 735 patients inclus, 525 (71 %) ont reçu de l'albumine, allant de 4,8 % à 97,4 % des patients dans tous les établissements, et 475 (64,6 %) ont reçu de l'albumine de manière précoce (solution à 5 % ou 25 %). Dans les modèles ajustés, le sexe féminin et l'admission préopératoire à l'hôpital ont été associés à une utilisation précoce, tandis que l'insuffisance cardiaque, le sexe féminin, la gravité des saignements, un âge plus avancé et l'utilisation antérieure d'albumine étaient des prédicteurs d'une administration tardive. L'utilisation précoce d'albumine n'a pas été associée à des différences en matière d'insuffisance rénale aiguë (rapport de cotes ajusté [RCA] 1,77; intervalle de confiance [IC] à 95 %, 0,96 à 3,27; P = 0,07), de mortalité (RCA = 1,66; IC 95 %, 0,99 à 2,78; P = 0,05), ou de durée de séjour à l'USI (P = 0,11) ou à l'hôpital (P = 0,67). CONCLUSION: L'utilisation de l'albumine est fréquente mais très variable au sein des établissements et entre ceux-ci. L'utilisation de l'albumine n'a pas été associée à une amélioration des devenirs. Des études randomisées contrôlées de haute qualité devraient clarifier son rôle chez les patients de chirurgie cardiaque.

Fibrinogen Supplementation and Its Indications.

Adequate plasma levels of fibrinogen are essential for clot formation, and in severe bleeding, fibrinogen reaches a critically low plasma concentration earlier than other coagulation factors. Although the critical minimum concentration of fibrinogen to maintain hemostasis is a matter of debate, many patients with coagulopathic bleeding require fibrinogen supplementation. Among the treatment options for fibrinogen supplementation, fibrinogen concentrate may be viewed by some as preferable to fresh frozen plasma or cryoprecipitate. The authors review major studies that have assessed fibrinogen treatment in trauma, cardiac surgery, end-stage liver disease, postpartum hemorrhage, and pediatric patients. Some but not all randomized controlled trials have shown that fibrinogen concentrate can be beneficial in these settings. The use of fibrinogen as part of coagulation factor concentrate based therapy guided by point-of-care viscoelastic coagulation monitoring (ROTEM [rotational thromboelastometry] or TEG [thromboelastography]) appears promising. In addition to reducing patients' exposure to allogeneic blood products, this strategy may reduce the risk of complications such as transfusion-associated circulatory overload, transfusion-related acute lung injury, and thromboembolic adverse events. Randomized controlled trials are challenging to perform in patients with critical bleeding, and more evidence is needed in this setting. However, current scientific rationale and clinical data support fibrinogen repletion in patients with ongoing bleeding and confirmed fibrinogen deficiency.

Which is the preferred blood product for fibrinogen replacement in the bleeding patient with acquired hypofibrinogenemia-cryoprecipitate or fibrinogen concentrate?

The importance of the targeted treatment of acquired hypofibrinogenemia during hemorrhage with a concentrated fibrinogen product (either cryoprecipitate or fibrinogen concentrate) cannot be underestimated. Fibrinogen concentrate is a pathogen inactivated, pooled product that offers a highly purified single factor concentrate. Cryoprecipitate is a pooled product that comes with a spectrum of other coagulation factors which may further enhance (additional procoagulant effect) or even disturb (prothrombotic risk) hemostasis. The pros and cons of each product are discussed.