1
|
Lavoie P, Arbour C, Garneau AB, Côté J, Crétaz M, Denault A, Gosselin É, Lapierre A, Mailhot T, Tessier V. A dimensional analysis of experienced intensive care unit nurses' clinical decision-making for bleeding after cardiac surgery. Nurs Crit Care 2024. [PMID: 38993090 DOI: 10.1111/nicc.13116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 06/03/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Bleeding following cardiac surgery is common and serious, yet a gap persists in understanding how experienced intensive care nurses identify and respond to such complications. AIM To describe the clinical decision-making of experienced intensive care unit nurses in addressing bleeding after cardiac surgery. STUDY DESIGN This qualitative study adopted the Recognition-Primed Decision Model as its theoretical framework. Thirty-nine experienced nurses from four adult intensive care units participated in semi-structured interviews based on the critical decision method. The interviews explored their clinical judgements and decisions in bleeding situations, and data were analysed through dimensional analysis, an alternative to grounded theory. RESULTS Participants maintained consistent vigilance towards post-cardiac surgery bleeding, recognizing it through a haemorrhagic dimension associated with blood loss and chest drainage and a hypovolemic dimension focusing on the repercussions of reduced blood volume. These dimensions organized their understanding of bleeding types (i.e., normal, medical, surgical, tamponade) and necessary actions. Their decision-making encompassed monitoring bleeding, identifying the cause, stopping the bleeding, stabilizing haemodynamic and supporting the patient and family. Participants also adapted their actions to specific circumstances, including local practices, professional autonomy, interprofessional dynamics and resource availability. CONCLUSIONS Nurses' decision-making was shaped by their personal attributes, the patient's condition and contextual circumstances, underscoring their expertise and pivotal role in anticipating actions and adapting to diverse conditions. The concept of actionability emerged as the central dimension explaining their decision-making, defined as the capability to implement actions towards specific goals within the possibilities and constraints of a situation. RELEVANCE TO CLINICAL PRACTICE This study underscores the need for continual updates to care protocols to align with current evidence and for quality improvement initiatives to close existing practice gaps. Exploring the concept of actionability further, developing adaptability-focused educational programmes, and understanding decision-making intricacies are crucial for informing nursing education and decision-support systems.
Collapse
Affiliation(s)
- Patrick Lavoie
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Caroline Arbour
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Hôpital du Sacré-Cœur de Montréal, CIUSSS du Nord-de-l'Île-de-Montréal, Montreal, Quebec, Canada
| | - Amélie Blanchet Garneau
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Centre de recherche en santé publique, Montreal, Quebec, Canada
| | - José Côté
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Maude Crétaz
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - André Denault
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Émilie Gosselin
- School of Nursing, Université de Sherbrooke, Sherbrooke, Québec, Canada
- Clinical Research Center, Centre hospitalier universitaire de Sherbrooke (CRC-CHUS), Sherbrooke, Québec, Canada
| | - Alexandra Lapierre
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Tanya Mailhot
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
- Research Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Virginie Tessier
- School of Design, Faculty of Environmental Design, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Schoerghuber M, Kuenzer T, Biancari F, Dalén M, Hansson EC, Jeppsson A, Schlachtenberger G, Siegemund M, Voetsch A, Pregartner G, Lindenau I, Zimpfer D, Berghold A, Mahla E, Zirlik A. Platelet inhibitor withdrawal and outcomes after coronary artery surgery: an individual patient data meta-analysis. Eur J Cardiothorac Surg 2024; 66:ezae265. [PMID: 38970368 PMCID: PMC11246165 DOI: 10.1093/ejcts/ezae265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 06/19/2024] [Accepted: 07/04/2024] [Indexed: 07/08/2024] Open
Abstract
OBJECTIVES To evaluate the association between guideline-conforming as compared to shorter than recommended withdrawal period of P2Y12 receptor inhibitors prior to isolated on-pump coronary artery bypass grafting (CABG) and the incidence of severe bleeding and ischaemic events. Randomized controlled trials are lacking in this field. METHODS We searched PUBMED, Embase and other suitable databases for studies including patients on P2Y12 receptor inhibitors undergoing isolated CABG and reporting bleeding and postoperative ischaemic events from 2013 to March 2024. The primary outcome was incidence of Bleeding Academic Research Consortium type 4 (BARC-4) bleeding defined as any of the following: perioperative intracranial bleeding, reoperation for bleeding, transfusion of ≥5 units of red blood cells, chest tube output of ≥2 l. The secondary outcome was postoperative ischaemic events according to the Academic Research Consortium 2 Consensus Document. Patient-level data provided by each observational trial were synthesized into a single dataset and analysed using a 2-stage IPD-MA. RESULTS Individual data of 4837 patients from 7 observational studies were synthesized. BARC-4 bleeding, 30-day mortality and postoperative ischaemic events occurred in 20%, 2.6% and 5.2% of patients. After adjusting for EuroSCORE II and cardiopulmonary bypass time, guideline-conforming withdrawal was associated with decreased BARC-4 bleeding risk in patients on clopidogrel [adjusted odds ratio (OR) 0.48; 95% confidence intervals (CI) 0.28-0.81; P = 0.006] and a trend towards decreased risk in patients on ticagrelor (adjusted OR 0.48; 95% CI 0.22-1.05; P = 0.067). Guideline-conforming withdrawal was not significantly associated with 30-day mortality risk (clopidogrel: adjusted OR 0.70; 95% CI 0.30-1.61; ticagrelor: adjusted OR 0.89; 95% CI 0.37-2.18) but with decreased risk of postoperative ischaemic events in patients on clopidogrel (clopidogrel: adjusted OR 0.50; 95% CI 0.30-0.82; ticagrelor: adjusted OR 0.78; 95% CI 0.45-1.37). BARC-4 bleeding was associated with 30-day mortality risk (adjusted OR 4.76; 95% CI 2.67-8.47; P < 0.001). CONCLUSIONS Guideline-conforming preoperative withdrawal of ticagrelor and clopidogrel was associated with a 50% reduced BARC-4 bleeding risk when corrected for EuroSCORE II and cardiopulmonary bypass time but was not associated with increased risk of 30-day mortality or postoperative ischaemic events.
