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Wang J, Hou J, Feng K, Wu H, Liu Q, Zhou Z, Li H, Luo L, Fu G, Shang L, Chen G, Huang S, Wu Z. Development and validation of a postoperative bleeding complications prediction model in infective endocarditis. Int J Cardiol 2024; 396:131432. [PMID: 37827281 DOI: 10.1016/j.ijcard.2023.131432] [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: 07/06/2023] [Revised: 09/23/2023] [Accepted: 10/08/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES Bleeding complications are one of the most serious postoperative complications after cardiac surgery and are associated with high mortality, especially in patients with infective endocarditis (IE). Our objectives were to identify the risk factors and develop a prediction model for postoperative bleeding complications in IE patients. METHODS The clinical data of IE patients treated from October 2013 to January 2022 were reviewed. Multivariate logistic regression analysis was used to evaluate independent risk factors for postoperative bleeding complications and develop a prediction model accordingly. The prediction model was verified in a temporal validation cohort. The performance of the model was evaluated in terms of its discrimination power, calibration, precision, and clinical utility. RESULTS A total of 423 consecutive patients with IE who underwent surgery were included in the final analysis, including 315 and 108 patients in the training cohort and validation cohort, respectively. Four variables were selected for developing a prediction model, including platelet counts, systolic blood pressure, heart failure and vegetations on the mitral and aortic valves. In the training cohort, the model exhibited excellent discrimination power (AUC = 0.883), calibration (Hosmer-Lemeshow test, P = 0.803), and precision (Brier score = 0.037). In addition, the model also demonstrated good discrimination power (AUC = 0.805), calibration (Hosmer-Lemeshow test, P = 0.413), and precision (Brier score = 0.067) in the validation cohort. CONCLUSIONS We developed and validated a promising risk model with good discrimination power, calibration, and precision for predicting postoperative bleeding complications in IE patients.
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Affiliation(s)
- Junjie Wang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jian Hou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Kangni Feng
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huawei Wu
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Quan Liu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Huayang Li
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Li Luo
- Department of Cardiac Surgery, First Affiliated Hospital of Xi'an Jiaotong University, China
| | - Guangguo Fu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liqun Shang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Guangxian Chen
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Cardiothoracic Surgery ICU, First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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2
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Shou BL, Zhou AL, Ong CS, Alejo DE, DiNatale JM, Larson EL, Lawton JS, Schena S. Impact of intraoperative blood products, fluid administration, and persistent hypothermia on bleeding leading to reexploration after cardiac surgery. J Thorac Cardiovasc Surg 2023:S0022-5223(23)00967-4. [PMID: 37839660 DOI: 10.1016/j.jtcvs.2023.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/06/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Abstract
OBJECTIVE Risk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration. METHODS We retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding. RESULTS Of 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P < .001) and 30-day mortality (14% vs 2%, P < .001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after ∼6 L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration. CONCLUSIONS We found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Alice L Zhou
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Chin Siang Ong
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Conn
| | - Diane E Alejo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Joseph M DiNatale
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Emily L Larson
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Stefano Schena
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wis
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Rijpkema M, Vlot EA, Stehouwer MC, Bruins P. Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass? Perfusion 2023:2676591231199218. [PMID: 37734336 DOI: 10.1177/02676591231199218] [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: 09/23/2023]
Abstract
BACKGROUND Heparin rebound is a common observed phenomenon after cardiac surgery with CPB and is associated with increased postoperative blood loss. However, the administration of extra protamine may lead to increased blood loss as well. Therefore, we want to investigate the relation between heparin rebound and postoperative blood loss and the necessity to provide extra protamine to reverse heparin rebound. METHODS We searched PubMed, Cochrane, EMBASE, Google Scholar and Web of Science to review the question: "Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass." Combination of search words were framed within four major categories: heparin rebound, blood loss, cardiac surgery and cardiopulmonary bypass. All studies that met our question were included. Quality assessment was performed using the Cochrane risk of bias (RoB2) tool for randomized controlled trials and the risk of bias in non-randomized studies of intervention (ROBINS-I) for non-randomised trials. RESULTS 4 randomized and 17 non-randomized studies were included. The mean incidence of heparin rebound was 40%. The postoperative heparin levels, due to heparin rebound, were often below or equal to 0.2 IU/mL. We could not demonstrate an association between heparin rebound and postoperative blood loss or transfusion requirements. However the quality of evidence was poor due to a broad variety of definitions of heparin rebound, measured by various coagulation tests and studies with small sample sizes. CONCLUSION The influence of heparin rebound on postoperative bleeding seems to be negligible, but might get significant in conjunction with incomplete heparin reversal or other coagulopathies. For that reason, it might be useful to get a picture of the entire coagulation spectrum after cardiac surgery, as can be done by the use of a viscoelastic test in conjunction with an aggregometry test.
