Advertisement

Bleeding and Re-exploration After Cardiac Surgery

  • Xun ZhouEmail author
  • Cecillia Lui
  • Glenn J. R. Whitman
Chapter
  • 12 Downloads

Abstract

A unique constellation of preoperative and intraoperative factors place cardiac surgical patients at an increased risk of postoperative bleeding. A comprehensive strategy is required to minimize the morbidity and mortality associated with bleeding in cardiac surgery. Preoperative measures include correction of preexisting coagulopathies and ensuring platelet quantity and function whenever possible. Medical management of postoperative bleeding requires timely recognition of coagulopathies to allow for focused and directed treatment, potentially with transfusion of blood products, antifibrinolytics, or coagulation factor concentrates. The administration of blood products should be protocolized and evidence-based, given the well-recognized risks associated with inappropriate transfusion. A restrictive transfusion threshold should be employed for patients with asymptomatic anemia. Balanced transfusion with packed red blood cells, plasma, and platelets should be considered in patients with significant bleeding requiring a massive transfusion protocol. Surgical re-exploration should be considered when bleeding persists despite optimal medical management. While re-exploration is associated with increased risk of complications, it can potentially avoid the morbidity and long-term sequelae of multiple blood transfusions. A discrete source of bleeding is only identified in as few as 67% of patients who are re-explored. However, the use of fibrin sealants and other hemostatic agents can greatly improve the likelihood of successfully controlling bleeding.

Keywords

Bleeding Blood transfusion Blood-component transfusion Cardiac surgery Re-exploration 

