1
|
Hofmann A, Shander A, Blumberg N, Hamdorf JM, Isbister JP, Gross I. Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up? Anesth Analg 2022; 135:511-523. [PMID: 35977361 DOI: 10.1213/ane.0000000000006138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.
Collapse
Affiliation(s)
- Axel Hofmann
- From the Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth, Western Australia, Australia.,Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey.,College of Medicine, University of Florida, Gainesville, Florida.,School of Medicine at Mount Sinai, New York, New York.,Rutgers University, Newark, New Jersey
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey M Hamdorf
- From the Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - James P Isbister
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Irwin Gross
- Department of Medicine, Eastern Maine Medical Center, Bangor, Maine
| |
Collapse
|
2
|
De La Porte VM, De Meyer GRA, Schepens T, Verbrugghe W, Laga S, Allegaert M, Mertens P, Rodrigus I, Jorens PG. Reoperation for bleeding after cardiac surgery. Acta Chir Belg 2022; 122:312-320. [PMID: 33150853 DOI: 10.1080/00015458.2020.1847463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative cardio-surgical haemostatic management is centre-specific and experience-based, which leads to a variability in patient care. This study aimed to identify which postoperative haemostatic interventions may reduce the need for reoperation after cardiac surgery in adults. METHODS A retrospective case-control study in a tertiary centre. Adult, elective, primary cardiac surgical patients were selected (n = 2098); cases (n = 42) were patients who underwent reoperation within 72 h after the initial surgery. Interventions administered to control surgical bleeding were compared for the need to re-operate using multiple logistic regression. RESULTS Rate of cardiac surgical reoperation was 2% in the study population. Three variables were found to be associated with cardiac reoperation: preoperative administration of fresh frozen plasma (OR 5.45, CI 2.34-12.35), cumulative volume of chest tube drainage and cumulative count of packed red blood cells transfusion on ICU (OR 1.98, CI 1.56-2.51). CONCLUSION No significant difference among specific types of postoperative haemostatic interventions was found between patients who needed reoperation and those who did not. Perioperative transfusion of fresh frozen plasma, postoperative transfusion of packed cells and cumulative volume of chest tube drainage were associated with reoperation after cardiac surgery. These variables could help predict the need for reoperation.
Collapse
Affiliation(s)
| | - Gregory R A De Meyer
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Tom Schepens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Walter Verbrugghe
- Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Steven Laga
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiac Surgery, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Mathias Allegaert
- Department of Patient Care, Subdivision of Perfusion, Antwerp University Hospital, Edegem, Belgium
| | - Pieter Mertens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Anesthesiology, Antwerp University Hospital, Edegem, Belgium
| | - Inez Rodrigus
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Cardiac Surgery, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| | - Philippe G Jorens
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Intensive Care Medicine, Universitair Ziekenhuis Antwerpen, Edegem, Belgium
| |
Collapse
|
3
|
Rodrigues ARB, Benevides LMB, Crespo JCL, Santana-Santos E, Püschel VADA, Oliveira LBD. Factors associated with reoperation due to bleeding and outcomes after cardiac surgery: a prospective cohort study. Rev Esc Enferm USP 2022; 56:e20210451. [PMID: 35876855 DOI: 10.1590/1980-220x-reeusp-2021-0451en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 05/13/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Identify the incidence and factors associated with reoperation due to bleeding in the postoperative of a cardiac surgery, in addition to the clinical outcomes of patients. METHOD Prospective cohort study, conducted in an Intensive Care Unit (ICU), with adult patients undergoing cardiac surgery. Patients diagnosed with coagulopathies were excluded. The patients were followed up from hospitalization to hospital discharge. RESULTS A total of 682 patients were included, and the incidence of reoperation was 3.4%. The factors associated with reoperation were history of renal failure (p = 0.005), previous use of anticoagulant (p = 0.036), higher intraoperative heart rate (p = 0.015), need for transfusion of blood component during intraoperative (p = 0.040), and higher SAPS 3 score (p < 0.001). The outcomes associated with reoperation were stroke and cardiac arrest. CONCLUSÃO Reoperation was an event associated with greater severity, organic dysfunction, and worse clinical outcomes, but there was no difference in mortality between the groups.
