[The use of propofol does not increase the cost of the management of patients in heart surgery with extracorporeal circulation]

OBJECTIVES

Evaluation of the cost of propofol used for fast-track in cardiac surgery and its impact on global cost of management for anaesthesia and intensive care.

STUDY DESIGN

Case-control study, prospective (1998) and retrospective (1994).

PATIENTS

Twenty patients operated for cardiac surgery in 1998 and scheduled for fast-track anaesthesia. Twenty patients in 1994 matched for different criteria to the patient of 1998.

METHODS

In 1998, all drugs, materials used and X-rays, biochemical assays performed were prospectively collected and their cost calculated. In 1994, similar calculations were done retrospectively. Comparison of duration of mechanical ventilation, hospitalization in intensive care and in the hospital were performed.

RESULTS

Cost of anaesthesia was similar in 1994 and 1998 (2,646 FF versus 2,294 FF). Global cost of management was significantly lower in 1998 in comparison to 1994 (5,439 FF versus 8,558 FF). Duration of mechanical ventilation, hospitalization in intensive care and in the hospital were shorter in 1998 than in 1994.

CONCLUSION

Despite a higher cost of propofol for anaesthesia and postoperative sedation in comparison to midazolam, the global cost of management decreased significantly in relation to a one day decrease in hospitalization in the intensive care unit.

Clinical outcomes and resource usage in 100 consecutive patients after off-pump coronary bypass procedures

BACKGROUND

Cardiopulmonary bypass initiates a cascade of inflammatory processes that may result in end-organ damage, leading to the increased prevalence of noncardiac complications. Therefore, off-pump coronary artery bypass graft (OP-CAB) procedures have recently been introduced into clinical practice.

METHODS

This study was a case-controlled study that compared the outcomes and cost of 100 consecutive OP-CAB procedures with a control group of 100 contemporary matched conventional coronary artery bypass grafting procedures. All operations were performed by a single surgeon (J.H.L. ) and complete revascularization that used off-pump techniques was achieved with the use of innovative exposure techniques to the lateral and posterior wall vessels.

RESULTS

An average of 3.1 grafts per patient were performed in the OP-CAB group (range, 1-5). The incidence of conversion to conventional coronary artery bypass grafting was 1%. The overall mortality rate was 2.0%. There were no instances of stroke, renal failure, or sternal infections in the OPCAB group. Thus, the OP-CAB group had a shorter length of stay (6.1+/-2.5 versus 7.1+/-3.3 d; P =.003), with a corresponding reduction in variable direct cost per case of 29% (P<.001).

CONCLUSION

Our experience suggests that OP-CAB procedures are feasible for most patients who currently require complete revascularization. It is associated with very a low morbidity rate and may represent the ideal revascularization strategy for patients at high risk for undergoing cardiopulmonary bypass.

Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost

OBJECTIVE

Crash back on bypass (crash-BOB) is occasionally required in the resuscitation of patients developing life-threatening complications following cardiac surgery. This study aims to determine the incidence, aetiology and cost-effectiveness of such intervention.

METHODS

Retrospective review of all crash-BOB patients over 5.5 years at one hospital.

