Patient blood management in elective bypass cardiac surgery: A 2-step single-centre interventional trial to analyse the impact of an educational programme and erythropoiesis stimulation on red blood cell transfusion.

Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. Perioperative patient blood management (PBM) is widely recommended in current practice guidelines. The aim of this protocol is to analyse the effect of a global perioperative PBM programme on the red blood cell (RBC) transfusion ratio, morbidities and rehabilitation score in elective cardiac surgery.This study is a prospective, single-centre trial with a 2-step protocol, A and B, as follows: A: non-drug intervention: the caregiver is given a blood management educational programme; B: drug intervention: systematic correction of perioperative iron, vitamin deficiencies, and anaemia. This study was designed to enrol 900 patients (500 in group A and 400 in group B) in a rolling period starting at anaesthesia consultation and ending 3 months after surgery. The primary objective was a 20% reduction in RBC transfusion after implementation of PBM programmes (protocol A + B) when compared to our previous transfusion ratio in the first half of 2018 (30.4% vs 38%). The secondary objectives were to evaluate the impact for each step of the study on the RBC transfusion rate, morbidity and the quality of postoperative rehabilitation.The strength of this study is its evaluation of the effect of a global PBM programme on RBC transfusion in cardiac surgery through a 2-step protocol. We aim to assess for the first time the impact of non-drug and drug interventions on RBC transfusion, comorbidities and delayed rehabilitation parameters. TRIALS REGISTRATIONS: ClinicalTrials.gov, NCT04040023: registered 29 July 2019.

Stroke output variations calculated by esophageal Doppler is a reliable predictor of fluid response.

OBJECTIVE: Esophageal Doppler allows continuous monitoring of stroke volume index (SVI) and corrected flow time (FTc). We hypothesized that variations in stroke output index SOI (SVI/FTc) during volume expansion can predict the hemodynamic response to subsequent fluid loading better than the static values. DESIGN AND SETTING: Prospective study in the intensive care unit of a university hospital. PATIENTS: Fifty-one patients with circulatory failure were monitored by esophageal Doppler. INTERVENTIONS: Patients who responded to a first fluid challenge received a second one. Patients who responded to both were classified as responders-responders, and those who did not respond to the second as responders-nonresponders. In these two groups we compared DeltaSVI, DeltaFTc, and DeltaSOI during each fluid challenge and also static values at the end of each fluid challenge. MEASUREMENTS AND RESULTS: After the first fluid challenge DeltaSOI and DeltaSVI were significantly higher in patients who responded to subsequent volume expansion than in patients who no longer responded. ROC curves showed that DeltaSOI was a better predictor of fluid responsiveness than DeltaSVI. During volume expansion a DeltaSOI value of 11% discriminated between responders and nonresponders to subsequent volume expansion with a sensitivity of 91% and a specificity of 97%. There was no significant difference between the two groups for FTc value at the end of first fluid challenge. CONCLUSIONS: Analysis of DeltaSOI during fluid challenge predicts response to subsequent fluid challenge and FTc is not a reliable indicator of cardiac preload.

Regional citrate anticoagulation in continuous venovenous haemodiafiltration using commercial solutions.

BACKGROUND: Treatment with trisodium citrate provides an effective means of regional anticoagulation during continuous renal replacement therapy (CRRT). We evaluated the efficacy, safety and cost of a regional citrate anticoagulation protocol using commercial solutions in 17 critically ill patients treated with continuous venovenous haemodiafiltration (CVVHDF). We performed a total of 22 sessions. METHODS: We delivered an A.C.D-A(541(R)) solution containing 112.9 mmol/l disodium citrate (3.22%) at a median rate of 260 (190-280) ml/h via the pre-filter port of a COBE PRISMA with an AN-69 dialyser, while adjusting the rate to maintain post-filtered ionized calcium (iCa(2+)) between 0.25 and 0.4 mmol/l. Plasma iCa(2+) was maintained at >1.1 mmol/l by infusion of calcium chloride at a median rate of 1.70 (1.36-2.27) mmol/h. The dialysate was easily modified according to the acid-base status of each patient. Both replacement and dialysate solutions were delivered at 1200 ml/h. Each session was scheduled for 48 h and biological parameters were assessed every 6 h. RESULTS: The mean dialyser survival was 39 +/- 11 h (median 41.5 h; range 13-48 h). We observed dialyser clotting in four cases (18%). There were no bleeding events or modifications of coagulation parameters. The citrate solution, replacement solution and dialysate were obtained as commercial products. Both the replacement and dialysate solutions contained calcium. The extra cost of this technique was 25 euro;/day as compared to anticoagulation with heparin. CONCLUSIONS: We designed an efficient method of regional citrate anticoagulation for CVVHDF by using commercial solutions. The monitoring of patients was as intensive as during heparin anticoagulation for CRRT. Because of the higher cost of this method, it should be proposed only for patients with high bleeding risk.