Collapse
Affiliation(s)
| | | | - Jeiel Carlos Lamonica Crespo
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Instituto do Coração, São Paulo, SP, Brazil
| | | | | | - Larissa Bertacchini de Oliveira
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas HCFMUSP, Instituto do Coração, São Paulo, SP, Brazil
| |
Collapse
|
4
|
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
|
5
|
Rodrigues ARB, Benevides LMB, Crespo JCL, Santana-Santos E, Püschel VADA, Oliveira LBD. Fatores associados à reoperação por sangramento e desfechos após cirurgia cardíaca: estudo de coorte prospectivo. Rev Esc Enferm USP 2022. [DOI: 10.1590/1980-220x-reeusp-2021-0451pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: Identificar a incidência e os fatores associados à reoperação devido sangramento no pós-operatório de cirurgia cardíaca, além dos desfechos clínicos dos pacientes. Método: Estudo de coorte prospectivo, realizado em Unidade de Terapia Intensiva (UTI), com pacientes adultos submetidos à cirurgia cardíaca. Foram excluídos pacientes com diagnóstico de coagulopatias. Os pacientes foram acompanhados desde a internação até a saída hospitalar. Resultados: Foram incluídos 682 pacientes e a incidência de reoperação foi 3,4 %. Os fatores associados à reoperação foram: histórico de insuficiência renal (p = 0,005), uso prévio de anticoagulante (p = 0,036), maior frequência cardíaca intraoperatória (p = 0,015), necessidade de transfusão de hemocomponentes no intraoperatório (p = 0,040) e maior pontuação no SAPS 3 (p < 0,001). Os desfechos associados a reoperação foram: acidente vascular encefálico e parada cardiorrespiratória. Conclusão: A reoperação foi um evento associado a maior gravidade, disfunção orgânica, e piores desfechos clínicos, porém não houve diferença de mortalidade entre os grupos.
Collapse
|
6
|
Nuttall GA, Smith MM, Smith BB, Christensen JM, Santrach PJ, Schaff HV. A Blinded Randomized Trial Comparing Standard Activated Clotting Time Heparin Management to High Target Active Clotting Time and Individualized Hepcon HMS Heparin Management in Cardiopulmonary Bypass Cardiac Surgical Patients. Ann Thorac Cardiovasc Surg 2021; 28:204-213. [PMID: 34937821 PMCID: PMC9209891 DOI: 10.5761/atcs.oa.21-00222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: High-dose heparin has been suggested to reduce consumption coagulopathy. Materials and Methods: In a randomized, blinded, prospective trial of patients undergoing elective, complex cardiac surgery with cardiopulmonary bypass, patients were randomized to one of three groups: 1) high-dose heparin (HH) receiving an initial heparin dose of 450 u/kg, 2) heparin concentration monitoring (HC) with Hepcon Hemostasis Management System (HMS; Medtronic, Minneapolis, MN, USA) monitoring, or 3) a control group (C) receiving a standard heparin dose of 300 u/kg. Primary outcome measures were blood loss and transfusion requirements. Results: There were 269 patients block randomized based on primary versus redo sternotomy to one of the three groups from August 2001 to August 2003. There was no difference in operative bleeding between the groups. Chest tube drainage did not differ between treatment groups at 8 hours (median [25th percentile, 75th percentile] for control group was 321 [211, 490] compared to 340 [210, 443] and 327 [250, 545], p = 0.998 and p = 0.540, for HH and HC treatment groups, respectively). The percentage of patients receiving transfusion was not different among the groups. Conclusion: Higher heparin dosing accomplished by either activated clot time or HC monitoring did not reduce 24-hour intensive care unit blood loss or transfusion requirements.
