Caroline Gerrard

We have developed a risk stratification score to identify cardiac surgical patients at higher risk of severe postoperative bleeding to aid a decision of whether to use a specific intervention preoperatively.We prospectively created a database of 11592 consecutive patients, who underwent cardiac surgery with cardiopulmonary bypass. An adverse outcome was formally defined as a mean blood loss exceeding 2 ml kg(-1)h(-1) measured between arrival in the intensive care unit (ICU) and the earliest of the elapse of 3h; the start of transfusion of any one of fresh-frozen plasma, platelets or cryoprecipitate; return to theatre or death. Univariate and multivariate associations of severe postoperative bleeding with patient characteristics, clinical features and procedure details were analysed on a development set. The final risk stratification scheme was then evaluated on a test set.Severe postoperative bleeding was associated with urgent or emergency surgery, surgery that was not coronary artery bypass grafting or single valve surgery, presence of aortic valve disease, low body mass index and older age. A risk stratification score was constructed from the above variables to define preoperative categories that demonstrated high, medium and low risk of severe postoperative bleeding. Patients deemed to be at high, medium and low risk by our preoperative scoring had a 21% (95% confidence interval: 18-24%), 8% (7-10%) and 3% (2-4%) rate of severe postoperative bleeding, respectively, within the test set.We have developed a simple risk stratification score that can separate, preoperatively, patients into risk groups with markedly different rates of severe postoperative bleeding.

Administration of coagulation factor concentrates to treat bleeding after cardiac surgery with cardiopulmonary bypass might be a strategy for reducing allogeneic blood transfusions, particularly for patients treated with warfarin preoperatively. We performed an exploratory analysis on whether the use of prothrombin complex concentrate (PCC) is safe and effective compared with fresh frozen plasma (FFP) to treat coagulopathy after pulmonary endarterectomy surgery with deep hypothermic circulatory arrest.Consecutive adult patients who underwent pulmonary endarterectomy surgery between January 2010 and September 2012 and received PCC or FFP to treat coagulopathy were studied. Blood loss during the first 12 hours of admission to the intensive care unit and patient outcomes were compared with propensity score adjustment.Three hundred fifty-one patients underwent pulmonary endarterectomy surgery, all of whom had warfarin discontinued for up to 5 days before surgery; bleeding complications requiring transfusion of blood products were observed in 108 (31%) patients. Of those, 55 received only FFP and 45 received only PCC, whereas 8 received both. Blood loss was significantly greater in the FFP group compared with the PCC group after 12 hours (median [interquartile range], 650 mL [325-1075] vs 277 mL [175-608], P = 0.008). However, there was no difference in the frequency of patients receiving a red blood cell transfusion (number [percent], 44 [80%] vs 34 [76%], P = 0.594) or in the number of units of red blood cells transfused (median [interquartile range], 2 [1-4] vs 3 [1-5] units, P = 0.181). The final propensity score included preoperative international normalized ratio, postoperative activated partial thromboplastin time, and postoperative platelet count. After inclusion of the propensity score in the regression analyses, there were no differences between patients receiving only PCC and patients receiving only FFP in the need for renal replacement therapy (odds ratio [OR] 2.39, 95% confidence interval [CI] 0.51-11.20, P = 0.27), 30-day-mortality (OR 0.32, 95% CI 0.03-3.36, P = 0.35), intracranial hemorrhage (OR 0.73, 95% CI 0.14-3.89, P = 0.71), hospital length of stay (hazard ratio 0.77, 95% CI 0.50-1.19, P = 0.24), or duration of intensive care stay (hazard ratio 0.91, 95% CI 0.59-1.40, P = 0.66).This retrospective analysis suggests that PCC may be an alternative to FFP in patients previously treated with warfarin who are coagulopathic after major cardiac surgery. Randomized controlled studies powered to evaluate efficacy and important postoperative outcomes for patients receiving PCC versus FFP for coagulopathic bleeding after cardiopulmonary bypass are warranted.

We aimed to identify the impact of re-exploration for bleeding after coronary artery bypass grafting (CABG) and the effect of time delay, re-exploration within 12h (<12h) versus 12h or later (>or=12h).Analyses of prospective clinical data on 3220 consecutive patients who underwent CABG between 2003 and 2005 were performed. Pearson chi(2) tests, Fisher's exact tests, Student's t-tests, Mann-Whitney U tests, or univariate logistic regression analysis were used to assess the effects of pre-operative and operative characteristics on re-exploration, and the effects of re-exploration and time delay on adverse outcomes. Predictors of re-exploration and its effect on adverse outcomes were further evaluated using multiple logistic regression analysis.One hundred ninety-one patients (5.9%) underwent re-exploration for bleeding. Re-explored patients as a group in comparison to the non-re-explored group had increased postoperative blood loss, transfusion requirements, duration of mechanical ventilation, ICU stay, intra-aortic balloon pump (IABP) and haemofiltration support, and mortality (all p<0.001). One hundred fifty-seven (82%) of the 191 patients were re-explored <12h. The group of patients who were re-explored <12h in comparison to >or=12h group had shorter ICU stay (median 3 vs 8.5 days; p<0.001), less IABP support (22.3 vs 44.1%; p=0.009) and a lower mortality (7 vs 29.4%; p=0.001). There was no significant difference in blood loss or transfusion requirements between the two groups. The predicted EuroSCORE risks of the <12h group was 6.66% and the observed mortality was 7% (p=0.865). The observed mortality of 29.4% in the >or=12h group was significantly higher than the predicted EuroSCORE risks of 7.59% (p<0.001).Patients requiring re-exploration for bleeding are at higher risk of adverse outcomes and this risk is increased if time to re-exploration is prolonged for 12h or longer.

