Publications by authors named "Evan Pivalizza"

80 Publications

Adult liver transplant anesthesiology practice patterns and resource utilization in the United States: Survey results from the society for the advancement of transplant anesthesia.

Clin Transplant 2021 Oct 12:e14504. Epub 2021 Oct 12.

Department of Anesthesiology, University of Colorado, Aurora, CO.

Introduction: Liver transplant anesthesiology is an evolving and expanding subspecialty, and programs have, in the past, exhibited significant variations of practice at transplant centers across the United States. In order to explore current practice patterns, the Quality & Standards Committee from the Society for the Advancement of Transplant Anesthesia (SATA) undertook a survey of liver transplant anesthesiology program directors.

Methods: Program directors were invited to participate in an online questionnaire. A total of 110 program directors were identified from the 2018 Scientific Registry of Transplant Recipients (SRTR) database. Replies were received from 65 programs (response rate of 59%).

Results: Our results indicate an increase in transplant anesthesia fellowship training and advanced training in transesophageal echocardiography (TEE). We also find that the use of intraoperative TEE and viscoelastic testing is more common. However, there has been a reduction in the use of veno-venous bypass, routine placement of pulmonary artery catheters and the intraoperative use of anti-fibrinolytics when compared to prior surveys.

Conclusion: The results show considerable heterogeneity in practice patterns across the country that continues to evolve. However, there appears to be a movement towards the adoption of specific structural and clinical practices. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/ctr.14504DOI Listing
October 2021

What proceduralists need to know about emicizumab for patients with hemophilia A.

Proc (Bayl Univ Med Cent) 2020 Dec 14;34(2):334-335. Epub 2020 Dec 14.

Department of Hematology, UTHealth McGovern Medical School, Houston, Texas.

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http://dx.doi.org/10.1080/08998280.2020.1851628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901412PMC
December 2020

Fluid Management During Kidney Transplantation: A Consensus Statement of the Committee on Transplant Anesthesia of the American Society of Anesthesiologists.

Transplantation 2021 08;105(8):1677-1684

UTHealth McGovern Medical School, Houston, TX.

Background: Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients.

Methods: Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence.

Results: Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status.

Conclusions: These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.
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http://dx.doi.org/10.1097/TP.0000000000003581DOI Listing
August 2021

Anesthesiology Resident Performance on the US Medical Licensing Examination Predicts Success on the American Board of Anesthesiology BASIC Staged Examination: An Observational Study.

J Educ Perioper Med 2020 Jul-Sep;22(3):E646. Epub 2020 Jul 1.

Background: Correlation has been found between the US Medical Licensing Examination (USMLE) Step 1 examination results and anesthesiology resident success on American Board of Anesthesiology (ABA) examinations. In 2014, the ABA instituted the BASIC examination at the end of the postgraduate year-2 year. We hypothesized a similar predictive value of USMLE scores on BASIC examination success.

Methods: After the Committee for the Protection of Human Subjects at UTHealth Institutional Review Board approved and waived written consent, we retrospectively evaluated USMLE Step examination performance on first-time BASIC examination success in a single academic department from 2014-2018.

Results: Over 5 years, 120 residents took the ABA BASIC examination and 108 (90%) passed on the first attempt. Ten of 12 first-time failures were successful on repeat examination but analyzed in the failure group. Complete data was available for 92 residents (76.7%), with absent scores primarily reflecting osteopathic graduates who completed Comprehensive Osteopathic Medical Licensing Examination of the United States level examinations rather than USMLE. In the failure cohort, all 3 USMLE examination step scores were lower ( < .02). USMLE Step 1 score independently predicted success on the BASIC examination (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.17, < .001). Although USMLE Step 2 score predicted BASIC examination success (OR 1.10, 95% CI 1.04-1.18, = .001), this did not remain after adjustment for Step 1 score using multiple logistic regression ( = .11). In multivariable logistical regression, first clinical anesthesia in-training examination score and USMLE Step 1 score were significant for predictors of success on the BASIC exam.

Conclusions: In anesthesiology residency training, our preliminary single-center data is the first to suggest that USMLE Step 1 performance could be used as a predictor of success on the recently introduced ABA BASIC Examination. These findings do not support recent action to change USMLE scoring to a pass/fail report.
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http://dx.doi.org/10.46374/volxxii-issue3-MarkhamDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7664601PMC
July 2020

Moderate Intraoperative Use of Hydroxyethyl Starch Solutions Is Safe.