Collapse
Affiliation(s)
- Gregory A Nuttall
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon M Christensen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Paula J Santrach
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Hartzell V Schaff
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
7
|
Qureshi SH, Ruel M. Commentary: A Long-Lasting Complication: Re-exploration for Bleeding and Its Negative Correlation With Long-Term Survival. Semin Thorac Cardiovasc Surg 2021; 33:776-777. [PMID: 33600978 DOI: 10.1053/j.semtcvs.2020.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Saqib H Qureshi
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| |
Collapse
|
8
|
Montgomery CL, Thanh NX, Stelfox HT, Norris CM, Rolfson DB, Meyer SR, Zibdawi MA, Bagshaw SM. The Impact of Preoperative Frailty on the Clinical and Cost Outcomes of Adult Cardiac Surgery in Alberta, Canada: A Cohort Study. CJC Open 2020; 3:54-61. [PMID: 33458633 PMCID: PMC7801203 DOI: 10.1016/j.cjco.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/08/2020] [Indexed: 11/24/2022] Open
Abstract
Background There is limited information about the impact of frailty on public payer costs in cardiac surgery. This study aimed to determine quality-adjusted life-years (QALYs) and costs associated with preoperative frailty in patients referred for cardiac surgery. Methods We retrospectively compared costs of frailty in a cohort of 529 patients aged ≥ 50 years who were referred for nonemergent cardiac surgery in Alberta. Patients were screened preoperatively for frailty, defined as a score of 5 or greater on the Clinical Frailty Scale. The primary outcome measure was public payer costs attributable to frailty, calculated in a difference-in-difference (DID) model. Results The prevalence of frailty was 10% (n = 51; 95% confidence interval [CI], 7%-12%). Median (interquartile range) costs for frail patients were higher in the first year postsurgery ($200,709 [$146,177-$486,852] vs $147,730 [$100,674-$177,025]; P < 0.001) compared to nonfrail; the difference-in-difference attributable cost of frailty was $57,836 (95% CI, $–28,608-$144,280). At 1 year, frail patients had fewer QALYs realized compared to nonfrail patients (0.71 [0.57-0.77] vs 0.82 [0.75-0.86], P < 0.001), whereas QALYs gained were similar (0.02 [–0.02-0.05] vs 0.02 [0.00–0.04], P = 0.58, median difference 0.003 [95% CI, –0.01-0.02]) in frail and nonfrail patients. Conclusions Frailty screening identified a population with greater impairment in quality-of-life and greater healthcare costs. Costs attributable to frailty represent opportunity costs that should be considered in future cardiac surgical services planning in the context of our aging population and the growing prevalence of frailty.
Collapse
Affiliation(s)
- Carmel L. Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author: Dr Carmel Montgomery, Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 CSB, 11350-83 Ave, Edmonton, Alberta T6G 2G3, Canada. Tel.: +1-780-248-1256; fax: +1-780-492-1500.
| | - Nguyen X. Thanh
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Henry T. Stelfox
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Colleen M. Norris
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Darryl B. Rolfson
- Division of Geriatric Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Steven R. Meyer
- Division of Cardiac Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamad A. Zibdawi
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sean M. Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
9
|
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
|
10
|
Agarwal S, Choi SW, Fletcher SN, Klein AA, Gill R. The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1-year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care. Anaesthesia 2020; 76:19-26. [PMID: 32406071 DOI: 10.1111/anae.15070] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2020] [Indexed: 12/11/2022]
Abstract
Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.
Collapse
Affiliation(s)
- S Agarwal
- Department of Anaesthesia, Manchester University Hospitals, Manchester, UK
| | - S W Choi
- Department of Anaesthesiology, University of Hong Kong
| | - S N Fletcher
- Departments of Anaesthesia and Critical Care, St George's Hospital, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - R Gill
- Shackleton Department of Anaesthesia, University Hospital Southampton, UK
| | | |
Collapse
|
11
|
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
|
12
|
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]
|
13
|
Right pericardial window opening: a method of preventing pericardial effusion. Gen Thorac Cardiovasc Surg 2019; 68:485-491. [PMID: 31559587 DOI: 10.1007/s11748-019-01213-4] [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: 04/10/2019] [Accepted: 09/14/2019] [Indexed: 10/25/2022]
Abstract
AIM In this study, we aimed to investigate the superiority of right pericardial window (RPW) versus posterior pericardial drain placing for the parameters of pericardial effusion and the postoperative complications at the patients who has undergone cardiac surgery. MATERIALS AND METHODS Between July and September 2018, 120 adult patients (mean age 50.30 ± 14.61) who underwent cardiac surgery without the necessity of opening the pleura were included in the study. In Group 1, the RPW was opened (n = 60), and Group 2 posterior pericardial drainage tube was placed without RPW (n = 60). Risk factors and postoperative complication were evaluated and compared between the Groups. RESULTS Cardiac tamponade occurrence was not significantly different between the Groups (Group 1, n = 0 and Group 2, n = 3, p = 0.079). Postoperative transthoracic echocardiographic controls revealed significant pericardial effusion in Group 2 (6.90 mm ± 13.02 mm) compared to Group 1 (2.30 mm ± 5.60 mm) (p = 0.013). Postoperative creatinine levels were 0.75 ± 0.26 in Group 1 and 0.88 ± 0.36 in Group 2 (p = 0.022). A significant decrease in glomerular filtration rate was observed in Group 2 (102.7 ± 24.5 and 91.2 ± 28, p = 0.019). Postoperative acute renal failure was significantly higher in Group 2 compared to Group 1 (p < 0.001). Postoperative new onset atrial fibrillation occurred in 4 patients in Group 1 and 8 in Group 2 (p = 0.224). The duration of intensive care unit stay was 36.00 ± 22.31 h in Group 1 and 53.60 ± 59.50 h in Group 2 (p = 0.034). Development of pneumothorax, pneumonia and pleural effusion were not statistically different between the Groups (p = 0.079, 0.171, 0.509). CONCLUSION RPW application is more effective on preventing postoperative complications in cardiac surgery instead of placing drains in posterior pericardium.