BackgroundThe aim of this study was to examine the impact of prolonged intensive care unit (ICU) stay on in-hospital mortality and long-term survival.MethodsProspectively collected data from 6,101 consecutive patients who underwent surgery between 2003 and 2007 were analyzed. Prolonged ICU stay was defined as a total duration of ICU stay of 3 days or more postoperatively, including readmissions; patients with an ICU stay less than 3 days were identified as controls. Univariate and multiple variable analyses were performed to identify risk factors associated with prolonged ICU stay.ResultsOf 6,101 patients, 1,139 (18.7%) patients had a prolonged ICU stay. These patients had a higher ICU mortality (10%) compared with controls (0.6%; p < 0.001). On discharge from the ICU, their hospital mortality was still 6-fold higher (1.2%) compared with controls (0.2%; p < 0.001). Finally, the patients who had prolonged ICU stays had lower survival after discharge from the ICU—89.2% and 81.2% at 1 year and 3 years, respectively, compared with 97.8% and 93.6%, respectively, for controls (p < 0.001). Multiple variable analysis revealed prolonged ICU stay to be an independent predictor of prolonged hospital stay, higher hospital mortality, and poorer long-term survival (all p < 0.001).ConclusionsProlonged ICU stay is an important predictor of adverse immediate, short-term, and long-term outcomes after cardiac operations. The aim of this study was to examine the impact of prolonged intensive care unit (ICU) stay on in-hospital mortality and long-term survival. Prospectively collected data from 6,101 consecutive patients who underwent surgery between 2003 and 2007 were analyzed. Prolonged ICU stay was defined as a total duration of ICU stay of 3 days or more postoperatively, including readmissions; patients with an ICU stay less than 3 days were identified as controls. Univariate and multiple variable analyses were performed to identify risk factors associated with prolonged ICU stay. Of 6,101 patients, 1,139 (18.7%) patients had a prolonged ICU stay. These patients had a higher ICU mortality (10%) compared with controls (0.6%; p < 0.001). On discharge from the ICU, their hospital mortality was still 6-fold higher (1.2%) compared with controls (0.2%; p < 0.001). Finally, the patients who had prolonged ICU stays had lower survival after discharge from the ICU—89.2% and 81.2% at 1 year and 3 years, respectively, compared with 97.8% and 93.6%, respectively, for controls (p < 0.001). Multiple variable analysis revealed prolonged ICU stay to be an independent predictor of prolonged hospital stay, higher hospital mortality, and poorer long-term survival (all p < 0.001). Prolonged ICU stay is an important predictor of adverse immediate, short-term, and long-term outcomes after cardiac operations.

Summary Anaemia is common before cardiac surgery and is associated with increased morbidity and mortality. The World Health Organization (WHO) definition of anaemia is lower for women than for men by 10 g.l −1 , potentially putting women at a disadvantage compared with men with regard to pre‐operative optimisation. Our hypothesis was that women with borderline anaemia (defined by us as haemoglobin concentration 120–129 g.l −1 ) would have a higher rate of red cell transfusion, morbidity and mortality than non‐anaemic women (haemoglobin ≥ 130 g.l −1 ). This retrospective observational study included all adult patients admitted for elective cardiac surgery from January 2013 to April 2016. During the study period, 1388 women underwent cardiac surgery. Pre‐operatively, 333 (24%) had a haemoglobin level &lt; 120 g.l −1 ; 408 (29%) 120–129 g.l −1 ; and 647 (47%) ≥ 130 g.l −1 . Compared with non‐anaemic women, women with borderline anaemia were more likely to be transfused (68.6% vs. 44.5%; RR 1.5, 95% CI 1.4–1.7; p &lt; 0.0001) and were transfused with more units of red cells, mean ( SD ) 1.8 (2.8) vs. 1.3 (3.0); p &lt; 0.0001. Hospital length of stay was significantly longer in the borderline anaemia group compared with non‐anaemic women, median ( IQR [range]) 8 (6–12 [3–45]) vs. 7 (6–11 [4–60]); p = 0.0159. Short‐ and long‐term postoperative survival was comparable in both groups. Borderline anaemia is associated with increased red cell transfusion and prolonged hospital stay. Future research should address whether correction of borderline anaemia results in improved outcomes.

