Daily Anesthesiology Research Analysis
Analyzed 66 papers and selected 3 impactful papers.
Summary
Analyzed 66 papers and selected 3 impactful articles.
Selected Articles
1. Integrating GFAP Testing With Clinical Scores for Prehospital Large Vessel Occlusion Detection in Patients With Acute Stroke (DETECT LVO).
Adding a prehospital point-of-care GFAP test to established LVO stroke scales significantly increased AUCs for predicting large vessel occlusion among 353 suspected stroke patients. This biomarker-plus-score approach may reduce mis-triage and expedite direct routing to endovascular-capable centers.
Impact: Demonstrates a pragmatic, scalable enhancement to prehospital stroke triage by combining a hemorrhage-excluding biomarker with LVO scales, improving accuracy where minutes matter.
Clinical Implications: EMS systems could incorporate point-of-care GFAP testing alongside LVO scales to better identify ischemic LVO and safely bypass non-endovascular centers. Protocols should be prospectively validated and adapted to local transport times and resources.
Key Findings
- Combining GFAP with LVO scores increased AUCs for LVO detection across five scales; for example, RACE AUC rose from 0.845 to 0.892 and FAST-ED from 0.859 to 0.899.
- Cohort included 353 suspected stroke patients; 101 ischemic strokes had LVOs confirmed by CT angiography.
- Approach leverages GFAP negativity to exclude intracerebral hemorrhage, refining the prehospital identification of likely LVO ischemic stroke.
Methodological Strengths
- Point-of-care biomarker measured prehospital with CT-angiographic reference standard for LVO.
- Evaluation across multiple validated LVO scales with AUC, sensitivity, and specificity comparisons.
Limitations
- Single-center retrospective analysis based on a prospective cohort; external validity uncertain.
- No prospective clinical outcome assessment (e.g., treatment times, functional outcomes) or real-time decision impact analysis.
Future Directions: Prospective multicenter trials integrating GFAP-guided triage should assess workflow impact, treatment times, and functional outcomes, and evaluate cost-effectiveness and thresholds for different EMS settings.
BACKGROUND: Clinical scores indicating large vessel occlusion (LVO) in acute stroke patients could streamline triage of patients with suspected LVO to endovascular centers. GFAP (glial fibrillary acidic protein) is a promising blood biomarker for indicating intracerebral hemorrhage in acute stroke. This study evaluates whether positive LVO score results combined with a prehospital negative GFAP test (thereby excluding intracerebral hemorrhage) could improve the accuracy of LVO detection. METHODS: This retrospective diagnostic accuracy study (DETECT LVO) is based on the prospective DETECT study (2022-2024, tertiary care hospital RKH Klinikum Ludwigsburg, Germany), which evaluated the rapid intracerebral hemorrhage detection in acute stroke, measuring prehospital plasma GFAP levels on a point-of-care platform (i-STAT Alinity Abbott). For DETECT LVO 5, established LVO scores (Rapid Arterial Occlusion Evaluation, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Emergency Medical Stroke Assessment, Cincinnati Prehospital Stroke Scale) were retrospectively calculated from paramedic protocols. LVOs were diagnosed with CT-angiography as follows: occlusion of the internal carotid artery, middle cerebral artery, and basilar artery. Diagnostic accuracy for LVO detection was determined using the area under the curve, sensitivity, specificity, positive predictive values, and negative predictive values. RESULTS: Three hundred fifty-three patients suspected of acute stroke (ischemic stroke, n=258; intracerebral hemorrhage, n=76; stroke mimics, n=19) with a mean age of 74.6 years were included. One hundred one patients with ischemic stroke suffered from LVO (internal carotid artery=23.8%; middle cerebral artery=64.4%; and basilar artery=11.9%). Integrating GFAP to LVO scores significantly increased area under the curve (95% CI) for LVO detection (Field Assessment Stroke Triage for Emergency Destination, 0.859 [0.818-0.893] to 0.899 [0.862-0.928]; Rapid Arterial Occlusion Evaluation, 0.845 [0.802-0.880] to 0.892 [0.855-0.923]; 3-Item Stroke Scale, 0.788, [0.741-0.829] to 0.865 [0.824-0.898]; Emergency Medical Stroke Assessment, 0.840 [0.796-0.875] to 0.870 [0.830-0.910]; Cincinnati Prehospital Stroke Scale, 0.827 [0.784-0.865] to 0.862 [0.821-0.896]; CONCLUSIONS: Integrating LVO scores combined with GFAP measurements into the prehospital work-up of patients with acute stroke improves diagnostic accuracy for LVO prediction. In the future, this could enable direct transfers of patients with suspected LVO to endovascular centers with reduced misdiagnosis rates. Independent replication in diverse prehospital cohorts is warranted to confirm these findings.
2. Postoperative reduction in thrombin generation induced by elevated levels of tissue factor pathway inhibitor in cardiac surgery: a prospective observational study.
In CPB cardiac surgery, TFPI levels were markedly elevated at the end of surgery, coinciding with reduced peak thrombin generation and prolonged whole-blood coagulation time. Neutralization experiments implicated TFPI as a mechanistic driver of impaired thrombin generation via factor Xa inhibition.
Impact: Provides mechanistic evidence linking post-CPB anticoagulant milieu to TFPI, informing targeted strategies for managing early postoperative coagulopathy beyond heparin reversal.
Clinical Implications: Persistent hypocoagulability after heparin reversal may be driven by elevated TFPI; viscoelastic and thrombin generation-guided hemostatic management could be tailored, and TFPI-targeted approaches warrant exploration.