RESULTS

The incidence of crash-BOB was 0.8% and occurred at a mean of 7 h post-operatively (range 1 h-20 days). Pre-operative Parsonnet scores were similar to the overall population of patients undergoing surgery in our institution (mean score 10; range 0-45). The original cardiac operations were coronary revascularization (39), valve surgery (12) and others (4). Indications for crash-BOB were cardiac arrest (23), bleeding (20), hypotension (7), ischaemia (1) and others (4). Of the 55 patients, 20 died on the operating table. Of the remaining 35, a further 12 died in hospital. Overall survival was therefore 42%. Where crash-BOB was for bleeding, 17 of 20 patients (85%) survived to leave theatre, of whom 11 patients (55%) left hospital alive. In the 35 non-bleeders, only 18 (51%) survived crash-BOB and 12 (34%) left hospital alive. Sixteen patients required a second period of aortic cross-clamping of whom 13 (81%) survived to leave theatre, and 11 (69%) left hospital alive. Conversely, of nine patients in whom no specific diagnosis was found during crash-BOB, only two (22%) survived the procedure and none survived to hospital discharge. Multiple logistic regression identified pre-operative Parsonnet score (P=0.045) and the need for aortic cross-clamping to deal with an identified surgical problem (P=0.03) as significant predictors of hospital survival. Indication for crash-BOB (bleeder/non-bleeder) failed to reach significance (P=0.08). Age, sex, intra-aortic balloon pump use at the primary procedure, and time following the primary procedure to crash-BOB were not identified as predictors of hospital survival. Of the 23 hospital survivors, three patients suffered a stroke post-operatively and made a good functional recovery prior to discharge. Two patients developed sternal wound dehiscence requiring surgical rewiring. At follow-up (mean 3 years, range 1-6 years), 19 patients were in NYHA class I and four were in class II. Crash-BOB patients required an average of 8 extra intensive care days and 2 extra ward days. The total cost of these resources was pound164900 (including theatre time, cardiopulmonary bypass and intra-aortic balloon pump use). This was equivalent to pound7170 per life saved.

CONCLUSIONS

Crash-BOB occurred in 0.8% of cases and was associated with a survival to discharge of 42%, and a justifiable cost of only pound7170 per life saved. Establishing an accurate diagnosis for the cause of clinical deterioration resulting in crash-BOB intervention was important, and the need for a further period of aortic cross-clamping did not preclude a favourable outcome.

Economic outcome of off-pump coronary artery bypass surgery: a prospective randomized study

BACKGROUND

Emphasis on cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. The revival of interest in off-pump (beating heart) coronary artery bypass surgery may influence the economic outcome. This study examines these effects.

METHODS

Two hundred patients undergoing first-time coronary artery bypass surgery were prospectively randomized to either conventional cardiopulmonary bypass and cardioplegic arrest or off-pump surgery. Variable and fixed direct costs were obtained for each group during operative and postoperative care. The data were analyzed using parametric methods.

RESULTS

There was no difference between the groups with respect to pre- and intraoperative patient variables. Off-pump surgery was significantly less costly than conventional on-pump surgery with respect to operating materials, bed occupancy, and transfusion requirements (total mean cost per patient: on pump, $3,731.6+/-1,169.7 vs off-pump, $2,615.13+/-953.6; p < 0.001). Morbidity was significantly higher in the on-pump group, which was reflected in an increased cost.

CONCLUSIONS

Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass and cardioplegic arrest.

Off-pump surgery decreases postoperative complications and resource utilization in the elderly

BACKGROUND

Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients.

METHODS

Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65.

RESULTS

Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency.

CONCLUSIONS

OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.

Cost-effectiveness of minimally invasive coronary artery bypass surgery

BACKGROUND

Coronary artery bypass grafting without cardiopulmonary bypass is gaining popularity as an alternative to conventional on-pump technique for myocardial revascularization. This includes minimally invasive direct coronary artery bypass (MIDCAB) and full sternotomy off-pump (OPCAB) methods. These two approaches should be evaluated for financial and clinical appropriateness.

METHODS

Records of patients who had single or double bypass (internal mammary artery and/or saphenous vein) grafts between January 1997 and June 1998 were reviewed. These included 44 MIDCAB, 62 OPCAB, and 243 conventional coronary artery bypass (CCAB) patients. Univariate analysis was applied to pre, intra, and postoperative variables, comparing MIDCAB and OPCAB to the CCAB group. Procedural cost information was obtained from participating institutions.

RESULTS

MIDCAB patients compared to CCAB patients had a higher predicted risk (5.4+/-11 versus 2.3+/-2.8, p = 0.012) and OPCAB patients had a predicted risk of 5.3+/-7.8. MIDCAB and OPCAB procedures required less operating room time and blood utilization. Observed operative mortality rates were MIDCAB 4.5%, OPCAB 1.6%, and CCAB 2.8% (not significant). Mean hospital costs were CCAB at $19,000, OPCAB at $15,000, and $17,000 for MIDCAB.

CONCLUSIONS

Off pump procedures currently reflect acute episode-of-care cost savings over CCAB.