Traditionally, a fibrinogen level > 1 g L(-1) has been viewed as the critical plasma concentration required for hemostasis. No definitive trial has investigated the plasma fibrinogen hemostatic threshold and fibrinogen replacement in complex surgical patients with acquired bleeding.To explore the plasma fibrinogen level required for hemostasis in cardiothoracic surgery patients and assess the association of fibrinogen replacement therapy (using cryoprecipitate or fibrinogen concentrate) with reducing postoperative bleeding rate.Data from a prospectively collated database were used to examine the relationship between postoperative plasma fibrinogen level and the postoperative rate of bleeding within the hour of plasma fibrinogen measurement (n = 430) and to explore the effect of cryoprecipitate infusion (n = 76) or fibrinogen concentrate administration (n = 8) on postoperative bleeding rate.A low plasma fibrinogen level was significantly associated with bleeding, with an odds ratio of 3.06 for every 1 g L(-1) decrease in fibrinogen (95% confidence interval 1.05-8.90) with adjustment for confounders. A fibrinogen threshold associated with excess bleeding was not identified, but this relationship was a continuum. There was no reduction in bleeding following administration of cryoprecipitate or fibrinogen concentrate to raise the post-infusion fibrinogen level to a median of 2.00 and 1.70 g L(-1) , respectively.There is a continuum of bleeding severity with reducing fibrinogen concentration. Fibrinogen concentrate or cryoprecipitate infusion did not significantly reduce bleeding rate; however, confirmation by a randomized controlled trial is required. It remains uncertain whether low postoperative fibrinogen levels are causally associated with postoperative bleeding.

Objective The aim of this study was to develop a statistical model based on patient parameters to predict the length of stay (LOS) in the intensive care unit (ICU) following cardiac surgery in a single center. Design Data were collected from patients admitted to the ICU following cardiac surgery over a 10-year period (2006-2016). Both the additive and logistic EuroSCORE were calculated, and logistic regression analysis was carried out to formulate a model relating the predicted LOS to the EuroSCORE. This model was used to stratify patients into short stay (less than 48 hours) or long stay (more than 48 hours). Setting ICU at Papworth Hospital, Cambridgeshire. Participants A total of 18,377 consecutive patients who had been in ICU following cardiac surgery (coronary graft bypass surgery, valve surgery, or a combination of both). Interventions This was an observational study. Measurements and Main Results The authors have shown that both the additive and logistic EuroSCORE can be used to stratify cardiac surgical patients in various predicted LOS in ICU. Further adjustments can be made to increase the number of patients correctly identified as either short stay or long stay. Comparison of the model predictions to the data demonstrated a high overall accuracy of 79.77%, and receiver operating characteristic curve analysis showed the area under the curve to be 0.7296. Conclusion This analysis of an extensive data set shows that patient LOS in ICU after cardiac surgery in a single center can be predicted accurately using the simple cardiac operative risk scoring tool EuroSCORE. Using such predictions has the potential to improve ICU resource management. The aim of this study was to develop a statistical model based on patient parameters to predict the length of stay (LOS) in the intensive care unit (ICU) following cardiac surgery in a single center. Data were collected from patients admitted to the ICU following cardiac surgery over a 10-year period (2006-2016). Both the additive and logistic EuroSCORE were calculated, and logistic regression analysis was carried out to formulate a model relating the predicted LOS to the EuroSCORE. This model was used to stratify patients into short stay (less than 48 hours) or long stay (more than 48 hours). ICU at Papworth Hospital, Cambridgeshire. A total of 18,377 consecutive patients who had been in ICU following cardiac surgery (coronary graft bypass surgery, valve surgery, or a combination of both). This was an observational study. The authors have shown that both the additive and logistic EuroSCORE can be used to stratify cardiac surgical patients in various predicted LOS in ICU. Further adjustments can be made to increase the number of patients correctly identified as either short stay or long stay. Comparison of the model predictions to the data demonstrated a high overall accuracy of 79.77%, and receiver operating characteristic curve analysis showed the area under the curve to be 0.7296. This analysis of an extensive data set shows that patient LOS in ICU after cardiac surgery in a single center can be predicted accurately using the simple cardiac operative risk scoring tool EuroSCORE. Using such predictions has the potential to improve ICU resource management.

