Reduced re-exploration and blood product transfusion after the introduction of the Papworth haemostasis checklist†

Multidisciplinary Perspectives of Challenges in Infective Endocarditis Complicated by Septic Embolic-Induced Acute Myocardial Infarction

BACKGROUND

Infective endocarditis (IE) management is challenging, usually requiring multidisciplinary collaboration from cardiologists, infectious disease specialists, interventional cardiologists, and cardiovascular surgeons, as more than half of the cases will require surgical procedures. Therefore, it is essential for all healthcare providers involved in managing IE to understand the disease's characteristics, potential complications, and treatment options. While systemic embolization is one of the most frequent complications of IE, the coronary localization of emboli causing acute myocardial infarction (AMI) is less common, with an incidence ranging from 1% to 10% of cases, but it has a much higher rate of morbidity and mortality. There are no guidelines for this type of AMI management in IE.

METHODS

This narrative review summarizes the current knowledge regarding septic coronary embolization in patients with IE. Additionally, this paper highlights the diagnosis and management challenges in such cases, particularly due to the lack of protocols or consensus in the field.

RESULTS

Data extracted from case reports indicate that septic coronary embolization often occurs within the first two weeks of the disease. The aortic valve is most commonly involved with vegetation, and the occluded vessel is frequently the left anterior descending artery. Broad-spectrum antibiotic therapy followed by targeted antibiotic therapy for infection control is essential, and surgical treatment offers promising results through surgical embolectomy, concomitant with valve replacement or aspiration thrombectomy, with or without subsequent stent insertion. Thrombolytics are to be avoided due to the increased risk of bleeding.

CONCLUSIONS

All these aspects should constitute future lines of research, allowing the integration of all current knowledge from multidisciplinary team studies on larger patient cohorts and, subsequently, creating a consensus for assessing the risk and guiding the management of this potentially fatal complication.

Perioperative Complications in Infective Endocarditis

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.

Early Reexploration for Bleeding Is Associated With Improved Outcome in Cardiac Surgery

BACKGROUND

Reexploration after cardiac surgery, most frequently for bleeding, is a quality metric used to assess surgical performance. This may cause surgeons to delay return to the operating room in favor of attempting nonoperative management. This study investigated the impact of the timing of reexploration on morbidity and mortality.

METHODS

This study was a single-institution retrospective review of all adult cardiac surgery patients from July 2010 to June 2020. Time to reexploration was assessed, and outcomes were compared across increasing time intervals. Reported bleeding sites were classified into 5 groups, and bleeding rate (chest tube output) was compared across bleeding sites. Univariable analysis was performed using the Fisher exact and Kruskal-Wallis tests. Multivariable logistic regression models were used for risk-adjusted analyses.

RESULTS

Of 10 070 eligible patients, 251 (2.5%) required reexploration for postoperative bleeding. The most common site of bleeding was "any suture line" (n = 70; 28%). Interestingly, in 30% of cases (n = 75) "no active bleeding" site was reported. The highest rate of bleeding (mL/h) was observed in the "any mediastinal structure" group (median, 450; interquartile range [IQR], 185, 8878), and the lowest rate was noted in the "no active bleeding" group (median, 151.2; IQR, 102, 270). Both morbidity rates (0-4 hours, 12.3% vs 25-48 hours, 37.5%; P = .001) and mortality rates (0-4 hours, 3.1% vs 25-48 hours, 43.8%; P = .001) escalated significantly with increasing time to reexploration.

CONCLUSIONS

Delayed reexploration for bleeding after cardiac surgery is associated with increased risk for morbidity and mortality. Early surgical intervention, particularly within 4 hours, may improve outcomes. Implications from using reoperation as a performance metric may lead to unnecessary delay and patient harm.

Use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery: a scoping review protocol

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.

Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting

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.

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

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.

Outcomes in Dialysis-Dependent Indigenous and Non-Indigenous Patients Undergoing Cardiac Surgery at Townsville University Hospital

PURPOSE

Dialysis-dependent patients have a high risk of cardiovascular death but also a high risk for perioperative mortality in cardiac surgery. Our study examined surgical complications and mortality in Indigenous and non-Indigenous dialysis-dependent patients undergoing cardiac surgery at a single centre.

METHODOLOGY

The retrospective study reviewed 72 consecutive dialysis-dependent patients who underwent cardiac surgery between 2008 and 2018. Data was prospectively collected, and follow-up was obtained from physicians and general practitioners. Multivariable analysis was performed to determine predictors of mortality.

RESULTS

The median age of Indigenous Australian patients was 60 years, compared with 65 years for non-Indigenous patients. Indigenous Australian patients had a significantly higher rate of return to theatre (43% versus 17%). The predominant reason for return to theatre for the whole cohort was postoperative bleeding (n=16, 22%). The overall early mortality rate was 10%. There were 35 late deaths (49%) and overall survival at 5 years was 40.92±6.8% (95% CI: 28-54%). History of arrhythmia (p=0.019) was a significant risk factor for mortality, whilst patients who underwent isolated coronary artery bypass grafting (p=0.004), and those who received internal mammary artery grafts (p=0.021) had a reduced hazard ratio for mortality. The median follow-up time was 29 months (IQR 10-52 mo).

CONCLUSION

Dialysis-dependent Indigenous Australian patients present younger for cardiac surgery, with a higher prevalence of co-morbid diabetes and more extensive coronary artery disease. There was no statistically significant difference in early or late mortality between Indigenous and non-Indigenous patients. However, there was a higher rate of return to theatre amongst the Indigenous Australian cohort.

Hemostasis Checklist Reduces Bleeding and Blood Product Consumption After Cardiac Surgery

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.