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Thromboelastometry as guidance for blood management in patients undergoing cardiac surgery
Tromboelastometría como guía de administración de hemoderivados en cirugía cardiaca
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Sarrais Polo, A. Alonso Morenza, J. Rey Picazo, L. Álvarez Mercadal, R. Beltrao Sial, C. Aguilar Lloret" "autores" => array:6 [ 0 => array:4 [ "nombre" => "C." "apellidos" => "Sarrais Polo" "email" => array:1 [ 0 => "claudiasarrais@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Alonso Morenza" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J." "apellidos" => "Rey Picazo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Álvarez Mercadal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "Beltrao Sial" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "C." "apellidos" => "Aguilar Lloret" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Doce de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología Reanimación y Terapéutica del Dolor, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tromboelastometría como guía de administración de hemoderivados en cirugía cardiaca" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac surgery is one the costliest procedures in terms of blood products. Transfusion rates vary, depending on the experience of the hospital, the professionals involved, and the type of surgery. In contrast to other interventions, no global consensus on the management of intraoperative bleeding in cardiac surgery has yet been reached.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the case of cardiopulmonary bypass patients, a number of circumstances can aggravate the risk of coagulation abnormalities and microvascular bleeding<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a>: advanced age, preoperative administration of antiplatelet drugs and anticoagulants, the use of a cardiopulmonary bypass (CPB) pump, severe hypothermia, anticoagulation with high doses of heparin, platelet activation and subsequent dysfunction, haemodilution and fibrinolysis. The CPB induces a systemic inflammatory response with activation of both the coagulation and fibrinolytic systems, followed by coagulopathy caused by factor consumption and transiently reduced platelet count and function.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">3</span></a> This is considered one of the major causes of increased morbidity and mortality in patients undergoing cardiac surgery.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Recent studies have shown that haemostasis and prognosis are improved when algorithm-based transfusion protocols are used instead of strategies based on the individual decisions of treating physicians.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5–7</span></a> Based on this premise, the use of point-of-care coagulation tests is gaining ground over traditional laboratory tests.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">8,9</span></a> The latter, though useful, are time consuming, and in the case of an intraoperative haemorrhage, immediate results are usually needed in order to take the most appropriate therapeutic decision. Tests such as thromboelastometry are proving useful as a guide for blood transfusion, since they provide a comprehensive, dynamic picture of coagulation parameters by analysing the viscoelasticity of a small sample of whole blood. They can provide information on clot initiation, formation, stability, solidity and dissolution kinetics,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">10</span></a> and give a picture of the patient's haemostatic status within 2–3<span class="elsevierStyleHsp" style=""></span>min, thus reducing the need for blood transfusion and optimising haemostasis.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">11–13</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The main objective of our study was to compare intraoperative blood requirements in patients undergoing complex cardiac surgery using thromboelastometry-based transfusion algorithms vs decisions based on the clinical status and conventional laboratory tests. As a secondary measure, we compared results in terms of postoperative complications observed in the intensive care unit (ICU) stay and length of ICU stay.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study was carried out in the San Carlos Clinical Hospital in Madrid. Data were collected between December 2013 and May 2016, and subsequently analysed. The study was approved by the hospital's Institutional Review Board in its meeting of 11.18.2015, minutes 11.2/15 <span class="elsevierStyleSmallCaps">(P.C</span>.-I.C<span class="elsevierStyleSmallCaps">.</span> 15/476-E). Anaesthesia was administered by the same anaesthesiologist in all cases; however, the surgical team differed, and this is a potential source of bias.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This an analytical, interventional, comparative, non-randomised, prospective quasi-experimental study with a retrospective control group. Data from a group of patients in whom thromboelastometry-guided algorithm for blood product management were used were analysed prospectively from October 2014, the date the thromboelastography machine was introduced in our hospital, to May 2016. Data from the control group were collected retrospectively, from October 2014 to December 2013. The information was collected both from the medical records and all the paper documents relating to the different intraoperative interventions and the patient's stay in the ICU.