Our aim was to assess if peri-operative blood transfusion is an independent risk factor for mortality and morbidity in the elderly. We report the results of a cohort study of all patients aged 80 or more on the day of their emergency or elective cardiac surgery (n = 874), using routinely collected data from January 2003 to November 2007. The primary outcome was all-cause mortality in hospital. The secondary outcomes were duration of stay in the intensive care unit (ICU) and overall hospital stay. Confounding variables were used to build up a risk model using a multivariable logistic regression analysis, and blood transfusion was added to assess whether it had additional predictive value for hospital mortality. Patients were divided into three groups: (i) transfusion of 0-2 units of red blood cells; (ii) transfusion of > 2 units of red blood cells and (iii) transfusion of red blood cells plus other clotting products. The strongest independent predictors of hospital death were logistic EuroSCORE and body mass index. After inclusion of these two variables, the odds ratio for transfusion remained significant. Relative to 0-2 units, the odds ratio for > 2 units was 6.80 (95% CI 2.46-18.8), and for other additional blood products was 14.4 (95% CI 5.34-37.3), with a p value of < 0.001. Duration of stay in the ICU was significantly associated with the amount of blood products administered (median (IQR [range]) ICU stay 1 (1-2 [0-15]) day if transfused 0-2 units of red blood cells, 2 (1-6 [0-128]) days if transfused > 2 units of red blood cells and 3 (1-76 [0-114]) days if other clotting products were used; p value < 0.001). Hospital stay was also associated with the amount of red cells used (p < 0.001).

We explored the relationship between activated clotting time (ACT) and activated partial thromboplastin time (aPTT) when used to monitor anticoagulation in patients undergoing extracorporeal membrane oxygenation (ECMO) support.Data obtained in patients undergoing ECMO support between October 2012 and August 2013 in a single centre were reviewed. Clinical data were extracted from our Clinical Information System and ECMO database. ACT and aPTT values were paired when taken from the same patient, with the ACT preceding the aPTT and the heparin infusion rate was kept constant between samples. The aPTT and ACT were normalized by dividing by the mean of their respective reference ranges and are referred to as APR and N-ACT, respectively. Bivariate analysis and Bland-Altman plots were used to assess correlation and agreement. Mixed effects regression was used to model the effects of variables, including platelet count, creatinine and urea levels, plasma free haemoglobin, white cell count and ECMO flow rate on concordance between APR and N-ACT measurements.The Pearson product-moment correlation coefficient in 15 patients was calculated as r=0.55. The Bland-Altman plot shows a mean difference between the APR and the N-ACT of -0.08. The 95% limits of agreement were -0.67 to 0.51. Results from mixed effects regression analysis on data from the 15 patients identified platelet count (and thrombocytopenia) and urea as significant independent predictors of concordance between APR and N-ACT.We report a moderate degree of positive correlation between APR and N-ACT. We conclude that there is poor agreement between the ACT and aPTT for the heparin concentrations in patients supported with ECMO. Our results indicate that platelet count and urea are significant independent variables affecting concordance between ACT and aPTT measurements.

BackgroundMany retrospective studies report increased postoperative infection after allogenic blood transfusion. To investigate this phenomenon, we prospectively studied 232 patients undergoing cardiac surgery.MethodsPatients were screened daily for evidence of culture positive infections. Wounds were examined daily and defined on the ASEPSIS score. Chest radiographs and white cell counts and differentials were recorded on days 1, 2, and 4. The use of blood products was monitored blindly and independently. Patients were grouped according to transfusion status and compared using χ2 or Fisher's test. Logistic regression analyses were performed to identify predictors of transfusion and infection.ResultsOf 232 patients, 116 (50%) received blood product transfusion. Patients receiving blood had lower preoperative hemoglobin, were older, with a greater proportion of urgent/emergency or revision surgery, and were higher risk. Despite this, there were no differences in the frequency of chest infection (20% versus 15%, p = 0.38), urinary infection (3.5% versus 5.3%, p = 0 0.75), wound infection (3.5% versus 8.0%, p = 0.16), or overall infection (28% versus 30%, p = 0.89) comparing the transfused versus untransfused groups. There was no evidence to suggest that administration of blood products was associated with infection (odds ratio 0.92, p = 0.77).ConclusionsThe administration of blood per se did not lead to increased postoperative infection. Clinicians should reconsider withholding blood transfusion in patients solely owing to concerns of predisposition to infection.

The effectiveness and safety of aprotinin in cardiac surgery has been questioned. The study aim was to compare both the blood-sparing effect and side effects of aprotinin and tranexamic acid in patients undergoing pulmonary endarterectomy.Data were analyzed retrospectively for 200 consecutive patients who underwent pulmonary endarterectomy between October 2006 and September 2009. Pulmonary endarterectomy was performed with deep hypothermia (20°C) in all patients. Antifibrinolytic therapy changed from aprotinin to tranexamic acid in June 2008 after the withdrawal of aprotinin in the United Kingdom.Mean age was 55.9 years, and 58% of subjects were male. One hundred patients were studied in each group. Postoperatively, a higher incidence of seizures in the first 48 hours was seen with tranexamic acid compared with aprotinin (11% versus 4%, p = 0.06). This difference became statistically significant when excluding patients with structural brain lesions from both groups (7 versus 0, p = 0.02). Tranexamic acid patients had significantly higher median blood loss (700 mL versus 525 mL, p = 0.01). There was no significant difference between the groups in reexploration for bleeding, renal failure requiring hemofiltration, intensive care unit stay, median total stay in hospital, or in-hospital mortality.In our experience of patients undergoing pulmonary endarterectomy, the tranexamic acid group had a higher median blood loss and more seizures. The trend to increased seizure frequency in the tranexamic acid group may be a direct consequence of this treatment, consistent with other recently published reports.

Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery.The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes.Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102 165 ($134 198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit.The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.

Background Considerable mediastinal bleeding is a recognized complication after cardiac surgery and may require reexploration and blood product transfusion, both of which are associated with inferior clinical outcomes with greater morbidity and mortality. The aim of this study was to develop a hemostasis checklist, with the intention of reducing mediastinal bleeding after cardiac surgery. Methods A hemostasis checklist was developed with multidisciplinary collaboration. It contains 2 components: a series of surgical sites and factors affecting coagulation status. The checklist is performed at a time-out before sternal wire insertion. Analysis compared outcomes for patients undergoing cardiac surgery in the 1 year before and 2 years after implementation. Results A total of 5542 patients underwent surgery during the study. After we implemented the checklist, there was a significant reduction in the reexploration rate (3.5% versus 1.9%; P < .001) and the proportion of patients bleeding greater than 1 L in 12 hours (6.1% versus 2.8%; P < .001). There was a major reduction in consumption of blood products, saving $430,513. There was progressive improvement in the second year after implementation. Checklist implementation was also associated with reduced intensive care unit and hospital length of stay, adding to the financial benefit. Conclusions Implementation of a simple and quickly performed hemostasis checklist has had a sustained impact over the 2 years after implementation, reducing the incidence of noteworthy mediastinal bleeding and reexploration, which has resulted in a major reduction in blood product consumption. Together, these have resulted in an associated reduction in intensive care unit and hospital length of stay, and a considerable financial savings. This highlights that perioperative bleeding is a preventable complication. Considerable mediastinal bleeding is a recognized complication after cardiac surgery and may require reexploration and blood product transfusion, both of which are associated with inferior clinical outcomes with greater morbidity and mortality. The aim of this study was to develop a hemostasis checklist, with the intention of reducing mediastinal bleeding after cardiac surgery. A hemostasis checklist was developed with multidisciplinary collaboration. It contains 2 components: a series of surgical sites and factors affecting coagulation status. The checklist is performed at a time-out before sternal wire insertion. Analysis compared outcomes for patients undergoing cardiac surgery in the 1 year before and 2 years after implementation. A total of 5542 patients underwent surgery during the study. After we implemented the checklist, there was a significant reduction in the reexploration rate (3.5% versus 1.9%; P < .001) and the proportion of patients bleeding greater than 1 L in 12 hours (6.1% versus 2.8%; P < .001). There was a major reduction in consumption of blood products, saving $430,513. There was progressive improvement in the second year after implementation. Checklist implementation was also associated with reduced intensive care unit and hospital length of stay, adding to the financial benefit. Implementation of a simple and quickly performed hemostasis checklist has had a sustained impact over the 2 years after implementation, reducing the incidence of noteworthy mediastinal bleeding and reexploration, which has resulted in a major reduction in blood product consumption. Together, these have resulted in an associated reduction in intensive care unit and hospital length of stay, and a considerable financial savings. This highlights that perioperative bleeding is a preventable complication.

The effect of BMI on cost of intensive care unit (ICU) stay and ward stay in cardiac surgery is currently unknown. To assess these data on BMI, ICU stay and EuroSCORE were prospectively collected for 6100 patients undergoing cardiac surgery between 2000 and 2004. Patients were categorised according to BMI and comparisons were conducted, using non-parametric tests (Kruskal-Wallis and Mann-Whitney U-tests). One day in ICU was costed at pound1,300 and one ward-day pound300/day by this hospital's finance department. Despite similar median (due to a distribution skewed to a short ICU stay), a significant difference is observed between all 6 groups (Kruskal-Wallis; P<0.001) for ICU stay and ward stay. Underweight and morbidly obese patients had longer ICU stays compared with the ideal weight patients (P=0.010 and P=0.004, respectively); while overweight and obese patients had shorter ICU stays (P<0.001 and P=0.007, respectively). Underweight patients had a longer ward stay than ideal weight patients (P=0.005) but there was no difference between ideal and morbidly obese patients (P=0.789). These results demonstrate that BMI has a significant impact on ICU and ward stay with 'ideal weight' not always being ideal for patients undergoing cardiac surgery. This cost appears to be independent of EuroSCORE.

