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Introduction. In recent years, laboratory information systems (LIS) have become an element of medical institutions’ work, providing high quality and efficiency of clinical activities. Laboratory diagnosis plays a vital role in treating and preventing all known diseases, which requires compliance with specific quality criteria. Material and methods. A study was conducted with the historical control of the laboratory tests’ conditiona-lity before and after introducing LIS in the A.N. Bakulev National Medical Research Center of Cardiovascular Surgery. During 2018, quarterly an analysis of the reappointments of the following groups of laboratory tests was carried out: hematological test, immunochemical analysis, biochemical blood test, hemostasis system (coagulogram), platelet aggregation with ADP. Unfounded recognized studies assigned more than once for 48 hours in the absence of clinical justification. Results are provided using standard descriptive statistics methods. Results. After the work carried out in the fourth quarter, there was a decrease in the total number of appointments by 20% and a decrease in studies performed in terms of one patient. Conclusion. The introduction of LIS made it possible to obtain a tool for quantitative and qualitative analysis of the validity of the purpose of laboratory research and conduct an economic analysis of the results. The data obtained were subsequently used to develop laboratory profiles, allowing to continue the optimization of this area and the implementation of lean technologies in the clinic. Also, the data obtained made it possible to evaluate the knowledge and application of clinical recommendations to manage patients with various pathologies. During the verification of the results and analysis of the doctors’ explanatory notes, the laboratory process’s most compromised stages were identified.

Aim To evaluate possible social and economic benefits of correcting preoperative iron deficiency /iron deficiency anemia as a comorbidity in a model population in the process of transition from the routine practice to the optimized preparation of patients to elective surgery (as exemplified by several circulatory diseases: I20 – I25, class IX ICD 10).Material and methods By building imitation models depending on the patient blood management (PBM) practice, changes in years of life lost/saved adjusted for disability were evaluated, including in monetary terms, in relation to the annual number of operations performed for ischemic heart disease (IHD) (I20 – I25) in the age group of 17 years and older, as well as a potential effect of PBM on the applied health economics.Results With implementation of the PBM systemic measures in cardiac surgery, the potentially prevented annual social and economic damage will amount to more than 38 thousand years of life saved and more than 20.2 billion rubles in monetary terms. Furthermore, it will be possible to exclude 9435 hemotransfusion from the cardiosurgical practice, which will annually save more than 2.3 thousand liters of blood with a total cost of 77.7 million rubles in favor of clinical situations that have no alternative.Conclusion The implementation of PBM in cardiac surgery, the discipline with the highest levels of preoperative iron deficiency/anemia and the use of blood components, will not only improve the clinical outcomes and cost-effectiveness of surgical interventions, but will also prevent social and economic damage to the country.

We have read with great interest the article by Okonta and colleagues [1]. The recombinant activated factor VII (rFVIIa) was applied for treatment of the postoperative bleeding in children at our centre for the first time in 2003. We prospectively reviewed the results of its application in 70 patients aged 0-14 years who received rFVIIa at dose ranging from 90 to 120 mcg/kg. Haemostasis was achieved in 59 (84.2%) patients after rFVIIa administration [2]. We received the evidences of the high haemostatic potential of this drug, but it cannot be considered a panacea. While accumulating the experience, some unclarified issues appeared. Firstly, what are the reasons of a non-effective administration rFVIIa in the achievement of haemostasis? The second point is whether we can use rFVIIa within the prevention of the hemorrhage? And, lastly, what is the rate of the thrombotic complications? Should we perform laboratory control of the rFVIIa application? The idea of the rFVIIa administration in patients after cardiac surgery procedure consists of “bypassing” most of the coagulation reactions by creating an excess concentration of FVIIa. Therefore, its application is appropriate when coagulation factors are insufficient. But it will not be reasonable and effective under the circumstances of an excessive activation of natural anticoagulants or a deficiency in the final-stage components of the clot formation, e.g., fibrinogen, FXIII. The rFVIIa can be used as part of the complex therapy only after overcoming the above mentioned coagulation disorders. The administration of the rFVIIa with preventive goals should be excluded. First of all, rFVIIa does not have a replacement function in contrast to the prothrombin complex concentrates. Secondly, there is a risk of thrombosis in the background of the minimal changes of the haemostasis. The rate of this complication in the off-label usage of rFVIIa reaches 10.9% [3]. Due to this we recommend an application of rFVIIa only for treatment of patients with an International Normalized Ratio (INR) higher than 1.5 under the laboratory control of this parameter. The rFVIIa dosage should be titrated closely according the degree of coagulation disorders to achieve the target INR values of 1-1.2. So we consider that, the main indication for rFVIIa administration is the excessive bleeding due to the severe impairments of the thrombin generation. It can be used as a monotherapy or in combination with other drugs under the laboratory control of its efficacy. Conflict of Interest: None declared

