- Email: [email protected]
Point of Care Management of Perioperative Coagulopathy Reduces Blood Loss and Consumption of Blood Transfusion Products (Preliminary Results)
S326
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
p=0.02) and lower hemoglobin (11.5 vs 12.3, p=0.002). At 12-months, FPF patients had lower hemoglobin (11.5 vs 12.2, p=0.01). There was no significant difference in freedom from CLAD, CLAD free survival, or overall survival between FPF and IPF. Most FPF patients did not have genetic testing, but a subset of FPF patients with established short telomere syndrome (n=6) were more likely to develop severe neutropenia (50% vs 15.5%, p=0.02) and had worse survival (p=0.045) than patients transplanted for sporadic IPF. Conclusion: Transplant for familial IPF has outcomes similar to sporadic IPF, but is associated with more cytopenia post-transplant. A subset of FPF with short telomere syndrome may have increased incidence of marrow failure and worse post-transplant survival than sporadic IPF. 812 Point of Care Management of Perioperative Coagulopathy Reduces Blood Loss and Consumption of Blood Transfusion Products (Preliminary Results) M. Durila,1 J. Vajter,1 R. Lischke,2 J. Berousek,1 and T. Vymazal.1 1Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University, Prague, Prague, Czech Republic; and the 2 3rd Department of Surgery, 1st Faculty of Medicine, Charles University, Motol University Hospital, Prague, Prague, Czech Republic. Purpose: Lung transplantation is very often accompanied with significant bleeding and coagulopathy. Standard perioperative management consists of administering fresh frozen plasma (FFP) and red blood cells. These transfusion products are generally administered according to anesthesiologist’s decision based on his personal experience. However, point of care (POC) monitoring of coagulopathy is available nowadays such as thrombolestometry (ROTEM), platelet function analyzer (PFA 200) and agregometry (Multiplate) to conduct administering of blood products or coagulation factors. The purpose of this study is to find out if POC management of bleeding and coagulopathy can reduce perioperative blood loss and consumption of blood products compared to standard approach. Methods: Eighteen patients undergoing bilateral lung transplantation were randomized into 2 groups (from January 2018). In the first group (9 patients), management of bleeding and coagulopathy was done by anesthesiologist based on his clinical experience - standard approach, in the second group (9 patients), management of bleeding and coagulopathy was based on results of POC methods such as ROTEM, PFA 200, Multiplate. Results: In POC group we found significantly reduced consumption of FFP and red blood cells during surgery and 24 hours after surgery. Also, perioperative blood loss was decreased in POC group comparing to standard approach group. Results are summarized in Table. Conclusion: Management of bleeding and coagulopathy based on results of POC methods such as ROTEM, PFA 200 and Multiplate significantly reduces consumption of blood products and decreases perioperative blood loss, despite a small number of patients.
Blood loss and blood transfusion products reduction Standard approach Blood loss during surgery (ml) FFP consumption during surgery (units) Red blood cells consumption during surgery (units) FFP consumption 24 hours after surgery (units) Red blood cells consumption 24 hours after surgery (units)
8300 33 17 7 6
POC approach 6250 0 7 0 2
813 Progression of Mitral Valve Regurgitation after Lung Transplantation W.Y. Shi, B. Levvey, A.D. Zimmet, S.F. Marasco, G. Snell and D.C. McGiffin. Alfred Hospital, Melbourne, Australia. Purpose: Development of early post-operative mitral valve regurgitation (MR) after lung transplantation is associated with substantial morbidity and may be an under-recognised phenomenon. Data is limited to single case reports only. We sought to review our centre’s experience.