Collapse
|
14
|
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
|
15
|
Hsu PS, Yang HY, Chen JL, Tsai YT, Lin CY, Ke HY, Lin YC, Tsai CS. The implication of seniority of supervising attending surgeon on the reexploration rate following elective coronary artery bypass grafting. J Formos Med Assoc 2018; 118:354-361. [PMID: 29936106 DOI: 10.1016/j.jfma.2018.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/19/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND AIMS During coronary artery bypass graft (CABG) surgery, the residual hemostasis procedures, from weaning cardiopulmonary bypass to closing sternotomy, are always completed by residents and supervised by attending surgeons. We want to evaluate the teaching effectiveness for residents under the supervision of attending surgeons with different levels of seniority. MATERIALS AND METHODS Between January 1st 2001 and December 31st 2010, 2279 consecutive CABG surgeries were performed in our medical center. In total, 83 patients underwent a reexploration for postoperative bleeding. All causes of bleeding were identified and recorded. Competent attending surgeons were defined as having >3 years' experience and young attending surgeons with ≦3 years' experience. We compared the reexploration rate and aimed to identify the common sources of bleeding by the two groups. We also assessed the impact of attending experience on the outcomes and major complications after reexploration. RESULTS There were 36 surgical bleeding and 17 non-surgical bleeding in the young group and 16 surgical bleeding and 14 non-surgical bleeding in the competent group. The young group experienced more mediastinal drainage before a reexploration and a longer time interval to a reexploration. However, both are without statistical significance. Furthermore, the young group has a significant longer hospital stay. The most common intra-pericardium surgical bleeding included two-stage cannulation, side branch of the left internal mammary artery (LIMA), and side branch of vein grafts. The most common extra-pericardium surgical bleeding included a puncture hole by sternal wires, LIMA bed, and fragile sternum. CONCLUSION Young attending surgeons indeed had both higher incidence of reexploration and surgical bleeding after a CABG. However, the supervisor experience only impacted hospital stay, not major complications or mortality after a reexploration. This might imply the competent attending surgeons provide higher teaching effectiveness for the hemostasis procedure after CABG.