Although fibrinogen is a key factor in thrombosis, its role in the pathogenesis of haemostatic disturbances after cardiac surgery is often underestimated. Therefore we were glad to read the article by Gielen et al. [1]. Apparently during the postoperative period, decrease in fibrinogen often coincides with the deficiency of other clotting factors and platelet dysfunction, and the level of postoperative blood loss does not depend only on the fibrinogen concentration. Thus, there are no linear connections between blood loss and the level of fibrinogen. However, we cannot underestimate the contribution of this clotting factor in the mechanical stability of clots, which also depends on platelets, coagulation factor XIII and von Willebrand factor. The deficiency of those factors, primarily fibrinogen, leads to the decrease in the fibrin monomer and its polymerization, which further results in delayed thrombus formation along with increase of fibrinolysis sensitivity and blood loss. Based on thromboelastography data, a feedback loop exists between the fibrinogen level and maximum lysis [2]. Therefore, the fibrinogen level serves as an integral value of the formation and stabilization of the clot. It is necessary to note that the velocity of fibrin formation may be affected by the absolute quantity of fibrinogen and its concentration, therefore hypofibrinogenaemia may be the result either of fibrinogen loss or haemodilution. The main target of haemodilution is the formation and stability of the clot, but not the thrombin formation [3]. We tested the connection between pre- and postoperative coagulation values and the level of blood loss after cardiac surgical procedures in children. For patients with congenital heart disease, we consider a threshold fibrinogen concentration of 2.5 g/l to be necessary for prevention of bleeding. In cases with lower concentrations of fibrinogen, we observed postoperative blood losses of 0.75 ml/kg/h to 1.27 ml/kg/h [4]. Hypofibrinogenaemia in children may be caused by hypotrophy due to social (early artificial feeding) and medical factors, impaired hepatic protein synthesis, and a decrease in terminal elimination half-life in cyanotic patients. A postoperative level of fibrinogen less than 2 g/l led to blood loss of 0.61 to 0.85 ml/kg/h [2]. Indeed, there is insufficient evidence to prove that the use of fibrinogen concentrate after cardiac surgery is successful. However, a controlled replacement therapy of blood loss via the use of fibrinogen concentrate in hypofibrinogenaemia is efficient and abolishes the deficiency of other haemostasis components without the risk of thrombosis development. On the other hand, based on stoichiometry, a possible way to circumvent a low level of fibrinogen concentration may be the optimization of the circulating blood volume via the application of ultrafiltration. Conflict of interest: none declared

We have read with great interest the article by Chandra and colleagues [1]. Anticoagulation in patients with warfarin-associated intracranial haemorrhage and a high risk of thrombosis and embolism are difficult questions in modern practice. It applies not only to patients with prosthetic heart valves, but also with venous thrombosis, atrial fibrillation, etc. The frequency of this complication is about 0.25-1.1% per year [2]. According to the study by Yung et al., the predictors of mortality in patients with warfarin-associated intracranial haemorrhage are the degree of initial anticoagulation (INR >3), greater stroke severity and intraventricular haemorrhage [2]. In other words, the amount and duration of bleeding depending on the capacity of the coagulation of blood determines the degree of the brain damage. So we need a rapid and careful recruitment of coagulation, which can be achieved by using the prothrombin complex concentrates. Vitamin K and fresh frozen plasma cannot fully satisfy these requirements. To reduce the risk of thrombotic events, prothrombin complex concentrates should be used, which comprise the proteins C and S. The frequency of thrombotic complications in that case does not exceed 1% [3]. Anticoagulant therapy may be resumed after the normalization of the INR, but not before carrying out neurosurgical intervention, if necessary. For its performance, we recommend using anticoagulants with a short half-life, such as unfractionated heparin or bivalirudin. It is advisable to administer these drugs with continuous intravenous infusion and close monitoring of partial thromboplastin time (PTT) (or ecarin clotting time for bivalirudin). The normal range of these coagulation parameters should be above 1.5-2. In case of re-bleeding, the infusion of anticoagulation drugs can be stopped easily. It is noted that Bertram et al. showed no rebleeding after intracerebral haemorrhage in patients with the normal INR and increased PTT values [4]. Subsequently patients should receive the anticoagulants with prolonged action, prescribed in the hospital. A number of studies have shown a lower risk of intracranial haemorrhage in patients who received non-warfarin anticoagulant therapy, for instance antiplatelet drugs, factor Xa inhibitors [5].