Collapse
Affiliation(s)
- Michael Schoerghuber
- Division of Anaesthesiology and Intensive Care Medicine 2, Medical University of Graz, Graz, Austria
| | - Thomas Kuenzer
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Fausto Biancari
- Department of Internal Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Magnus Dalén
- Department of Cardiac Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Emma C Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Martin Siegemund
- Intensive Care Medicine, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Andreas Voetsch
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Ines Lindenau
- Department of Anaesthesiology and Intensive Care Medicine, Hospital Oberwart, Oberwart, Austria
| | - Daniel Zimpfer
- Division of Cardiac Surgery, University Heart Center Graz, Medical University of Graz, Graz, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Division of Anaesthesiology and Intensive Care Medicine 2, Medical University of Graz, Graz, Austria
| | - Andreas Zirlik
- Division of Cardiology, University Heart Center Graz, Medical University of Graz, Graz, Austria
| |
Collapse
|
3
|
Hermanns H, Alberts T, Preckel B, Strypet M, Eberl S. Perioperative Complications in Infective Endocarditis. J Clin Med 2023; 12:5762. [PMID: 37685829 PMCID: PMC10488631 DOI: 10.3390/jcm12175762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/27/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
Infective endocarditis is a challenging condition to manage, requiring collaboration among various medical professionals. Interdisciplinary teamwork within endocarditis teams is essential. About half of the patients diagnosed with the disease will ultimately have to undergo cardiac surgery. As a result, it is vital for all healthcare providers involved in the perioperative period to have a comprehensive understanding of the unique features of infective endocarditis, including clinical presentation, echocardiographic signs, coagulopathy, bleeding control, and treatment of possible organ dysfunction. This narrative review provides a summary of the current knowledge on the incidence of complications and their management in the perioperative period in patients with infective endocarditis.
Collapse
Affiliation(s)
| | - Tim Alberts
- Department of Anesthesiology, Amsterdam UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; (H.H.); (B.P.); (M.S.); (S.E.)
| | | | | | | |
Collapse
|
4
|
Schoerghuber M, Bärnthaler T, Prüller F, Mantaj P, Cvirn G, Toller W, Klivinyi C, Mahla E, Heinemann A. Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo. Br J Anaesth 2023; 131:452-462. [PMID: 37087333 PMCID: PMC10485366 DOI: 10.1016/j.bja.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation. METHODS Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis. RESULTS Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline. CONCLUSIONS Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.
Collapse
Affiliation(s)
- Michael Schoerghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria.
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Polina Mantaj
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Cvirn
- Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria
| |
Collapse
|
5
|
Spadaccio C, Rose D, Nenna A, Taylor R, Bittar MN. Early Re-Exploration versus Conservative Management for Postoperative Bleeding in Stable Patients after Coronary Artery Bypass Grafting: A Propensity Matched Study. J Clin Med 2023; 12:jcm12093327. [PMID: 37176767 PMCID: PMC10179715 DOI: 10.3390/jcm12093327] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Postoperative bleeding requiring re-exploration in cardiac surgery has been associated with complications impacting short-term outcomes and perioperative survival. Many aspects of decision-making for re-exploration still remain controversial, especially in hemodynamically stable patients with significant but not acutely cumulating chest drain output. We investigated the impact of re-exploratory surgery on short-term outcomes in a "borderline population" of CABG patients who experienced significant non-acute bleeding, but that were not in critically hemodynamic unstable conditions. METHODS A prospectively collected database of 8287 patients undergoing primary isolated elective CABG was retrospectively interrogated. A population of hemodynamically stable patients experiencing significant non-acute or rapidly cumulating bleeding (>1000 mL of blood loss in 12 h, <200 mL per hour in the first 5 h) with normal platelet and coagulation tests was identified (N = 1642). Patients belonging to this group were re-explored (N = 252) or treated conservatively (N = 1390) based on the decision of the consultant surgeon. Clinical outcomes according to the decision-making strategy were compared using a propensity score matching (PSM) approach. RESULTS After PSM, reoperated patients exhibited significantly higher overall blood product consumption (88.4% vs. 52.6% for red packed cells, p = 0.001). The reoperated group experienced higher rates of respiratory complications (odds ratio 5.8 [4.29-7.86] with p = 0.001 for prolonged ventilation), prolonged stay in intensive care unit (coefficient 1.66 [0.64-2.67] with p = 0.001) and overall length of stay in hospital (coefficient 2.16 [0.42-3.91] with p = 0.015) when compared to conservative management. Reoperated patients had significantly increased risk of multiorgan failure (odds ratio 4.59 [1.37-15.42] with p = 0.014) and a trend towards increased perioperative mortality (odds ratio 3.12 [1.08-8.99] with p = 0.035). CONCLUSIONS Conservative management in hemodynamically stable patients experiencing significant but non-critical or emergency bleeding might be a safe and viable option and might be advantageous in terms of reduction of postoperative morbidities and hospital stay.
