Abstract
IntroductionExcessive bleeding (EB) after cardiopulmonary bypass (CPB) may lead to increased mortality, morbidity, transfusion requirements and re-intervention. Less than 50% of patients undergoing re-intervention exhibit surgical sources of bleeding. We studied clinical and genetic factors associated with EB.MethodsWe performed a nested case-control study of 26 patients who did not receive antifibrinolytic prophylaxis. Variables were collected preoperatively, at intensive care unit (ICU) admission, at 4 and 24 hours post-CPB. EB was defined as 24-hour blood loss of >1 l post-CPB. Associations of EB with genetic, demographic, and clinical factors were analyzed, using SPSS-12.2 for statistical purposes.ResultsEB incidence was 50%, associated with body mass index (BMI)< 26.4 (25–28) Kg/m2, (P = 0.03), lower preoperative levels of plasminogen activator inhibitor-1 (PAI-1) (P = 0.01), lower body temperature during CPB (P = 0.037) and at ICU admission (P = 0.029), and internal mammary artery graft (P = 0.03) in bypass surgery. We found a significant association between EB and 5G homozygotes for PAI-1, after adjusting for BMI (F = 6.07; P = 0.02) and temperature during CPB (F = 8.84; P = 0.007). EB patients showed higher consumption of complement, coagulation, fibrinolysis and hemoderivatives, with significantly lower leptin levels at all postoperative time points (P = 0.01, P < 0.01 and P < 0.01).ConclusionExcessive postoperative bleeding in CPB patients was associated with demographics, particularly less pronounced BMI, and surgical factors together with serine protease activation.
Highlights
Excessive bleeding (EB) after cardiopulmonary bypass (CPB) may lead to increased mortality, morbidity, transfusion requirements and re-intervention
The characterization of the hemostatic defects responsible for EB is crucial for specific treatment and optimal clinical management of the patient [2], current risk stratification based on clinical, procedural, and biological markers is only partially successful and postoperative bleeding remains a serious problem for cardiac surgery patients
We found statistically significant associations between EB and patients in the lower body mass index (BMI) group
Summary
Excessive bleeding (EB) after cardiopulmonary bypass (CPB) may lead to increased mortality, morbidity, transfusion requirements and re-intervention. When blood interacts with non-endothelial surfaces of the cardiopulmonary bypass machine, cellular and humoral pathways are activated, including the complement system, the coagulation system, and the fibrinolytic system. These in turn activate inflammatory response cells such as leukocytes and platelets. Together these molecular pathways and activated cells mediate the frequently observed clinical sequelae such as edema, tissue and organ damage, and hyperfibrinolysis [1]. Major bleeding in cardiopulmonary bypass patients requires higher amounts of hemoderivatives and is associated with a higher incidence of reintervention, leading to a higher morbidity and mortality. Fewer than 50% exhibit surgical sources of bleeding [3]
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