COMPARING THE EFFECTIVENESS OF CONCENTRATE OF ALL PROTHROMBIN COMPLEX FACTORS WITH RECOMBINANT HUMAN COAGULATION FACTOR VIIa IN THE TREATMENT OF BLEEDING AFTER CARDIAC SURGERY.

OBJECTIVE: Aim: The authors evaluated the effectiveness of treatment with recombinant human coagulation factor VIIa and concentrate of all prothrombin complex factors in patients with massive postoperative bleeding that could not be controlled with traditional therapy. PATIENTS AND METHODS: Materials and Methods: In the period from 2020 to 2021, recombinant human coagulation factor VIIa was administered to 18 patients after cardiac surgery (group I), while the concentrate of all prothrombin complex factors was administered to 16 patients postoperatively (group II). During this period, 647 patients were operated on. The patients had normal coagulation screening tests (APTT, INR, TT, fibrinogen level, and PLT level) before surgery. Mean blood loss before and after administration of eptacog alfa and the total prothrombin complex concentrate was assessed. The mean dose of eptacog alfa was 30.95 mcg/kg b.w., and the total prothrombin complex factor concentrate dose was 14.17 mcg/kg b.w. After transfusion with red blood cell concentrate, fresh frozen plasma, and platelet concentrate, in the absence of improvement in the dynamics of postoperative drainage, it was decided to include recombinant human coagulation factor VIIa or a concentrate of all prothrombin complex factors in the treatment. RESULTS: Results: After administration of recombinant human coagulation factor VIIa at a dose of 30.95 mcg/kg b.w., bleeding stopped in 12 patients, but the remaining 6 patients required reoperation due to persistently high drainage. The decision to perform a rethoracotomy was made by a team of cardiothoracic surgeons and anesthesiologists, taking into account the dynamics of drainage (bleeding) and the hemodynamic stability of the patient. After the administration of concentrate of all prothrombin complex factors at a dose of 14.17 U/kg b.w., bleeding stopped in 12 patients. Four patients required reoperation due to persistent bleeding. CONCLUSION: Conclusions: Treatment with recombinant human coagulation factor VIIa and concentrate of all prothrombin complex factors is effective and safe for cardiac surgery patients.

Remifentanil and sevoflurane based anesthesia combined with bilateral erector spinae plane block in patients undergoing off-pump coronary artery bypass graft surgery.

INTRODUCTION: Working on the institutional Enhanced Recovery After Surgery (ERAS Cardio) protocol for off-pump coronary artery bypass graft surgery (OP-CABG) we have noticed that patients treated according to the modified anesthesia protocol had not only significantly shorter time of respiratory support and intensive care unit stay but also lower postoperative troponin T concentration than patients who had standard fentanyl/sevoflurane-based anesthesia. AIM: To compare the perioperative course of patients undergoing OP-CABG surgery and receiving standard fentanyl/sevoflurane anesthesia and those anesthetized according to the institutional ERAS Cardio protocol with remifentanil, sevoflurane, and bilateral extensor spinae plane (ESP) block. MATERIAL AND METHODS: Design: a prospective, open-label, observational study performed in a tertiary health center. Participants: 30 consecutive patients undergoing off-pump coronary bypass graft surgery. Interventions: 15 patients had standard anesthesia with etomidate, fentanyl, and rocuronium for induction and fentanyl/sevoflurane for maintenance (standard group); 15 others had bilateral single shot ESP block, then etomidate, remifentanil and rocuronium for induction, and remifentanil/sevoflurane for maintenance of anesthesia. RESULTS: Median time to extubation was 7.6 (5.5-12.5) h and 1.7 (1-3.25) h in "standard care" and ERAS groups, respectively (p = 0.00002). Length of stay in the intensive care unit was also shorter for patients in the ERAS group 20.5 (18-24) vs. 48 (42-48) h (p = 0.00001). Troponin concentration increased to a lesser extent in patients from the ERAS group: an increase of 151.8 (71.9-174.3) ng/ml vs. 253.8 (126.6-373.1) ng/ml, p = 0.008. CONCLUSIONS: Remifentanil/sevoflurane anesthesia combined with bilateral ESP block shortens mechanical ventilation time and ICU stay, and decreases postoperative troponin-T concentration in patients undergoing off-pump coronary bypass graft surgery.

Implementation of Enhanced Recovery After Surgery (ERAS) protocol in off-pump coronary artery bypass graft surgery. A prospective cohort feasibility study.

BACKGROUND: Coronary artery bypass graft (CABG) is the most commonly performed cardiac surgery procedure. Although some complications related to the cardiopulmonary bypass circuit are avoided during off-pump CABG (OP-CABG) procedures, prolonged mechanical ventilation and severe postoperative pain are still important issues. METHODS: This prospective cohort study aimed to assess the impact of the institutional Enhanced Recovery After Surgery (ERAS) protocol in patients undergoing OP-CABG. This protocol contained several modifications to the perioperative period, among which bilateral erector spinae plane block, remifentanil infusion, and patient-controlled analgesia (PCA) with oxycodone were the most important factors (ERAS group). The ERAS group was compared with the retrospective cohort (same surgeon) before the ERAS protocol was implemented (standard care group). The outcomes measured included the postoperative mechanical ventilation time, ICU and hospital stay, postoperative drainage time, postoperative troponin T level, pain severity evaluated via a numerical rating scale, and the total consumption of opioids in both groups of patients. RESULTS: Overall, 57 patients were analyzed - 29 in the ERAS group and 28 in the standard care group. The time of mechanical ventilation, thoracic drainage, and ICU and hospital stay was shorter in the ERAS group than in the standard care group. The pain was less intense in the ERAS patients, and the postoperative opioid demand was reduced. Moreover, the increase of the postoperative troponin T concentration was lower in the ERAS group. CONCLUSIONS: Our study showed that ERAS protocol implementation could improve patient outcomes after OP-CABG surgery.