Collapse
Affiliation(s)
- Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - David Rose
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| | - Antonio Nenna
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Rebecca Taylor
- Research and Development, Blackpool Teaching Hospitals, Blackpool FY3 8NR, UK
| | - Mohamad Nidal Bittar
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NR, UK
| |
Collapse
|
6
|
Irabor BE, Kothari A, Hong J, Burnette-Chiang B, Kent D, Duhamel T, Arora RC. Use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery: a scoping review protocol. BMJ Open 2022; 12:e064098. [PMID: 36002220 PMCID: PMC9413285 DOI: 10.1136/bmjopen-2022-064098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION A major complication of cardiac surgery is bleeding which can require surgical re-exploration and the transfusion of allogeneic blood products. Re-operative procedures for bleeding have been associated with higher rates of mortality and morbidity, therefore an intervention to reduce this complication would be important. Previous investigation has demonstrated that low-cost solutions, such as the use of an intraoperative haemostatic checklist may result in the reduction of bleeding and subsequent transfusion. The goals of this scoping review aim to assess the efficacy of the use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery. Specifically, the objective is to understand if the use of intraoperative haemostatic checklists has been associated with a reduction in bleeding and blood product utilisation in patients undergoing non-emergent cardiac surgery. METHODS AND ANALYSIS A scoping review of literature identifying randomised control and observational trials, reporting on haemostatic checklists in cardiac surgery, will be undertaken. The proposed review will be guided by the methodological framework proposed by Arksey and O'Malley. A search will be conducted for published and unpublished (grey) literature. Published literature will be searched in the following electronic databases: Scopus, MEDLINE, EMBASE and the Cochrane Library. Relevant grey literature will be identified through conference abstracts. Outcomes chosen are patient centred to ensure reduced bleeding and overall positive experience that reduces complications intraoperatively. ETHICS AND DISSEMINATION This study does not require ethical approval as the data used are from available publications. Our dissemination strategy includes peer-review publication, presentation at conferences and relevant stakeholders.
Collapse
Affiliation(s)
| | - Asha Kothari
- Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jonathan Hong
- Department of Cardiac Surgery, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | | | - David Kent
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Todd Duhamel
- Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
7
|
Gauger MS, Kaufmann P, Kamber F, Quitt J, Berdajs D, Bolliger D, Mauermann E. Rotational Thromboelastometry Values After On-Pump Cardiac Surgery - A Retrospective Cohort Study. Semin Cardiothorac Vasc Anesth 2022; 26:209-220. [PMID: 35616448 DOI: 10.1177/10892532221088216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Viscoelastic coagulation monitoring is recommended for coagulation management after cardiac surgery, but optimum target values are poorly defined. AIMS To determine "to-be-expected" values in rotational thromboelastometry (ROTEM) after heparin reversal, to correlate ROTEM parameters with fibrinogen levels and platelet count, and to estimate the effect of hemoglobin levels on these measurements. METHODS We retrospectively analyzed 571 consecutive adult patients undergoing cardiac surgery with cardiopulmonary bypass from 12/2018 to 08/2020. ROTEM and conventional laboratory measurements were performed 5 to 10 minutes after protamine administration. RESULTS Clotting times in EXTEM, INTEM, and FIBTEM were significantly prolonged (72.6%, 96.1%, and 31.8% above reference ranges, respectively). Clot firmness parameters in EXTEM and INTEM were relevantly reduced (7.9% to 14.4% and 9.1% to 32.3% below the reference ranges, respectively). There was an excellent linear correlation of FIBTEM amplitude after 10 min (A10) and of maximal clot firmness (MCF) with fibrinogen concentrations (r = .81 and .80). Areas under receiver operating characteristic (AUROC) for identifying hypofibrinogenemia <1.5 g/L were between .80 and .87. No effect of hematocrit was observed. We also found a linear correlation of EXTEM, INTEM, and EXTEM-FIBTEM at both A10 and MCF with platelet counts (.32 to .68). The AUROCs for identifying thrombocytopenia (<100,000/μL) were .79 to .84, and were greater for A10 than for MCF measurements (P=.074, .001, and <.001, respectively). CONCLUSIONS "To-be-expected" ROTEM values after CPB are different from the published reference ranges. ROTEM parameters might allow for reliable estimation of fibrinogen level and platelet count without being influenced by hematocrit.
Collapse
Affiliation(s)
- Maria S Gauger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Philip Kaufmann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Firmin Kamber
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Jonas Quitt
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Denis Berdajs
- Clinic for Cardiac Surgery, University Hospital Basel, Basel, Switzerland
| | - Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW Major bleeding in cardiac surgery is commonly encountered, and, until recently, most frequently managed with fresh frozen plasma (FFP). However, a Cochrane review found this practice to be associated with a significant increase in red blood cell (RBC) transfusions and costs. These findings have led to off-label uses of prothrombin complex concentrates (PCCs) in cardiac surgery. The purpose of this review is to compare and contrast the use of FFP and PCC, review the components, limitations and risks of different types of PCCs, and discuss the latest evidence for the use of PCC versus FFP in cardiac surgery. RECENT FINDINGS A recent review and meta-analysis suggests that PCC administration in cardiac surgery is more effective than FFP in reducing RBC transfusions and costs. SUMMARY The current data supports the use of 4F-PCC instead of FFP as the primary hemostatic agent in cases of major bleeding in cardiac surgery. The use of PCCs is associated with reduced rates of RBC transfusions while maintaining a favorable safety profile. Clear advantages of PCC over FFP include its smaller volume, higher concentration of coagulation factors and shorter acquisition and administration times.