Collapse
Affiliation(s)
- Po-Shun Hsu
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsiang-Yu Yang
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jia-Lin Chen
- Department of Anesthesia, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Ting Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yuan Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hong-Yan Ke
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yi-Chang Lin
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Sung Tsai
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| |
Collapse
|
16
|
Grieshaber P, Heim N, Herzberg M, Niemann B, Roth P, Boening A. Active Chest Tube Clearance After Cardiac Surgery Is Associated With Reduced Reexploration Rates. Ann Thorac Surg 2018; 105:1771-1777. [DOI: 10.1016/j.athoracsur.2018.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 11/29/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
|
17
|
Ikeme S, Weltert L, Lewis KM, Bothma G, Cianciulli D, Pay N, Epstein J, Kuntze E. Cost-effectiveness analysis of a sealing hemostat patch (HEMOPATCH) vs standard of care in cardiac surgery. J Med Econ 2018; 21:273-281. [PMID: 29096598 DOI: 10.1080/13696998.2017.1400977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND A recent randomized controlled trial showed that patients undergoing ascending aorta surgery treated with HEMOPATCH to control bleeding had a significantly better hemostasis success rate than with dry or wet gauze compression or similar standard of care (SOC). OBJECTIVE To compare the cost-effectiveness using two different agents for hemostasis (HEMOPATCH vs dry or wet gauze compression or similar SOC) in cardiac surgery from the European hospital perspective. METHODS A literature-based cost-effectiveness model estimating average cost per successful hemostasis event was developed based on the hemostasis efficacy difference (HEMOPATCH = 97.6%, SOC = 65.8%, p < .001). Additional clinically significant end-points studied in the trial (blood transfusions and surgical revisions) were also analyzed. It was assumed that each surgery utilized two units of HEMOPATCH (dimensions of 4.5 × 9 cm) and two units of SOC. Product acquisition costs for HEMOPATCH and SOC were included along with outcome-related costs derived from the literature and inflation-adjusted to 2017 EUR and GBP. Results are presented for an average hospital with an annual case load of 574 cardiac surgeries. One-way and probabilistic sensitivity analyses were performed. RESULTS Considering only product acquisition cost, HEMOPATCH had an incremental cost-effectiveness ratio (ICER) of €1,659, €1,519, €1,623, and £1,725 per hemostasis success when compared to SOC for Italy, Spain, France, and the UK, respectively. However, when considering the cost and potential difference in the frequency of transfusions and revisions compared to SOC, the use of HEMOPATCH was associated with an annual reduction of six revisions and 60 transfusions, improving the ICER to €1,440, €1,222, €1,461, and £1,592, respectively. Sensitivity analysis demonstrated model robustness. CONCLUSIONS This analysis supports the use of HEMOPATCH over SOC in cardiac surgery in European hospitals to improve hemostasis success rates and potential cost offsets from reduced transfusions, complications, and surgical revisions.
Collapse
Affiliation(s)
- Shelly Ikeme
- a Baxter Healthcare Corporation , Deerfield , IL , USA
| | | | - Kevin M Lewis
- a Baxter Healthcare Corporation , Deerfield , IL , USA
| | | | | | | | | | - Erik Kuntze
- c Baxter Healthcare Corporation , Zurich , Switzerland
| |
Collapse
|
18
|
Williams B, Wehman B, Mazzeffi MA, Odonkor P, Harris RL, Kon Z, Tanaka KA. Acute Intracardiac Thrombosis and Pulmonary Thromboembolism After Cardiopulmonary Bypass. Anesth Analg 2018; 126:425-434. [DOI: 10.1213/ane.0000000000002259] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
19
|
Biancari F, Kinnunen EM, Kiviniemi T, Tauriainen T, Anttila V, Airaksinen JKE, Brascia D, Vasques F. Meta-analysis of the Sources of Bleeding after Adult Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 32:1618-1624. [PMID: 29338997 DOI: 10.1053/j.jvca.2017.12.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to pool data on the proportion and prognostic impact of sources of bleeding in patients requiring re-exploration after adult cardiac surgery. DESIGN Systematic review of the literature and meta-analysis. SETTING Multistitutional study. MEASUREMENTS AND MAIN RESULTS A literature review was performed to identify studies published since 1990 evaluating the outcome after reoperation for bleeding or tamponade after adult cardiac surgery. Eighteen studies including 5,1497 patients fulfilled the selection criteria. Reoperation for bleeding/tamponade was performed in 2,455 patients (4.6%; 95% confidence interval [CI] 3.9%-5.2%, I2 92%). These had a significantly higher risk of in-hospital/30-day mortality compared with patients not reoperated for bleeding (pooled rates: 9.3% v 2.3%; risk ratio 3.30; 95% CI 2.52-4.32; I2 47%; 8 studies; 25,463 patients). Surgical sites of bleeding were identified in 65.7% of cases (95% CI 58.3%-73.2%; I2 94%), cardiac site bleeding in 40.9% of cases (95% CI 29.7%-52.0%; I2 94%), and mediastinal/sternum site bleeding in 27.0% of cases (95% CI 16.8%-37.3%; I2 94%). The main sites of bleeding were the body of the graft (20.2%), the sternum (17.0%), vascular sutures (12.5%), the internal mammary artery harvest site (13.0%), and anastomoses (9.9%). In metaregression, surgical site bleeding was associated with a lower risk of in-hospital/30-day mortality compared with diffuse bleeding (p = 0.003). CONCLUSIONS Surgical site bleeding is identified in two-thirds of patients undergoing re-exploration after adult cardiac surgery. Meticulous surgical technique and systematic intraoperative checking of potential surgical sites of bleeding at the time of the original cardiac surgery may reduce the risk of such a severe complication.