Advances in perfusion technology--an overview

The introduction of minimally invasive approaches to cardiac surgery offered the opportunity to reduce patient's pain associated with median stemotomy as well as infection and postoperative bleeding. This technique required the use of one small venous cannula necessitating the implementation of kinetic assisted venous drainage (KAVD). However, KAVD proved costly due to the use of a centrifugal pump and could be de-primed if air was introduced into the venous line. Vacuum assisted venous drainage (VAVD), an easy to learn technique, was proved to be a better, safe and less expensive alternative as it required lower prime and small cannulae. Blunt trauma could also be avoided as large cannulae were not used.

Economic evaluation of high-dose and low-dose aprotinin therapy during cardiopulmonary bypass

BACKGROUND

Aprotinin therapy is now widely used during cardiac surgery. This study examined the clinical and economic effectiveness of high-dose or low-dose aprotinin in comparison to placebo.

METHODS

In a double blind, randomized study, three groups of 50 patients received high-dose aprotinin costing AUS$614 per patient (AUS$ = Australian dollars), low-dose aprotinin costing AUS$220 per patient or placebo. Resource use influenced by aprotinin therapy was measured.

RESULTS

Both doses were effective in reducing chest drainage and postoperative transfusion requirements, high-dose being more effective than low-dose. Both doses reduced the rate of reoperations for hemostasis. A base case of statistically significant differences associated with the high-dose and low-dose aprotinin showed cost savings of AUS$77 and AUS$348 per patient, respectively. If the demonstrated less significant reductions in operating room and ward stay are included, these savings become AUS$463 and AUS$715, respectively. Alternately, if cross-matches are replaced by group-and-hold and cell savers are not used, the savings per patient would be AUS$196 and AUS$467, respectively.

CONCLUSIONS

While high-dose aprotinin is clinically more effective than low-dose aprotinin, low-dose therapy demonstrates greater cost savings.

Modifying risk for extracorporeal circulation: trial of four antiinflammatory strategies

BACKGROUND

Despite recent rediscovery of beating heart cardiac surgical techniques, extracorporeal circulation remains appropriate for most heart operations. To minimize deleterious effects of cardiopulmonary bypass, antiinflammatory strategies have evolved.

METHODS

Four state-of-the-art strategies were studied in a prospective, randomized, preoperatively risk stratified, 400-patient study comprising primary (n = 358), reoperative (n = 42), coronary (n = 307), valve (n = 27), ascending aortic (n = 9), and combined operations (n = 23). Groups were as follows: standard, roller pump, membrane oxygenator, methylprednisolone (n = 112); aprotinin, standard plus aprotinin (n = 109); leukocyte depletion, standard plus a leukocyte filtration strategy (n = 112); and heparin-bonded circuitry, centrifugal pumping with surface modification (n = 67).

RESULTS

Analysis of variance, linear and logistic regression, and Pearson correlation were applied. Actual mortality (2.3%) was less than half the risk stratification predicted mortality (5.7%). The treatment strategies effectively attenuated markers of the inflammatory response to extracorporeal circulation. Compared with the other groups the heparin-bonded circuit had highly significantly decreased complement activation (p = 0.00001), leukocyte filtration blunted postpump leukocytosis (p = 0.043), and the aprotinin group had less fibrinolysis (p = 0.011). Primary end points, length of stay, and hospital charges, were positively correlated with operation type, age, pump time, body surface area, stroke, pulmonary sequelae, predicted risk for stroke, predicted risk for mortality, and risk strata/treatment group interaction (p = 0.0001). In low-risk patients, leukocyte filtration reduced length of stay by 1 day (p = 0.02) and mean charges by $2,000 to $6,000 (p = 0.05). For high-risk patients, aprotinin reduced mean length of stay up to 10 fewer days (p = 0.02) and mean charges by $6,000 to $48,000 (p = 0.0007).

CONCLUSIONS

These pharmacologic and mechanical strategies significantly attenuated the inflammatory response to extracorporeal circulation. This translated variably into improved patient outcomes. The increased cost of treatment was offset for selected strategies through the added value of significantly reduced risk.