Collapse
Affiliation(s)
- Jeans M Santana
- Department of Anesthesiology, Tufts Medical Center, Boston, Massachusetts, USA
| | | |
Collapse
|
9
|
Five-minute Test to Prevent Postcardiotomy Re-exploration. JTCVS Tech 2022; 12:121-129. [PMID: 35403041 PMCID: PMC8987325 DOI: 10.1016/j.xjtc.2021.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/16/2021] [Indexed: 11/22/2022] Open
|
10
|
OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6555495. [DOI: 10.1093/ejcts/ezac208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/18/2022] [Accepted: 03/18/2022] [Indexed: 11/12/2022] Open
|
11
|
Senage T, Gerrard C, Moorjani N, Jenkins DP, Ali JM. Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting. J Thorac Dis 2021; 13:5670-5682. [PMID: 34795917 PMCID: PMC8575859 DOI: 10.21037/jtd-21-1241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
Background Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG). Methods A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival. Results Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500–1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival. Conclusions Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.
Collapse
Affiliation(s)
- Thomas Senage
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK.,SPHERE (MethodS in Patient-Centred Outcomes and Health Research), University of Nantes, Nantes, France
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| |
Collapse
|
12
|
Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results. J Clin Med 2021; 10:jcm10143163. [PMID: 34300329 PMCID: PMC8305575 DOI: 10.3390/jcm10143163] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 12/31/2022] Open
Abstract
The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5–51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.
Collapse
|
13
|
Elassal AA, Al-Ebrahim KE, Debis RS, Ragab ES, Faden MS, Fatani MA, Allam AR, Abdulla AH, Bukhary AM, Noaman NA, Eldib OS. Re-exploration for bleeding after cardiac surgery: revaluation of urgency and factors promoting low rate. J Cardiothorac Surg 2021; 16:166. [PMID: 34099003 PMCID: PMC8183590 DOI: 10.1186/s13019-021-01545-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/24/2021] [Indexed: 11/05/2023] Open
Abstract
BACKGROUND Re-exploration of bleeding after cardiac surgery is associated with significant morbidity and mortality. Perioperative blood loss and rate of re-exploration are variable among centers and surgeons. OBJECTIVE To present our experience of low rate of re-exploration based on adopting checklist for hemostasis and algorithm for management. METHODS Retrospective analysis of medical records was conducted for 565 adult patients who underwent surgical treatment of congenital and acquired heart disease and were complicated by postoperative bleeding from Feb 2006 to May 2019. Demographics of patients, operative characteristics, perioperative risk factors, blood loss, requirements of blood transfusion, morbidity and mortality were recorded. Logistic regression was used to identify predictors of re-exploration and determinants of adverse outcome. RESULTS Thirteen patients (1.14%) were reexplored for bleeding. An identifiable source of bleeding was found in 11 (84.6%) patients. Risk factors for re-exploration were high body mass index, high Euro SCORE, operative priority (urgent/emergent), elevated serum creatinine and low platelets count. Re-exploration was significantly associated with increased requirements of blood transfusion, adverse effects on cardiorespiratory state (low ejection fraction, increased s. lactate, and prolonged period of mechanical ventilation), longer intensive care unit stay, hospital stay, increased incidence of SWI, and higher mortality (15.4% versus 2.53% for non-reexplored patients). We managed 285 patients with severe or massive bleeding conservatively by hemostatic agents according to our protocol with no added risk of morbidity or mortality. CONCLUSION Low rate of re-exploration for bleeding can be achieved by strict preoperative preparation, intraoperative checklist for hemostasis implemented by senior surgeons and adopting an algorithm for management.
Collapse
Affiliation(s)
- Ahmed Abdelrahman Elassal
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia. .,Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt.