</p><p id="par0035" class="elsevierStylePara elsevierViewall">All adult patients undergoing scheduled cardiac surgery with a high risk of severe bleeding were included in the study. High risk of bleeding was defined as<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a</span><p id="par0040" class="elsevierStylePara elsevierViewall">previous sternotomy;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b</span><p id="par0045" class="elsevierStylePara elsevierViewall">surgery secondary to endocarditis;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c</span><p id="par0050" class="elsevierStylePara elsevierViewall">aortic arch surgery.</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">The patients were divided into 2 groups:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Group A: patients in whom intraoperative blood products were administered on the basis of their clinical and overall haemodynamic status using traditional transfusion guidelines supported by the results of the standard laboratory tests.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Group B: patients who were transfused on the basis of thromboelastometry-guided algorithms for blood product management.</p></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">Before the introduction of the thromboelastography machine, Group A patients routinely received platelets and fresh frozen plasma after disconnection from the CPB pump. Platelets were administered at a rate of 1 unit per 10–20<span class="elsevierStyleHsp" style=""></span>kg patient weight (1 pool<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6 units) and plasma at a rate of 20<span class="elsevierStyleHsp" style=""></span>ml/kg. Packed red blood cells (PRBC) were administered on the basis of the results of intraoperative tests. This strategy was based on the assumption that these patients are likely to present coagulation abnormalities for the reasons listed in the foregoing paragraphs, and supported by our long experience in this kind of intervention and the number of patients treated in our hospital (more than 700 major cardiac surgeries per year). Despite the established strategy, the decision to administer blood products was ultimately taken by the treating anaesthesiologist.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In group B, a Rotem<span class="elsevierStyleSup">®</span> delta analyser was used for thromboelastometry testing 3 times over the course of the intervention:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">1)</span><p id="par0080" class="elsevierStylePara elsevierViewall">Baseline: immediately after anaesthetic induction (intem, extem, fibtem and heptem test).</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">2)</span><p id="par0085" class="elsevierStylePara elsevierViewall">Before disconnection from the CPB pump (only heptem test).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">3)</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ten minutes after the administration of protamine (intem, extem, fibtem and heptem test).</p></li></ul></p><p id="par0095" class="elsevierStylePara elsevierViewall">Thromboelastometry testing was repeated to reassess the haemostatic status of the patient each time any type of blood product was administered to correct abnormalities in the analysis, and each time a blood component was administered.</p><p id="par0100" class="elsevierStylePara elsevierViewall">A sample size of 62 patients, 31 patients per group, was calculated on the basis of statistical inference for hypothesis testing studies, given the statistical difference required for clinical relevance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.05), the parameters of the study variables used in the literature and previous studies, and possible losses.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The outcome variables were intraoperative consumption of blood products: PRBC (transfused units), fresh frozen plasma (transfused units), platelets (pooled units transfused), prothrombin complex (number of 600<span class="elsevierStyleHsp" style=""></span>IU vials administered) and fibrinogen (grammes administered) per patient. The secondary variables were length of postoperative ICU stay (measured in days) and postoperative respiratory complications (presence and type), which are very often associated with blood transfusion. Respiratory complications were defined as: tracheal intubation lasting more than 48<span class="elsevierStyleHsp" style=""></span>h, acute respiratory failure, extended ICU stay due to pleural effusion, reintubation and/or readmission to the ICU due to respiratory complications. ICU stay was either standard stay or extended stay (lasting 7 days or more).</p><p id="par0110" class="elsevierStylePara elsevierViewall">It is important to bear in mind the potential for bias derived from the manual recording of data in the case of group and differences in the composition of the surgical team in some interventions.</p><p id="par0115" class="elsevierStylePara elsevierViewall">The statistical analysis was performed on SPSS 20.0. Qualitative variables were described using frequency tables and quantitative variables were tested using the Student's <span class="elsevierStyleItalic">t</span> test or the Mann–Whitney test, according to their distribution. The data were divided into categories in order to use the Chi-square test for parametric variables and the Mann–Whitney <span class="elsevierStyleItalic">U</span> for nonparametric variables.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0120" class="elsevierStylePara elsevierViewall">A total of 80 patients were included in the analysis, 31 in group A and 49 in group B. To determine the homogeneity of our study groups, we analysed the prevalence of numerous variables and the sex and age distribution of patients in both groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). This showed that the groups were homogeneously distributed, except for oral anticoagulation (acenocoumarol), which was more frequent in group B.