A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients.

Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy.

Materials And Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements.

Validation of a Point-of-Care Analyzer for Determining Anticoagulation Status During Air Transport.

Objective: We evaluated a point-of-care prothrombin time (PT)/international normalized ratio (INR) cartridge-based analyzer for its feasibility, accuracy, and value in critical care air transport.

Methods: In this prospective study, blood samples from 10 randomly selected adult patients were tested with the cartridge during transport to determine feasibility. The cartridge results were compared with the laboratory results for the same samples.

Looking Under the Streetlight? A Framework for Differentiating Performance Measures by Level of Care in a Value-Based Payment Environment.

The majority of quality measures used to assess providers and hospitals are based on easily obtained data, focused on a few dimensions of quality, and developed mainly for primary/community care and population health. While this approach supports efforts focused on addressing the triple aim of health care, many current quality report cards and assessments do not reflect the breadth or complexity of many referral center practices.In this article, the authors highlight the differences between population health efforts and referral care and address issues related to value measurement and performance assessment.

Relation of Activated Clotting Times During Percutaneous Coronary Intervention to Outcomes.

Monitoring anticoagulation using the activated clotting time (ACT) in patients treated with heparin and undergoing percutaneous coronary intervention (PCI) is one of the most frequently used tests in invasive cardiology. However, despite its widespread use and guideline endorsement, uncertainty remains regarding the association of ACT with outcomes in contemporary practice. We reviewed all PCI procedures performed at the Mayo Clinic (Rochester, Minnesota) from October 2001 to December 2012 and evaluated the association between the ACT before device activation and in-hospital and 1-year outcomes.

Inclusion of short-term care patients affects the perceived performance of specialists: a retrospective cohort study.

Background: Current publicly reported quality performance measures directly compare primary care to specialty care. Specialists see short-term patients referred due to poor control of their disease who then return to their local provider. Our study looked to determine if outcomes measured in short-term care patients differed from those in long-term care patients and what impact those differences may have on quality performance profiles for specialists.

Widely used track and trigger scores: are they ready for automation in practice?

Introduction: Early Warning Scores (EWS) are widely used for early recognition of patient deterioration. Automated alarm/alerts have been recommended as a desirable characteristic for detection systems of patient deterioration. We undertook a comparative analysis of performance characteristics of common EWS methods to assess how they would function if automated.

Fresh and citrated whole-blood specimens can produce different thromboelastography results in patients on extracorporeal membrane oxygenation.

Objectives: To compare thromboelastography (TEG) tracings obtained from fresh and citrated whole-blood samples in patients on extracorporeal membrane oxygenation (ECMO) or after cardiopulmonary bypass and in healthy volunteers.

Methods: Samples of fresh and citrated whole blood were analyzed for 25 patients and 4 healthy volunteers. Thromboelastography analysis was performed in both plain and heparinase cups.

Treatment of chronic tendinopathy with ultrasound-guided needle tenotomy and platelet-rich plasma injection.

Objective: To determine whether ultrasound (US)-guided percutaneous needle tenotomy followed by a platelet-rich plasma (PRP) injection would result in pain reduction, functional improvement, or structural alterations in patients with chronic, recalcitrant tendinopathy.

Design: Part A was a retrospective observational study. Part B was a prospective observational study.

Use of an autologous blood recovery system during emergency pericardiocentesis in the electrophysiology laboratory.

Introduction: Emergency pericardiocentesis during electrophysiology procedures is often associated with significant aspiration of pericardial blood, requiring transfusion. We sought to assess the feasibility of urgent use of an autologous blood recovery system in the electrophysiology laboratory to autotransfuse blood aspirated from the pericardium.

Methods And Results: We retrospectively analyzed Mayo Clinic electrophysiology records for patients who had ablation procedure-related pericardial effusions requiring emergency pericardial drainage during an 8-month period.

Left ventricular function and heart failure in myocardial infarction: impact of the new definition in the community.

Objectives: The aim of this study is to evaluate ventricular function and the occurrence of heart failure (HF) among persons with myocardial infarction (MI) meeting only troponin criteria compared to persons meeting creatine kinase and its MB fraction (CK-MB) criteria.

Background: The 2000 American College of Cardiology/European Society of Cardiology MI definition enabled identification of MIs meeting only troponin-based criteria. Data on ventricular function and HF among these are lacking.

Evaluation of the BiliChek noninvasive bilirubin analyzer for prediction of serum bilirubin and risk of hyperbilirubinemia.

We identified clinical and laboratory variables affecting the relationship between transcutaneous and serum bilirubin levels and determined whether transcutaneous bilirubin values could be used to predict the risk of hyperbilirubinemia. Median bias between transcutaneous and diazo serum bilirubin was 2.0 mg/dL (34.

Correlation of point-of-care International Normalized Ratio to laboratory International Normalized Ratio in hemodialysis patients taking warfarin.

Background And Objectives: To determine whether point-of-care (POC) International Normalized Ratio (INR) test results correlate with plasma INR measures in intermittent hemodialysis (IHD) patients on warfarin. Anemia is thought to reduce the accuracy of POC INR assay results. Whether POC INR testing could be implemented for hemodialysis patients on chronic warfarin, who are often anemic despite hematopoietic therapy, has not been established.

Accuracy of capillary whole blood international normalized ratio on the CoaguChek S, CoaguChek XS, and i-STAT 1 point-of-care analyzers.

We evaluated the accuracy of capillary whole blood international normalized ratio (INR) on the CoaguChek S (Roche Diagnostics, Indianapolis, IN), CoaguChek XS (Roche Diagnostics), and i-STAT 1 (i-STAT, East Windsor, NJ) point-of-care (POC) analyzers compared with venous plasma INRs determined by a reference laboratory method. Overall agreement between POC and laboratory plasma INR was very good, with median bias between capillary whole blood and laboratory plasma INRs varying from 0.0 to -0.