| | | | - Ragab Shehata Debis
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia
| | - Ehab Sobhy Ragab
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| | | | | | - Amr Ragab Allam
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Department of Cardiac Surgery, Naser Institute of Research and Treatment, Cairo, Egypt
| | - Ahmed Hasan Abdulla
- Department of Surgery, Cardiac Surgery Unit, King Abdulaziz University, Jeddah, 21589, Saudi Arabia.,Cardiothoracic Surgery Department, Alahrar Hospital, Zagazig, Egypt
| | | | - Nada Ahmed Noaman
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Osama Saber Eldib
- Cardiothoracic Surgery Department, Zagazig University, Zagazig, Egypt
| |
Collapse
|
14
|
Pearse BL, Keogh S, Rickard CM, Fung YL. Barriers and facilitators to implementing evidence based bleeding management in Australian Cardiac Surgery Units: a qualitative interview study analysed with the theoretical domains framework and COM-B model. BMC Health Serv Res 2021; 21:550. [PMID: 34090421 PMCID: PMC8178922 DOI: 10.1186/s12913-021-06269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background Bleeding during cardiac surgery is a common complication that often requires the transfusion of blood products. The combination of bleeding and blood product transfusion incrementally increases adverse outcomes including infection and mortality. Following bleeding management guideline recommendations could assist with minimising risk but adherence is not high, and the cause for lack of adherence is not well understood. This study aimed to identify barriers and facilitators to practicing and implementing evidenced-based intra-operative, bleeding management in Australian cardiac surgery units. Methods We used a qualitative descriptive design to conduct semi-structured interviews with Australian cardiac surgeons, anaesthetists and perfusionists. The Theoretical Domains Framework (TDF) was utilised to guide interviews and thematically analyse the data. Categorised data were then linked with the three key domains of the COM-B model (capability, opportunity, motivation - behaviour) to explore and understand behaviour. Results Seventeen interviews were completed. Nine of the 14 TDF domains emerged as significant. Analysis revealed key themes to improving capability included, standardisation, monitoring, auditing and feedback of data and cross discipline training. Opportunity for change was improved with interpersonal and interdepartmental collaboration through shared goals, and more efficient and supportive processes allowing clinicians to navigate unfamiliar business and financial models of health care. Results suggest as individuals, clinicians had the motivation to make change and healthcare organisations have an obligation and a responsibility to partner with clinicians to support change and improve goal directed best practice. Conclusion Using a theory-based approach it was possible to identify factors which may be positively or negatively influence clinicians ability to implement best practice bleeding management in Australian cardiac surgical units. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06269-8.
Collapse
Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia. .,Departments of Surgery, Anaesthesia and Critical Care, The Prince Charles Hospital, Sippy Downs, QLD, Australia. .,School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia.
| | - Samantha Keogh
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Yoke L Fung
- School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia
| |
Collapse
|
15
|
Bartoszko J, Karkouti K. Managing the coagulopathy associated with cardiopulmonary bypass. J Thromb Haemost 2021; 19:617-632. [PMID: 33251719 DOI: 10.1111/jth.15195] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 11/23/2020] [Accepted: 11/24/2020] [Indexed: 12/29/2022]
Abstract
Cardiopulmonary bypass (CPB) has allowed for significant surgical advancements, but accompanying risks can be significant and must be expertly managed. One of the foremost risks is coagulopathic bleeding. Increasing levels of bleeding in cardiac surgical patients at the time of separation from CPB are associated with poor outcomes and mortality. CPB-associated coagulopathy is typically multifactorial and rarely due to inadequate reversal of systemic heparin alone. The components of the bypass circuit induce systemic inflammation and multiple disturbances of the coagulation and fibrinolytic systems. Anticipating coagulopathy is the first step in managing it, and specific patient and procedural risk factors have been identified as predictors of excessive bleeding. Medication management pre-procedure is critical, as patients undergoing cardiac surgery are commonly on anticoagulants or antiplatelet agents. Important adjuncts to avoid transfusion include antifibrinolytics, and perfusion practices such as red cell salvage, sequestration, and retrograde autologous priming of the bypass circuit have varying degrees of evidence supporting their use. Understanding the patient's coagulation status helps target product replacement and avoid larger volume transfusion. There is increasing recognition of the role of point-of-care viscoelastic and functional platelet testing. Common pitfalls in the management of post-CPB coagulopathy include overdosing protamine for heparin reversal, imperfect laboratory measures of thrombin generation that result in normal or near-normal laboratory results in the presence of continued bleeding, and delayed recognition of surgical bleeding. While challenging, the effective management of CPB-associated coagulopathy can significantly improve patient outcomes.
Collapse
Affiliation(s)
- Justyna Bartoszko
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University of Toronto, Toronto, ON, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
16
|
Atiq F, Wuijster E, de Maat MP, Kruip MJ, Cnossen MH, Leebeek FW. Criteria for low von Willebrand factor diagnosis and risk score to predict future bleeding. J Thromb Haemost 2021; 19:719-731. [PMID: 33370487 PMCID: PMC7986755 DOI: 10.1111/jth.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/01/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Important diagnostic and clinical aspects of moderately reduced von Willebrand factor (VWF) levels are still unknown. There is no clear evidence which cutoff value (0.50 vs 0.60 IU/ml) should be used to diagnose "low VWF." Also, the incidence of bleeding after the diagnosis has been made, and risk factors for bleeding are unknown yet. OBJECTIVES To investigate the incidence of postsurgical bleeding, postpartum hemorrhage (PPH), and traumatic and spontaneous bleeding after low VWF diagnosis, and to develop a risk score to predict future bleeding. METHODS We performed a cohort study in patients with historically lowest VWF levels of 0.31 to 0.60 IU/ml. Clinical data of patients were retrospectively collected. RESULTS We included 439 patients with low VWF. During a follow-up of 6.3 ± 3.7 years, 259 surgical procedures, 81 deliveries, and 109 spontaneous and traumatic bleeding episodes were reported. The incidence of postsurgical bleeding was 2.7%, whereas 10% of deliveries was complicated by PPH. Overall, 65 patients (14.8%) had bleeding requiring treatment, which was not different between patients with historically lowest VWF levels of 0.31-0.50 and 0.51-0.60 IU/ml (p = .154). Age <18 years, abnormal bleeding score at diagnosis, and being referred for bleeding symptoms at the time of diagnosis were independent risk factors for bleeding during follow-up, and therefore included in the risk score. CONCLUSIONS The cutoff value of low VWF diagnosis should be set at 0.60 IU/ml. Furthermore, a risk score is developed to identify individuals with a high risk for bleeding after low VWF diagnosis.
