Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
Ann Thorac Surg. 2020 Aug;110(2):457-463. doi: 10.1016/j.athoracsur.2019.10.076. Epub 2019 Dec 20.
Several studies have established morbidity associated with bleeding after cardiac surgery. Although reoperation has been implicated as the marker for this morbidity, there remains limited understanding regarding relative morbidities of reoperation and substantial transfusion.
The Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (July 2011-September 2018) was reviewed (N = 23,240). Substantial transfusion was defined as requiring greater than the reoperation group median red blood cells (5 units) and non-red blood cells (4 units). Patients were stratified into 4 subgroups: group 1, no reoperation without substantial transfusion (n = 22,365); group 2, reoperation without substantial transfusion (n = 351); group 3, no reoperation with substantial transfusion (n = 350); and group 4, reoperation with substantial transfusion (n = 167). Operative morbidity and mortality were compared.
Reoperation patients were older with a higher STS predicted risk of mortality (1.8% vs 1.2%, P < .001). Multivariable analysis demonstrated that group 4 increased the odds of renal failure (odds ratio [OR] 7.36, P < .001), stroke (OR 3.24, P = .002), and operative mortality (OR 8.68, P < .001) compared with group 1. Both group 2 and group 3 increased the odds of mortality and renal failure compared with group 1. However, group 3 had greater risk for renal failure (OR 3.48, P < .001) and mortality (OR 2.91, P < .001) than group 2.
Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion reoperative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone.
多项研究已经确定了心脏手术后出血相关的发病率。尽管再次手术已被认为是这种发病率的标志物，但对于再次手术和大量输血的相对发病率仍缺乏了解。
回顾了胸外科医师学会（STS）马里兰州成人心脏手术数据库（2011 年 7 月至 2018 年 9 月）（N=23240）。大量输血定义为需要超过再次手术组中位数的红细胞（5 单位）和非红细胞（4 单位）。患者分为 4 个亚组：第 1 组，无再次手术且无大量输血（n=22365）；第 2 组，无再次手术但有大量输血（n=351）；第 3 组，无再次手术且无大量输血（n=350）；第 4 组，有再次手术且有大量输血（n=167）。比较手术发病率和死亡率。
再次手术患者年龄较大，STS 预测死亡率较高（1.8%比 1.2%，P<0.001）。多变量分析表明，与第 1 组相比，第 4 组增加了肾衰竭（优势比[OR]7.36，P<0.001）、中风（OR 3.24，P=0.002）和手术死亡率（OR 8.68，P<0.001）的可能性。与第 1 组相比，第 2 组和第 3 组均增加了死亡率和肾衰竭的可能性。然而，与第 2 组相比，第 3 组肾衰竭（OR 3.48，P<0.001）和死亡率（OR 2.91，P<0.001）的风险更高。
尽管心脏手术后因出血而再次手术与发病率相关，但与有限输血的再次手术方法相比，大量输血而无再次手术似乎会增加发病率。与单纯大量输血相比，更好的再次手术时机和有指导的输血方法可能会降低发病率。
