An operational research approach to identify cardiac surgery patients at risk of severe post-operative bleeding

Feasibility and acceptability of continuous postoperative pericardial flushing for blood loss reduction in patients undergoing coronary artery bypass grafting

INTRODUCTION

Postoperative bleeding requires blood transfusion and surgical re-exploration that can affect the short- and long-term postoperative outcomes. Interventions that can be used in the postoperative period to reduce blood loss should be developed. Continuous postoperative pericardial flushing (CPPF) with an irrigation solution may reduce blood loss by preventing the accumulation of clots. This study examined the feasibility and acceptability of CPPF for reducing bleeding after coronary artery bypass surgery.

METHODS

This pilot study adopted a prospective and group comparison design. Between January and April 2018, 42 patients who underwent isolated coronary artery bypass surgery received CPPF from sternal closure up to 8 h postoperative. The mean actual blood loss in the CPPF group was compared to the mean of retrospectively group (n = 58). In the CPPF group, an extra infusion catheter was inserted through one of the tube incision holes and an irrigation solution (0.9% NaCl at 38 °C) was delivered to the pericardial cavity by using a volumetric pump. Safety aspects, feasibility issues, and complications were documented. The primary outcome was blood loss, and it was assessed 18 h after the surgery.

RESULTS

CPPF was successfully completed in 40 patients (95.24%). Method-related complications were not observed. Feasibility was good in this experimental setting. Blood loss was lower in the CPPF group (257.24 mL) than non-CPPF group (p < 0.001).

CONCLUSIONS

CPPF after coronary artery bypass grafting surgery is safe, effective, feasible, and acceptable. However, standardized randomized clinical trials are necessary to draw definitive conclusions.

Barriers to the secondary use of data in critical care

Purpose

We explore the challenges of the secondary use of data in clinical information systems which critical care units in the National Health Service (England) are facing.

Methods

We conducted an online survey of critical care units in England regarding their practices in collecting and using clinical information systems and data.

Results

Critical care units use clinical information systems typically independently of hospital information systems and focus mainly on using data for auditing, management reporting and research. Respondents reported that extracting data from their clinical information system was difficult and that they would use stored data more if it were easier to access. Data extraction takes time and who extracts data, the training they receive and the tools they use affect the extraction and use of data.

Conclusion

A number of key challenges affect the secondary use of data in critical care: a lack of integration of information systems within critical care and across departments; barriers to accessing data; mismatched data tools and user requests. Data are predominantly used for reporting and research with less emphasis on using data to inform clinical practice.

Phenotyping bleeding

PURPOSE OF REVIEW

Although recorded evidence of phenotyping bleeding disorders extends back two millennia, standardization of phenotyping has only begun in the past half century. This was spurred by the need for greater precision in diagnosing disorders in order to select proper laboratory tests and treatment, and the realization that the bleeding history provides prognostic information about the future risk of bleeding with surgery or invasive procedures.

RECENT FINDINGS

New bleeding assessment tools (BATs) have been developed, firstly, to evaluate the relative bleeding risks associated with new anticoagulants and antiplatelet agents, secondly, to assess the efficacy of new thrombopoiesis stimulating agents in preventing hemorrhage in patients with immune thrombocytopenia, and finally, to assess complex gene-gene and gene-environment interactions. New web-based systems allow many researchers to collaborate by sharing the same electronic phenotyping infrastructure. Major issues of validation remain, but at present the data indicate that the new BATs have relatively high negative predictive value for excluding a significant bleeding disorder, but disappointingly low positive predictive values.

SUMMARY

New instruments to phenotype bleeding have been developed to address a number of different important clinical and research goals. The improved standardization and opportunities for collaborative studies hold promise for maximizing diagnostic, prognostic, and scientific information.