Authors:
Evan G Pivalizza

Anesth Analg 2020 03;130(3):e95

Department of Anesthesiology, UTHealth McGovern Medical School, Houston, Texas,

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http://dx.doi.org/10.1213/ANE.0000000000004572DOI Listing
March 2020

Uncertainty and Certainty: Comment.

Authors:
Evan G Pivalizza

Anesthesiology 2020 12;133(6):1311

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http://dx.doi.org/10.1097/ALN.0000000000003564DOI Listing
December 2020

Plasma Volume and Cardiac Surgery: Is TEG R-Time a Better Indicator Than the INR?

J Cardiothorac Vasc Anesth 2020 11 3;34(11):3167. Epub 2020 Jul 3.

Department of Anesthesiology, UTHealth McGovern Medical School, Houston, TX.

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http://dx.doi.org/10.1053/j.jvca.2020.06.080DOI Listing
November 2020

Thrombelastograph Platelet Mapping During Hyperfibrinolysis.

J Cardiothorac Vasc Anesth 2020 Jun 16;34(6):1708-1710. Epub 2019 Dec 16.

UTHealth McGovern Medical School, Houston, TX.

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http://dx.doi.org/10.1053/j.jvca.2019.12.010DOI Listing
June 2020

Service Requirements of Liver Transplant Anesthesia Teams: Society for the Advancement of Transplant Anesthesia Recommendations.

Liver Transpl 2020 04 10;26(4):582-590. Epub 2020 Mar 10.

Department of Anesthesiology, University of Colorado, Aurora, CO.

There are disparities in liver transplant anesthesia team (LTAT) care across the United States. However, no policies address essential resources for liver transplant anesthesia services similar to other specialists. In response, the Society for the Advancement of Transplant Anesthesia appointed a task force to develop national recommendations. The Conditions of Transplant Center Participation were adapted to anesthesia team care and used to develop Delphi statements. A Delphi panel was put together by enlisting 21 experts from the fields of liver transplant anesthesiology and surgery, hepatology, critical care, and transplant nursing. Each panelist rated their agreement with and the importance of 17 statements. Strong support for the necessity and importance of 13 final items were as follows: resources, including preprocedure anesthesia assessment, advanced monitoring, immediate availability of consultants, and the presence of a documented expert in liver transplant anesthesia credentialed at the site of practice; call coverage, including schedules to assure uninterrupted coverage and methods to communicate availability; and characteristics of the team, including membership criteria, credentials at the site of practice, and identification of who supervises patient care. Unstructured comments identified competing time obligations for anesthesia and transplant services as the principle reason that the remaining recommendations to attend integrative patient selection and quality review committees were reduced to a suggestion rather than being a requirement. This has important consequences because deficits in team integration cause higher failure rates in service quality, timeliness, and efficiency. Solutions are needed that remove the time-related financial constraints of competing service requirements for anesthesiologists. In conclusion, using a modified Delphi technique, 13 recommendations for the structure of LTATs were agreed upon by a multidisciplinary group of experts.
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http://dx.doi.org/10.1002/lt.25711DOI Listing
April 2020

Comparison of temporal artery temperature and bladder temperature in the postanesthesia care unit.

Proc (Bayl Univ Med Cent) 2019 Oct 15;32(4):502-504. Epub 2019 Jul 15.

Department of Anesthesiology, University of Texas McGovern Medical SchoolHoustonTexas.

To verify that temporal artery (TA) temperature measured in the postanesthesia care unit (PACU) in noncardiac surgical patients is a valid reflection of core temperature, a prospective, observational, institutional review board-approved study was conducted in a large, academic tertiary care hospital. The study developed from an initial quality improvement project. A total of 276 patients who had an indwelling bladder catheter as standard of care were enrolled when a research student was available over a 6-month period in 2015. Infrared TA temperature was measured (average of three readings) simultaneously with bladder temperature on PACU arrival. Mean temperature in the bladder and TA groups was >36°C with a clinically negligible difference (0.125°C; 90% confidence interval, 0.059-0.192). Agreement between bladder and TA temperatures, as well as between bladder and last operating room temperatures, was >95% by Bland-Altman analysis. A properly performed TA temperature measure on PACU arrival is an acceptable representation of core temperature for purposes of quality assessment, patient comfort, and regulatory requirements.
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http://dx.doi.org/10.1080/08998280.2019.1624097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6793965PMC
October 2019

Gender Distribution in Professional Anesthesiology Activities.