Methods: From 1990 to 2018, 1330 patients underwent lung transplantation at our centre (1032 bilateral, 298 single). We identified patients in whom significant MR developed post-operatively. Clinical and investigative data were evaluated. Results: We identified 7 patients who developed severe MR post-lung transplantation. Five patients had undergone bilateral sequential lung transplantation while 2 underwent single right lung transplant Indications for transplantation were interstitial lung disease (ILD) in 4, chronic obstructive airways disease (COAD) in 2 and primary pulmonary arterial hypertension (PAH) in 1. Pre-operatively, 2 had trivial MR, 4 patients had mild, and 1 had moderate.. Three patients (2 ILD, 1 PAH) had pre-operative pulmonary hypertension with right ventricular dilatation and systolic dysfunction. Post-transplant MR was discovered intra-operatively in 2 patients, 4 were diagnosed within 6 months and one was diagnosed at 9 months post-transplant. Five patients underwent mitral valve surgery (2 repair, 3 replacement) between 1 day to 1.2 years post-transplant. One patient underwent transcatheter mitral valve repair at 3 months. Indications for mitral procedures were cardiogenic shock in 1, and progressive symptoms in the other 5. One patient had non-operative management of the mitral valve but required right pneumonectomy for graft necrosis. There were two mortalities at 5 and 13 years due to cancer and stroke respectively. Conclusion: Development of significant mitral valve regurgitation is a rare but morbid complication after lung transplantation. We postulate that this phenomenon may be related to changes in left ventricular geometry due to RV unloading after lung transplantation coupled with unmasking of mild degenerative mitral valve disease. As an increasing number of patients with PAH and ILD with RV dysfunction undergo lung transplantation, post-transplant MR should be recognised as a rare but hemodynamically important complication that may require intervention. 814 Alternative Therapeutic Approach for the Management of Symptomatic Hyperammonemia Syndrome after Lung Transplantation A.M. Emtiazjoo,1 S. Chandrashekaran,1 C. Lin,1 H. Alnuaimat,1 A. Shahmohammadi,1 A. Kamel,2 T. Veasey,2 T. Machuca,3 M. Pipkin,3 and A. Pelaez.1 1Medicine, University of Florida, Gainesville, FL; 2 Pharmacy, University of Florida, Gainesville, FL; and the 3Surgery, University of Florida, Gainesville, FL. Purpose: Symptomatic Hyperammonemia syndrome after Lung Transplantation (HSLT) is a fatal complication with a mortality rate exceeding 75%. The current management of HSLT consists of a multimodality approach that includes intravenous administration of an ammonia scavenger (Ammonul), with an estimated cost of $93,000 per day. Although the enteral formulation of an alternative ammonia scavenger (Buphenyl) costs far less, at $4,823 per day, its efficacy has not been established for treatment of HSLT. This study evaluated the efficacy of a multimodal approach to management of symptomatic HSLT using Buphenyl as a replacement for Ammonul (Table 1). Methods: This was a retrospective chart review analysis of patients who underwent lung transplantation at UFHealth Shands Hospital, from May 01, 2016 till September 30, 2018. Results: There were 129 lung transplants performed at UFHealth Shands Hospital during the study period. Six patients developed symptomatic HSLT and required treatment during this timeframe (Table 2). Fifty-percent developed severe neurological symptoms with hemodynamic instability and signs of multi-organ failure. The other 50% presented with altered mental status with no other systemic symptoms. One patient was treated with the Ammonul formula, and the remaining five patients were treated with the Buphenyl formula. All 6 patients were successfully treated with no reoccurrence of HSLT. Examination of etiological work-ups for HSLT, including urea cycle disorders, liver dysfunction, or infectious causes of HSLT were unrevealing. Conclusion: The use of Buphenyl, as an alternative to Ammonul, is safe, efficacious, and cost-effective. Early diagnosis and implementation of a multi-modal approach are crucial for successful management of HSLT.
The Journal of Heart and Lung Transplantation, Vol 38, No 4S, April 2019
p=0.02) and lower hemoglobin (11.5 vs 12.3, p=0.002). At 12-months, FPF patients had lower hemoglobin (11.5 vs 12.2, p=0.01). There was no significant difference in freedom from CLAD, CLAD free survival, or overall survival between FPF and IPF. Most FPF patients did not have genetic testing, but a subset of FPF patients with established short telomere syndrome (n=6) were more likely to develop severe neutropenia (50% vs 15.5%, p=0.02) and had worse survival (p=0.045) than patients transplanted for sporadic IPF. Conclusion: Transplant for familial IPF has outcomes similar to sporadic IPF, but is associated with more cytopenia post-transplant. A subset of FPF with short telomere syndrome may have increased incidence of marrow failure and worse post-transplant survival than sporadic IPF. 812 Point of Care Management of Perioperative Coagulopathy Reduces Blood Loss and Consumption of Blood Transfusion Products (Preliminary Results) M. Durila,1 J. Vajter,1 R. Lischke,2 J. Berousek,1 and T. Vymazal.1 1Anesthesiology and Intensive Care Medicine, Second Faculty of Medicine, Charles University, Prague, Prague, Czech Republic; and the 2 3rd Department of Surgery, 1st Faculty of Medicine, Charles University, Motol University Hospital, Prague, Prague, Czech Republic. Purpose: Lung transplantation is very often accompanied with significant bleeding and coagulopathy. Standard perioperative management consists of administering fresh frozen plasma (FFP) and red blood cells. These transfusion products are generally administered according to anesthesiologist’s decision based on his personal experience. However, point of care (POC) monitoring of coagulopathy is available nowadays such as thrombolestometry (ROTEM), platelet function analyzer (PFA 200) and agregometry (Multiplate) to conduct administering of blood products or coagulation factors. The purpose of this study is to find out if POC management of bleeding and coagulopathy can reduce perioperative blood loss and consumption of blood products compared to standard approach. Methods: Eighteen patients undergoing bilateral lung transplantation were randomized into 2 groups (from January 2018). In the first group (9 patients), management of bleeding and coagulopathy was done by anesthesiologist based on his clinical experience - standard approach, in the second group (9 patients), management of bleeding and coagulopathy was based on results of POC methods such as ROTEM, PFA 200, Multiplate. Results: In POC group we found significantly reduced consumption of FFP and red blood cells during surgery and 24 hours after surgery. Also, perioperative blood loss was decreased in POC group comparing to standard approach group. Results are summarized in Table. Conclusion: Management of bleeding and coagulopathy based on results of POC methods such as ROTEM, PFA 200 and Multiplate significantly reduces consumption of blood products and decreases perioperative blood loss, despite a small number of patients.