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Significantly less fresh frozen plasma was transfused in group B, with 2% of transfused patients versus 80.6% in Group A (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). With regard to platelet transfusion, 64.5% of patients were transfused in group A (20 of 31 patients) compared to 46.9% in group B (23 of 49 patients); however, these differences were not significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.124). We observed a reduction in the number of units of homologous blood transfused in group B, with an average rate of 2.67 units (standard deviation [SD] 2.22) versus 3.9 PRBC in group A (SD 3.24), although the difference was not statistically significant (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.069). After stratifying the transfusion of PRBC (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), it was observed that the number of patients requiring significant PRBC transfusion decreased in Group B at the expense of an increase in patients who required smaller amounts. The number of patients requiring of high doses (≥2<span class="elsevierStyleHsp" style=""></span>g) of fibrinogen increased in group B with respect to group A (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In group A, ≥2<span class="elsevierStyleHsp" style=""></span>g fibrinogen were administered in 3.2% of patients versus 22.4% of patients in group B (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace"><</span><span class="elsevierStyleHsp" style=""></span>0.024).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Respiratory complications were defined as: tracheal intubation lasting more than 48<span class="elsevierStyleHsp" style=""></span>h, acute respiratory failure, extended ICU stay due to pleural effusion, reintubation and/or readmisstion to the ICU due to respiratory complications. Without substratifying by type, a significant decrease in such complications was observed in group B (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><p id="par0135" class="elsevierStylePara elsevierViewall">The average length of postoperative stay in the ICU was 7.94 days (SD 10.47) in group A and 5.12 days (SD 6.57) in group B. The percentage of patients requiring extended ICU stays was lower in group B (10.2%) versus group A (29%) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.031) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The results obtained suggest that in cardiac interventions with a high risk of bleeding and clotting abnormalities, thromboelastometry testing significantly reduces the administration of fresh frozen plasma compared with pre-thromboelastometry transfusion figures, a finding that has also been reported in other studies performed in patients with similar characteristics.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a> Although this is no doubt due to the fact that, before the introduction of thromboelastometry testing, plasma was administered as a matter of routine in patients undergoing this type of surgery, our results serve to highlight the difference between transfusion guided by clinical status and experience (which are perfectly valid in the absence of other resources) and by rapid, objective, point of care coagulation monitoring. These data indicate, therefore, that coagulation factor deficiencies are not as severe as previously thought, despite the loss of other haemostatic elements.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The allogeneic red blood cell transfusion rate, meanwhile, shows a tendency to decrease, probably because improving haemostasis and reducing the haemodilution caused by the administration of plasma reduces transfusion requirements, a finding also reported in similar studies.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5,12</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Our findings regarding platelet transfusion are perhaps the most contradictory. Although the protocol used for patients in group A included the systematic administration of platelets, the data collected showed that, as the treating anaesthesiologist was at libery to override the protocol, up to 35.5% of patients did not receive platelets. Although this did not significant change the fluid management strategy, it does show a certain tendency towards platelet-saving, thanks to thromboelastometry. These results suggest that access to coagulation tests has meant that fewer patients undergoing this type of surgery require platelet transfusion than previously assumed, although it of course remains essential to correct platelet deficiencies to optimise haemostasis. The difference is that thromboelastometry can now be used to guide fluid management without having to wait for analytical results.</p><p id="par0155" class="elsevierStylePara elsevierViewall">With regard to fibrinogen, practice had led us to believe that administration had increased with the use of viscoelastic tests. However, an analysis of stratified data shows that 22.4% of patients in group B received ≥2<span class="elsevierStyleHsp" style=""></span>g fibrinogen compared with only 3.2% in group A. It seems, therefore, that the fibrinogen deficit in this type of patient is greater than had been assumed before the introduction of thromboelastometry. Other authors have also reported higher fibrinogen requirements in CPB patients.