Factors associated with the increased bleeding in the postoperative period of cardiac surgery: A cohort study

Sex-based outcomes in surgical repair of acute type A aortic dissection: A meta-analysis and meta-regression

OBJECTIVE

Epidemiologic variation with respect to sex has been established in aortic dissection. However, current literature on sex-based outcomes in patients with aortic dissection is conflicting. In this study we aimed to compare perioperative outcomes according to sex in patients treated surgically for acute type A aortic dissection.

METHODS

PubMed/MEDLINE, Embase, and Web of Science were searched for studies that reported sex-based differences in postoperative outcomes among patients with acute type A aortic dissection. The primary outcome was in-hospital/30-day mortality, and secondary outcomes included postoperative stroke, renal failure requiring dialysis, and reoperation for bleeding. Data were aggregated using the random effects model as pooled risk ratio (RR). Meta-regression was applied to identify sources of heterogeneity between studies.

RESULTS

Nine of 1022 studies were included for final analysis comprising 3338 female and 5979 male participants. Compared with male sex, female sex was associated with similar in-hospital/30-day mortality (RR, 1.04; 95% CI, 0.85-1.28; P = .67), postoperative stroke risk (RR, 1.07; 95% CI, 0.91-1.25; P = .43), and postoperative risk of acute renal failure requiring dialysis (RR, 0.84; 95% CI, 0.59-1.19; P = .32). A decreased risk of reoperation for bleeding (RR, 0.84; 95% CI, 0.75-0.94; P < .01) was observed in female participants. Meta-regression analysis indicated that differences in preoperative shock were a source of heterogeneity in the sex difference in in-hospital/30-day mortality across studies.

CONCLUSIONS

Among patients treated surgically for acute type A aortic dissection, female sex was not associated with increased risk of short-term mortality nor with major postoperative complications. Male sex was associated with a greater risk of postoperative bleeding.

Factors associated with reoperation due to bleeding and outcomes after cardiac surgery: a prospective cohort study

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.

Fatores associados à reoperação por sangramento e desfechos após cirurgia cardíaca: estudo de coorte prospectivo

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.

Factors associated with excessive bleeding following elective on-pump coronary artery bypass grafting

INTRODUCTION

Excessive bleeding following cardiac surgery is associated with worse outcomes. We aimed to analyze preoperative and operative factors associated with excessive bleeding in coronary artery bypass patients to better understand which patients are under increased risk.

METHODS

The study was conducted as an observational study in a tertiary center for cardiac surgery by retrospective analysis of the hospital database. Patients were grouped according to chest tube output within the postoperative 24 h. Patients in the 4th percentile of chest tube output per kilogram were categorized as having excessive bleeding. Patients with excessive bleeding were compared with the other patients for preoperative and operative factors. Factors significant in univariate analysis were carried onto the multivariate analysis.

RESULTS

Patients with excessive bleeding were more likely to be males (91.4% vs. 78.7%, p = .002), have lower body mass index (BMI) (27.4 vs. 29.2, p < .001), and low platelets (6.9% vs. 1.5%, p = .006). Cardiopulmonary bypass (101.8 vs. 110.9 min, p = .022) time was longer in the excessive bleeding group. Patients with excessive bleeding were more likely to have more than three vessels revascularized. Male sex, lower BMI, low platelets, and longer cardiopulmonary bypass time were independently associated with increased bleeding.

CONCLUSION

Male sex, lower BMI, low platelet count, and longer cardiopulmonary bypass time are associated with extensive bleeding after elective coronary artery bypass surgery (CABG). Patients with higher bleeding risk should be identified preoperatively to account for adverse outcomes after CABG.

Continuous ultrafiltration during extracorporeal circulation and its effect on lactatemia: A randomized controlled trial

Introduction

Hyperlactatemia occurs during or after extracorporeal circulation in the form of lactic acidosis, increasing the risk of postoperative complications and the mortality rate. The aim of this study was to evaluate whether continuous high-volume hemofiltration with volume replacement through a polyethersulfone filter during the extracorporeal circulation procedure decreases postoperative lactatemia and its consequences.

Materials and methods

This was a randomized controlled trial. Patients were randomly divided into two groups of 32: with or without continuous high-volume hemofiltration through a polyethersulfone membrane. Five patients were excluded from each group during the study period. The sociodemographic characteristics, filter effects, and blood lactate levels at different times during the procedure were evaluated. Secondary endpoints were studied, such as the reduction in the intubation time and time spent in ICU.

Results

Lactatemia measurements performed during the preoperative and intraoperative phases were not significantly different between the two groups. However, the blood lactate levels in the postoperative period and at 24 hours in the intensive care unit showed a significant reduction and a possible clinical benefit in the hemofiltered group. Following extracorporeal circulation, the mean lactate level was higher (difference: 0.77 mmol/L; CI 0.95: 0.01–1.53) in the nonhemofiltered group than in the hemofiltered group (p<0.05). This effect was greater at 24 hours (p = 0.019) in the nonhemofiltered group (difference: 1.06 mmol/L; CI 0.95: 0.18–1.93) than in the hemofiltered group. The reduction of lactatemia is associated with a reduction of inflammatory mediators and intubation time, with an improvement in liver function.

Conclusions

The use and control of continuous high-volume hemofiltration through a polyethersulfone membrane during heart-lung surgery could potencially prevent postoperative complications. The reduction of lactatemia implied a reduction in intubation time, a decrease in morbidity and mortality in the intensive care unit and a shorter hospital stay.