Anesth Analg 2019 11;129(5):e179-e180

Department of Anesthesiology, UTHealth McGovern Medical School, Houston, Texas,

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http://dx.doi.org/10.1213/ANE.0000000000004423DOI Listing
November 2019

Objective Epidural Space Identification Using Continuous Real-Time Pressure Sensing Technology: A Randomized Controlled Comparison With Fluoroscopy and Traditional Loss of Resistance.

Anesth Analg 2019 11;129(5):1319-1327

Department of Restorative Dentistry, Stony Brook School of Dental Medicine, New York, New York.

Background: Performance of epidural anesthesia and analgesia depends on successful identification of the epidural space (ES). While multiple investigations have described objective and alternative methodologies to identify the ES, traditional loss of resistance (LOR) and fluoroscopy (FC) are currently standard of care in labor and delivery (L&D) and chronic pain (CP) management, respectively. While FC is associated with high success, it exposes patients to radiation and requires appropriate radiological equipment. LOR is simple but subjective and consequently associated with higher failure rates. The purpose of this investigation was to compare continuous, quantitative, real-time, needle-tip pressure sensing using a novel computer-controlled ES identification technology to FC and LOR for lumbar ES identification.

Methods: A total of 400 patients were enrolled in this prospective randomized controlled noninferiority trial. In the CP management arm, 240 patients scheduled to receive a lumbar epidural steroid injection had their ES identified either with FC or with needle-tip pressure measurement. In the L&D arm, 160 female patients undergoing lumbar epidural catheter placements were randomized to either LOR or needle-tip pressure measurement. Blinded observers determined successful ES identification in both arms. A modified intention-to-treat protocol was implemented, with patients not having the procedure for reasons preceding the intervention excluded. Noninferiority of needle-tip pressure measurement regarding the incidence of successful ES identification was claimed when the lower limit of the 97.27% confidence interval (CI) for the odds ratio (OR) was above 0.50 (50% less likely to identify the ES) and P value for noninferioirty <.023.

Results: Demographics were similar between procedure groups, with a mild imbalance in relation to gender when evaluated through a standardized difference. Noninferiority of needle-tip pressure measurement was demonstrated in relation to FC where pain management patients presented a 100% success rate of ES identification with both methodologies (OR, 1.1; 97.27% CI, 0.52-8.74; P = .021 for noninferiority), and L&D patients experienced a noninferior success rate with the novel technology (97.1% vs 91%; OR, 3.3; 97.27% CI, 0.62-21.54; P = .019) using a a priori noninferiority delta of 0.50.

Conclusions: Objective lumbar ES identification using continuous, quantitative, real-time, needle-tip pressure measurement with the CompuFlo Epidural Computer Controlled Anesthesia System resulted in noninferior success rates when compared to FC and LOR for CP management and L&D, respectively. Benefits of this novel technology may include nonexposure of patients to radiation and contrast medium and consequently reduced health care costs.
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http://dx.doi.org/10.1213/ANE.0000000000003873DOI Listing
November 2019

Evaluation and control of waste anesthetic gas in the postanesthesia care unit within patient and caregiver breathing zones.

Proc (Bayl Univ Med Cent) 2019 Jan 20;32(1):43-49. Epub 2018 Dec 20.

Department of Anesthesiology, Critical Care, and Pain Medicine, The University of Texas MD Anderson Cancer CenterHoustonTexas.