Collapse
Affiliation(s)
- Ferdows Atiq
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Esmee Wuijster
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Moniek P.M. de Maat
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marieke J.H.A. Kruip
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Marjon H. Cnossen
- Department of Pediatric HematologyErasmus MC‐Sophia Children’s HospitalUniversity Medical Center RotterdamRotterdamThe Netherlands
| | - Frank W.G. Leebeek
- Department of HematologyErasmus MCUniversity Medical Center RotterdamRotterdamThe Netherlands
| |
Collapse
|
17
|
Ali JM, Gerrard C, Clayton J, Moorjani N. Hemostasis Checklist Reduces Bleeding and Blood Product Consumption After Cardiac Surgery. Ann Thorac Surg 2020; 111:1570-1577. [PMID: 32956672 DOI: 10.1016/j.athoracsur.2020.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/23/2020] [Accepted: 07/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Considerable mediastinal bleeding is a recognized complication after cardiac surgery and may require reexploration and blood product transfusion, both of which are associated with inferior clinical outcomes with greater morbidity and mortality. The aim of this study was to develop a hemostasis checklist, with the intention of reducing mediastinal bleeding after cardiac surgery. METHODS A hemostasis checklist was developed with multidisciplinary collaboration. It contains 2 components: a series of surgical sites and factors affecting coagulation status. The checklist is performed at a time-out before sternal wire insertion. Analysis compared outcomes for patients undergoing cardiac surgery in the 1 year before and 2 years after implementation. RESULTS A total of 5542 patients underwent surgery during the study. After we implemented the checklist, there was a significant reduction in the reexploration rate (3.5% versus 1.9%; P < .001) and the proportion of patients bleeding greater than 1 L in 12 hours (6.1% versus 2.8%; P < .001). There was a major reduction in consumption of blood products, saving $430,513. There was progressive improvement in the second year after implementation. Checklist implementation was also associated with reduced intensive care unit and hospital length of stay, adding to the financial benefit. CONCLUSIONS Implementation of a simple and quickly performed hemostasis checklist has had a sustained impact over the 2 years after implementation, reducing the incidence of noteworthy mediastinal bleeding and reexploration, which has resulted in a major reduction in blood product consumption. Together, these have resulted in an associated reduction in intensive care unit and hospital length of stay, and a considerable financial savings. This highlights that perioperative bleeding is a preventable complication.
Collapse
Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom.
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| | - James Clayton
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| |
Collapse
|
18
|
Gunertem E, Urcun S, Pala AA, Budak AB, Ercisli MA, Gunaydin S. Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery. Perfusion 2020; 36:277-284. [DOI: 10.1177/0267659120941327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. Methods: The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. Results: Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. Conclusion: Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.
Collapse
Affiliation(s)
- Eren Gunertem
- Department of Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Salim Urcun
- Department of Cardiovascular Surgery, Adiyaman Training and Research Hospital, Adiyaman, Turkey
| | - Arda Aybars Pala
- Department of Cardiovascular Surgery, Adiyaman Training and Research Hospital, Adiyaman, Turkey
| | - Ali Baran Budak
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | | | - Serdar Gunaydin
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| |
Collapse
|
19
|
Marteinsson SA, Heimisdóttir AA, Axelsson TA, Johannesdottir H, Arnadottir LO, Gardarsdottir HR, Johnsen A, Sigurdsson MI, Helgadottir S, Gudbjartsson T. Reoperation for bleeding following coronary artery bypass surgery with special focus on long-term outcomes. SCAND CARDIOVASC J 2020; 54:265-273. [PMID: 32351135 DOI: 10.1080/14017431.2020.1751265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Objectives: We studied the incidence and risk factors of reoperation for bleeding following CABG in a nationwide cohort with focus on long-term complications and survival. Design: A retrospective study on 2060 consecutive, isolated CABG patients operated 2001-2016. Outcome of reoperated patients (n = 130) were compared to non-reoperated ones (n = 1930), including major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Risk factors for reoperation were determined using multivariate logistic regression and a Cox proportional hazards model to assess prognostic factors of long-term survival. Median follow-up was 7.6 years. Results: One hundred thirty patients (6.3%) were reoperated with an annual decrease of 4.1% per year over the study period (p=.04). Major complications (18.5 vs. 9.6%) and 30-day mortality (8.5 vs. 1.9%,) were higher in the reoperation group (p<.001). The use of clopidogrel preoperatively (OR 3.62, 95% CI: 1.90-6.57) and reduced left ventricular ejection fraction (OR 2.23, 95% CI: 1.25-3.77) were the strongest predictors of reoperation, whereas off-pump surgery was associated with a lower reoperation risk (OR 0.44, 95% CI: 0.22-0.85). After exluding patients that died within 30 days postoperatively, no difference in long-term survival or freedom from MACCE was found between groups, and reoperation was not an independent risk factor for long-term mortality in multivariate analysis. Conclusions: The reoperation rate in this study was relatively high but decreased significantly over time. Reoperation was associated with twofold increased risk for major complications and fourfold 30-day mortality, but comparable long-term MACCE and survival rates. This implies that if patients survive the first 30 days following reoperation, their long-term outcome is comparable to non-reoperated patients.
