Risk Factors of Bleeding in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly being used for circulatory shock. Bleeding is a frequent complication and is associated with increased mortality. The purpose of our study was to identify factors associated with early major bleeding after VA ECMO initiation. METHODS: We performed a retrospective observational study based on our database. In accordance with the Extracorporeal Life Support Organization definition, the population was divided in two groups: major bleeding events (group B) and no major bleeding events (group O). We collected data on all major bleeding events occurring during the first 48 hours after VA ECMO initiation. RESULTS: Of the 243 patients analyzed, 111 patients (46%) had an early major bleeding event. Independent risk factors associated with early major bleeding events were postcardiotomy VA ECMO (odds ratio [OR] 1.98; 95% confidence interval [CI], 1.08 to 3.62; P = .02), body mass index (OR 0.91; 95% CI, 0.85 to 0.98; P = .01), hemoglobinemia (OR 0.8; 95% CI, 0.7 to 0.92; P = .002), fibrinogen (OR 0.67; 95% CI, 0.52 to 0.84; P = .001), and pH (OR 0.15; 95% CI, 0.02 to 1.04; P = .05). By using a receiver-operating characteristics curve analysis, hemoglobin level less than 9 g dL-1, fibrinogen level less than 2 g L-1, pH lower than 7.12, and body mass index below 25 kg/m2 were identified to predict early major bleeding events. Major bleeding events were independently associated with mortality (OR 2.54; CI 95%, 1.38 to 4.66; P = .01). CONCLUSIONS: We found that postcardiotomy VA ECMO, hemoglobin levels less than 9 g dL-1, fibrinogen levels less than 2 g L-1, pH lower than 7.12, and body mass index below 25 kg/m2 were associated with a higher risk for early major bleeding events.

A single dose of tramadol in continuous wound analgesia with levobupivacaine does not reduce post-sternotomy pain: a randomized controlled trial.

BACKGROUND: Medial sternotomy is commonly used in cardiac surgery, although it results in intense post-operative pain. The placement of a sternal wound catheter for the administration of local anesthetic represents an effective technique. An initial bolus of tramadol in the sternal wound catheter could potentiate the effect of the local anesthetic and decrease both the post-operative pain and the morphine consumption. PATIENTS AND METHODS: We conducted a prospective, randomized, double-blind study at the University Hospital Center, Dijon, France. Patients requiring scheduled or non-extreme emergency surgery for valve disease, aorta disease, atrial myxoma, or coronary artery bypass graft via sternotomy were included. A sternal wound catheter was inserted at the end of the surgery. The patients were randomized to receive either a 2 mg/kg bolus of tramadol (n=80) or a placebo (n=80) in the wound catheter. The bolus administration was followed by a continuous infusion of 1.25% levobupivacaine for the first 48 hrs following surgery. The patients' morphine consumption during the first 48 hrs after extubation was recorded. The other investigated variables were the patients' rescue analgesia, arterial blood gasses, and length of stay in the intensive care unit and in hospital, as well as the incidence of chronic pain at the four-month follow-up point. RESULTS: The morphine consumption was found to be comparable in the two groups (38 mg vs 32 mg, p=0.102). No effect was found in terms of the arterial blood gasses, lengths of stay, or incidence of chronic pain. CONCLUSION: The addition of tramadol to the local anesthetic delivered via a wound catheter following sternotomy did not reduce the patients' post-operative morphine consumption. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02851394.

Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study.

BACKGROUND: No study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course. METHODS: After retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS). RESULTS: One hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6-34) vs 5 mg (2-18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66-115) vs 77 mmol/l (IQR: 69-95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1-5) vs 5 (3-6) hours, p = 0.001 and 2 (1-3) vs 3 (2-5) days, p = 0.037). CONCLUSION: The use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results. TRIAL REGISTRATION: This study was retrospectively registered to ct2 (identifier: NCT03816592 ) on January 25, 2019.