Moulton M J, Creswell L L, Mackey M E, Cox J L, Rosenbloom M
Department of Surgery, Division of Cardiothoracic Surgery, Washington University, St. Louis, MO 63110, USA.
J Thorac Cardiovasc Surg. 1996 May;111(5):1037-46. doi: 10.1016/s0022-5223(96)70380-x.
Although previous studies have included early reexploration for bleeding as a risk factor in analyzing adverse outcomes after cardiac operations, reexploration for bleeding has not been systematically examined as a multivariate risk factor for increased morbidity and mortality after cardiac surgery. Furthermore, multivariate predictors of the need for reexploration have not been identified. Accordingly, we performed a retrospective analysis of 6100 patients requiring cardiopulmonary bypass from January 1, 1986, to December 31, 1993.
Eighty-five patients who had ventricular assist devices were excluded from further analysis because of the prevalence of bleeding and the significant morbidity and mortality associated with placement of a ventricular assist device, unrelated to reexploration. In the remaining 6015 patients, potential adverse outcomes analyzed included operative mortality, mediastinitis, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, sepsis, atrial arrhythmias, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, urgency of the operation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and the bypass and crossclamp time.
The overall incidence of reexploration was 4.2% (253/6015). Four independent risk factors--increased patient age (p < 0.001), preoperative renal insufficiency (p = 0.02), operation other than coronary bypass (p < 0.001), and prolonged bypass time (p = 0.0.3)--were identified as predictors of the need for reexploration. The preoperative use of aspirin, heparin, or thrombolytic agents and the bleeding time were not identified as predictors. Reexploration for bleeding was identified as a strong independent risk factor for operative mortality (p = 0.005), renal failure (p < 0.0001), prolonged mechanical ventilation (p < 0.0001), adult respiratory distress syndrome (p = 0.03), sepsis (p < 0.0001), and atrial arrhythmias (p = 0.006).
These data indicate that meticulous attention to surgical hemostasis and possibly application of recently developed modalities designed to facilitate perioperative correction of coagulopathy could improve outcomes after cardiac operations.
尽管以往研究在分析心脏手术后不良结局时已将因出血进行早期再次手术探查作为一个危险因素，但因出血进行再次手术探查作为心脏手术后发病率和死亡率增加的多变量危险因素尚未得到系统研究。此外，尚未确定再次手术探查必要性的多变量预测因素。因此，我们对1986年1月1日至1993年12月31日期间需要进行体外循环的6100例患者进行了回顾性分析。
85例使用心室辅助装置的患者被排除在进一步分析之外，因为这些患者出血发生率高，且与再次手术探查无关的心室辅助装置置入相关的显著发病率和死亡率。在其余6015例患者中，分析的潜在不良结局包括手术死亡率、纵隔炎、中风、肾衰竭、成人呼吸窘迫综合征、机械通气时间延长、脓毒症、房性心律失常和室性心律失常。为控制其他危险因素的混杂效应，我们进行了多变量逻辑回归分析。逻辑模型中考虑的潜在协变量包括年龄、性别、种族、再次手术史、手术紧急程度、充血性心力衰竭、既往心肌梗死、肾衰竭、糖尿病、高血压、慢性阻塞性肺疾病或中风以及体外循环和主动脉阻断时间。
再次手术探查的总体发生率为4.2%（253/6015）。四个独立危险因素——患者年龄增加（p<0.001）、术前肾功能不全（p = 0.02）、非冠状动脉搭桥手术（p<0.001）和体外循环时间延长（p = 0.03）——被确定为再次手术探查必要性的预测因素。术前使用阿司匹林、肝素或溶栓药物以及出血时间未被确定为预测因素。因出血进行再次手术探查被确定为手术死亡率（p = 0.005）、肾衰竭（p<0.0001）、机械通气时间延长（p<0.0001）、成人呼吸窘迫综合征（p = 0.03）、脓毒症（p<0.0001）和房性心律失常（p = 0.006）的强有力独立危险因素。
这些数据表明，认真关注手术止血以及可能应用最近开发的旨在促进围手术期凝血功能障碍纠正的方法，可能会改善心脏手术后的结局。
