Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
J Thorac Cardiovasc Surg. 2024 Sep;168(3):873-884.e4. doi: 10.1016/j.jtcvs.2023.10.011. Epub 2023 Oct 13.
Risk factors for severe postoperative bleeding after cardiac surgery remain multiple and incompletely elucidated. We evaluated the impact of intraoperative blood product transfusions, intravenous fluid administration, and persistently low core body temperature (CBT) at intensive care unit arrival on risk of perioperative bleeding leading to reexploration.
We retrospectively queried our tertiary care center's Society of Thoracic Surgeons Institutional Database for all index, on-pump, adult cardiac surgery patients between July 2016 and September 2022. Intraoperative fluid (crystalloid and colloid) and blood product administrations, as well as perioperative CBT data, were harvested from electronic medical records. Linear and nonlinear mixed models, treating surgeon as a random effect to account for inter-surgeon practice differences, were used to assess the association between above factors and reexploration for bleeding.
Of 4037 patients, 151 (3.7%) underwent reexploration for bleeding. Reexplored patients experienced remarkably greater postoperative morbidity (23% vs 6%, P < .001) and 30-day mortality (14% vs 2%, P < .001). In linear models, progressively increasing IV crystalloid administration (adjusted odds ratio, 1.11, 95% confidence interval, 1.03-1.19) and decreasing CBT on intensive care unit arrival (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.37) were associated with greater risk of bleeding leading to reexploration. Nonlinear analysis revealed increasing risk after ∼6 L of crystalloid administration and a U-shaped relationship between CBT and reexploration risk. Intraoperative blood product transfusion of any kind was not associated with reexploration.
We found evidence of both dilution- and hypothermia-related effects associated with perioperative bleeding leading to reexploration in cardiac surgery. Interventions targeting modification of such risk factors may decrease the rate this complication.
心脏手术后严重术后出血的风险因素仍然很多且尚未完全阐明。我们评估了术中血液制品输注、静脉输液、以及重症监护病房到达时核心体温（CBT）持续偏低对导致再次探查的围手术期出血风险的影响。
我们回顾性地查询了我们的三级护理中心的胸外科医生协会机构数据库，以获取 2016 年 7 月至 2022 年 9 月期间所有索引、体外循环、成人心脏手术患者的资料。从电子病历中提取术中液体（晶体和胶体）和血液制品的使用以及围手术期 CBT 数据。线性和非线性混合模型，将外科医生视为随机效应，以解释外科医生之间实践差异，用于评估上述因素与出血再探查之间的关联。
在 4037 名患者中，有 151 名（3.7%）因出血而行再次探查。接受再次探查的患者术后并发症发生率显著更高（23% vs 6%，P<0.001）和 30 天死亡率（14% vs 2%，P<0.001）。在线性模型中，逐渐增加的 IV 晶体液输注（调整后的优势比，1.11，95%置信区间，1.03-1.19）和到达重症监护病房时 CBT 的降低（调整后的优势比，1.20；95%置信区间，1.05-1.37）与出血导致再次探查的风险增加相关。非线性分析显示，在晶体液输注约 6 L 后风险增加，并在 CBT 与再次探查风险之间呈现 U 形关系。任何类型的术中血液制品输注均与再次探查无关。
我们发现有证据表明心脏手术后导致再次探查的围手术期出血与稀释和低温相关效应有关。针对这些风险因素的干预措施可能会降低该并发症的发生率。
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