Key Findings
- At the end of surgery, TFPI increased to 54 ng/mL (median) from 18 ng/mL preoperatively (P < 0.001) while peak thrombin generation decreased to 98.1 nM from 268 nM (P < 0.001).
- TFPI correlated positively with whole-blood coagulation time (Rs = 0.643) and negatively with peak thrombin generation (Rs = -0.624).
- Anti-TFPI antibody neutralized the reduction in peak thrombin generation, implicating TFPI causally in impaired thrombin generation post-CPB.
Methodological Strengths
- Prospective perioperative sampling at predefined time points with multimodal coagulation assessment (TG assay and dielectric coagulometry).
- Mechanistic neutralization using anti-TFPI antibody strengthens causal inference.
Limitations
- Single-center study with unspecified sample size in abstract, limiting precision and generalizability.
- Clinical outcome correlations (e.g., bleeding, transfusion) were not reported.
Future Directions: Quantify TFPI dynamics across larger cohorts, link to bleeding/transfusion outcomes, and test TFPI-modulating strategies in postoperative hemostasis algorithms.
PURPOSE: Tissue factor pathway inhibitor (TFPI) is an intrinsic anticoagulant factor, and its plasma concentration is elevated by heparin administration. Because several hours are required to return to normal range after heparin reversal, we investigated the role of TFPI in the inhibition of thrombin generation (TG) in patients undergoing cardiac surgery. METHODS: Blood samples were collected from adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) before, at the end of, and 1 day after surgery. Plasma concentration of TFPI, peak height of the TG assay (peak TG), and whole blood coagulation time by dielectric blood coagulometry using a Russell's viper venom cartridge system were evaluated. Nonparametric correlation was evaluated using Spearman's method, and time-dependent change was analyzed using repeated measures analysis of variance. RESULTS: The plasma concentration of TFPI was higher (54 [47-60] ng/mL vs. 18 [13-27] ng/mL; P < 0.001) and the peak TG value was lower (98.1 [48.9-148] nM vs. 268 [244-309]; P < 0.001) at the end of surgery than before surgery. Plasma TFPI concentration showed a positive correlation with whole blood coagulation time as measured by dielectric blood coagulometry (Rs = 0.643) and a negative correlation with peak TG (Rs = - 0.624). Anti-TFPI antibody neutralized reduction in peak TG. CONCLUSIONS: In patients undergoing cardiac surgery using CPB, the increase in plasma TFPI concentration at the end of surgery causes a reduction in TG and impairment of whole blood coagulation via a mechanism that includes inhibition of factor Xa activity.
3. Severe post-operative bleeding after heart transplantation.
In 446 adult heart transplant recipients, 25% experienced severe postoperative bleeding (UDPB ≥3). Independent predictors included long-term mechanical circulatory support, lower preoperative hemoglobin, and longer CPB duration; severe bleeding nearly doubled adjusted 1-year mortality.
Impact: Defines incidence, risk factors, and prognostic impact of severe bleeding after heart transplantation—critical information for perioperative planning in a high-risk population.
Clinical Implications: Preoperative optimization of hemoglobin, minimizing CPB duration, and tailored hemostatic strategies are priorities, especially in recipients bridged with mechanical circulatory support.
Key Findings
- Severe postoperative bleeding occurred in 25% (112/446) of heart transplant recipients using UDPB ≥3.
- Independent predictors: long-term mechanical cardiac support (adjOR 2.21), lower preoperative hemoglobin (adjOR 0.85 per unit), and longer CPB duration (adjOR 1.08 per 10 minutes).
- Severe bleeding was associated with higher 1-year mortality (adjusted HR 1.91; 35% vs 13%).
Methodological Strengths
- Two-center cohort with comprehensive multivariable modeling including time-to-event analysis for mortality.
- Use of standardized bleeding definition (UDPB) enhances comparability.
Limitations
- Observational design susceptible to residual confounding; prevention strategies not tested.
- Practice patterns may vary between centers and over time (2015–2022), potentially affecting generalizability.
Future Directions: Design multicenter prospective studies to test targeted bleeding prevention bundles in high-risk subgroups, and validate predictive models incorporating MCS, hemoglobin, and CPB time.
BACKGROUND: Post-operative bleeding is frequent in cardiac surgery, but its incidence, risk factors and consequences remain largely unknown after heart transplantation. The main objective of this study was to describe the incidence of severe bleeding complications after adult heart transplantation. METHODS: We conducted an observational study including all adult patients who received a heart transplant between 2015 and 2022, in two French referral centers. The primary endpoint was the incidence of severe bleeding complications defined by a UDPB score ≥ 3 (Universal Definition of Perioperative Bleeding). Multivariable logistic regression was used to identify variables associated with the incidence of severe post-operative bleeding. The impact of severe post-operative bleeding on one-year mortality was evaluated using a multivariable Cox regression model. RESULTS: Among the 446 patients included, 112 (25%) developed severe bleeding. In multivariable analysis, long-term mechanical cardiac support (adjOR 2.21 [1.01-4.88]), preoperative hemoglobin (adjOR 0.85 [0.76-0.95]) and the duration of CPB (per 10min increase, adjOR=1.08 [1.03-1.15]) were associated with severe bleeding. Severe postoperative bleeding was associated with an increased mortality at one-year (35% vs 13%, p<0.001), with an adjusted HR of 1.91 (95% CI, 1.18-3.09, p=0.008). CONCLUSIONS: This study reports a high incidence of severe hemorrhagic complications following heart transplantation, particularly in patients with mechanical circulatory support. Bleeding complications were associated with a significant increase in morbidity and mortality. Larger-scale studies are needed to identify and evaluated potential prevention strategies.