Desmopresin ve traneksamik asitin acil izole koroner arter bypass greftleme (KABG) ameliyatında kan ürünü kullanımına ve postoperatif kanama üzerine etkisi

Yıl 2020, Cilt: 11 Sayı: 3, 93 - 99, 22.06.2020

Naim Boran Tümer Atike Tekeli Kunt Serdar Günaydın Kanat Özışık Eren Günertem Ali Baran Budak Seyhan Babaroğlu Onur Karahasanoğlu

https://doi.org/10.18663/tjcl.733844

Öz

Amaç: Kanama kalp cerrahisinde önemli bir sorundur ve artan morbidite ve mortalite ile ilişkili yüksek allojenik kan transfüzyonu riskine yol açar. Son yıllarda, literatürdeki çalışmalar desmopresinin (1-deamino-8-D-arginin vazopressin, DDAVP) cerrahi müdahalelerden sonra kan kaybını azalttığını bildirmişlerdir. Bu çalışmanın amacı, kardiyologlar tarafından P2Y12 inhibitörleri ile tedavi edilen ve acil koroner arter baypas greftleme (KABG) ameliyatı geçiren hastalarda desmopressin ve traneksamik asidin kan ürünü kullanımı ve postoperatif kanama üzerindeki etkisini analiz etmektir.
Gereç ve Yöntemler: Acil izole KABG ameliyatı geçiren ve öncesinde P2Y12 inhibitörleri ile tedavi edilmiş 62 erişkin hastanın prospektif olarak toplanan verileri retrospektif olarak incelendi. Hastaların perioperatif verileri birlikte demografik verileri, laboratuvar bulguları, göğüs tüplerinden kan kaybı miktarı, kan ürünü kullanım miktarı, yeniden torakotomi ihtiyacı, morbidite ve mortalite sonuçları değerlendirildi. Hasta popülasyonu iki gruba ayrıldı: Grup I: Perioperatif traneksamik asit ve DDAVP alan hastalar (n=26); ve Grup II: Perioperatif olarak sadece traneksamik asit alan hastalar (n=36).
Bulgular: İki hasta grubu başlangıçta benzer özelliklere sahipti. Grup I ve II arasında göğüs tüplerinden postoperatif kan kaybı, yeniden torakotomi, alyuvar ve trombosit transfüzyonları açısından istatistiksel olarak anlamlı fark vardı (p <0.05). İki grup arasında taze donmuş plazma transfüzyonu, inotropik destek ve mortalite açısından istatistiksel olarak anlamlı bir fark gözlenmemiştir.
Sonuç: Acil izole KABG ameliyatı geçirenlerde traneksamik asitle birlikte desmopresin kullanımının perioperatif/ postoperatif kanamayı ve kan ürünü kullanımını azalttığını düşünüyoruz. 

Anahtar Kelimeler

Desmopresin, Traneksamik Asit, Kan yönetimi, KABG

The effect of desmopressin and tranexamic acid on blood product use and postoperative bleeding after emergent isolated coronary artery bypass grafting (CABG) surgery

Öz

Aim: Bleeding is a major problem in cardiac surgery, and results in a high risk of allogeneic blood transfusion associated with increased morbidity and mortality. In recent years, studies in the literature reported that desmopressin (1-deamino-8-D-arginine vasopressin, DDAVP) reduces the blood loss after surgical interventions. The aim of the present study is to analyze the effect of desmopressin and tranexamic acid on blood product use and postoperative bleeding in patients that were pretreated with P2Y12 inhibitors by cardiologists and undergone emergent coronary artery bypass grafting (CABG) surgery.
Material and Methods:The prospectively collected data of 62 adult patients who underwent emergent isolated CABG surgery and pretreated with P2Y12 inhibitors by cardiologists were retrospectively reviewed. The perioperative data of the patients included their demographic data, laboratory findings, the amount of blood loss from chest tubes, the amount of blood product use, need of re-thoracotomy, morbidity and mortality. The patient population was divided into two groups: Group I: Patients that received tranexamic acid and DDAVP perioperatively (n=26); and Group II: Patients that received only tranexamic acid perioperatively (n=36).
Results: The two groups of patients had similar characteristics at baseline. There was a statistically significant difference between Group I and II regarding postoperative blood loss from the chest tubes, re-thoracotomy, red blood cell and thrombocyte transfusions (p<0.05). No statistically significant differences were observed between the two groups in terms of fresh frozen plasma transfusion, inotropic support and mortality.
Conclusion: We suggest that desmopressin in addition to tranexamic acid reduces bleeding and the amount of blood product use in patients undergoing emergent isolated CABG surgery.