Blood loss and blood transfusion products reduction Standard approach Blood loss during surgery (ml) FFP consumption during surgery (units) Red blood cells consumption during surgery (units) FFP consumption 24 hours after surgery (units) Red blood cells consumption 24 hours after surgery (units)
8300 33 17 7 6
POC approach 6250 0 7 0 2
813 Progression of Mitral Valve Regurgitation after Lung Transplantation W.Y. Shi, B. Levvey, A.D. Zimmet, S.F. Marasco, G. Snell and D.C. McGiffin. Alfred Hospital, Melbourne, Australia. Purpose: Development of early post-operative mitral valve regurgitation (MR) after lung transplantation is associated with substantial morbidity and may be an under-recognised phenomenon. Data is limited to single case reports only. We sought to review our centre’s experience.
Methods: From 1990 to 2018, 1330 patients underwent lung transplantation at our centre (1032 bilateral, 298 single). We identified patients in whom significant MR developed post-operatively. Clinical and investigative data were evaluated. Results: We identified 7 patients who developed severe MR post-lung transplantation. Five patients had undergone bilateral sequential lung transplantation while 2 underwent single right lung transplant Indications for transplantation were interstitial lung disease (ILD) in 4, chronic obstructive airways disease (COAD) in 2 and primary pulmonary arterial hypertension (PAH) in 1. Pre-operatively, 2 had trivial MR, 4 patients had mild, and 1 had moderate.. Three patients (2 ILD, 1 PAH) had pre-operative pulmonary hypertension with right ventricular dilatation and systolic dysfunction. Post-transplant MR was discovered intra-operatively in 2 patients, 4 were diagnosed within 6 months and one was diagnosed at 9 months post-transplant. Five patients underwent mitral valve surgery (2 repair, 3 replacement) between 1 day to 1.2 years post-transplant. One patient underwent transcatheter mitral valve repair at 3 months. Indications for mitral procedures were cardiogenic shock in 1, and progressive symptoms in the other 5. One patient had non-operative management of the mitral valve but required right pneumonectomy for graft necrosis. There were two mortalities at 5 and 13 years due to cancer and stroke respectively. Conclusion: Development of significant mitral valve regurgitation is a rare but morbid complication after lung transplantation. We postulate that this phenomenon may be related to changes in left ventricular geometry due to RV unloading after lung transplantation coupled with unmasking of mild degenerative mitral valve disease. As an increasing number of patients with PAH and ILD with RV dysfunction undergo lung transplantation, post-transplant MR should be recognised as a rare but hemodynamically important complication that may require intervention. 814 Alternative Therapeutic Approach for the Management of Symptomatic Hyperammonemia Syndrome after Lung Transplantation A.M. Emtiazjoo,1 S. Chandrashekaran,1 C. Lin,1 H. Alnuaimat,1 A. Shahmohammadi,1 A. Kamel,2 T. Veasey,2 T. Machuca,3 M. Pipkin,3 and A. Pelaez.1 1Medicine, University of Florida, Gainesville, FL; 2 Pharmacy, University of Florida, Gainesville, FL; and the 3Surgery, University of Florida, Gainesville, FL. Purpose: Symptomatic Hyperammonemia syndrome after Lung Transplantation (HSLT) is a fatal complication with a mortality rate exceeding 75%. The current management of HSLT consists of a multimodality approach that includes intravenous administration of an ammonia scavenger (Ammonul), with an estimated cost of $93,000 per day. Although the enteral formulation of an alternative ammonia scavenger (Buphenyl) costs far less, at $4,823 per day, its efficacy has not been established for treatment of HSLT. This study evaluated the efficacy of a multimodal approach to management of symptomatic HSLT using Buphenyl as a replacement for Ammonul (Table 1). Methods: This was a retrospective chart review analysis of patients who underwent lung transplantation at UFHealth Shands Hospital, from May 01, 2016 till September 30, 2018. Results: There were 129 lung transplants performed at UFHealth Shands Hospital during the study period. Six patients developed symptomatic HSLT and required treatment during this timeframe (Table 2). Fifty-percent developed severe neurological symptoms with hemodynamic instability and signs of multi-organ failure. The other 50% presented with altered mental status with no other systemic symptoms. One patient was treated with the Ammonul formula, and the remaining five patients were treated with the Buphenyl formula. All 6 patients were successfully treated with no reoccurrence of HSLT. Examination of etiological work-ups for HSLT, including urea cycle disorders, liver dysfunction, or infectious causes of HSLT were unrevealing. Conclusion: The use of Buphenyl, as an alternative to Ammonul, is safe, efficacious, and cost-effective. Early diagnosis and implementation of a multi-modal approach are crucial for successful management of HSLT.