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

Abstract

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.

Viscoelastic testing in cardiac surgery

“…7 Re-exploration is known to lead to an increase in morbidity, renal failure and death. 8 Point of care testing with viscoelastic hemostatic assays (VHA) provide prompt assessment of global hemostasis. Both ROTEM (Instrumentation Laboratory, Werfen) and TEG (Haemonetics) have been used in the context of algorithm-based care in cardiac surgery demonstrating a reduction in transfusion.…”

“…Up to 5% of all cardiac surgery patients require emergency re‐exploration for bleeding in the immediate postoperative period 7 . Re‐exploration is known to lead to an increase in morbidity, renal failure and death 8 …”

Universally Implemented Enhanced Recovery After Cardiac Surgery

“…Currently, this practice is not undertaken commonly, with closure through sternal wires being the usual approach. Although rigid sternal fixation may promote bone healing and recovery, it may cause serious problems for patients requiring emergency resternotomy, which occurs in ~3-4% 7 , or those requiring redo surgery at a later time.…”

Strategies to eradicate resternotomy after cardiac surgery from clinical practice

“…There are around 37,000 adult cardiac procedures undertaken each year in the UK, and a small proportion of these patients go back to the operating theatre in the first few postoperative hours or days for resternotomy. In this issue, Agarwal et al publish their UK-wide audit of resternotomy within 24 h of cardiac surgery [3].…”

“…In this issue, Agarwal et al. publish their UK‐wide audit of resternotomy within 24 h of cardiac surgery [3].…”