Collapse
Affiliation(s)
| | | | - Tomas A Axelsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Hera Johannesdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Linda O Arnadottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Helga R Gardarsdottir
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Arni Johnsen
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Department of Anesthesia and Intensive Care, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Solveig Helgadottir
- Department of Anesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| |
Collapse
|
20
|
Bolliger D, Lancé MD. Factor Concentrate-Based Approaches to Blood Conservation in Cardiac Surgery: European Perspectives in 2020. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00382-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
21
|
Pearse BL, Keogh S, Rickard CM, Faulke DJ, Smith I, Wall D, McDonald C, Fung YL. Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model. J Multidiscip Healthc 2020; 13:27-41. [PMID: 32021232 PMCID: PMC6970603 DOI: 10.2147/jmdh.s232888] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/11/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose Excessive bleeding is an acknowledged consequence of cardiac surgery, occurring in up to 10% of adult patients. This clinically important complication leads to poorer patient outcomes. Clinical practice guidelines are available to support best practice however variability in bleeding management practice and related adverse outcomes still exist. This study had two objectives: 1) to gain insight into current bleeding management practice for adult cardiac surgery in Australia and how that compared to guidelines and literature; and 2) to understand perceived difficulties clinicians face implementing improvements in bleeding management. Methods A national cross-sectional questionnaire survey was utilized. Perspectives were sought from cardiac surgeons, cardiac anesthesiologists and perfusionists. Thirty-nine closed-ended questions focused on routine bleeding management practices to address pre and intra-operative care. One open-ended question was asked; “What would assist you to improve bleeding management with cardiac surgery patients?” Quantitative data were analysed with SPSS. Qualitative data were categorized into the domains of the Theoretical Domains Framework; the domains were then mapped to the COM-B model. Results Survey responses from 159 Anesthesiologists, 39 cardiac surgeons and 86 perfusionists were included (response rate 37%). Four of the recommendations queried in this survey were reported as routinely adhered to < 50% of the time, 9 queried recommendations were adhered to 51–75% of the time and 4 recommendations were routinely followed >76% of the time. Conclusion There is a wide variation in peri-operative bleeding management practice among cardiac anaesthesiologists, surgeons and perfusionists in Australian cardiac surgery units. Conceptualizing factors believed necessary to improve practice with the TDF and COM-B model found that bleeding management could be improved with a standardized approach including; point of care diagnostic assays, a bleeding management algorithm, access to concentrated coagulation factors, cardiac surgery specific bleeding management education, multidisciplinary team agreement and support, and an overarching national approach.
Collapse
Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia.,Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Samantha Keogh
- School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Daniel J Faulke
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Ian Smith
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Douglas Wall
- Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Yoke L Fung
- School of Health and Sports Sciences, University of Sunshine Coast, Sunshine Coast, QLD, Australia
| |
Collapse
|
22
|
Adam EH, Meier J, Klee B, Zacharowski K, Meybohm P, Weber CF, Pape A. Factor XIII activity in patients requiring surgical re-exploration for bleeding after elective cardiac surgery - A prospective case control study. J Crit Care 2019; 56:18-25. [PMID: 31805464 DOI: 10.1016/j.jcrc.2019.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/05/2019] [Accepted: 11/15/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Surgical re-exploration due to postoperative bleeding is associated with increased morbidity and mortality. The aim of our study was to assess a potential association between the level of postoperative FXIII activity and need for re-exploration due to bleeding in patients undergoing cardiothoracic surgery. MATERIALS AND METHODS In our prospective single center observational cohort study, we enrolled patients who underwent elective cardiothoracic surgery. Patients who required re-exploration (RE group) were matched to patients from the study population (non-RE group). RESULTS The study included 64 patients, out of a cohort of 678 patients, of whom 32 required surgical re-exploration due to bleeding within the first 24 h. Between patients of the RE and non-RE group, a significantly reduced FXIII activity was observed postoperatively (59.0 vs 71.1; p = .014). Multivariable analysis revealed reduced FXIII activity (p = .048) as a parameter independently associated with surgical re-exploration. Further, reduced FXIII activity (p = .037) and surgical re-exploration (p = .01) were significantly associated with increased 30 day mortality. In multivariable analysis re-exploration was independently associated with increased risk of 30 day mortality (p = .004, HR 9.68). CONCLUSIONS Reduced postoperative FXIII activity may be associated with the need for surgical re-exploration. Postoperative assessment of FXIII activity should therefore be considered in patients undergoing elective cardiothoracic surgery.
Collapse
Affiliation(s)
- Elisabeth H Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Jens Meier
- Department of Anaesthesiology and Intensive Care Medicine, Kepler University Hospital, Med Campus III, Krankenhausstr. 9, 4021 Linz, Austria.
| | - Bernd Klee
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| | - Christian F Weber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany; Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Asklepios Clinics Hamburg, AK Wandsbek, Alphonsstr. 14, 22043 Hamburg, Germany.
| | - Andreas Pape
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University, Theodor-Stern Kai 7, 60590 Frankfurt/Main, Germany.