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">14</span></a> A reasonable explanation for this is that the drastic decrease in plasma transfusion also affects the amount of fibrinogen administered by the same route, so that the need for additional fibrinogen is to be expected to a certain extent. The most important lesson to be drawn from our results is the need for a new approach to the use of fresh frozen plasma, and in particular, the need for early, aggressive fibrinogen replacement. Depletion of this component of haemostasis is probably the most significant factor in the fluid management of CPB patients, and calls for further research.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Although we observed a slight increase in the use of prothrombin complex, the difference was not significant, and did not represent a substantial change in the management of these patients.</p><p id="par0165" class="elsevierStylePara elsevierViewall">We observed a significant decrease in the incidence of postoperative respiratory complications, probably due to a more conservative use of plasma. In group A, 25.8% of patients presented respiratory complications, versus 6.1% in group B. This, however, was not attributable solely to the lower fresh frozen plasma transfusion rate.</p><p id="par0170" class="elsevierStylePara elsevierViewall">With regard to postoperative stay in the ICU, 29% of patients in group A required extended stay versus 10.2% in group B. Savings in the administration of fresh frozen plasma most probably helped reduce the incidence of respiratory complications, and this together with improved haemostasis, resulted in a shorter stay in the ICU.</p><p id="par0175" class="elsevierStylePara elsevierViewall">It is important to interpret our results in the light of the slight demographic differences between our study groups. An additional factor that could also have affected the validity of our findings was our failure to stratify our analysis by type of surgery. This is something that should be taken into consideration in future studies.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Given that fibrinolysis is one of the causes of excessive blood loss after cardiac surgery with CPB,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> further studies that evaluate this parameter are needed to consolidate the existing evidence on its role in blood loss and transfusion.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Subsequent studies should also evaluate other types of complications not necessarily directly related to transfusion. This would help clinicians optimise both the perioperative and long-term prognosis, morbidity and mortality of cardiac patients.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">The use of thromboelastometry to guide blood transfusion decisions in patients undergoing cardiac surgery with a high risk of bleeding has marked a turning point in routine clinical practice in our centre.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a> The results of this study suggest that the haemostatic failures presented by CPB patients do not fit the patterns assumed before the availability of this thromboelastometric analysis.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Changing the fluid management strategy in these patients can significantly improve their morbidity and mortality. This calls for further studies into strategies that can optimise the haemostatic management of our patients.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1008325" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec968001" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1008326" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec968000" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-07-03" "fechaAceptado" => "2017-10-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec968001" "palabras" => array:4 [ 0 => "Thromboelastometry" 1 => "Cardiac surgery" 2 => "Blood products management" 3 => "Point-of-care testing" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec968000" "palabras" => array:4 [ 0 => "Tromboelastometría" 1 => "Cirugía cardiaca" 2 => "Transfusión de hemoderivados" 3 => "Test a pie de cama" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analytical and comparative non-randomised quasi-experimental prospective study with a retrospective control group. The inclusion criteria for the 80 patients were: patients undergoing cardiac surgery who had had prior cardiac surgery, endocarditis surgery or aortic arch surgery. Thirty-one patients were treated following routine transfusion practice during surgery (group A). The other 49 patients were treated with thromboelastometrically guided transfusion algorithms (group B).</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The main objective was blood products transfused, and postoperative adverse events and ICU stay were the secondary objectives.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Statistical analysis showed lower transfusion rates of fresh-frozen plasma in group B compared to group A (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001), as well as red blood cell transfusion during surgery with an average transfusion rate of 3.9 units in group A in comparison to 2.67 units in group B (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.125). Moreover, fibrinogen infusion was increased in group B compared to group A (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.019). In addition, a lower rate of respiratory adverse events was found in group B (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.019). There was a significant decrease in ICU stays over 7 days in group B compared to group A (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.031).