ObjectivesThe aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications.DesignA retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation.SettingTertiary cardiothoracic ICU.ParticipantsA total of 2,098 patients were included and analyzed.InterventionsNone.Measurements and Main ResultsThe composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation.ConclusionsEscalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation. The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications. A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation. Tertiary cardiothoracic ICU. A total of 2,098 patients were included and analyzed. None. The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation. Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.

To study the effect of administration of tranexamic acid on the use of blood and blood products, return to theatre for post-operative bleeding and the length of intensive care stay after primary cardiac surgery, data for 4191 patients, of all priorities, who underwent primary cardiac operation during the period between 30/10/00 and 21/09/04 were analysed.Retrospective analysis of data collected prospectively during the study period. The main outcome measures were whether or not patients were transfused with red blood cells, fresh frozen plasma or any blood product, the proportion of patients returned to theatre for investigation for post-operative bleeding and length of stay in the intensive care unit. We performed univariate analysis to identify the factors influencing the outcome measures and multivariate analysis to identify the effect of administration of tranexamic acid on the outcome measures.Administration of tranexamic acid was an independent factor affecting the transfusion of red blood cells, fresh frozen plasma or any blood product. It was also an independent factor influencing the rate of return to theatre for exploration of bleeding. The odds of receiving a transfusion or returning to theatre for bleeding were significantly lower in patients receiving tranexamic acid. The administration of tranexamic acid also significantly decreased blood loss. We did not find any association between the administration of tranexamic acid and the length of intensive care stay.Based on the analysis of 4191 patients who underwent a primary cardiac operation, administration of tranexamic acid decreased the number of patients exposed to a transfusion or returned to theatre for bleeding in our institute.

Vox SanguinisVolume 97, Issue 2 p. 172-182 Red cell transfusion in elective cardiac surgery patients A. Schiferer, A. SchifererSearch for more papers by this authorS. Panzer, S. PanzerSearch for more papers by this authorH. W. Reesink, H. W. ReesinkSearch for more papers by this authorW. Baulig, W. BauligSearch for more papers by this authorS. Bélisle, S. BélisleSearch for more papers by this authorC. Gerrard, C. GerrardSearch for more papers by this authorH. Grubitzsch, H. GrubitzschSearch for more papers by this authorC. Von Heymann, C. Von HeymannSearch for more papers by this authorC. Isetta, C. IsettaSearch for more papers by this authorG. Janvier, G. JanvierSearch for more papers by this authorM. Kastrup, M. KastrupSearch for more papers by this authorA. Lassnigg, A. LassniggSearch for more papers by this authorJ.-J. Lehot, J.-J. LehotSearch for more papers by this authorP. Raivio, P. RaivioSearch for more papers by this authorE. R. Schmid, E. R. SchmidSearch for more papers by this authorD. Schmidlin, D. SchmidlinSearch for more papers by this authorR. Suojaranta-Ylinen, R. Suojaranta-YlinenSearch for more papers by this authorA. Vuylsteke, A. VuylstekeSearch for more papers by this authorA. Westerlind, A. WesterlindSearch for more papers by this authorA. Zuckermann, A. ZuckermannSearch for more papers by this authorM. Hiesmayr, M. HiesmayrSearch for more papers by this author A. Schiferer, A. SchifererSearch for more papers by this authorS. Panzer, S. PanzerSearch for more papers by this authorH. W. Reesink, H. W. ReesinkSearch for more papers by this authorW. Baulig, W. BauligSearch for more papers by this authorS. Bélisle, S. BélisleSearch for more papers by this authorC. Gerrard, C. GerrardSearch for more papers by this authorH. Grubitzsch, H. GrubitzschSearch for more papers by this authorC. Von Heymann, C. Von HeymannSearch for more papers by this authorC. Isetta, C. IsettaSearch for more papers by this authorG. Janvier, G. JanvierSearch for more papers by this authorM. Kastrup, M. KastrupSearch for more papers by this authorA. Lassnigg, A. LassniggSearch for more papers by this authorJ.-J. Lehot, J.-J. LehotSearch for more papers by this authorP. Raivio, P. RaivioSearch for more papers by this authorE. R. Schmid, E. R. SchmidSearch for more papers by this authorD. Schmidlin, D. SchmidlinSearch for more papers by this authorR. Suojaranta-Ylinen, R. Suojaranta-YlinenSearch for more papers by this authorA. Vuylsteke, A. VuylstekeSearch for more papers by this authorA. Westerlind, A. WesterlindSearch for more papers by this authorA. Zuckermann, A. ZuckermannSearch for more papers by this authorM. Hiesmayr, M. HiesmayrSearch for more papers by this author First published: 10 July 2009 https://doi.org/10.1111/j.1423-0410.2009.01186.xCitations: 9AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume97, Issue2August 2009Pages 172-182 RelatedInformation

