Dacey L J, Munoz J J, Baribeau Y R, Johnson E R, Lahey S J, Leavitt B J, Quinn R D, Nugent W C, Birkmeyer J D, O'Connor G T
Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
Arch Surg. 1998 Apr;133(4):442-7. doi: 10.1001/archsurg.133.4.442.
To assess mortality and risk factors associated with reexploration for hemorrhage in patients undergoing coronary artery bypass grafting (CABG).
Regional cohort study. Patient characteristics, treatment variables, and outcome measures were collected prospectively.
All 5 centers performing cardiac surgery in Maine, New Hampshire, and Vermont.
A consecutive cohort of 8586 patients undergoing isolated CABG between 1992 and 1995.
Postoperative hemorrhage leading to reexploration, in-hospital mortality, and length of stay.
A total of 305 patients (3.6%) underwent reexploration for bleeding. In these patients, in-hospital mortality was nearly 3 times higher (9.5% vs 3.3% for patients not requiring reoperation, P<.001) and average length of stay from surgery to discharge was significantly longer (14.5 days vs 8.6 days, P<.001). High rates of reexploration for hemorrhage were observed in patients with prolonged (> 150 minutes) cardiopulmonary bypass (39 [11.1%] of 351) and in those requiring an intra-aortic balloon pump intraoperatively (12 [8%] of 139). In multivariate analysis, older age, smaller body surface area, prolonged cardiopulmonary bypass, and number of distal anastomoses were associated with increased bleeding risks. The use of thrombolytic therapy within 48 hours of surgery was weakly but not significantly associated with the need for reexploration. Factors not significantly associated with reexploration included patient sex, preoperative ejection fraction, surgical priority, history of liver disease, myocardial infarction, prior CABG, renal failure, and diabetes mellitus.
Hemorrhage requiring reexploration after CABG is associated with markedly increased mortality and length of stay. Patients predicted to have increased risks of bleeding may benefit from prophylactic use of aprotinin, aminocaproic acid, or other agents shown to reduce hemorrhage.
评估冠状动脉旁路移植术（CABG）患者因出血而再次手术的死亡率及相关危险因素。
区域队列研究。前瞻性收集患者特征、治疗变量及结局指标。
缅因州、新罕布什尔州和佛蒙特州所有开展心脏手术的5个中心。
1992年至1995年间连续入选的8586例行单纯CABG的患者。
术后因出血导致再次手术、住院死亡率及住院时间。
共有305例患者（3.6%）因出血接受再次手术。这些患者的住院死亡率几乎高出近3倍（9.5%对比无需再次手术患者的3.3%，P<0.001），且从手术到出院的平均住院时间显著更长（14.5天对比8.6天，P<0.001）。在体外循环时间延长（>150分钟）的患者中（351例中的39例[11.1%]）以及术中需要使用主动脉内球囊反搏的患者中（139例中的12例[8%]），观察到因出血而再次手术的发生率较高。多因素分析显示，年龄较大、体表面积较小、体外循环时间延长及远端吻合口数量与出血风险增加相关。术后48小时内使用溶栓治疗与再次手术需求存在较弱但无显著意义的关联。与再次手术无显著关联的因素包括患者性别、术前射血分数、手术优先级、肝病病史、心肌梗死、既往CABG、肾衰竭及糖尿病。
CABG术后因出血需要再次手术与死亡率及住院时间显著增加相关。预计出血风险增加的患者可能从预防性使用抑肽酶、氨基己酸或其他已证实可减少出血的药物中获益。