This study (NCT02428413) evaluated waste anesthetic gas (WAG) in the postanesthesia care unit (PACU) and assessed the utility of the ISO-Gard mask in reducing nursing exposure to WAG. We hypothesized that WAG levels in the patient's breathing zone upon recovery would exceed the recommended levels, leading to increased exposure of the PACU nurses, with use of the ISO-Gard mask limiting this exposure. A total of 125 adult patients were recruited to participate. Patients were randomized to receive the standard oxygen delivery mask or the ISO-Gard face mask postoperatively. Continuous particulate concentrations were measured using infrared spectrophotometers placed within the patients' and nurses' 6-inch breathing zone. Maximum WAG measurements were obtained every 30 seconds, and the duration of maximum WAG >2 ppm and its proportion relative to the total collection period were calculated. We observed a statistically significant difference in desflurane duration and proportion of maximum WAG >2 ppm in both patient and PACU nurse breathing zones. Therefore, patients and PACU nurses using routine care were exposed to WAG levels >2 ppm during the 1-hour postoperative period, and the ISO-Gard mask effectively reduced the amount of WAG detected in the immediate 1-hour postoperative recovery phase.
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http://dx.doi.org/10.1080/08998280.2018.1502017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442871PMC
January 2019

Use of Thrombelastography as a global monitor of hemostasis.

Authors:
Evan G Pivalizza

Transfusion 2019 02;59(2):825

Department of Anesthesiology, UTHealth McGovern Medical School - Houston, Houston, Texas.

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http://dx.doi.org/10.1111/trf.15092DOI Listing
February 2019

The Anesthesiologist's Response to Hurricane Natural Disaster Incidents: Hurricane Harvey.

Anesthesiol Clin 2019 Mar 19;37(1):151-160. Epub 2018 Dec 19.

Department of Anesthesiology, University of Texas McGovern Medical School, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA. Electronic address:

From personal experience and available resources, such as the American Society of Anesthesiologists Committee on Trauma and Emergency Preparedness templates from the manual for department procedures, the authors describe the primarily flooding impact of Hurricane Harvey in their area of Texas. They review the necessary analysis, development, and implementation of logistics; staffing and relief models; coordination with hospital partners; and dissemination of the planned procedures. The authors emphasize the commitment of anesthesiologists to patient care and rescue efforts outside of the operating room.
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http://dx.doi.org/10.1016/j.anclin.2018.09.005DOI Listing
March 2019

Association and Effect of Opioid Abuse-Related Readmission.

Authors:
Evan G Pivalizza

Anesthesiology 2019 01;130(1):174

UTHealth McGovern Medical School, Houston, Texas.

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http://dx.doi.org/10.1097/ALN.0000000000002497DOI Listing
January 2019

Limitation of the Internationalized Normalized Ratio in Guiding Perioperative Plasma Transfusion.

Anesth Analg 2019 01;128(1):e14

Department of Anesthesiology, UTHealth McGovern Medical School, Houston, Texas,

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http://dx.doi.org/10.1213/ANE.0000000000003899DOI Listing
January 2019

In Response.

Anesth Analg 2018 12;127(6):e106-e107

Department of Anesthesiology, UT Health McGovern Medical School, Houston, Texas, Gulf Coast Regional Blood Center, Houston, Texas Department of Surgery, UT Health McGovern Medical School, Houston, Texas.

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http://dx.doi.org/10.1213/ANE.0000000000003792DOI Listing
December 2018

Anesthesia Duration Does Not Exist in a Surgical Vacuum.

Authors:
Evan G Pivalizza

JAMA Facial Plast Surg 2018 12;20(6):525

Department of Anesthesiology, University of Texas McGovern Medical School, Houston.

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http://dx.doi.org/10.1001/jamafacial.2018.1123DOI Listing
December 2018

More on Fatigue Mitigation for Anesthesiology Residents.

Anesth Analg 2018 08;127(2):e32

Department of Anesthesiology, University of Texas McGovern Medical School, Houston, Texas,

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http://dx.doi.org/10.1213/ANE.0000000000003518DOI Listing
August 2018

Whole Blood for Resuscitation in Adult Civilian Trauma in 2017: A Narrative Review.

Anesth Analg 2018 07;127(1):157-162

Surgery, University of Texas Health McGovern Medical School, Houston, Texas.