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Using thromboelastometry guidance for blood management led to a meaningful reduction of fresh frozen plasma transfusion during surgery. This probably resulted in a reduction in respiratory adverse events after surgery and length of ICU stay in our patients.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and method" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La tromboelastometría evalúa la coagulación analizando la viscoelasticidad de una muestra de sangre. Nuestro objetivo principal fue evaluar los resultados de su uso como guía de administración de hemoderivados en cirugía cardiaca y, secundariamente, las complicaciones postoperatorias y el tiempo de hospitalización en UCI.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y método</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Estudio analítico, de intervención, cuasiexperimental, comparativo, no aleatorizado, prospectivo, con un grupo control retrospectivo. Se incluyeron 80 pacientes reintervenidos de cualquier cirugía cardiaca, o cirugías por endocarditis o del arco aórtico. En 31 pacientes los hemoderivados intraoperatorios se administraron según pautas clínicas tradicionales (grupo A). Los 49 pacientes restantes recibieron hemoderivados siguiendo algoritmos basados en el análisis tromboelastométrico (grupo B). El objetivo principal fue la administración de hemoderivados y los objetivos secundarios fueron: estancia en UCI y complicaciones postoperatorias.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hubo una importante disminución en la administración de plasma fresco congelado en el grupo B respecto al A (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001), así como una disminución en la transfusión intraoperatoria de sangre: 3,9 concentrados de hematíes de media por paciente en el grupo A frente a 2,67 en el grupo B (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,125). Se incrementó la administración de fibrinógeno, con una p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,019. Se encontró una menor tasa de complicaciones respiratorias (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,019) en el grupo B y una reducción significativa de las estancias mayores de 7 días en el grupo B respecto al A (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,031).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La tromboelastometría condujo a una importante disminución en la utilización de plasma fresco congelado, contribuyendo muy probablemente al descenso en la incidencia de complicaciones respiratorias y en la menor estancia en UCI.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y método" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sarrais Polo C, Alonso Morenza A, Rey Picazo J, Álvarez Mercadal L, Beltrao Sial R, Aguilar Lloret C. Tromboelastometría como guía de administración de hemoderivados en cirugía cardiaca. Rev Esp Anestesiol Reanim. 2018;65:129–134.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Age expressed as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">AF: atrial fibrillation; AP: antiplatelet therapy; CKI: chronic renal failure; COPD: chronic obstructive pulmonary disease; DL: dyslipidemia; DM: diabetes mellitus; HTN: arterial hypertension; <span class="elsevierStyleItalic">M</span>: men; MI: previous acute myocardial infarction; OAC: oral anticoagulation; <span class="elsevierStyleItalic">W</span>: women.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group A (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group B (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>49) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> (<0.05) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66.12<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>11.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">W</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>58, <span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleItalic">W</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>55, <span class="elsevierStyleItalic">M</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HTN (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.072 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DL (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.059 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">DM (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.691 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CKI (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.653 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">OAC (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AP (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.633 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MI (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.098 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AF (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.185 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.098 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1707574.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient characteristics by group.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Results expressed in percentages.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">FFP: fresh frozen plasma; ICU: intensive care unit.