References

  1. 1.
    Mehran R, Rao SV, Bhatt DL, et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the bleeding academic research consortium. Circulation. 2011;123:2736–47.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Hansson EC, Jidéus L, Åberg B, et al. Coronary artery bypass grafting-related bleeding complications in patients treated with ticagrelor or clopidogrel: a nationwide study. Eur Heart J. 2016;37:189–97.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Kaufman RM, Djulbegovic B, Gernsheimer T, et al. Platelet transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2015;162:205–13.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Capodanno D, Musumeci G, Lettieri C, et al. Impact of bridging with perioperative low-molecular-weight heparin on cardiac and bleeding outcomes of stented patients undergoing non-cardiac surgery. Thromb Haemost. 2015;114:423–31.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Aboul-Hassan SS, Stankowski T, Marczak J, et al. The use of preoperative aspirin in cardiac surgery: a systematic review and meta-analysis. J Card Surg. 2017;32:758–74.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Jia Z, Tian G, Ren Y, Sun Z, Lu W, Hou X. Pharmacokinetic model of unfractionated heparin during and after cardiopulmonary bypass in cardiac surgery. J Transl Med. 2015;13:1–11.CrossRefGoogle Scholar
  7. 7.
    Harker LA, Malpass TW, Branson HE, Hessel EA, Slichter SJ. Mechanism of abnormal bleeding in patients undergoing cardiopulmonary bypass: acquired transient platelet dysfunction associated with selective alpha-granule release. Blood. 1980;56:824–34.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Hoffman WS, Tomasello DN, MacVaugh H. Control of postcardiotomy bleeding with PEEP. Ann Thorac Surg. 1982;34:71–3.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Salzman EW, Weinstein MJ, Weintraub RM, et al. Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. N Engl J Med. 1986;314:1402–6.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Bignami E, Cattaneo M, Crescenzi G, et al. Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial. Acta Anaesthesiol Scand. 2016;60:892–900.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Sivapalan P, Bäck AC, Ostrowski SR, Ravn HB, Johansson PI. Transfusion requirements in elective cardiopulmonary bypass surgery patients: predictive value of Multiplate and Thromboelastography (TEG) Platelet Mapping Assay. Scand J Clin Lab Invest. 2017;77:345–51.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Cammerer U, Dietrich W, Rampf T, Braun SL, Richter JA. The predictive value of modified computerized thromboelastography and platelet function analysis for postoperative blood loss in routine cardiac surgery. Anesth Analg. 2003;96:51–7.PubMedPubMedCentralGoogle Scholar
  13. 13.
    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.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Avidan MS, Alcock EL, Da Fonseca J, et al. Comparison of structured use of routine laboratory tests or near-patient asessment with clinical judgement in the management of bleeding after cardiac surgery. Br J Anaesth. 2004;92:178–86.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Paone G, Likosky DS, Brewer R, et al. Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg. 2014;97:87–94.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med. 2006;34:1608–16.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Blumberg N. Deleterious clinical effects of transfusion immunomodulation: proven beyond a reasonable doubt. Transfusion. 2005;45(2 Suppl):33S–9S.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Horvath KA, Acker MA, Chang H, et al. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg. 2013;95:2194–201.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Goel R, Patel EU, Cushing MM, et al. Association of perioperative red blood cell transfusions with venous thromboembolism in a north American Registry. JAMA Surg. 2018;21287:1–8.Google Scholar
  20. 20.
    Vamvakas EC. Platelet transfusion and postoperative infection in cardiac surgery. Transfusion. 2007;47:352–4.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    McGrath T, Koch CG, Xu M, et al. Platelet transfusion in cardiac surgery does not confer increased risk for adverse morbid outcomes. Ann Thorac Surg. 2008;86:543–53.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med. 2017;377:2133–44.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409–17.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Reeves BC, Pike K, Rogers CA, et al. A multicentre randomised controlled trial of transfusion indication threshold reduction on transfusion rates, morbidity and health-care resource use following cardiac surgery (TITRe2). Health Technol Assess (Rockv). 2016;20:1–259.Google Scholar
  25. 25.
    Murphy GJ, Pike K, Rogers CA, et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med. 2015;372:997–1008.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Carson JL, Guyatt G, Heddle NM, et al. Clinical practice guidelines from the AABB: red blood cell transfusion thresholds and storage. JAMA. 2016;316:2025–35.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Arnékian V, Camous J, Fattal S, Rézaiguia-Delclaux S, Nottin R, Stéphan F. Use of prothrombin complex concentrate for excessive bleeding after cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;15:382–9.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Cappabianca G, Mariscalco G, Biancari F, et al. Safety and efficacy of prothrombin complex concentrate as first-line treatment in bleeding after cardiac surgery. Crit Care. 2016;20:1–9.Google Scholar
  29. 29.
