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Problem-solving in cardiac surgery: empiricism vs. algorithm in the management of microvascular bleeding (MVB): 059

Finamore, G.; Ferrante, M.; Conti, E.; Pede, V.; Martinez, R.; LaMonica, R.; Rodella, G.; Amari, B.

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European Journal of Anaesthesiology: June 2004 - Volume 21 - Issue - p 24-25

Introduction: Abnormal blood losses are frequent after cardiac surgery and can increase morbility and mortality as well as adding the risks of transfusions and re-exploration. Multi-factorial genesis warrants a systematic approach and a targeted therapy. Use of algorithms could be an answer [1]. We have analysed the clinical impact of our diagnostic-therapeutic algorithm for management of MVB.

Method: We compared 100 pts (Algorithm Group) who underwent cardiac surgery in a two months period with 81 pts (Control Group) having operations in the two previous months and without a standardized protocol. The algorithm was made on the basis of literature and our Point of Care (POC) tests availability (TEG, PFA100). The use of the algorithm was triggered in the operating room by the persistence of MVB after heparin neutralization, or in ICU by bleeding > 150mL/h.

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We examined blood losses, number and kind of transfusions and number of re-explorations.

Results: Main results are listed in the table.

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Table:
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Discussion: Fewer pts treated according to the algorithm received FFP and those that did received less, as a result of more targeted therapy. Main advantages of algorithm implementation appeared to be: 1) Systematic identification of mechanism of bleeding; 2) Targeted and standardized therapy; 3) Identification of patients who needed reexploration. Besides evaluating platelet function by POC, it had a pivotal role as a guide for the targeted use of low cost therapy, DDAVP. The real clinical and economic impact of a “rational” vs. “empirical” approach should be weighed up in the future.

Reference:

1 Despotis GJ, Grishaber JE, Goodnough LT. The effect of an intraoperative treatment algorithm on physicians' transfusion practice in cardiac surgery. Transfusion 1994; 34: 290-296.
© 2004 European Society of Anaesthesiology