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group A (%)<br>n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>31 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group B (%)<br>n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>49 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">FFP</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><0.01</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Platelets</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.124</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Packed red blood cells (units)</td><td class="td" title="table-entry " align="left" valign="top"><3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="top">0.069</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3–5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Fibrinogen (g)</td><td class="td" title="table-entry " align="left" valign="top"><2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.019</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">≥2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Prothrombin complex</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.145</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">83.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">69.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Respiratory complications</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.019</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Stay in ICU</td><td class="td" title="table-entry " align="left" valign="top"><7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top">0.031</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">>7 days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1707573.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevención, diagnóstico y tratamiento de la hemorragia en cirugía cardiaca" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Paniagua" 1 => "G. Fita" 2 => "L. Rivera" 3 => "F. Parramon" 4 => "T. Koller" 5 => "C. Basora" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2012.09.015" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2013" "volumen" => "60" "paginaInicial" => "149" "paginaFinal" => "160" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23177528" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0095" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point of care testing and cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "S.N. Weitzel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2014.01.009" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2014" "volumen" => "28" "paginaInicial" => "207" "paginaFinal" => "209" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24630469" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0100" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="http://www.biomedcentral.com/1471-2253/14/80">http://www.biomedcentral.com/1471-2253/14/80</a>" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of three point-of-care testing devices to detect hemostatic changes in adult elective cardiac surgery: a prospective observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Espinosa" 1 => "R. Stenseth" 2 => "V. Videm" 3 => "H. Pleym" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1471-2253-14-80" "Revista" => array:5 [ "tituloSerie" => "BMC Anesthesiol" "fecha" => "2014" "volumen" => "14" "paginaInicial" => "80" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25276093" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0105" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practical use of thromboelastometry in the management of perioperative coagulopathy and bleeding" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "B. Williams" 1 => "J. McNeil" 2 => "A. Crabbe" 3 => "K.A. Tanaka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tmrv.2016.08.005" "Revista" => array:6 [ "tituloSerie" => "Transfus Med Rev" "fecha" => "2017" "volumen" => "31" "paginaInicial" => "11" "paginaFinal" => "25" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27622549" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0110" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Haemostatic management of cardiac surgical haemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.W. Besser" 1 => "E. Ortmann" 2 => "A.A. Klein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/anae.12898" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2015" "volumen" => "70" "paginaInicial" => "87" "paginaFinal" => "95" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25440401" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0115" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point-of-care thromboelastography/thromboelastometry-based coagulation management in cardiac surgery: a meta-analysis of 8332 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Deppe" 1 => "C. Weber" 2 => "J. Zimmermann" 3 => "E.W. Kuhn" 4 => "I. Slottosch" 5 => "O.J. Liakopoulos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jss.2016.03.008" "Revista" => array:6 [ "tituloSerie" => "J Surg Res" "fecha" => "2016" "volumen" => "203" "paginaInicial" => "424" "paginaFinal" => "433" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27363652" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0120" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Transfusion of allogeneic blood products in proximal aortic surgery with hypothermic circulatory arrest: effect of thromboelastometry-guided transfusion management" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Fassl" 1 => "P. Matt" 2 => "F. Eckstein" 3 => "M. Filipovic" 4 => "M. Gregor" 5 => "U. Zenklusen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2013.02.009" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2013" "volumen" => "27" "paginaInicial" => "1181" "paginaFinal" => "1188" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23962459" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0125" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.F. Weber" 1 => "K. Gorlinger" 2 => "D. Meininger" 3 => "E. Herrmann" 4 => "T. Bingold" 5 => "A. Moritz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e318264c644" "Revista" => array:6 [ "tituloSerie" => "Anesthesiology" "fecha" => "2012" "volumen" => "117" "paginaInicial" => "531" "paginaFinal" => "547" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22914710" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0130" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Point-of-care monitoring of haemostasis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S.V. Mallett" 1 => "M. Armstrong" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Anaesthesia" "fecha" => "2015" "volumen" => "1" "paginaInicial" => "73" "paginaFinal" => "77" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0135" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The influence of laboratory coagulation tests and clotting factor levels on Rotation Thromboelastometry (ROTEM(R)) during major surgery with hemorrhage" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "O.M. Theusinger" 1 => "C.M. Schröder" 2 => "J. Eismon" 3 => "M.Y. Emmert" 4 => "B. Seifert" 5 => "D.R. Spahn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1213/ANE.0b013e31829569ac" "Revista" => array:6 [ "tituloSerie" => "Anesth Analg" "fecha" => "2013" "volumen" => "117" "paginaInicial" => "314" "paginaFinal" => "321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23780419" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0140" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Does incorporation of thromboelastography improve bleeding prediction following adult cardiac surgery?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.D. Sharma" 1 => "A. Al-Achi" 2 => "J.F. Seccombe" 3 => "R. Hummel" 4 => "M. Preston" 5 => "D. Behrend" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/MBC.0000000000000095" "Revista" => array:6 [ "tituloSerie" => "Blood Coagul Fibrinolysis" "fecha" => "2014" "volumen" => "25" "paginaInicial" => "561" "paginaFinal" => "570" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24717423" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0145" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Roles of thrombelastography and thromboelastometry for patient blood management in cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Bolliger" 1 => "K.A. Tanaka" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tmrv.2013.08.004" "Revista" => array:6 [ "tituloSerie" => "Transfus Med Rev" "fecha" => "2013" "volumen" => "27" "paginaInicial" => "213" "paginaFinal" => "220" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24075802" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0150" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thromboelastometrically guided transfusion protocol during aortic surgery with circulatory arrest: a prospective, randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Girdauskas" 1 => "J. Kempfert" 2 => "T. Kuntze" 3 => "M.A. Borger" 4 => "J. Enders" 5 => "J. Fassl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jtcvs.2010.04.043" "Revista" => array:6 [ "tituloSerie" => "J Thorac Cardiovasc Surg" "fecha" => "2010" "volumen" => "140" "paginaInicial" => "1117" "paginaFinal" => "1124" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20951260" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0155" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "El nivel plasmático de fibrinógeno al ingreso en la unidad de cuidados intensivos es un potente predictor del sangrado postoperatorio después de la cirugía cardiaca con bypass cardiopulmonar" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Kindo" 1 => "T. Hoang Minh" 2 => "S. Gerelli" 3 => "S. Perrier" 4 => "N. Meyer" 5 => "M. Schaeffer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Cir Cardiov" "fecha" => "2015" "volumen" => "22" "paginaInicial" => "55" "paginaFinal" => "57" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0160" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "De las técnicas de ahorro de sangre al «patient blood management»" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Basora Macaya" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.redar.2012.09.022" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Anestesiol Reanim" "fecha" => "2013" "volumen" => "60" "paginaInicial" => "245" "paginaFinal" => "248" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23182649" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0165" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The use of thromboelastometry and tranexamic acid reduces blood loss and transfusion requirements in cardiac surgery under cardiopulmonary bypass" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Ichikawa" 1 => "M. Kodaka" 2 => "T. Kitahara" 3 => "N. Sato" 4 => "K. Nishiyama" 5 => "K. Nakano" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Masui" "fecha" => "2015" "volumen" => "64" "paginaInicial" => "131" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26121803" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0170" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TEG<span class="elsevierStyleSup">®</span>- or ROTEM<span class="elsevierStyleSup">®</span>-based individualized goal-directed coagulation algorithms: Don’t wait – act now!" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "D.R. Spahn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s13054-014-0637-3" "Revista" => array:5 [ "tituloSerie" => "Crit Care" "fecha" => "2014" "volumen" => "18" "paginaInicial" => "637" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25672839" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300027/v3_201803240409/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000003/v3_201803240409/S2341192918300027/v3_201803240409/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300027?idApp=UINPBA00004N" ]
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