Objectives To assess postoperative pain intensity and the analgesic requirements in the postoperative period in patients undergoing sternotomy for pulmonary endarterectomy involving deep hypothermic circulatory arrest. Design Retrospective cohort study. Setting Single-center hospital study. Participants Patients 18 years and older undergoing sternotomy for cardiac surgery between August 2012 and August 2014. Interventions No modification to usual clinical practice. Measurements and Main Results Intraoperative opioid and steroid administration, referral to the chronic pain unit, intensive care unit pain scores, and analgesic administration in the first 48 hours after the admission to the intensive care unit were recorded. Postoperative pain was evaluated by means of a categoric verbal scale from no pain (0) to severe pain (3); this is the routine analgesic scale used in the authors’ intensive care unit. A total of 200 consecutive patients undergoing pulmonary endarterectomy (PEA group) were included in the study. No patient in the PEA group received morphine during surgery. The mean (standard deviation) postoperative pain intensity score at 24 hours was 0.30 (0.54) in the PEA group. Postoperative morphine was administered in 39% of patients. No PEA patient was referred to the chronic pain unit after hospital discharge. Conclusion The total analgesic requirements and pain score of patients undergoing sternotomy for pulmonary endarterectomy with deep hypothermic circulatory arrest seemed to be low. To assess postoperative pain intensity and the analgesic requirements in the postoperative period in patients undergoing sternotomy for pulmonary endarterectomy involving deep hypothermic circulatory arrest. Retrospective cohort study. Single-center hospital study. Patients 18 years and older undergoing sternotomy for cardiac surgery between August 2012 and August 2014. No modification to usual clinical practice. Intraoperative opioid and steroid administration, referral to the chronic pain unit, intensive care unit pain scores, and analgesic administration in the first 48 hours after the admission to the intensive care unit were recorded. Postoperative pain was evaluated by means of a categoric verbal scale from no pain (0) to severe pain (3); this is the routine analgesic scale used in the authors’ intensive care unit. A total of 200 consecutive patients undergoing pulmonary endarterectomy (PEA group) were included in the study. No patient in the PEA group received morphine during surgery. The mean (standard deviation) postoperative pain intensity score at 24 hours was 0.30 (0.54) in the PEA group. Postoperative morphine was administered in 39% of patients. No PEA patient was referred to the chronic pain unit after hospital discharge. The total analgesic requirements and pain score of patients undergoing sternotomy for pulmonary endarterectomy with deep hypothermic circulatory arrest seemed to be low.

Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG).A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival.Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500-1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival.Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.

Introduction:The combination of antiplatelet therapies has been recommended in patients undergoing percutaneous coronary interventions or suffering from acute coronary syndrome [1].However, when given before coronary artery bypass grafting (CABG), most studies have reported an increase in early postoperative bleeding and blood product requirements [2,3].These controversial findings could be partly explained by various antifibrinolytic strategies.The aim of our study was to evaluate the impact of clopidogrel associated with aspirin on postoperative bleeding and transfusion requirement in patients undergoing CABG, in which a standardized anti-fibrinolytic protocol was used.Method: After approval by our ethical committee, 217 consecutive CABG patients were enrolled in a prospective and observational study.Exclusion criteria included off-pump procedure, combined surgery, redo-CABG and preoperative platelet II b/III a receptor inhibitor exposure.Clopidogrel group (n ϭ 60) included patients having aspirin and clopidogrel exposure five days prior to surgery.Aspirin group (n ϭ 157) included patients only treated with aspirin.Aprotinin was intra-operatively used in all patients (2 ϫ 10 6 UIK followed by a continuous infusion of 250 ϫ 10 3 UIK/h).Student's t-test and Fisher's exact test were used.Results: There was no significant difference between the groups regarding demographic and intra-operative data.However, patients of the clopidogrel group had a higher prevalence of unstable angina (33 versus 19% P Ͻ 0.05) and left main artery stenosis (27 versus 13% P Ͻ 0.05).In the postoperative period, chest tube output was not significantly different between groups at H12 and H24 (Figure).Additionally, transfusion requirement (40 versus 36%, NS) and rates of re-exploration (0 versus 2%, NS) were similar in both groups.Figure.Median (25-75% and 5-95% percentiles).Mann-Whitney U-test was used. Conclusion:Our results suggest that the combination of antiplatelet therapies, based on aspirin and clopidogrel, could be safety maintained until surgery without an increase in postoperative bleeding and blood transfusion requirement.

The study aim was to compare both the blood sparing effect and side effects of aprotinin and tranexamic acid in patients undergoing pulmonary thromboendarterectomy (PTE).