Pharmacoeconomics analysis in a pediatric population

BACKGROUND

Pharmacoeconomics is becoming increasingly important in the health-care environment, but pharmacoeconomic studies are fraught with problems. Pharmacoeconomics can be applied to analysis of the benefits of pharmacologic hemostasis.

METHODS

This article reviews the available methods of pharmacoeconomic analysis and their inherent methodologic concerns. It reviews pharmacoeconomic studies of pharmacologic hemostasis, with particular focus on the Pediatric Reoperative Open Heart Surgery study. In this study, patients were randomized to receive either high-dose aprotinin, low-dose aprotinin, or placebo. Results were analyzed from the viewpoint of cost-benefit, cost-effectiveness calculated with use of a roll-back decision tree, and cost-effective ratios.

RESULTS

Cost-benefit analysis showed low-dose aprotinin to have a greater cost-benefit than high-dose aprotinin, cost-effectiveness analysis and analysis of cost-effective ratios showed high-dose aprotinin to be more cost-effective than low-dose aprotinin, and all analyses showed aprotinin to be preferable to placebo.

CONCLUSIONS

Aprotinin in pediatric repeat open heart operations not only has a cost-benefit but is cost-effective as well.

A method for perfusion of the leg during cardiopulmonary bypass via femoral cannulation

Minimally invasive approaches for cardiac operations currently are gaining increasing attention. Some of these approaches require cannulation of the femoral vessels for cardiopulmonary bypass. A potential complication of femoral cannulation is ischemic injury to the lower extremity in some cases that require long bypass times. To minimize this risk we have begun cannulating the common femoral artery distally, as well as proximally. This technique perfuses the leg for the duration of cardiopulmonary bypass, and it can be accomplished with minimal increases in cost and operative time.

Heparin-bonded circuits: clinical outcomes and costs

The aim of this study was to use meta-analysis to combine the results of numerous studies and examine the impact of heparin-bonded circuits on clinical outcomes and the resulting costs. Heparin-bonded circuits, both ionically and covalently bonded, are examined separately. The results of the study provide evidence that heparin-bonded circuits result in improved clinical outcomes when compared to the identical nonheparin-bonded circuits. These improved clinical outcomes result in subsequent lower costs per patient with their use. However, differences are apparent in the significance and magnitude of these outcomes between ionically and covalently bonded circuits. Covalently bonded circuits provide a greater magnitude and significance of improvement in clinical outcomes than ionically bonded circuits. Total cost savings can be expected to be three times greater with covalently bonded circuits ($3231 versus $1068). It was concluded that the choice regarding the use of a heparin-bonded circuits and the type of heparin-bonded circuit used has the potential to alter clinical outcomes and subsequent costs. Cost consideration cannot be ignored, but clinical benefits should be the main rationale for the choice of cardiopulmonary bypass circuit. This analysis provides evidence that clinical benefits and cost savings can both be derived from use of the same technology-covalently bonded circuits.

Cost-benefit and efficacy of aprotinin compared with epsilon-aminocaproic acid in patients having repeated cardiac operations: a randomized, blinded clinical trial

BACKGROUND

Aprotinin and epsilon-aminocaproic acid are routinely used to reduce bleeding during cardiac surgery. The marked difference in average wholesale cost between these two drug therapies (aprotinin, $1,080 vs. epsilon-aminocaproic acid, $11) has generated significant controversy regarding their relative efficacies and costs.

METHODS

In a multicenter, randomized, prospective, blinded trial, patients having repeated cardiac surgery received either a high-dose regimen of aprotinin (total dose, 6 x 10(6) kallikrein inactivator units) or epsilon-aminocaproic acid (total dose, 270 mg/kg).