Collapse
Affiliation(s)
- Fausto Biancari
- Department of Surgery, University of Turku, Turku, Finland; Department of Surgery, University of Oulu, Oulu, Finland; Heart Center, Turku University Hospital and University of Turku, Turku, Finland.
| | | | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Vesa Anttila
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Debora Brascia
- Department of Surgery, University of Turku, Turku, Finland
| | | |
Collapse
|
20
|
Strauss E, Mazzeffi M, Williams B, Key N, Tanaka K. Perioperative management of rare coagulation factor deficiency states in cardiac surgery. Br J Anaesth 2017; 119:354-368. [DOI: 10.1093/bja/aex198] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2017] [Indexed: 01/21/2023] Open
|
21
|
How detrimental is reexploration for bleeding after cardiac surgery? J Thorac Cardiovasc Surg 2017; 154:927-935. [DOI: 10.1016/j.jtcvs.2016.04.097] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Revised: 03/28/2016] [Accepted: 04/05/2016] [Indexed: 11/22/2022]
|
22
|
|
23
|
Brown E, Clarke J, Edward KL, Giandinoto JA. Point-of-care testing of activated clotting time in the ICU: is it relevant? ACTA ACUST UNITED AC 2016; 25:608-12. [PMID: 27281594 DOI: 10.12968/bjon.2016.25.11.608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Over the past 50 years there have been significant advances in both the clinical techniques and equipment used in the intensive care environment. One traditionally used point-of-care test is activated clotting time (ACT), a coagulation test primarily used during cardiopulmonary bypass surgery to monitor the anticoagulation effects of heparin. The ACT test has since emerged into the intensive care environment to guide clinical assessment and management of haemostasis in postoperative cardiac patients. OBJECTIVES The aim of this integrative systematic review was to critique the available research evaluating the effectiveness of ACT point-of-care testing in the intensive care unit for adult patients following cardiopulmonary bypass and cardiac surgery and any impacts this may have on nursing care. METHODS A systematic search of Medline, CINAHL and PubMed was undertaken. RESULTS The search identified five research papers reporting on the use of ACT point-of-care testing in the intensive care unit for adult cardiac surgical patients. Meta-analysis was not performed due to the lack of homogeneity between the papers included. CONCLUSIONS There was a lack of clear evidence for the use of the ACT point-of-care test after cardiac surgery in the intensive care environment. This review has highlighted that conventional laboratory tests are generally more accurate and reliable than this point-of-care test in guiding nursing care management.
