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Active Bleeding after Cardiac Surgery: A Prospective Observational Multicenter Study
Pascal H Colson1,2, Philippe Gaudard1,3, Jean-Luc Fellahi4
1Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Academic Hospital, Montpellier University, Montpellier, France.
Insights
Active bleeding after cardiac surgery (AB) affects 2.6% of patients. A new definition based on chest tube blood loss and reoperation helps assess early bleeding, guiding management and identifying complication risks.
Area of Science:
- Cardiovascular Surgery
- Critical Care Medicine
- Hematology
Background:
- Postoperative bleeding is a significant concern following cardiac surgery.
- Standardized definitions for active bleeding (AB) are lacking, complicating accurate incidence estimation and management.
- Chest drainage monitoring is crucial for assessing intraoperative and postoperative blood loss.
Purpose of the Study:
- To establish a precise definition for active bleeding (AB) post-cardiac surgery based on chest tube output.
- To determine the incidence, characteristics, and management strategies for AB.
- To identify risk factors associated with postoperative complications in cardiac surgery patients.
Main Methods:
- A prospective, longitudinal observational study was conducted across 29 French centers.
- Active bleeding (AB) was defined as blood loss > 1.5 ml/kg/h for 6 consecutive hours within 24 hours or reoperation for hemostasis within 12 hours.
- Logistic regression analysis identified risk factors for postoperative complications.
Main Results:
- The incidence of active bleeding (AB) was 2.6% (129/4,904 patients), with 52 requiring reoperation.
- AB incidence varied significantly between centers (0-16%) but was not linked to surgical experience.
- Risk factors for postoperative complications included body surface area, preoperative creatinine, emergency surgery, acidosis, and red blood cell transfusion.
Conclusions:
- The proposed definition of active bleeding (AB) (> 1.5 ml/kg/h for 6 hours or early reoperation) is a relevant and objective measure.
- This definition, independent of transfusion and adjusted for body weight, allows for real-time assessment of early postoperative bleeding.
- Accurate AB assessment can improve clinical practice and patient outcomes.
Main Objectives:
To estimate the incidence of active bleeding after cardiac surgery (AB) based on a definition directly related on blood flow from chest drainage; to describe the AB characteristics and its management; to identify factors of postoperative complications.
Methods:
AB was defined as a blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or in case of reoperation for hemostasis during the first 12 postoperative hours. The definition was applied in a prospective longitudinal observational study involving 29 French centers; all adult patients undergoing cardiac surgery with cardiopulmonary bypass were included over a 3-month period. Perioperative data (including blood product administration) were collected. To study possible variation in clinical practice among centers, patients were classified into two groups according to the AB incidence of the center compared to the overall incidence: "Low incidence" if incidence is lower and "High incidence" if incidence is equal or greater than overall incidence. Logistic regression analysis was used to identify risk factors of postoperative complications.
Results:
Among 4,904 patients, 129 experienced AB (2.6%), among them 52 reoperation. Postoperative bleeding loss was 1,000 [820;1,375] ml and 1,680 [1,280;2,300] ml at 6 and 24 hours respectively. Incidence of AB varied between centers (0 to 16%) but was independent of in-centre cardiac surgical experience. Comparisons between groups according to AB incidence showed differences in postoperative management. Body surface area, preoperative creatinine, emergency surgery, postoperative acidosis and red blood cell transfusion were risk factors of postoperative complication.
Conclusions:
A blood loss > 1.5 ml/kg/h for 6 consecutive hours within the first 24 hours or early reoperation for hemostasis seems a relevant definition of AB. This definition, independent of transfusion, adjusted to body weight, may assess real time bleeding occurring early after surgery.
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