RESULTS

Two hundred four patients were studied. Overall (data are median [25th-75th percentiles]), aprotinin-treated patients had less postoperative thoracic drainage (511 ml [383-805 ml] vs. 655 ml [464-1,045 ml]; P = 0.016) and received fewer platelet transfusions (0 [range, 0-1] vs. 1 [range, 0-2]; P = 0.036). The surgical field was more likely to be considered free of bleeding in aprotinin-treated patients (44% vs. 26%; P = 0.012). No differences, however, were seen in allogeneic erythrocyte transfusions or in the time required for chest closure. Overall, direct and indirect bleeding-related costs were greater in aprotinin- than in epsilon-aminocaproic acid-treated patients ($1,813 [$1,476-2,605] vs. $1,088 [range, $511-2,057]; P = 0.0001). This difference in cost per case varied in magnitude among sites but not in direction.

CONCLUSIONS

Aprotinin was more effective than epsilon-aminocaproic acid at decreasing bleeding and platelet transfusions. Epsilon-aminocaproic acid, however, was the more cost-effective therapy over a broad range of estimates for bleeding-related costs in patients undergoing repeated cardiac surgery. A cost-benefit analysis using the lower cost of half-dose aprotinin ($540) still resulted in a significant cost advantage using epsilon-aminocaproic therapy (P = 0.022).

Extracorporeal circuit sterility after 168 hours

One of the most important tasks of the perfusionist is the proper assembly of the extracorporeal circuit (ECC) prior to the initiation of cardiopulmonary bypass (CPB). The ECC is usually assembled, primed and debubbled 30 minutes to one hour prior to the patient entering the operating room. But there are occasions when the ECC may have been set up and the previously scheduled procedure cancelled. Perfusionists in this situation have found themselves in a quandary; dispose of the ECC because of required nursing compliance and the sterility question, or keep it and use it later because of the economic impact on the "bottom line". Some hospitals may have satisfactorily answered the question of ECC sterility after 24 hours without observation, but the few reported papers regarding this issue, and our desire to save these circuits, inspired us to find out if they were in fact sterile after having been open for a long period of time. The purpose of this study was to evaluate ECC sterility using an open reservoir oxygenator, over a time period of seven days. After obtaining 792 bacterial cultures from three sites within the ECC, the study was terminated. There were no positive bacterial cultures during the study period. Assuming there is no deliberate contamination, pump circuits assembled in an unused operating room can be maintained sterile for a period of seven days.

The economics of uncomplicated mitral valve surgery

BACKGROUND AND AIMS OF THE STUDY

Comparisons of mitral valve (MV) replacement and reconstruction have demonstrated lower overall complication rates, better left ventricular (LV) function, and inferred overall lower cost for the latter procedure compared with the former. However, assessment of economic differences between the two procedures in routine cases, without complications, has not been reported. This study retrospectively evaluates the economic impact of uncomplicated MV repair versus replacement.

METHODS

As this study seeks only to evaluate economic comparisons between routine cases of mitral repair versus replacement, those patients having concomitant procedures performed (coronary revascularization or other valve procedure) or postoperative complications (i.e. pulmonary failure, wound infections, new-onset atrial fibrillation, return for bleeding, or neurologic sequelae) were excluded from the study. Among patients who underwent uncomplicated MV procedures, 30 were selected at random and reviewed.

RESULTS

Variables for MV replacement versus reconstruction included aortic cross-clamp time (112 +/- 54 versus 92 +/- 20 min; p = NS), cardiopulmonary bypass (CPB) time (189 +/- 70 versus 128 +/- 18 min; p < 0.05), total hospital stay (8.3 +/- 1.6 versus 5.6 +/- 1.6 days; p < 0.0001), and total hospital charges ($44,697 +/- 4903 versus $31,337 +/- 4484; p < 0.0001), respectively.

CONCLUSIONS

These data suggest that, beyond the recognized benefits of MV reconstruction, namely preservation of LV function and avoidance of long-term anticoagulation, there is an economic advantage to MV reconstruction for patients and payors, even in uncomplicated cases. These differences may become more apparent with longer follow-up and in patients having poor function or combined procedures. This finding reinforces the idea that MV reconstruction is the option of choice for patients with mitral regurgitation.

Cardiac operations in patients 90 years of age and older

BACKGROUND

Growth of the elderly population worldwide, and specifically in the United States, will continue to accelerate and will have a profound impact on the cost and delivery of health care resources in the future. A medical strategy that allows the elderly to live independently is essential to most cost-effective use of our resources. The question remains as to what will be the future of surgical therapy for this increasing population.

