Abnormal bleeding in the cardiac operating room: An observational study of interrater reliability between...

Postcardiopulmonary bypass bleeding is frequent and distinctive because of its associated coagulopathy. Despite diagnostic and therapeutic progress, substantial variability persists in hemostatic transfusion practices. Because transfusion of hemostatic components should target abnormal bleeding, this study assessed the situational awareness of anesthetists and surgeons in such situations.

A nationwide questionnaire using real intraoperative video clips-3 normal, 8 ambiguously abnormal, and 6 clearly abnormal situations-evaluated interrater reliability for identifying abnormal bleeding, inferring residual coagulopathy, and deciding on immediate hemostatic transfusion. Agreement was measured by Gwet's AC1 (γ [95% CI]) and classified per Landis and Koch. A generalized mixed linear model assessed the impact of abnormality level on intra-dyad agreement.

Among 47 surgeons and 54 anesthetists, interrater reliability for abnormal bleeding perception was "moderate" (γ = 0.47 [0.32-0.62]) but significantly lower for abnormal situations (γ = 0.43 [0.28-0.58] vs γ = 0.96 [0.91-1.00]), and "poor" for ambiguously abnormal ones (γ = 0.20 [0.03-0.37]). Reliability for identifying residual coagulopathy remained "poor" overall (γ = 0.27 [-0.28 to 0.58]). For clearly abnormal situations, agreement on immediate hemostatic transfusion was "moderate" (γ = 0.51 [0.44-0.58]) but differed by specialty (γ = 0.38 [0.28-0.49] for anesthetists vs γ = 0.65 [0.52-0.78] for surgeons), and intra-dyad agreement was 6 times lower than for ambiguously abnormal situations (odds ratio, 0.18 [0.17-0.19]).

Abnormal bleeding during cardiac surgery is complex and often difficult to assess instantly. Beyond cognitive aids, enhanced training to improve shared situational awareness and develop a common mental model could reduce practice variability and strengthen patient blood management and safety.