How detrimental is reexploration for bleeding after cardiac surgery?

Ruel, Marc; Chan, Vincent; Boodhwani, Munir; McDonald, Bernard; Ni, Xiaofeng; Gill, G. W.; Lam, Khanh; Hendry, Paul; Masters, Roy G.; Mesana, Thierry G.

doi:10.1016/j.jtcvs.2016.04.097

Cited by 62 publications

(61 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Other recent data from Canada and Sweden showed a resternotomy rate in these countries of between 4 and 6% [15,16]. This demonstrates that patients re-opened after cardiac surgery suffer a higher mortality than those undergoing emergency laparotomy.…”

Section: Discussionmentioning

confidence: 81%

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1‐year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

et al. 2020

View full text Add to dashboard Cite

Over 30,000 adult cardiac operations are carried out in the UK annually. A small number of these patients need to return to theatre in the first few days after the initial surgery, but the exact proportion is unknown. The majority of these resternotomies are for bleeding or cardiac tamponade. The Association of Cardiothoracic Anaesthesia and Critical Care carried out a 1-year national audit of resternotomy in 2018. Twenty-three of the 35 centres that were eligible participated. The overall resternotomy rate (95%CI) within the period of admission for the initial operation in these centres was 3.6% (3.37-3.85). The rate varied between centres from 0.69% to 7.6%. Of the 849 patients who required resternotomy, 127 subsequently died, giving a mortality rate (95%CI) of 15.0% (12.7-17.5). In patients who underwent resternotomy, the median (IQR [range]) length of stay on ICU was 5 (2-10 [0-335]) days, and time to tracheal extubation was 20 (12-48 [0-2880]) hours. A total of 89.3% of patients who underwent resternotomy were transfused red cells, with a median (IQR [range]) of 4 (2-7 [1-1144]) units of red blood cells. The rate (95%CI) of needing renal replacement therapy was 23.4% (20.6-26.5). This UK-wide audit has demonstrated that resternotomy after cardiac surgery is associated with prolonged intensive care stay, high rates of blood transfusion, renal replacement therapy and very high mortality. Further research into this area is required to try to improve patient care and outcomes in patients who require resternotomy in the first 24 h after cardiac surgery.

show abstract

Section: Discussionmentioning

confidence: 81%

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1‐year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

et al. 2020

View full text Add to dashboard Cite

show abstract

“…The reported mortality of the patients undergoing re-exploration has been high, in the range of 5.7% to 15.8%. [3][4][5][6][7][8] In our cohort, the reported mortality was 13.6%. Emergency surgery and a higher Euroscore are well documented because of mortality after cardiac surgery.…”

Section: Discussionmentioning

confidence: 99%

“…Postoperative hemorrhage requiring re‐exploration after cardiac surgery still remains a troublesome complication with an incidence of 15% in the early days of cardiac surgery from 2% to 6% nowadays 5,6,9,10,16 . There are many factors for reduction of the incidence of the re‐exploration as well as blood transfusion, of which one of the factors is performing OPCABG for revascularization 12‐14 .…”

Section: Discussionmentioning

confidence: 99%

“…It has been found to be an independent factor for mortality as well as major morbidity. 1,5,6,8 Some authors also evaluated the effect of timing of re-exploration on the adverse outcome; some authors reported a better outcome with early re-exploration while others demonstrated no benefit from early re-exploration. 6,[8][9][10][11] Re-exploration after coronary artery bypass surgery (CABG), which still remains the standard treatment for most patients with left coronary artery disease and multivessel disease, is also associated with higher mortality and morbidity.…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Re‐exploration after off‐pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing

Patel

Adalti

Runwal

et al. 2020

Journal of Cardiac Surgery

View full text Add to dashboard Cite

Objective: Re-exploration after cardiac surgery still remains a troublesome complication. There is still a scarcity of data about the effect of re-exploration after offpump coronary artery bypass grafting (OPCABG). We here represent our experience on re-exploration following OPCABG. Method: A total of 5990 OPCABG were performed at our center, out of these patients, 132 (2.2%) were re-explored in the operation room and were included in this study. The medical records of these patients were retrospectively reviewed. Results: The most common cause of re-exploration was bleeding (83.3%) and the most common site of bleeding was from graft/anastomosis (53.8%). The mean time to re-exploration was 9.75 ± 8.65 hours. The thirty-day mortality was 1.41%. On univariate and multiple regression analysis, emergency surgery, preoperative low platelet count, and the number of grafts were found to be independent risk factors for re-exploration. On multiple regression, emergency surgery, Euroscore II, low platelet count, low ejection fraction, re-exploration, time to re-exploration, blood products used, and high postoperative serum creatinine and bilirubin were found to be independent factors (P < .001) for mortality. On receiver-operating characteristic analysis, the optimum cutoff for time to re-exploration was 14 hours with a sensitivity of 81.3%, specificity of 80%, and area under the curve of 0.798. Patients who re-explored late (>14 hours) had significantly high mortality (30.55% vs 7.3%) and morbidity. Conclusion: Delaying re-exploration is associated with a three fold increase in mortality and morbidity. So, a strategy of minimizing the incidence of re-exploration, like the use of minimally invasive surgery and early re-exploration with the judicial use of products, should be used to improve outcomes after re-exploration following OPCABG.

show abstract

“…Nevertheless, the decision often is vexing as to whether to manage continuing, moderate postoperative bleeding in the ICU with transfusion or to transport the patient to the surgical theatre for reexploration. We hope that future studies can help us better decide when the risks of reexploration, as identified by Ruel and colleagues, 1 are exceeded by the risks of watching and waiting.…”

mentioning

confidence: 94%

Adverse outcomes from reoperation after cardiac surgery: There's more to it than blood

Shah

Butterworth

2017

The Journal of Thoracic and Cardiovascular Surgery

View full text Add to dashboard Cite

Despite antifibrinolytic drugs and improved medical management of coagulopathy, bleeding sufficient to require reexploration after cardiac surgery continues to occur. But, which leads to adverse outcomes: bleeding or reexploration? Ruel and colleagues 1 provide valuable insights regarding the consequences of reexploration in their single-institution observational study of approximately 17,000 patients. A key finding from their study was that in-hospital mortality increased from 2.8% to 12% among patients requiring reexploration, greater than would be expected using standard risk adjustment. Reexploration also was associated with an increased likelihood of surgical site infection, intensive care unit (ICU) readmission, postoperative atrial fibrillation, and renal insufficiency, and with increased ICU and hospital lengths of stay. Ruel and colleagues 1 provide several interesting insights. Many of us would assume that worse outcomes associated with reexploration arise from its association with blood loss and blood transfusion. Of note, the authors found that reexploration was independently associated (odds ratio [OR], 3.4) with mortality, even with adjustment for blood product administration (OR, 1.02 per unit) in a multivariable model. This is robust evidence that the negative impact of reexploration on mortality and morbidity cannot be blamed on the ill effects of blood transfusions alone. The authors 1 confirmed previous findings that urgent or emergency surgery increases the likelihood of reexploration 2-4 and that delayed reexploration worsens outcomes. 4 Of the 4.2% individuals requiring reexploration, 54.2% underwent reexploration on the day of surgery. These patients had an OR of 2.0 (P < .001) for mortality, compared with 6.4 (P<.001) for those undergoing later reexplorations. We were intrigued by the authors' findings 1 that tricuspid valve repair was associated with both reexploration (OR, 2.6; P <.

show abstract

How detrimental is reexploration for bleeding after cardiac surgery?

Cited by 62 publications

References 24 publications

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1‐year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

The incidence and effect of resternotomy following cardiac surgery on morbidity and mortality: a 1‐year national audit on behalf of the Association of Cardiothoracic Anaesthesia and Critical Care

Re‐exploration after off‐pump coronary artery bypass grafting: Incidence, risk factors, and impact of timing

Adverse outcomes from reoperation after cardiac surgery: There's more to it than blood

Contact Info

Product

Resources

About