Objective To assess the safety of discharging cardiac surgical patients from the intensive care unit (ICU) to wards while the patients are still receiving a dopamine infusion. Design Retrospective, observational study. Setting Cardiothoracic ICU of a tertiary academic hospital in the United Kingdom. Participants The study comprised all cardiac surgical patients older than 18 years and admitted between September 1, 2015 and September 16, 2016 to the ICU and subsequently discharged to a surgical ward. Patients were divided in the following 2 groups: a dopamine group with patients discharged with a dopamine infusion and a control group with patients discharged without any dopamine infusion. Interventions None. Measurements and Main Results The hospital mortality rate was comparable in both groups (0.7% in the dopamine group v 0.2% in the control group [p = 0.11]), despite that the median logistic EuroSCORE was significantly higher in the dopamine group (7.0 v 3.8 [p < 0.01]). The ICU readmission rate was higher in the dopamine group (6.6% v 2.4%; p < 0.01). ICU and hospital lengths of stay were longer in the dopamine group (1.7 v 0.9 days [p < 0.01] and 11.4 v 8.0 days [p < 0.01], respectively). Conclusions Despite a higher ICU readmission rate, ICU discharge of patients on dopamine infusion was not associated with increased mortality. To assess the safety of discharging cardiac surgical patients from the intensive care unit (ICU) to wards while the patients are still receiving a dopamine infusion. Retrospective, observational study. Cardiothoracic ICU of a tertiary academic hospital in the United Kingdom. The study comprised all cardiac surgical patients older than 18 years and admitted between September 1, 2015 and September 16, 2016 to the ICU and subsequently discharged to a surgical ward. Patients were divided in the following 2 groups: a dopamine group with patients discharged with a dopamine infusion and a control group with patients discharged without any dopamine infusion. None. The hospital mortality rate was comparable in both groups (0.7% in the dopamine group v 0.2% in the control group [p = 0.11]), despite that the median logistic EuroSCORE was significantly higher in the dopamine group (7.0 v 3.8 [p < 0.01]). The ICU readmission rate was higher in the dopamine group (6.6% v 2.4%; p < 0.01). ICU and hospital lengths of stay were longer in the dopamine group (1.7 v 0.9 days [p < 0.01] and 11.4 v 8.0 days [p < 0.01], respectively). Despite a higher ICU readmission rate, ICU discharge of patients on dopamine infusion was not associated with increased mortality.

We read with interest the article by Nuttall et al1Nuttall G.A Erchul D.T Haight T.J et al.A comparison of bleeding and transfusion in patients who undergo coronary artery bypass grafting via sternotomy with and without cardiopulmonary bypass.J Cardiothorac Vasc Anesth. 2003; 17: 447-451Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar describing the comparison of patients who undergo coronary artery bypass grafting with and without cardiopulmonary bypass. However, in their conclusions, they state that despite not reversing the heparin at the end of the off-pump coronary artery bypass (OPCAB) surgery, it was associated with an overall reduction in allogeneic transfusion requirements. This conclusion is somewhat surprising given that it appears that a high proportion of the OPCAB patients did receive protamine. The number of patients in the OPCAB group receiving protamine is not stated, but within Table 2, the median value of protamine dose for the OPCAB group is 50 mg. Because there were 100 patients in this group, at least 51 of them must have received at least 50 mg of protamine. With 50% of the OPCAB patients receiving protamine, it may be misleading to conclude that heparin was not reversed in the OPCAB group.

Editor—The randomised controlled trial on mechanical methods of reducing blood transfusion in cardiac surgery by McGill et al is laudable, but we challenge the BMJ for highlighting this paper on the front cover with the headline: “Cell salvage reduces the need for a transfusion.”1 We believe that the journal has a responsibility not to exaggerate the perceived importance of findings, either in press releases or by other means.2 The authors themselves highlighted the main limitations of the study in their discussion, and we believe that such declarations are important safeguards against widespread use of the described methods without further scientific evaluation. The authors comment on the high cost of transfusion, but they did not include a cost analysis in their study. We understand the risks associated with transfusion and agree that these in themselves may justify any added cost. However, introducing strict transfusion guidelines and monitoring their use is certainly a step that should precede the introduction of new equipment. We have been reinforcing transfusion guidelines for the past two years in our institution and are continuously monitoring blood transfusion in our hospital. Interestingly, when looking at a similar patient population to that of McGill et al, but lacking the research methods and statistics, we have achieved a similar decrease in use of all blood products, mainly by insuring that blood is transfused only when required and blood products given when need is documented (table). Despite our programme, blood products are still administered too often outside the hospital guidelines, and we think that we could decrease their use even further before introducing new expensive equipment to our routine practice. The BMJ 's cover may only reinforce incorrect practices by encouraging widespread use of techniques without common sense. We agree that the combination of acute normovolaemic haemodilution and cell salvage did not confer any benefit in this study, but McGill et al have not explored acute normovolaemic haemodilution as such and therefore no conclusion can be made with certainty about the absence of benefit of acute normovolaemic haemodilution itself. In the author's own words, this study adds to many others that are inconclusive because of the quality of the evidence. We believe that the BMJ 's cover, while attractive, may have mislead readers, and we therefore question the rationale behind such a decision.