Bleeding-related re-exploration is a life-threatening complication after cardiac surgery. Nurses must be aware of important risk factors for this complication so that their assessment, monitoring and evaluation activities can be prioritized, focused and anticipated.
Aims:
To identify the predictive factors for bleeding-related re-exploration after cardiac surgery and to describe the sources of postoperative bleeding.
Methods:
This is a prospective cohort study at a tertiary cardiac school-hospital in São Paulo/SP, Brazil. Adult patients (n=323) submitted to surgical correction of acquired cardiac diseases were included. Potential risk factors for bleeding-related re-exploration within the 24 hours following admission to the intensive care unit were investigated in the patients’ charts. A univariate analysis and a multiple analysis through logistic regression were conducted to identify the outcome predictors. The area under the receiver-operating characteristic curve was calculated as a measure of accuracy considering the cut-off points with the highest sensitivity and specificity.
Results:
The univariate factors significantly associated with bleeding-related re-exploration were a lower preoperative platelet count, a lower number of bypasses in coronary artery bypass surgery and postoperatively, a lower body temperature, infusion of lower intravenous volume, a higher positive end-expiratory pressure during mechanical ventilation and transfusion of blood products. The independent predictors of bleeding-related re-exploration included postoperative red blood cell transfusion, and transfusion of fresh frozen plasma, platelet or cryoprecipitate units. These predictors had a sensitivity of 87.5%, a specificity of 99.28% and an accuracy of 97.93%.
Conclusions:
Blood product transfusion postoperatively is an independent predictor of bleeding-related re-exploration. Surgical errors prevailed as sources of bleeding.
CurreyJBottiM. The haemodynamic status of cardiac surgical patients in the initial 2-h recovery period. Eur J Cardiovasc Nurs2005; 4: 207–214.
2.
ChristensenMCDziewiorFKempelA. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth2012; 26: 46–51.
3.
StoneGWClaytonTCMehranR. Impact of major bleeding and blood transfusions after cardiac surgery: Analysis from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial. Am Heart J2012; 163: 522–529.
4.
HorvathKAAckerMAChangH. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg2013; 95: 2194–2201.
5.
MataraciIPolatATokerME. Postoperative revision surgery for bleeding in a tertiary heart center. Asian Cardiovasc Thorac Ann2010; 18: 266–271.
6.
VivacquaAKochCGYousufAM. Morbidity of bleeding after cardiac surgery: Is it blood transfusion, re-exploration for bleeding, or both?Ann Thorac Surg2011; 91: 1780–1790.
7.
AlströmUGranathFFribergÖ. Risk factors for re-exploration due to bleeding after coronary artery bypass grafting. Scand Cardiovasc J2012; 46: 39–44.
8.
BiancariFMikkolaRHeikkinenJ. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: A systematic review and meta-analysis. Eur J Cardiothorac Surg2012; 41: 50–55.
9.
KristensenKLRauerLJMortensenPE. Re-exploration for bleeding in cardiac surgery. Interact Cardiovasc Thorac Surg2012; 14: 709–713.
10.
HaneyaADiezCKolatP. Re-exploration for bleeding or tamponade after cardiac surgery: Impact of timing and indication on outcome. Thorac Cardiovasc Surg. Epub ahead of print 29September2014. ]DOI: http://dx.doi.org/10.1055/s-0034–1390154.
11.
AlströmULevinLÅStåhleE. Cost analysis of re-exploration for bleeding after coronary artery bypass graft surgery. Br J Anaesth2012; 108: 216–222.
12.
HoKMBertenshawCSameS. Differential associations between body mass index and outcomes after elective adult cardiac surgery: A linked data cohort study. Anaesth Intensive Care2013; 41: 573–583.
13.
BiancariFMikkolaRHeikkinenJ. Individual surgeon’s impact on the risk of re-exploration for excessive bleeding after coronary artery bypass surgery. J Cardiothorac Vasc Anesth2012; 26: 550–556.
14.
BiancariFAiraksinenKELipGY. Benefits and risks of using clopidogrel before coronary artery bypass surgery: Systematic review and meta-analysis of randomized trials and observational studies. J Thorac Cardiovasc Surg2012; 143: 665–675.e4.
15.
MiceliADugganSMAresuG. Combined clopidogrel and aspirin treatment up to surgery increases the risk of postoperative myocardial infarction, blood loss and re-exploration for bleeding in patients undergoing coronary artery bypass grafting. Eur J Cardiothorac Surg2013; 43: 722–728.
16.
NijjerSSWatsonGAthanasiouT. Safety of clopidogrel being continued until the time of coronary artery bypass grafting in patients with acute coronary syndrome: A meta-analysis of 34 studies. Eur Heart J2011; 32: 2970–2988.
17.
MehtaRHShengSO’BrienSM. Re-exploration for bleeding in patients undergoing coronary artery bypass surgery: Incidence, risk factors, time trends, and outcomes. Circ Cardiovasc Qual Outcomes2009; 2: 583–590.
18.
Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion. Perioperative blood transfusion and blood conservation in cardiac surgery: The Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists Clinical Practice Guideline. Ann Thorac Surg2007; 83(5 Suppl.): s27–s86.
19.
KarlssonMTernströmLHyllnerM. Plasma fibrinogen level, bleeding, and transfusion after on-pump coronary artery bypass grafting surgery: A prospective observational study. Transfusion2008; 48: 2152–2158.
20.
DixonBReidDCollinsM. The operating surgeon is an independent predictor of chest tube drainage following cardiac surgery. J Cardiothorac Vasc Anesth2014; 28, 242–246.
21.
GielenCDekkersOStijnenT. The effects of pre- and postoperative fi brinogen levels on blood loss after cardiac surgery: A systematic review and meta-analysis. Interact Cardiovasc Thorac Surg2014; 18: 292–299.
22.
RosengartTKRomeiserJLWhiteLJ. Platelet activity measured by a rapid turnaround assay identifies coronary artery bypass grafting patients at increased risk for bleeding and transfusion complications after clopidogrel administration. J Thorac Cardiovasc Surg2013; 146: 1259–1266.
23.
BoschYAl DieriRten CateH. Preoperative thrombin generation is predictive for the risk of blood loss after cardiac surgery: A research article. J Cardiothorac Surg2013; 8: 154–162.
24.
EmeklibasNKammererIBachJ. Preoperative hemostasis and its association with bleeding and blood component transfusion requirements in cardiopulmonary bypass surgery. Transfusion2013; 53: 1226–1234.
25.
DasarathanCVaidyanathanKChandrasekaranD. Does preoperative clopidogrel increase bleeding after coronary bypass surgery?Asian Cardiovasc Thorac Ann2011; 19: 52–56.
26.
KarkoutiKMcCluskeySASyedS. The influence of perioperative coagulation status on postoperative blood loss in complex cardiac surgery: A prospective observational study. Anesth Analg2010; 110: 1533–1540.
27.
FiranescuCEMartensEJSchönbergerJP. Postoperative blood loss in patients undergoing coronary artery bypass surgery after preoperative treatment with clopidogrel. A prospective randomised controlled study. Eur J Cardiothorac Surg2009; 36: 856–862.
28.
SalisSMazzantiVVMerliG. Cardiopulmonary bypass duration is an independent predictor of morbidity and mortality after cardiac surgery. J Cardiothorac Vasc Anesth2008; 22: 814–822.
29.
Hernández-GonzálezMASolorioSLuna-QuinteroC. [Factors associated to heavy bleeding during heart surgery with cardiopulmonary bypass]. Arch Cardiología de México2008; 78: 273–278. [Spanish.]
30.
BerroetaCBenbaraAProvenchèreS. A comparison of bilateral with single internal mammary artery grafts on postoperative mediastinal drainage and transfusion requirement. Anesth Analg2006; 103: 1380–1385.
31.
CarrollRCChavezJJSniderCC. Correlation of perioperative platelet function and coagulation tests with bleeding after cardiopulmonary bypass surgery. J Lab Clin Med2006; 147: 197–204.
32.
McDonaldSBRennaMSpitznagelEL. Preoperative use of enoxaparin increases the risk of postoperative bleeding and re-exploration in cardiac surgery patients. J Cardiothorac Vasc Anesth2005; 19: 4–10.
33.
MianaLAAtikFAMoreiraLF. Risk factors for postoperative bleeding after adult cardiac surgery. Rev Bras Cir Cardiovasc2004; 19: 280–286.
34.
CammererUDietrichWRampfT. The predictive value of modified computerized thromboelastography and platelet function analysis for postoperative blood loss in routine cardiac surgery. Anesth Analg2003; 96: 51–57.
35.
MakarMTaylorJZhaoM. Perioperative coagulopathy, bleeding, and hemostasis during cardiac surgery. A comprehensive review. ICU Director2010; 1: 17–27.
36.
ČanádyováJZmekoDMokráčekA. Re-exploration for bleeding or tamponade after cardiac operation. Interact Cardiovasc Thorac Surg2012; 14: 704–707.
37.
LoorGVivacquaASabikJF3rd. Process improvement in cardiac surgery: Development and implementation of a reoperation for bleeding checklist. J Thorac Cardiovasc Surg2013; 146: 1028–1032.
38.
ThieleRHRaphaelJ. A 2014 update on coagulation management for cardiopulmonary bypass. Semin Cardiothorac Vasc Anesthesia2014; 18: 177–189.
39.
StephensSShahASWhitmanGJR. Lung injury and acute respiratory distress syndrome after cardiac surgery. Ann Thorac Surg2013; 95: 1122–1129.
40.
BorgesDLNinaVJSCostaMAG. Effects of different PEEP levels on respiratory mechanics and oxygenation after coronary artery bypass grafting. Rev Bras Cir Cardiovasc2013; 28: 380–385.
OrlovDMcCluskeySASelbyR. Platelet dysfunction as measured by a point-of-care monitor is an independent predictor of high blood loss in cardiac surgery. Anesth Analg2014; 118: 257–263.