In-patient international normalized ratio self-testing instruction after mechanical heart valve implantation.

Background: Patient self-testing of the international normalized ratio (INR) has been shown to improve management of anticoagulation with warfarin and reduce risks of thromboembolism and bleeding. Self-testing instruction usually begins several weeks after hospital discharge. We evaluated the feasibility of in-hospital INR self-testing instruction in patients recovering from valve replacement.

Aspirin responsiveness in healthy volunteers measured with multiple assay platforms.

Background: We evaluated the sensitivity, precision, and concordance of 4 assays designed to detect aspirin responsiveness or resistance.

Methods: Twenty-nine healthy laboratory volunteers took 80 mg aspirin for 7 days, and a subset of volunteers took 325 mg aspirin for an additional 7 days. We measured platelet function by light transmission aggregometry with arachidonic acid, PFA-100, and VerifyNow.

Evaluation of the impact of hematocrit and other interference on the accuracy of hospital-based glucose meters.

Background: Most glucose meter comparisons to date have focused on performance specifications likely to impact subcutaneous dosing of insulin. We evaluated four hospital-based glucose meter technologies for accuracy, precision, and analytical interferences likely to be encountered in critically ill patients, with the goal of identifying and discriminating glucose meter performance specifications likely to impact intensive intravenous insulin dosing.

Methods: Precision, both within-run and day-to-day, was evaluated on all four glucose meters.

Comparison of lactate values between point-of-care and central laboratory analyzers.

Measurement of lactate levels is important in the care of critically ill adult and pediatric patients. We compared 3 whole blood lactate methods (Radiometer ABL 725, Radiometer Medical A/S, Bronshoj, Denmark; i-STAT, i-STAT, East Windsor, NJ; and Nova Lactate Plus, Nova Biomedical, Waltham, MA) with 2 plasma-based methods (Roche Integra, Roche Diagnostics, Indianapolis, IN; and Vitros, Ortho Clinical Diagnostics, Rochester, NY). The Vitros LAC slide assay was used as the reference method.

Accuracy of roche accu-chek inform whole blood capillary, arterial, and venous glucose values in patients receiving intensive intravenous insulin therapy after cardiac surgery.

Intravenous insulin protocols are increasingly common in the intensive care unit to maintain normoglycemia. Little is known about the accuracy of point-of-care glucometers for measuring glucose in this patient population or the impact of sample source (capillary, arterial, or venous whole blood) on the accuracy of glucometer results. We compared capillary, arterial, and venous whole blood glucose values with laboratory plasma glucose values in 20 patients after cardiac surgery.

Redefinition of myocardial infarction: prospective evaluation in the community.

Background: The 2000 European Society of Cardiology/American College of Cardiology definition for myocardial infarction (MI) combines ischemic symptoms, electrocardiographic changes, and troponin rather than creatine kinase levels. The use of troponins will increase the detection of MI by a magnitude to be quantified, and the clinical acceptance of the new definition is unknown.

Method And Results: Subjects presenting to an Olmsted County facility with a troponin T value > or = 0.

Excessive bleeding and transfusion in a prior cardiac surgery is associated with excessive bleeding and transfusion in the next surgery.

If there is a genetic predisposition to excessive bleeding, there should be an association in excessive blood loss between multiple cardiac surgeries. We retrospectively determined in 174 patients the association of excessive bleeding between 2 cardiac surgeries with cardiopulmonary bypass between January 19, 1990 and June 25, 2002. Excessive bleeding was defined by 2 criteria: (a) postoperating room chest tube blood loss over 24 h more than or equal to 750 mL (chest tube drainage [CTD] > or = 750) and (b) transfusion of any non-red blood cell (RBC) blood products.

Can N-acetylcysteine reverse the antiplatelet effects of clopidogrel? An in vivo and vitro study.

Background: The active metabolite of clopidogrel binds the P2Y12 ADP receptor on the platelet surface via a disulfide bond. N-Acetylcysteine (NAC) is able to reduce disulfide bonds. We postulated that NAC might reverse clopidogrel's effect on platelets.

Importance of device evaluation for point-of-care prothrombin time international normalized ratio testing programs.

Objective: To determine the accuracy of 2 commercially available point-of-care devices relative to plasma international normalized ratio (INR) values.

Patients And Methods: Point-of-care INR testing was performed with the CoaguChek and ProTime 3 devices in consecutive patients attending an anticoagulation clinic between June 18, 2003, and August 6, 2003. Results were compared with plasma INRs using a sensitive thromboplastin (International Sensitivity Index, 1.

Patient satisfaction with point-of-care international normalized ratio testing and counseling in a community internal medicine practice.

Point-of-care international normalized ratio (POC INR) testing is increasingly used to monitor anticoagulant therapy. This study assessed patient satisfaction with registered nurse--managed POC INR testing in a primary care internal medicine practice. One hundred eighty-seven of the first 216 (87%) patients using the program responded to the survey.

Frozen preoperative autologous blood donation for heart transplantation at the Mayo Clinic from 1988 to 1999.

Background: Preoperative autologous blood donation (PABD) has been used to reduce the need for allogeneic RBC transfusion, decreasing risk and conserving supply. A frozen PABD program for heart transplant patients was instituted at the Mayo Clinic in 1988, but participation has steadily declined. The aims of this study were to determine how the availability of PABD influenced the transfusion RBC components, whether the availability of PABD reduced exposure to allogeneic RBC components, and the costs of providing PABD units.