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Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement.

ABSTRACT: Moderate (MHCA) versus deep (DHCA) hypothermia for circulatory arrest in aortic arch surgery has been purported to reduce coagulopathy and bleeding complications, although there are limited data supporting this claim. This study aimed to compare bleeding-related events after aortic hemiarch replacement with MHCA versus DHCA.Patients who underwent hemiarch replacement at a single institution from July 2005 to August 2014 were stratified into DHCA and MHCA groups (minimum systemic temperature ?20°C and >20°C, respectively) and compared. Then, 1:1 propensity matching was performed to adjust for baseline differences.During the study period, 571 patients underwent hemiarch replacement: 401 (70.2%) with DHCA and 170 (29.8%) with MHCA. After propensity matching, 155 patients remained in each group. There were no significant differences between matched groups with regard to the proportion transfused with red blood cells, plasma, platelet concentrates, or cryoprecipitate on the operative day, the rate of reoperation for bleeding, or postoperative hematologic laboratory values. Among patients who received plasma, the median transfusion volume was statistically greater in the DHCA group (6 vs 5 units, P = .01). MHCA also resulted in a slight reduction in median volume of blood returned via cell saver (500 vs 472 mL, P < .01) and 12-hour postoperative chest tube output (440 vs 350, P < .01). Thirty-day mortality and morbidity did not differ significantly between groups.MHCA compared with DHCA during hermiarch replacement may slightly reduce perioperative blood-loss and plasma transfusion requirement, although these differences do not translate into reduced reoperation for bleeding or postoperative mortality and morbidity.

SUBMITTER: Keenan JE

PROVIDER: S-EPMC5154360 | biostudies-literature | 2016 Dec

REPOSITORIES: biostudies-literature

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Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement.

Keenan Jeffrey E JE Wang Hanghang H Gulack Brian C BC Ganapathi Asvin M AM Andersen Nicholas D ND Englum Brian R BR Krishnamurthy Yamini Y Levy Jerrold H JH Welsby Ian J IJ Hughes G Chad GC

The Journal of thoracic and cardiovascular surgery 20160828 6

<h4>Background</h4>Moderate (MHCA) versus deep (DHCA) hypothermia for circulatory arrest in aortic arch surgery has been purported to reduce coagulopathy and bleeding complications, although there are limited data supporting this claim. This study aimed to compare bleeding-related events after aortic hemiarch replacement with MHCA versus DHCA.<h4>Methods</h4>Patients who underwent hemiarch replacement at a single institution from July 2005 to August 2014 were stratified into DHCA and MHCA groups ...[more]

PMID: 27692949

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Project description:ObjectiveTo determine the use of epinephrine (adrenaline) before defibrillation for treatment of in-hospital cardiac arrest due to a ventricular arrhythmia and examine its association with patient survival.DesignPropensity matched analysis.Setting2000-18 data from 497 hospitals participating in the American Heart Association’s Get With The Guidelines-Resuscitation registry.ParticipantsAdults aged 18 and older with an index in-hospital cardiac arrest due to an initial shockable rhythm treated with defibrillation.InterventionsAdministration of epinephrine before first defibrillation.Main outcome measuresSurvival to discharge; favorable neurological survival, defined as survival to discharge with none, mild, or moderate neurological disability measured using cerebral performance category scores; and survival after acute resuscitation (that is, return of spontaneous circulation for >20 minutes). A time dependent, propensity matched analysis was performed to adjust for confounding due to indication and evaluate the independent association of epinephrine before defibrillation with study outcomes.ResultsAmong 34 820 patients with an initial shockable rhythm, 7054 (20.3%) were treated with epinephrine before defibrillation, contrary to current guidelines. In comparison with participants treated with defibrillation first, participants receiving epinephrine first were less likely to have a history of myocardial infarction or heart failure, but more likely to have renal failure, sepsis, respiratory insufficiency, and receive mechanical ventilation before in-hospital cardiac arrest (standardized differences >10% for all). Treatment with epinephrine before defibrillation was strongly associated with delayed defibrillation (median 4 minutes v 0 minutes). In propensity matched analysis (6569 matched pairs), epinephrine before defibrillation was associated with lower odds of survival to discharge (22.4% v 29.7%; adjusted odds ratio 0.69; 95% confidence interval 0.64 to 0.74; P<0.001), favorable neurological survival (15.8% v 21.6%; 0.68; 0.61 to 0.76; P<0.001) and survival after acute resuscitation (61.7% v 69.5%; 0.73; 0.67 to 0.79; P<0.001). The above findings were consistent in a range of sensitivity analyses, including matching according to defibrillation time.ConclusionsContrary to current guidelines that prioritize immediate defibrillation for in-hospital cardiac arrest due to a shockable rhythm, one in five patients are treated with epinephrine before defibrillation. Use of epinephrine before defibrillation was associated with worse survival outcomes.

Project description:BACKGROUND:Aortic arch surgery remains the only viable life-saving treatment for aortic arch disease. However, the necessity for cessation of systemic blood flow with hypothermic cardiac arrest carries substantial risk of morbidity and mortality, including poor neurological outcomes and kidney failure. While uncontrolled studies have suggested the safety of operating at warmer temperatures, significant variables remain un-investigated, supporting the need for a randomized clinical trial (RCT) to produce evidence-based guidelines for perfusion strategies in aortic surgery. This study proposes a multi-center RCT in order to compare outcomes of warmer hypothermic strategies during aortic hemiarch surgery on a composite endpoint of neurologic and acute kidney injury (AKI). METHODS/DESIGN:This is a prospective multi-center, single-blind two-arm RCT comparing mild (32 °C) versus moderate (26 °C) hypothermic cardiac arrest in patients (n = 282) undergoing hemiarch surgery with antegrade cerebral perfusion (ACP). The primary endpoint is a composite of neurological injury (incidence of transient ischemic attack and/or stroke) and Kidney Disease Improving Global Outcomes (KDIGO) stage 1 or higher AKI. Secondary outcomes include death, cardiopulmonary bypass time, bleeding, transfusion rates, prolonged mechanical ventilation, myocardial infarction, length of stay, and quality of life measures. Patients will undergo 1:1 block randomization to each treatment arm on day of surgery. Sequence of operation will be at the surgeon's discretion with mandatory guidelines for temperature and ACP administration. Perioperative management will occur as per enrolling center standard of care. Neurocognitive function will be assessed for neurological injury using validated neurological screening tests: NIHSS, MOCA, BI, and MRS throughout patient follow-up. Diagnosis and classification of AKI will be based on rising creatinine values as per the KDIGO criteria. Study duration for each patient will be 60 ± 14 days. DISCUSSION:It is hoped that performing hemiarch surgery using mild hypothermia (32 °C) and selective ACP will result in a 15% absolute risk reduction in the composite outcomes. The potential of this risk reduction will translate into improved patient outcomes, survival, and long-term financial savings to the health care system. In addition, the results of this trial will be used to create the first-ever guidelines for temperature management strategy during aortic surgery. TRIAL REGISTRATION:This trial is registered on ClinicalTrials.gov with the registration number NCT02860364. Registration date August 9th, 2016.

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Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement.

Publications

Does moderate hypothermia really carry less bleeding risk than deep hypothermia for circulatory arrest? A propensity-matched comparison in hemiarch replacement.

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