Collapse
Affiliation(s)
- Ellenora Brown
- Nurse Unit Manager, Intensive Care Unit, St Vincent's Private Hospital, Melbourne, Australia
| | - Jody Clarke
- Clinical Nurse Educator, Intensive Care Unit, St Vincent's Private Hospital, Melbourne, Australia
| | - Karen-leigh Edward
- Associate Professor of Nursing Research, Faculty of Health Sciences, Australian Catholic University, and Director/Chair, Nursing Research Unit, St Vincent's Private Hospital, Melbourne, Australia
| | - Jo-Ann Giandinoto
- Research Associate, Faculty of Health Sciences, Australian Catholic University and Nursing Research Unit, St Vincent's Private Hospital, Melbourne, Australia
| |
Collapse
|
24
|
Plicner D, Mazur P, Hymczak H, Stoliński J, Litwinowicz R, Drwiła R, Undas A. Preoperative platelet aggregation predicts perioperative blood loss and rethoracotomy for bleeding in patients receiving dual antiplatelet treatment prior to coronary surgery. Thromb Res 2015; 136:519-25. [PMID: 26003782 DOI: 10.1016/j.thromres.2015.04.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/13/2015] [Accepted: 04/28/2015] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Patients scheduled for coronary artery bypass graft surgery (CABG) are commonly treated with clopidogrel. We sought to assess the relation between preoperative platelet aggregation and bleeds in CABG patients on clopidogrel. MATERIAL AND METHODS In a case-control study, we compared 52 consecutive patients undergoing isolated CABG on aspirin and clopidogrel 75mg/d versus 50 controls on aspirin monotherapy. Platelet aggregation induced by 10μmol/l adenosine di-phosphate (ADP) in platelet-rich plasma was measured in subjects on clopidogrel within 5days prior to surgery. ADP-induced aggregation of ≥50% was used to define subjects with satisfactory inhibition of platelet reactivity. RESULTS In 29 patients with preoperative ADP-induced aggregation ≥50%, compared with 23 subjects with aggregation <50%, lower chest-tube drainage volumes (after 6h, p=0.002; and 12h, p=0.001) and fewer rethoracotomies were observed (p=0.03). The former group was characterized with lower transfusion rates of packed red blood cells (p=0.009), platelet concentrate (p=0.04) and fresh frozen plasma (p=0.001). Patients with ADP-induced aggregation ≥50% did not differ from untreated controls regarding the postoperative drainage, transfusions and rethoracotomy. The incidence of thromboembolic events and death during perioperative period were similar in all groups. Multivariate logistic regression identified ADP-induced aggregation <50% as the only independent predictor of rethoracotomy (OR=2.94 [1.12-7.75], p=0.029). CONCLUSIONS Patients on aspirin and clopidogrel <5days before CABG who had preoperative ADP-induced platelet aggregation ≥50% have bleeding risk similar to those receiving aspirin monotherapy. Reduced platelet reactivity to ADP can predict postoperative bleeding in CABG patients on dual antiplatelet therapy.
Collapse
Affiliation(s)
| | - Piotr Mazur
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
| | | | | | - Radosław Litwinowicz
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Rafał Drwiła
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| |
Collapse
|
25
|
Lopes CT, Brunori EHFR, Santos VB, Moorhead SA, Lopes JDL, de Barros ALBL. Predictive factors for bleeding-related re-exploration after cardiac surgery: A prospective cohort study. Eur J Cardiovasc Nurs 2015; 15:e70-7. [PMID: 25888608 DOI: 10.1177/1474515115583407] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/31/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Bleeding-related re-exploration is a life-threatening complication after cardiac surgery. Nurses must be aware of important risk factors for this complication so that their assessment, monitoring and evaluation activities can be prioritized, focused and anticipated. AIMS To identify the predictive factors for bleeding-related re-exploration after cardiac surgery and to describe the sources of postoperative bleeding. METHODS This is a prospective cohort study at a tertiary cardiac school-hospital in São Paulo/SP, Brazil. Adult patients (n=323) submitted to surgical correction of acquired cardiac diseases were included. Potential risk factors for bleeding-related re-exploration within the 24 hours following admission to the intensive care unit were investigated in the patients' charts. A univariate analysis and a multiple analysis through logistic regression were conducted to identify the outcome predictors. The area under the receiver-operating characteristic curve was calculated as a measure of accuracy considering the cut-off points with the highest sensitivity and specificity. RESULTS The univariate factors significantly associated with bleeding-related re-exploration were a lower preoperative platelet count, a lower number of bypasses in coronary artery bypass surgery and postoperatively, a lower body temperature, infusion of lower intravenous volume, a higher positive end-expiratory pressure during mechanical ventilation and transfusion of blood products. The independent predictors of bleeding-related re-exploration included postoperative red blood cell transfusion, and transfusion of fresh frozen plasma, platelet or cryoprecipitate units. These predictors had a sensitivity of 87.5%, a specificity of 99.28% and an accuracy of 97.93%. CONCLUSIONS Blood product transfusion postoperatively is an independent predictor of bleeding-related re-exploration. Surgical errors prevailed as sources of bleeding.