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Affiliation(s)
- Marije Rijpkema
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eline A Vlot
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco C Stehouwer
- Department of extracorporeal circulation, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Bruins
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
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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.
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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
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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.
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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
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6
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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.
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Bezerra ASDM, Santos VB, Lopes CT, de Barros ALBL. Effect of nurse-initiated forced-air warming blanket on the reduction of hypothermia complications following coronary artery bypass grafting: a randomized clinical trial. Eur J Cardiovasc Nurs 2021; 20:445-453. [PMID: 33620461 DOI: 10.1093/eurjcn/zvaa023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 11/08/2020] [Indexed: 11/14/2022]
Abstract
AIMS To evaluate the effect of postoperative forced-air warming (FAW) on the incidence of excessive bleeding (ExB), arrhythmia, acute myocardial infarction (AMI), and blood product transfusion in hypothermic patients following on-pump CABG and compare temperatures associated with the use of FAW and warming with a sheet and wool blanket. METHODS AND RESULTS A randomized clinical trial conducted with 200 patients undergoing isolated on-pump CABG from January to November 2018. Patients were randomly assigned into an Intervention Group (IG, FAW, n = 100) and Control Group (CG, sheet and blanket, n = 100). The tympanic temperature of all patients was measured over a 24-h period. ExB was the primary outcome, while arrhythmia, AMI, and blood product transfusion were secondary outcomes. The effect of the interventions on the outcomes was investigated through using bivariate logistic regression, with a level of significance of 5%. The IG was 79% less likely to experience bleeding than the CG [odds ratio (OR) = 0.21, confidence interval (CI) 95% 0.12-0.39, P < 0.001]; the occurrence of AMI in the IG was 94% lower than that experienced by the CG (OR = 0.06, CI 95% 0.01-0.48, P < 0.001); and the IG was also 77% less likely to experience arrhythmia than the CG (OR = 0.23, CI 95% 0.12-0.47, P < 0.001); no difference was found between groups in terms of blood product transfusion (P < 0.279). CONCLUSIONS These findings show that FAW can be used following CABG until patients reach normothermia to avoid undesirable clinical outcomes. TRIAL REGISTRATION REBeC RBR-5t582g.
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Affiliation(s)
- Amanda Silva de Macêdo Bezerra
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil.,Instituto Dante Pazzanese de Cardiologia (IDPC), Divisão de Enfermagem. 500 Dr Dante Pazzanese Av, Ibirapuera, São Paulo-SP, 04012-909, Brazil
| | - Vinícius Batista Santos
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil
| | - Camila Takáo Lopes
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil
| | - Alba Lúcia Bottura Leite de Barros
- Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE-UNIFESP), Departamento de Enfermagem Clínica e Cirúrgica and Programa de Pós Graduação em Enfermagem, 754 Napoleão de Barros St, Vila Clementino, São Paulo-SP, 04024-002, Brazil
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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.
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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
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9
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Luan T, Zhuang Y, Nie W, Yang S, Wu Y, Wang R, Dai Y, Zhang H. The death risk factors of patients undergoing re-exploration for bleeding or tamponade after isolated off-pump coronary artery bypass grafting: a case-control study. BMC Cardiovasc Disord 2021; 21:204. [PMID: 33888070 PMCID: PMC8063367 DOI: 10.1186/s12872-021-02017-2] [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] [Received: 01/30/2021] [Accepted: 04/14/2021] [Indexed: 11/12/2022] Open
Abstract
Background The purpose of the study is to identify off-pump patients who are at higher risk of mortality after re-exploration for bleeding or tamponade. Methods We analyzed the data of 3256 consecutive patients undergoing isolated off-pump coronary artery bypass grafting (OPCABG) in our heart center from 2013 through 2020. Fifty-eight patients underwent re-exploration after OPCABG. The 58 patients were divided into death group and survival group according to their discharge status. Propensity score matching (PSM) was performed to analysis the risk factors of death. 15 pairs of cases of two groups were matched well. Results The mortality rate of patients underwent re-exploration after OPCABG for bleeding or tamponade was 27.59% (16/58). In the raw data, we found the patients in death group had higher body mass index (BMI) (P = 0.030), higher cardiac troponin T (cTnT) (P = 0.028) and higher incidence of heart failure before OPCABG (P = 0.003). After PSM, the levels of lactic acid before and after re-exploration (P = 0.028 and P < 0.001) were higher in death group. And the levels of creatinine (P = 0.002) and cTnT (P = 0.017) were higher in the death group after re-exploration. The death group had longer reoperation time (P = 0.010). In addition, the perioperative utilization rate of intra-aortic ballon pump (IABP) (P = 0.027), continuous renal replacement therapy (CRRT) (P < 0.001) and platelet transfusion (P = 0.017) were higher than survival group. Conclusions The mortality rate of patients undergoing re-exploration for bleeding or tamponade after isolated OPCABG is high. More attention should be paid to patients with above risk factors and appropriate measures should be taken in time.
