Khan NE, et al. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004 Jan 1;350(1):21-8. [PMID 14702424]
- on pump vs off pump
- followed up at 3 months
- mean of 3 grafts -> on pump grafts had a significant increase in patency
Levin RL et al. Methylene blue reduces mortality and morbidity in vasoplegic patients after cardiac surgery. Ann Thorac Surg. 2004 Feb;77(2):496-9. [PMID 14759425]
- NO is a mediator involved in post cardiac surgery vasoplegia (SIRS)
- methylene blue (2mg/kg) vs placebo
- P P <0.05 considered significant
- n =
- vasoplegia defined as: hypotension, MAP <50mmHg, low filling pressures, CVP <5, normal or elevated cardiac index of > 2.5L/min/m2, low peripheral resistance <800 dyn/s/cm-5, vasopressor drug requirements
- exclusion criteria: off pump CABG, bacterial endocarditis, aortic dissection, urgent or emergency procedure
- those presenting with vasoplegic syndrome were randomized
- difference between groups – more arterial grafts done in control group (41 to 30)
- vasoplegic syndrome – 56/638 = 8.8%
- 28 methylene blue vs 28 placebo
- haemodynamic parameters the same prior to treatment
- dramatic resolution of vasoplegia!
- better outcomes in every area of study!
(ROOBY) Study Group. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009 Nov 5;361(19):1827-37.
- n = 2200
- randomised to on pump vs off pump
- primary short term outcomes: death, major complications (reoperation, new mechanical support, cardiac arrest, coma, stroke, renal failure requiring dialysis) within 30 days
- primary long-term outcomes: 1 year mortality, non-fatal MI @ 1 year, repeat revascularisation @ 1 year
- secondary endpoints: completeness of revascularisation, graft patency @ 1 year, neuropsychological test -> no difference in primary short term outcomes -> no difference in survival -> trend towards greater complications in off pump (primary long term) -> off pump group received less grafts then were originally planned -> off pump group grafts were less patent -> no difference in neuropsychological outcomes -> less transfusions in off pump group -> off pump: longer OT times, LOS same, time of ventilation same
- SUMMARY: better to due CABG on pump
Hajjar LA et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010 Oct 13;304(14):1559-67 [PMID 20940381]
- RCT (Brazil)
- n = 502
- restrictive (HCT > 30%) vs liberal transfusion strategy (HCT > 24%)
- non-inferiority study
- primary outcome = 30 day all cause mortality and severe morbidity (cardiogenic shock, ARDS, AKI + RRT)
- non-inferiority margin of 8%
- inclusion criteria: CABG and/or valve
- exclusion criteria: < 18 years, no bypass, emergency procedure, aortic procedures, LV aneurysm resection, inability to receive blood products, enrollment in another study, chronic anaemia, platelets < 150, coagulopathy, pregnancy, neoplasm, endocarditis, congenital heart defect, hepatic dysfunction, ESRF, refusal (basically: otherwise well, elective adults who are low risk) – from start of surgery to discharge from ICU
- weird stuff: -> EF and renal impairment not used in exclusion criteria -> blood bank gave those under going cardiac surgery young blood (do we do that?) -> etomidate for induction -> high O2 post (0.6 to 1.0 to keep SpO2 > 95%) -> no milrinone used -> given methylprednisolone 10mg/kg at induction (why?) -> aminocaproic acid rather than TXA2 -> no cell salvage -> intraoperative coagulopathy treated in our manner -> mannitol on pump -> anterograde plegia -> albumin and starch used intraoperatively -> respiratory complications defined as MV > 48 hours (this is pretty generous) -> assumed a 10% incidence in primary outcome (this is pretty generous -> the risk of death or severe morbidity is a lot less than 10% in low risk cardiac patients). -> no difference in FFP, platelets and cryoprecipitate use -> restrictive group: although transfused to a HCT > 24% -> Hb in this group was not less than 90! -> no leukodepletion
- results: -> Hb 105 (liberal group) and 91 (restrictive group) – significant difference -> they had a 10 and 11% primary event rate! Man that is high. -> no difference in primary end-point between groups -> number of transfused RBC’s was an independent risk factor for clinical complications or death @ 30 days (with a hazard ratio 1.2)
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.