Collapse
Affiliation(s)
- Camila T Lopes
- Paulista Nursing School, Federal University of Sao Paulo (EPE-UNIFESP), Brazil
| | | | | | | | | | | |
Collapse
|
26
|
Forcillo J, Perrault LP. Armentarium of topical hemostatic products in cardiovascular surgery: an update. Transfus Apher Sci 2013; 50:26-31. [PMID: 24412443 DOI: 10.1016/j.transci.2013.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Within Canada, 2.6 million in-hospital surgical procedures are completed annually. Significant bleeding following is the most common surgical complication, occurring in up to 25% of all surgeries. Bleeding causes increased mortality and morbidity, by increasing the number of transfusions required, secondary to increased cumulative blood loss, and by causing hemodynamic instability. A solution to this issue encountered during surgery is the use of hemostatic products. The objectives of this manuscript are (1) to review the spectrum of hemostatic products available in cardiovascular surgery and (2) to provide an update on new topical products soon available, or in development, for optimizing hemostasis during surgical procedures.
Collapse
Affiliation(s)
- Jessica Forcillo
- Cardiac Surgery Department, Montreal Heart Institute, Université de Montréal, Canada
| | - Louis P Perrault
- Cardiac Surgery Department, Montreal Heart Institute, Université de Montréal, Canada.
| |
Collapse
|
27
|
Tanaka KA, Egan K, Szlam F, Ogawa S, Roback JD, Sreeram G, Guyton RA, Chen EP. Transfusion and hematologic variables after fibrinogen or platelet transfusion in valve replacement surgery: preliminary data of purified lyophilized human fibrinogen concentrate versus conventional transfusion. Transfusion 2013; 54:109-18. [DOI: 10.1111/trf.12248] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Revised: 03/31/2013] [Accepted: 04/01/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Kenichi A. Tanaka
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Katherine Egan
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Fania Szlam
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Satoru Ogawa
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - John D. Roback
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Gautam Sreeram
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Robert A. Guyton
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| | - Edward P. Chen
- Department of Anesthesiology; University of Pittsburgh Medical Center; Pittsburgh Pennsylvania
- Department of Anesthesiology; Emory University School of Medicine; Atlanta Georgia
- Department of Pathology; Emory University School of Medicine; Atlanta Georgia
- Department of Surgery (Cardiothoracic); Emory University School of Medicine; Atlanta Georgia
| |
Collapse
|
28
|
Time from adenosine di-phosphate receptor antagonist discontinuation to coronary bypass surgery in patients with acute coronary syndrome: meta-analysis and meta-regression. Int J Cardiol 2013; 168:1955-64. [PMID: 23340485 DOI: 10.1016/j.ijcard.2012.12.087] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 11/05/2012] [Accepted: 12/27/2012] [Indexed: 12/21/2022]
Abstract
BACKGROUND Adenosine di-phosphate receptor antagonists (ADPRAs) blunt hemostasis for several days after administration. This effect, aimed at preventing cardiac ischemic complications particularly in patients with acute coronary syndromes (ACS), may increase perioperative bleeding in the case of cardiac surgery. Practice Guidelines recommend withholding ADPRAs for at least 5days prior to surgery, though with a weak base of evidence. The purpose of this study was to systematically review observational and experimental studies of early or late preoperative discontinuation of ADPRAs prior to coronary artery bypass grafting (CABG) for patients with ACS. METHODS MEDLINE, EMBASE, the Cochrane Library databases up to December 2011; and reference lists. Observational and experimental studies that compared early ADPRA discontinuation with late discontinuation, or no discontinuation, in patients with ACS undergoing CABG. RESULTS There were 19 studies, including 14,046 participants, 395 deaths and 309 reoperations due to bleeding. ADPRA late discontinuation up to CABG was associated with an increased risk of postoperative mortality (OR 1.46, 95% confidence interval (CI) 1.10 to 1.93) and reoperations due to bleeding (OR 2.18; 95% CI 1.47 to 2.62). Between-study heterogeneity was low. Meta-analysis limited to high quality or prospective studies gave consistent results. In most instances, the 95% prediction intervals for summary risk estimates confirmed the risk across study groups. CONCLUSIONS ADPRA late discontinuation prior to CABG is associated with an increased risk of death and reoperations due to bleeding in patients with ACS. The confidence in the estimates of risk for late discontinuation is moderate to high.
Collapse
|
29
|
Current world literature. Curr Opin Cardiol 2012; 27:682-95. [PMID: 23075824 DOI: 10.1097/hco.0b013e32835a0ad8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|