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Affiliation(s)
- Tongxiao Luan
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China.,Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China
| | - Yingzhu Zhuang
- Qingdao Fuwai Cardiovascular Hospital, 201 Nanjing Road, Qingdao, 266034, Shandong Province, China
| | - Weihong Nie
- Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China
| | - Sumin Yang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yuhui Wu
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Rongmei Wang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Yunyan Dai
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China
| | - Hong Zhang
- Department of Cardiovascular Surgery, Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266000, Shandong Province, China. .,Qingdao University, 308 Ningxia Road, Qingdao, 266071, Shandong Province, China.
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10
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Nammas W, Dalén M, Rosato S, Gherli R, Reichart D, Gatti G, Onorati F, Faggian G, De Feo M, Bancone C, Chocron S, Khodabandeh S, Santarpino G, Rubino AS, Maselli D, Nardella S, Salsano A, Gherli T, Nicolini F, Zanobini M, Saccocci M, Bounader K, D’Errigo P, Kiviniemi T, Kinnunen EM, Perrotti A, Airaksinen J, Mariscalco G, Ruggieri VG, Biancari F. Impact of preoperative thrombocytopenia on the outcome after coronary artery bypass grafting. Platelets 2018; 30:480-486. [DOI: 10.1080/09537104.2018.1466389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Wail Nammas
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Stefano Rosato
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | | | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Marisa De Feo
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Ciro Bancone
- Division of Cardiac Surgery, Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | - Sidney Chocron
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Sorosh Khodabandeh
- Department of Molecular Medicine and Surgery, Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Santarpino
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany; Città di Lecce Hospital GVM Care&Research, Lecce, Italy
| | | | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Saverio Nardella
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | - Tiziano Gherli
- Division of Cardiac Surgery, University of Parma, Parma, Italy
| | | | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico – Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico – Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Paola D’Errigo
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Eeva-Maija Kinnunen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Andrea Perrotti
- Department of Thoracic and Cardio-Vascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Vito G. Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Fausto Biancari
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Surgery, University of Turku, Turku, Finland
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11
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Stein LH, Rubinfeld G, Balsam LB, Ursomanno P, DeAnda A. Too Cold to Clot? Does Intraoperative Hypothermia Contribute to Bleeding After Aortic Surgery? AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2018; 5:106-116. [PMID: 29657946 DOI: 10.12945/j.aorta.2017.16.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 03/12/2017] [Indexed: 11/18/2022]
Abstract
Background We determined the impact of intraoperative hypothermia on postoperative bleeding after thoracic aortic surgery. Methods We retrospectively analyzed 98 consecutive patients who underwent aortic surgery with deep hypothermic circulatory arrest between 2010 and 2014. We evaluated lowest temperature, absolute decrease in temperature, and rewarming rate. Univariate and multivariate regression were used to determine relationships between temperature, clinical characteristics, and measures of postoperative bleeding. Results The mean age of patients was 60.5 ± 15.1 years, with 64.3% male and 60% Caucasian. The lowest temperatures recorded were 13.5 ± 4.6°C at the bypass circuit. Change in hematocrit was associated with ethnicity, preoperative hematocrit, and rewarming rate. Chest tube output was associated with body mass index, preoperative platelet count, prior cardiac surgery, cardiopulmonary bypass (CPB) duration, intraoperative blood product transfusion, lowest surface temperature, and change in surface temperature. Postoperative packed red blood cell transfusion was associated with ejection fraction, chronic obstructive pulmonary disease (COPD), platelet count, partial thromboplastin time, CPB duration, and lowest blood temperature. Fresh frozen plasma transfusion correlated with COPD, CPB duration, and final blood temperature. Platelet transfusion correlated with body mass index and preoperative platelet count. Unplanned reoperation for bleeding was associated with final temperature and change in temperature. Conclusion We found no consistent associations between intraoperative temperature and indicators of bleeding. Intraoperative cooling strategies should be based on optimal end-organ protection rather than fear of postoperative bleeding; rewarming strategies may ameliorate the risk of coagulopathy.
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Affiliation(s)
- Louis H Stein
- Division of Cardiothoracic Surgery, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Gregory Rubinfeld
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Leora B Balsam
- Department of Cardiothoracic Surgery, NYU Langone Medical Center, New York, New York, USA
| | - Patricia Ursomanno
- Maimonides Heart and Vascular Center, Maimonides Medical Center, Brooklyn, New York, USA
| | - Abe DeAnda
- Division of Cardiothoracic Surgery, University of Texas Medical Branch-Galveston, Galveston, Texas, USA
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12
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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.
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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
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