After a hiatus of several decades, the concept of cold whole blood (WB) is being reintroduced into acute clinical trauma care in the United States. Initial implementation experience and data grew from military medical applications, followed by more recent development and data acquisition in civilian institutions. Anesthesiologists, especially those who work in acute trauma facilities, are likely to be presented with patients either receiving WB from the emergency department or may have WB as a therapeutic option in massive transfusion situations. In this focused review, we briefly discuss the historical concept of WB and describe the characteristics of WB, including storage, blood group compatibility, and theoretical hemolytic risks. We summarize relevant recent retrospective military and preliminary civilian efficacy as well as safety data related to WB transfusion, and describe our experience with the initial implementation of WB transfusion at our level 1 trauma hospital. Suggestions and collective published experience from other centers as well as ours may be useful to those investigating such a program. The role of WB as a significant therapeutic option in civilian trauma awaits further prospective validation.
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http://dx.doi.org/10.1213/ANE.0000000000003427DOI Listing
July 2018

Dramatic change in cerebral oximetry during liver transplantation.

Proc (Bayl Univ Med Cent) 2018 Apr 8;31(2):185-186. Epub 2018 Feb 8.

Department of Anesthesiology, University of Texas McGovern Medical School, Houston, Texas.

We report dramatic changes in bilateral cerebral tissue oxygenation in a patient undergoing an orthotopic liver transplant coincident with clamping and subsequent restoration of flow through the inferior vena cava. Although hemodynamic stability was maintained with low-dose vasopressor support, cardiac output was decreased, suggesting preload dependence of the measured cerebral oxygenation. Further investigation is warranted in patients with end-stage liver disease and interruption of venous return.
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http://dx.doi.org/10.1080/08998280.2017.1416238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5914474PMC
April 2018

Perioperative Coagulation Management in Liver Transplant Recipients.

Transplantation 2018 04;102(4):578-592

Department of Anesthesiology, University of Tennessee, Memphis, TN.

We review contemporary coagulation management for patients undergoing liver transplantation. A better understanding of the complex physiologic changes that occur in patients with end-stage liver disease has resulted in significant advances in anesthetic and coagulation management. A group of internationally recognized experts have critically evaluated current approaches for coagulopathy detection and management. Strategies for blood component and factor replacement have been evaluated and recommended therapies proposed. Pharmacologic treatment and prevention of coagulopathy, management of patients receiving antiplatelet medications, and the role of transesophageal echocardiography for early detection and management of thromboses are presented.
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http://dx.doi.org/10.1097/TP.0000000000002092DOI Listing
April 2018

The New Kidney Donor Allocation System and Implications for Anesthesiologists.

Semin Cardiothorac Vasc Anesth 2018 Jun 4;22(2):223-228. Epub 2017 Sep 4.

1 UTHealth McGovern Medical School, Houston, TX, USA.

Given potential disparity and limited allocation of deceased donor kidneys for transplantation, a new federal kidney allocation system was implemented in 2014. Donor organ function and estimated recipient survival in this system has implications for perioperative management of kidney transplant recipients. Early analysis suggests that many of the anticipated goals are being attained. For anesthesiologists, implications of increased dialysis duration and burdens of end-stage renal disease include increased cardiopulmonary disease, challenging fluid, hemodynamic management, and central vein access. With no recent evidence to guide anesthesia care within this new system, we describe the kidney allocation system, summarize initial data, and briefly review organ systems of interest to anesthesiologists. As additional invasive and echocardiographic monitoring may be indicated, one consideration may be development of a dedicated anesthesiology team experienced in management and monitoring of complex patients, in a similar manner as has been done for liver transplant recipients.
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http://dx.doi.org/10.1177/1089253217728128DOI Listing
June 2018

Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist.

Anesth Analg 2017 09;125(3):884-890

From the Departments of *Anesthesiology and †Surgery, University of Texas McGovern Medical School-Houston, Houston, Texas.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technique that allows for temporary occlusion of the aorta in patients with severe, life-threatening, trauma-induced noncompressible hemorrhage arising below the diaphragm. REBOA utilizes a transfemoral balloon catheter inserted in a retrograde fashion into the aorta to provide inflow control and support blood pressure until definitive hemostasis can be achieved. Initial retrospective and registry clinical data in the trauma surgical literature demonstrate improvement in systolic blood pressure with balloon inflation and improved survival compared to open aortic cross-clamping via resuscitative thoracotomy. However, there are no significant reports of anesthetic implications and perioperative management in this challenging cohort. In this narrative, we review the principles, technique, and logistics of REBOA deployment, as well as initial clinical outcome data from our level-1 American College of Surgeons-verified trauma center. For anesthesiologists who may not yet be familiar with REBOA, we make several suggestions and recommendations for intraoperative management based on extrapolation from these initial surgical-based reports, opinions from a team with increasing experience, and translated experience from emergency aortic vascular surgical procedures. Further prospective data will be necessary to conclusively guide anesthetic management, especially as potential complications and implications for global organ function, including cerebral and renal, are recognized and described.
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http://dx.doi.org/10.1213/ANE.0000000000002150DOI Listing
September 2017

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery.