    Fredericks C, Kubasiak JC, Mentzer CJ, Yon JR. Massive transfusion: an update for the anesthesiologist. World J Anesthesiol. 2017;6:14.CrossRefGoogle Scholar
  30. 30.
    Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313:471–82.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Gill R, Herbertson M, Vuylsteke A, et al. Safety and efficacy of recombinant activated factor VII: a randomized placebo-controlled trial in the setting of bleeding after cardiac surgery. Circulation. 2009;120:21–7.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Hoffmann T, Assmann A, Dierksen A, et al. A role for very low-dose recombinant activated factor VII in refractory bleeding after cardiac surgery: lessons from an observational study. J Thorac Cardiovasc Surg. 2018;156:1564–1573.e8.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Fergusson DA, Hébert PC, Mazer CD, et al. A comparison of aprotinin and lysine analogues in high-risk cardiac surgery. N Engl J Med. 2008;358:2319–31.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Ferraris V, Shore-lesserson L, Baker RA, et al. STS/SCA/AmSECT clinical practice guidelines : anticoagulation during cardiopulmonary bypass. J Extra Corpor Technol. 2018;50:5–18.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Koster A, Faraoni D, Levy JH. Antifibrinolytic therapy for cardiac surgery. Anesthesiology. 2015;123:214–21.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Jacobs JP, Shahian DM, D’Agostino RS, et al. The Society of Thoracic Surgeons National Database 2017 annual report. Ann Thorac Surg. 2017;104:1774–81.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Biancari F, Mikkola R, Heikkinen J, Lahtinen J, Airaksinen KEJ, Juvonen T. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis. Eur J Cardio-Thoracic Surg. 2012;41:50–5.CrossRefGoogle Scholar
  38. 38.
    Mehta RH, Sheng S, O’Brien SM, et al. Reoperation for bleeding in patients undergoing coronary artery bypass surgery. Circ Cardiovasc Qual Outcomes. 2009;2:583–90.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Moulton MJ, Creswell LL, Mackey ME, Cox JL, Rosenbloom M. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg. 1996;111:1037–46.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Yellin A, Refaely Y, Paley M, Simansky D. Major bleeding complicating deep sternal infection after cardiac surgery. J Thorac Cardiovasc Surg. 2003;125:554–8.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Kristensen KL, Rauer LJ, Mortensen PE, Kjeldsen BJ. Reoperation for bleeding in cardiac surgery. Interact Cardiovasc Thorac Surg. 2012;14:709–13.PubMedPubMedCentralCrossRefGoogle Scholar
  42. 42.
    Vivacqua A, Koch CG, Yousuf AM, et al. Morbidity of bleeding after cardiac surgery: is it blood transfusion, reoperation for bleeding, or both? Ann Thorac Surg. 2011;91:1780–90.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Jonathan Unsworth-White M, Herriot A, Valencia O, et al. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Ann Thorac Surg. 1995;59:664–7.CrossRefGoogle Scholar
  44. 44.
    Karthik S, Grayson AD, McCarron EE, Pullan DM, Desmond MJ. Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay. Ann Thorac Surg. 2004;78:527–34.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Hammermeister KE, Burchfiel C, Johnson R, Grover FL. Identification of patients at greatest risk for developing major complications at cardiac surgery. Circulation. 1990;82(5 Suppl):IV380–9.PubMedPubMedCentralGoogle Scholar
  46. 46.
    Choong CK, Gerrard C, Goldsmith KA, Dunningham H, Vuylsteke A. Delayed re-exploration for bleeding after coronary artery bypass surgery results in adverse outcomes. Eur J Cardio-Thoracic Surg. 2007;31:834–8.CrossRefGoogle Scholar
  47. 47.
    Ottino G, De Paulis R, Pansini S, et al. Major sternal wound infection after open-heart surgery: a multivariate analysis of risk factors in 2,579 consecutive operative procedures. Ann Thorac Surg. 1987;44:173–9.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Whitson BA, Huddleston SJ, Savik K, Shumway SJ. Risk of adverse outcomes associated with blood transfusion after cardiac surgery depends on the amount of transfusion. J Surg Res. 2010;158:20–7.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Ranucci M, Bozzetti G, Ditta A, Cotza M, Carboni G, Ballotta A. Surgical reexploration after cardiac operations: why a worse outcome? Ann Thorac Surg. 2008;86:1557–62.PubMedCrossRefPubMedCentralGoogle Scholar
  50. 50.
    Rousou J, Levitsky S, Gonzalez-Lavin L, et al. Randomized clinical trial of fibrin sealant in patients undergoing resternotomy or reoperation after cardiac operations. A multicenter study. J Thorac Cardiovasc Surg. 1989;97:194–203.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Fanning WJ, Vasko JS, Kilman JW. Delayed sternal closure after cardiac surgery. Ann Thorac Surg. 1987;44:169–72.PubMedCrossRefPubMedCentralGoogle Scholar
  52. 52.
    Hashemzadeh K, Hashemzadeh S. In-hospital outcomes of delayed sternal closure after open cardiac surgery. J Card Surg. 2008;24:30–3.CrossRefGoogle Scholar
  53. 53.
    Fleck T, Kickinger B, Moidl R, et al. Management of open chest and delayed sternal closure with the vacuum assisted closure system: preliminary experience. Interact Cardiovasc Thorac Surg. 2008;7:801–4.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Pettersson GB, Bakaeen FG, Haddad O, et al. Advances in management of post cardiotomy open chest: use of negative pressure dressing in 588 adults. In: American Association for Thoracic Surgery Annual Meeting. Beverly, MA: AATS; 2018.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Division of Cardiac Surgery, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreUSA

Personalised recommendations