Anahtar Kelimeler

CABG, Desmopressin, Tranexamic Acid

Kaynakça

• 1. Ranucci M. Hemostatic and thrombotic issues in cardiac surgery. Seminars in thrombosis and hemostasis 2015; 41: 84-90.
• 2. Bignami E, Cattaneo M, Crescenzi G et al. Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial. Acta anaesthesiologica Scandinavica2016; 60: 892-900.
• 3. Leal-Noval SR, Rincon-Ferrari MD, Garcia-Curiel A et al. Transfusion of blood components and postoperative infection in patients undergoing cardiac surgery. Chest May 2001; 119: 1461-8.
• 4. Dyke C, Aronson S, Dietrich W et al. Universal definition of perioperative bleeding in adult cardiac surgery. The journal of thoracic and cardiovascular surgery 2014; 147: 1458-63.
• 5. Ohmes LB, Di Franco A, Guy TS et al. Incidence, risk factors, and prognostic impact of re-exploration for bleeding after cardiac surgery: A retrospective cohort study. International journal of surgery (London, England) 2017; 48: 166-73.
• 6. Pagano D, Milojevic M, Meesters MI et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2018; 53: 79-111.
• 7. Ferraris VA, Brown JR, Despotis GJ et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. The Annals of thoracic surgery 2011; 91: 944-82.
• 8. Willems A, De Groote F, Dumoulin M, Fils JF, Van der Linden P. Aprotinin versus tranexamic acid in children undergoing cardiac surgery: an observational study. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery 2019; 56: 688-95.
• 9. Hessel EA, What's New in Cardiopulmonary Bypass. Journal of cardiothoracic and vascular anesthesia. 2019; 33: 2296-326.
• 10. Pickard AS, Becker RC, Schumock GT, Frye CB. Clopidogrel-associated bleeding and related complications in patients undergoing coronary artery bypass grafting. Pharmacotherapy 2008; 28: 376-92.
• 11. Berger JS, Frye CB, Harshaw Q, Edwards FH, Steinhubl SR, Becker RC. Impact of clopidogrel in patients with acute coronary syndromes requiring coronary artery bypass surgery: a multicenter analysis. Journal of the American College of Cardiology 2008; 52: 1693-701.
• 12. Wallentin L, Becker RC, Budaj A et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. The New England journal of medicine 2009; 361: 1045-57.
• 13. Husted S, Emanuelsson H, Heptinstall S, Sandset PM, Wickens M, Peters G. Pharmacodynamics, pharmacokinetics, and safety of the oral reversible P2Y12 antagonist AZD6140 with aspirin in patients with atherosclerosis: a double-blind comparison to clopidogrel with aspirin. European heart journal 2006; 27: 1038-47.
• 14. Gurbel PA, Bliden KP, Butler K, et al. Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: the ONSET/OFFSET study. Circulation 2009; 120: 2577-85.
• 15. Kristensen KL, Rauer LJ, Mortensen PE, Kjeldsen BJ. Reoperation for bleeding in cardiac surgery. Interactive cardiovascular and thoracic surgery 2012; 14: 709-13.
• 16. Cattaneo M. The use of desmopressin in open-heart surgery. Haemophilia : the official journal of the World Federation of Hemophilia 2008; 14: 40-7.
• 17. Colucci G, Stutz M, Rochat S et al. The effect of desmopressin on platelet function: a selective enhancement of procoagulant COAT platelets in patients with primary platelet function defects. Blood 2014; 123: 1905-16.
• 18. Svensson PJ, Bergqvist PB, Juul KV, Berntorp E. Desmopressin in treatment of haematological disorders and in prevention of surgical bleeding. Blood reviews 2014; 28: 95-102.
• 19. Swieringa F, Lance MD, Fuchs B et al. Desmopressin treatment improves platelet function under flow in patients with postoperative bleeding. Journal of thrombosis and haemostasis 2015; 13: 1503-13.
• 20. Teng R, Mitchell PD, Butler K. The effect of desmopressin on bleeding time and platelet aggregation in healthy volunteers administered ticagrelor. Journal of clinical pharmacy and therapeutics 2014; 39: 186-91.
• 21. Desborough MJ, Oakland KA, Landoni G et al. Desmopressin for treatment of platelet dysfunction and reversal of antiplatelet agents: a systematic review and meta-analysis of randomized controlled trials. Journal of thrombosis and haemostasis : JTH 2017; 15: 263-72.
• 22. Kestin AS, Valeri CR, Khuri SF et al. The platelet function defect of cardiopulmonary bypass. Blood 1993; 82: 107-17.
• 23. Crescenzi G, Landoni G, Biondi-Zoccai G et al. Desmopressin reduces transfusion needs after surgery: a meta-analysis of randomized clinical trials. Anesthesiology 2008; 109: 1063-76.
• 24. Steinlechner B, Zeidler P, Base E et al. Patients with severe aortic valve stenosis and impaired platelet function benefit from preoperative desmopressin infusion. The Annals of thoracic surgery 2011; 91: 1420-6.
• 25. Salzman EW, Weinstein MJ, Weintraub RM et al. Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. A double-blind randomized trial. The New England journal of medicine. 1986; 314: 1402-6.
• 26. Despotis GJ, Levine V, Saleem R, Spitznagel E, Joist JH. Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomised controlled trial. Lancet (London, England) 1999; 354: 106-10.
• 27. Carless PA, Henry DA, Moxey AJ et al. Desmopressin for minimising perioperative allogeneic blood transfusion. The Cochrane database of systematic reviews. 2004(1):Cd001884.
• 28. Wademan BH, Galvin SD. Desmopressin for reducing postoperative blood loss and transfusion requirements following cardiac surgery in adults. Interactive cardiovascular and thoracic surgery 2014; 18: 360-70.
• 29. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Critical care (London, England) 2016; 20: 100.
• 30. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology 2015; 122: 241-75.
• 31. Kozek-Langenecker SA, Ahmed AB, Afshari A et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. European journal of anaesthesiology 2017; 34: 332-95.
• 32. Frontera JA, Lewin JJ, 3rd, Rabinstein AA et al. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage: A Statement for Healthcare Professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocritical care. 2016; 24: 6-46.