METHODS

We retrospectively studied the cases of 30 consecutive nonagenarians (mean age, 92.3 +/- 1.8 years) who underwent a cardiac operation within a 9-year period. All patients were in New York Heart Association class III or IV and underwent operation urgently or emergently.

RESULTS

The 30-day mortality rate was 10%, and the actuarial survival rates were 81% +/- 8% and 75% +/- 9% at 1 year and 2 years, respectively. Seventy-eight percent of survivors were in New York Heart Association class I or II within 2 years after operation and had an improved quality of life. The cost of providing care in this age group was 24% higher than in octogenarians.

CONCLUSIONS

Advanced age in and of itself (>90 years) should not be a contraindication to an open-heart operation, although morbidity, mortality, and cost may be higher. However, selective criteria identifying risks and benefits for individual patients should be applied. The aging of our population will have a profound impact on the cost and delivery of health care resources in the future. This issue must be addressed in the current debate on the provision of expensive procedures under a realigned national health-care system.

Conventional haemofiltration during routine coronary bypass surgery

The use of conventional ultrafiltration during cardiopulmonary bypass (CPB) has been well recognized as an efficient modality of therapy to reverse the effects of deliberate haemodilution. Routine use of the haemofilter was prospectively studied on 60 patients undergoing coronary artery bypass surgery. Group A consisted of 30 patients on whom the ultrafiltrator was used and compared to group B who did not receive the ultrafiltration technique. The COBE 1200 ultrafiltration device was used. The results of the study demonstrated that, in group A, the mean total amount of ultrafiltrate collected during bypass was 2510 +/- 804 ml per patient. The mean 24-h postoperative blood loss was 440 +/- 192 ml in group A and 451 +/- 136 ml in group B. The average bank blood transfused was 0.6 +/- 1.3 units per patient in group A and 0.75 +/- 1.5 units per patient in group B. Postoperative weight gain in group A averaged 3.5 +/- 3.45 lb per patient, compared to 4.8 +/- 3.7 lb per patient in group B. Postoperative length of stay averaged 6.4 +/- 1.5 days per patient in group A and 6.4 +/- 2.1 days per patient in group B. Overall patient charges averaged $33,706 +/- 8348 per patient in group A and $33,041 +/- 7674 per patient in group B. It was concluded that routine use of ultrafiltration during routine coronary artery bypass surgery with CPB offers no improvement in the quality of care nor does it decrease the patient's overall charges.

Potential for reduction in morbidity and cost with total leucocyte control for cardiac surgery

The economics of health care in the USA and abroad has caused a shift in the focus on therapeutic interventions that transcend issues of safety and clinical efficacy. Now, cost justification is emerging as a major consideration to influence clinical practice. This brief review of the medical literature attempts to identify leucocyte-mediated adverse reactions that develop in open-hear surgery, quantify the costs incurred to manage such reactions and infer the savings that may accrue by controlling the burden of leucocytes presented to the open-heart surgical patient using commercially available leucocyte reducing filtration technology.

Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients

A retrospective study was performed to determine the impact of a coagulation and transfusion management program on blood utilization in 1,079 sequential patients for myocardial revascularization and open ventricle or combined procedures. Four hundred and eighty-eight patients (group 1) before, and 591 patients (group 2) after institution of thromboelastography (TEG)-guided coagulation were studied and compared for transfusion requirements, donor exposure, and the incidence of reoperation for hemorrhage. Group 2 patients had a significantly lower incidence of overall transfusion (78.5% v 86.3%) during hospitalization and in total transfusion in the operating room (57.9% v 66.4%). The incidence of each transfusion subtype was also significantly lower in group 2 patients. Actual total median donor exposure was 8 in group 1 patients and 6 exposures in group 2 patients. Mediastinal reexploration for hemorrhage was 5.7% before institution of TEG-based coagulation monitoring and 1.5% in TEG-monitored patients. Use of TEG monitoring before reexploration has decreased the cost and potential risk for patients undergoing CABG surgery.