Paediatr Anaesth 2017 Feb 30;27(2):181-189. Epub 2016 Nov 30.

Department of Anesthesiology, The University of Texas Medical School, Houston, TX, USA.

Background: Functional Fibrinogen assay of the Thromboelastography (FFTEG), a whole blood viscoelastic hemostatic assay, has been used to estimate fibrinogen levels in adult patients undergoing major surgery but its performance in pediatric patients undergoing cardiac surgery requires evaluation. In this study, we evaluate the correlation between FFTEG parameters and standard laboratory tests for fibrinogen and platelet counts before and after cardiopulmonary bypass in children undergoing repair for congenital heart disease.

Methods: In this prospective observational study, whole blood samples were obtained from children less than 5 years of age undergoing congenital heart surgery with cardiopulmonary bypass before surgical incision and immediately after administration of protamine. Blood samples were analyzed for Thromboelastography, Functional Fibrinogen level measured by FFTEG (FLEV), complete blood counts with platelet count and plasma fibrinogen assay (LFib, Clauss). The primary outcome of this study was to assess the correlation between FFTEG parameters, LFib and platelet counts in neonates, infants, and small children less than 5 years old. Additionally, we studied if postbypass FFTEG parameters could predict critical thresholds of hypofibrinogenemia LFib ≤200 mg·dl .

Results: One hundred and five children (22 neonates, 51 infants, and 32 small children) were included in the final analysis. FLEV estimated higher fibrinogen levels than LFib in all patients. Before bypass, FLEV was on average 133 mg·dl higher than LFib (95% confidence interval, CI, 116-150, P < 0.001) for all the patients; after bypass, FLEV was 48 mg·dl (95% CI: 37-59, P < 0.001) higher than LFib for all the patients. Linear correlation coefficients between FLEV and LFib in all patients were R = 0.41 (95% CI: 0.24-0.56, P < 0.001) before bypass and increased to R = 0.63 (95% CI: 0.51-0.74, P < 0.001) after bypass. Bland Altman analysis performed on postbypass values of FLEV and LFib showed a positive bias of FLEV in estimation of LFib. The magnitude and the variability of the bias for all the patients group was decreased with lower mean of the difference of FLEV and LFib when the average values of FLEV and LFib were <200 mg·dl . Low linear correlations were noticed between maximal amplitude of platelet contribution to FFTEG and platelet counts both before and after bypass. For predicting the clinical thresholds of postbypass hypofibrinogenemia at plasma fibrinogen levels ≤200 mg·dl , FLEV and maximal amplitude of the fibrinogen clot generated area under receiver operative curves at 0.90 (95% CI = 0.76-1.0) in neonates, 0.6 (95% CI- 0.42-0.78) in infants, and 0.97 (95% CI = 0.91-1.0) in small children. Based on the receiver operative curves, values of postbypass hypofibrinogenemia with LFib ≤200 g·dl corresponded to cutoffs of FLEV ≤245 mg·dl and maximal amplitude of the fibrinogen clot ≤13.4 mm.

Conclusion: In pediatric patients undergoing cardiac surgery, FLEV derived from Functional Fibrinogen correlated linearly with plasma fibrinogen levels (Clauss) both before and after CPB. FLEV estimation of plasma fibrinogen was improved after CPB in neonates, infants, and small children. After CPB, FFTEG can be used to predict laboratory diagnosis of critical hypofibrinogenemia (≤200 mg·dl ) during pediatric cardiac surgery. Further studies are required to assess the impact of predictability of FFTEG on component transfusion during pediatric cardiac surgery.
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http://dx.doi.org/10.1111/pan.13048DOI Listing
February 2017
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