title: First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decreased allogeneic blood transfusion in cardiovascular surgery: a retrospective, single-center cohort study.
abstract: BACKGROUND
  Blood transfusion is associated with increased morbidity and mortality. We developed and implemented an algorithm for coagulation management in cardiovascular surgery based on first-line administration of coagulation factor concentrates combined with point-of-care thromboelastometry/impedance aggregometry.
  
  
  METHODS
  In a retrospective cohort study including 3,865 patients, we analyzed the incidence of intraoperative allogeneic blood transfusions (primary endpoints) before and after algorithm implementation.
  
  
  RESULTS
  Following algorithm implementation, the incidence of any allogeneic blood transfusion (52.5 vs. 42.2%; P < 0.0001), packed red blood cells (49.7 vs. 40.4%; P < 0.0001), and fresh frozen plasma (19.4 vs. 1.1%; P < 0.0001) decreased, whereas platelet transfusion increased (10.1 vs. 13.0%; P = 0.0041). Yearly transfusion of packed red blood cells (3,276 vs. 2,959 units; P < 0.0001) and fresh frozen plasma (1986 vs. 102 units; P < 0.0001) decreased, as did the median number of packed red blood cells and fresh frozen plasma per patient. The incidence of fibrinogen concentrate (3.73 vs. 10.01%; P < 0.0001) and prothrombin complex concentrate administration (4.42 vs. 8.9%; P < 0.0001) increased, as did their amount administered per year (179 vs. 702 g; P = 0.0008 and 162 × 10³ U vs. 388 × 10³ U; P = 0.0184, respectively). Despite a switch from aprotinin to tranexamic acid, an increase in use of dual antiplatelet therapy (2.7 vs. 13.7%; P < 0.0001), patients' age, proportion of females, emergency cases, and more complex surgery, the incidence of massive transfusion [(≥10 units packed red blood cells), (2.5 vs. 1.26%; P = 0.0057)] and unplanned reexploration (4.19 vs. 2.24%; P = 0.0007) decreased. Composite thrombotic/thromboembolic events (3.19 vs. 1.77%; P = 0.0115) decreased, but in-hospital mortality did not change (5.24 vs. 5.22%; P = 0.98).
  
  
  CONCLUSIONS
  First-line administration of coagulation factor concentrates combined with point-of-care testing was associated with decreased incidence of blood transfusion and thrombotic/thromboembolic events.
authors.affiliation: Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany. klaus@goerlinger.net
authors.forename: Klaus
authors.initials: K
authors.lastname: Görlinger
authors.forename: Daniel
authors.initials: D
authors.lastname: Dirkmann
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Hanke
authors.forename: Markus
authors.initials: M
authors.lastname: Kamler
authors.forename: Eva
authors.initials: E
authors.lastname: Kottenberg
authors.forename: Matthias
authors.initials: M
authors.lastname: Thielmann
authors.forename: Heinz
authors.initials: H
authors.lastname: Jakob
authors.forename: Jürgen
authors.initials: J
authors.lastname: Peters
mesh_terms: D000368:Aged; D000465:Algorithms; D001777:Blood Coagulation; D001779:Blood Coagulation Factors / Q000008:administration & dosage / Q000627:therapeutic use*; D001780:Blood Coagulation Tests; D016063:Blood Loss, Surgical; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D013504:Cardiovascular Surgical Procedures; D015331:Cohort Studies; D005260:Female; D005340:Fibrinogen / Q000008:administration & dosage; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D008297:Male; D008875:Middle Aged; D010949:Plasma; D017713:Platelet Transfusion; D019095:Point-of-Care Systems; D012189:Retrospective Studies; D013916:Thrombelastography / Q000379:methods
chemical_list: D001779:Blood Coagulation Factors; D005343:Fibrinolytic Agents; C025667:prothrombin complex concentrates; D005340:Fibrinogen; D006493:Heparin