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A cluster of severe postoperative bleeding following open heart surgery
M E Villarino1, S M Gordon, C Valdon
1Hospital Infections Program, Centers for Disease Control, Atlanta, GA 30333.
Insights
Large volumes of hetastarch (HES) may increase severe postoperative bleeding risk in elderly open heart surgery patients. This synthetic plasma expander may alter coagulation, necessitating vigilance for adverse reactions in older individuals.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Hematology
Background:
- Postoperative bleeding is a significant complication following open heart surgery.
- An unusual cluster of severe, nonsurgical postoperative bleeding occurred at a major medical center.
- Investigating the cause of this bleeding cluster is crucial for patient safety.
Purpose of the Study:
- To investigate a cluster of severe, nonsurgical postoperative bleeding in patients undergoing open heart surgery.
- To identify potential risk factors associated with this bleeding complication.
Main Methods:
- A cohort and case/control study design was employed.
- Data were collected from patients undergoing open heart surgery at the Palo Alto Veterans Administration Medical Center.
- Patient outcomes, including chest tube drainage and surgical re-exploration, were analyzed.
Main Results:
- A significant increase in nonsurgical postoperative bleeding incidence was observed during the outbreak period (6/28) compared to the pre-outbreak period (5/440).
- Older patients (mean age 67.8 years) and those receiving larger volumes of hetastarch (HES) (mean 19.4 ml/kg) were more likely to experience severe bleeding.
- No significant increase in surgical bleeding was noted during the outbreak.
Conclusions:
- The use of large volumes of hetastarch (HES) in elderly open heart surgery patients may elevate the risk of severe, nonsurgical postoperative bleeding.
- Alterations in the coagulation system are the probable mechanism for HES-induced bleeding.
- Healthcare providers should be aware of this potential adverse reaction, especially with increasing open heart surgery rates in the elderly population.
Objective:
To investigate a cluster of postoperative bleeding following open heart surgery.
Design:
A cohort and case/control study.
Setting:
Palo Alto Veterans Administration Medical Center, Palo Alto, California.
Participants:
Six (21.4%) of 28 patients undergoing open heart surgery who developed severe, nonsurgical, postoperative bleeding from July 1 through August 30, 1988 (outbreak period). All case-patients had chest tube drainage of greater than or equal to 1000 ml within 4 hours of surgery but did not have identifiable bleeding vessel(s) on exploration.
Results:
Upon comparison of the pre-outbreak (January 1986 through June 1988) and the outbreak period, a significant increase was found in the incidence of postoperative nonsurgical bleeding (5/440 versus 6/28, p = .0006), but not of postoperative surgical bleeding (8/440 versus 0/28, p = 1.0). Of all patients undergoing open heart surgery during the outbreak period, case patients were found to be older (67.8 versus 60.6, p = .02) and to have received a larger volume of hetastarch (HES), a synthetic colloidal plasma-volume expander (mean = 19.4 ml/kg versus 14.1 ml/kg, p = .02).
Conclusions:
We conclude that the use of large volumes of HES during surgery in the elderly open heart surgery patient may increase the risk for severe, nonsurgical postoperative bleeding, probably caused by alterations of the coagulation system. As the incidence of open heart surgery increases among the elderly, surgeons and anesthesiologists should be alert to possible adverse reactions from exposures not associated with adverse reactions in younger patients.