| |
Collapse
|
23
|
Bolliger D, Mauermann E. Re-exploration After Cardiac Surgery Impairs Outcome—But How to Stratify the Risk? J Cardiothorac Vasc Anesth 2019; 33:2938-2940. [DOI: 10.1053/j.jvca.2019.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/30/2019] [Indexed: 11/11/2022]
|
24
|
Beverly A, Ong G, Wilkinson KL, Doree C, Welton NJ, Estcourt LJ. Drugs to reduce bleeding and transfusion in adults undergoing cardiac surgery: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Anair Beverly
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Giok Ong
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Kirstin L Wilkinson
- Southampton University NHS Hospital; Paediatric and Adult Cardiothoracic Anaesthesia; Tremona Road Southampton UK SO16 6YD
| | - Carolyn Doree
- NHS Blood and Transplant; Systematic Review Initiative; Oxford UK
| | - Nicky J Welton
- University of Bristol; Population Health Sciences, Bristol Medical School; Bristol UK
| | - Lise J Estcourt
- NHS Blood and Transplant; Haematology/Transfusion Medicine; Level 2, John Radcliffe Hospital Headington Oxford UK OX3 9BQ
| |
Collapse
|
25
|
Kara H, Erden T. Feasibility and acceptability of continuous postoperative pericardial flushing for blood loss reduction in patients undergoing coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 68:219-226. [PMID: 31325107 DOI: 10.1007/s11748-019-01174-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Hakan Kara
- Department of Cardiovascular Surgery, Giresun Ada Hospital, Giresun, Turkey.
| | - Tuncay Erden
- Department of Cardiovascular Surgery, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| |
Collapse
|
26
|
Komarov RN, Karavaĭkin PA, Kuznetsov AA, Shcherbenev VM, Bredikhin RA, Gnevashev AS, Iudin AN, Tsekhanovich VN, Andreev DB. [Use of topical haemostatic agents in cardiovascular surgery]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:131-142. [PMID: 30994619 DOI: 10.33529/angio2019118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The problem of haemostasis in cardiovascular surgery is of current concern. Recent trends are towards increased use of topical haemostatic agents. Tachocomb has been used for more than 30 years in abdominal surgery and oncology. The purpose of the present publication is to analyse the literature data and formulate the indications for the use of Tachocomb in cardiovascular surgery. Multicenter randomized and local studies have demonstrated efficacy of Tachocomb in treatment of surgical haemorrhage in operations on the heart, thoracic aorta, carotid arteries and lower-limb arteries, resulting in significantly decreased time to achieve haemostasis, decreased volume of blood loss and haemotrasfusion, as well as reduced frequency of complications. Also shown was economic efficacy, including a shortened length of patients' hospital stay. This is followed by describing a wide spectrum of examples of alternative use of Tachocomb, including its use for seamless closure of defects of cardiac chamber walls, aero- and lymphostasis, prevention of formation of commissures. Convincing experimental and clinical results make it possible to formulate a series of indications for the use of Tachocomb in cardiovascular surgery.
Collapse
Affiliation(s)
- R N Komarov
- Clinic of Aortic and Cardiovascular Surgery, Chair of Hospital Surgery of Therapeutic Department, First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health, Moscow, Russia
| | - P A Karavaĭkin
- Clinic of Aortic and Cardiovascular Surgery, Chair of Hospital Surgery of Therapeutic Department, First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health, Moscow, Russia
| | - A A Kuznetsov
- Central Military Clinical Hospital named after A.A. Vishnevsky of the RF Ministry of Defence, Moscow, Russia
| | | | - R A Bredikhin
- Interregional Clinical and Diagnostic Centre, Kazan, Russia
| | - A S Gnevashev
- North-West Federal Medical Research Centre named after V.A. Almazov under the RF Ministry of Public Health, Saint Petersburg, Russia
| | - A N Iudin
- Ulyanovsk Regional Clinical Hospital, Ulyanovsk, Russia
| | | | - D B Andreev
- Federal Centre of Cardiovascular Surgery under the RF Ministry of Public Health, Khabarovsk, Russia
| |
Collapse
|
27
|
Karkouti K, Ho LTS. Preventing and managing catastrophic bleeding during extracorporeal circulation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:522-529. [PMID: 30504353 PMCID: PMC6246010 DOI: 10.1182/asheducation-2018.1.522] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The use of extracorporeal circulation for cardiac surgery and extracorporeal life support poses tremendous challenges to the hemostatic equilibrium given its diametric tendency to trigger hyper- and hypocoagulopathy. The necessity of anticoagulant therapy to counteract the hemostatic activation by the extracorporeal circuitry compounded by unfavorable patient and surgical factors significantly increase the risk of catastrophic bleeding in patients who require extracorporeal circulation. Preoperative measures, such as stratification of high-risk bleeding patients, and optimization of the modifiable variables, including anemia and thrombocytopenia, provide a crude estimation of the likelihood and may modify the risk of catastrophic bleeding. The anticipation for catastrophic bleeding subsequently prompts the appropriate preparation for potential resuscitation and massive transfusion. Equally important is intraoperative prevention with the prophylactic application of tranexamic acid, an antifibrinolytic agent that has promising benefits in reduction of blood loss and transfusion. In the event of uncontrolled catastrophic bleeding despite preemptive strategies, all effort must be centered on regaining hemostasis through surgical control and damage control resuscitation to protect against worsening coagulopathy and end organ failure. When control of bleeding is reinstated, management should shift focus from systemic therapy to targeted hemostatic therapy aimed at the potential culprits of coagulopathy as identified by point of care hemostatic testing. This review article outlines the strategies to appropriately intervene using prediction, prevention, preparation, protection, and promotion of hemostasis in managing catastrophic bleeding in extracorporeal circulation.
Collapse
Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Loretta T S Ho
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| |
Collapse
|