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Attributable harm of severe bleeding after cardiac surgery in hemodynamically stable patients

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Abstract

Background

We sought to quantify the effect of severe postoperative bleeding in hemodynamically stable patients following cardiac surgery.

Methods

We reviewed the charts of all cardiac surgery patients operated on at our institution between 2010 and 2014. After excluding patients with tamponade or MAP <60, we propensity matched patients having chest tube output >300 mL in the first postoperative hour, >200 mL in the second, and >100 mL in the third (“bleeding” group) with patients having <50 mL/h of chest tube output (“dry” group). The primary outcome was a composite of morbidity or mortality (excluding reexploration).

Results

5016 patients were operated on between 2010 and 2014; of these, we included the records of 84 bleeding and 498 dry patients. Propensity matching resulted in 68 pairs of patients well-matched on baseline and operative variables. As compared to matched dry patients, bleeding patients were more likely to experience the primary outcome of any morbidity/mortality (36.8 vs. 13.2 %, p = 0.002), as well as ventilation >24 h (33.8 vs. 7.4 %, p < 0.001) and 30-day mortality (11.8 vs. 1.5 %, p = 0.02). Of the 84 bleeding patients, 46 underwent reexploration for bleeding within 24 h of surgery. A subgroup analysis propensity matching bleeding patients who were or were not reexplored <24 h demonstrated similarly poor outcomes in each group (primary outcome, 44.7 % reexplored vs. 50.0 % non-reexplored, p = 0.65), though reexplored patients were far less likely to require hematoma evacuation/washout >24 h after surgery (0 vs. 18.4 %, p = 0.005).

Conclusions

Even among hemodynamically stable patients, severe bleeding is associated with markedly worse outcomes following cardiac surgery.

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Abbreviations

ASD:

Absolute standardized difference

BMI:

Body mass index

CABG:

Coronary artery bypass grafting

CI:

95 % confidence interval

CT:

Chest tube

CVA:

Cerebrovascular accident

D/C:

Discharge

EF:

Ejection fraction

GFR:

Glomerular filtration rate

IABP:

Intraaortic balloon pump

ICU:

Intensive care unit

IMA:

Internal mammary artery

INR:

International normalized ratio

NYHA:

New York Heart Association class

OP:

Output (i.e., chest tube output)

PVD:

Peripheral vascular disease

SD:

Standard deviation

STS:

Society for Thoracic Surgeons

References

  1. Dacey LJ, Munoz JJ, Baribeau YR, et al. Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factors. Northern New England Cardiovascular Disease Study Group. Arch Surg. 1998;133:442–7.

    Article  CAS  PubMed  Google Scholar 

  2. Karthik S, Grayson AD, McCarron EE et al. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg. 2004;78:527–34 (discussion 534).

  3. Karkouti K, Wijeysundera DN, Yau TM, et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion. 2004;44:1453–62.

    Article  PubMed  Google Scholar 

  4. Christensen MC, Dziewior F, Kempel A, et al. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth. 2012;26:46–51.

    Article  PubMed  Google Scholar 

  5. Schotola H, Brauer A, Meyer K, et al. Perioperative outcomes of cardiac surgery patients with ongoing ticagrelor therapy: boon and bane of a new drug. Eur J Cardiothorac Surg. 2014;46:198–205.

    Article  PubMed  Google Scholar 

  6. Pham HP, Shaz BH. Update on massive transfusion. Br J Anaesth. 2013;111(Suppl 1):i71–82.

    Article  PubMed  Google Scholar 

  7. Spiess BD, Gillies BS, Chandler W, et al. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth. 1995;9:168–73.

    Article  CAS  PubMed  Google Scholar 

  8. Afshari A, Wikkelso A, Brok J et al. Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev. 2011;CD007871.

  9. Ak K, Isbir CS, Tetik S, et al. Thromboelastography-based transfusion algorithm reduces blood product use after elective CABG: a prospective randomized study. J Card Surg. 2009;24:404–10.

    Article  PubMed  Google Scholar 

  10. Wikkelso A, Lunde J, Johansen M et al. Fibrinogen concentrate in bleeding patients. Cochrane Database Syst Rev. 2013;8:CD008864.

  11. Elizalde M, Slobodskoy L, Diodato M, et al. Use of recombinant factor VII in cardiac surgery. Recent Pat Cardiovasc Drug Discov. 2012;7:216–20.

    Article  CAS  PubMed  Google Scholar 

  12. Arnekian V, Camous J, Fattal S, et al. Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;15:382–9.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dyke C, Aronson S, Dietrich W, et al. Universal definition of perioperative bleeding in adult cardiac surgery. J Thorac Cardiovasc Surg. 2014;147(1458–1463):e1.

    Google Scholar 

  14. Biancari F, Mikkola R, Heikkinen J, et al. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2012;41:50–5.

    Article  PubMed  Google Scholar 

  15. Canadyova J, Zmeko D, Mokracek A. Re-exploration for bleeding or tamponade after cardiac operation. Interact Cardiovasc Thorac Surg. 2012;14:704–7.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Haneya A, Diez C, Kolat P, et al. Re-exploration for bleeding or tamponade after cardiac surgery: impact of timing and indication on outcome. Thorac Cardiovasc Surg. 2015;63:51–7.

    Article  PubMed  Google Scholar 

  17. Moulton MJ, Creswell LL, Mackey ME, et al. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg. 1996;111:1037–46.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

Dr. Magruder is the Irene Piccinini Investigator in Cardiac Surgery at Johns Hopkins. Dr. Crawford is the Hugh R. Sharp, Jr., Research Fellow in Cardiac Surgery at Johns Hopkins.

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Authors and Affiliations

  1. Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA

    J. Trent Magruder, Stephen Belmustakov, Rika Ohkuma, Sarah Collica, Joshua C. Grimm, Todd Crawford, John V. Conte, William A. Baumgartner & Glenn R. Whitman

  2. Department of Cardiac Surgery, School of Medicine, Vanderbilt University, Nashville, TN, USA

    Ashish S. Shah

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  1. J. Trent Magruder
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  2. Stephen Belmustakov
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  3. Rika Ohkuma
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  4. Sarah Collica
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  5. Joshua C. Grimm
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  6. Todd Crawford
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  7. John V. Conte
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  9. Ashish S. Shah
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  10. Glenn R. Whitman
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Corresponding author

Correspondence to Glenn R. Whitman.

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The authors have no financial conflicts of interest to report, nor were there any funding sources for this work.

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Magruder, J.T., Belmustakov, S., Ohkuma, R. et al. Attributable harm of severe bleeding after cardiac surgery in hemodynamically stable patients. Gen Thorac Cardiovasc Surg 65, 102–109 (2017). https://doi.org/10.1007/s11748-016-0714-4

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  • DOI: https://doi.org/10.1007/s11748-016-0714-4

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