Risk Of Reoperation For Bleeding Research Articles

A REVIEW OF EUROPEAN GUIDELINES FOR PATIENT BLOOD MANAGEMENT WITH A PARTICULAR EMPHASIS ON ANTIFIBRINOLYTIC DRUG ADMINISTRATION FOR CARDIAC SURGERY

<h3>Introduction</h3> Patient blood management (PBM) is a proactive approach towards improving the quality and appropriateness of care. PBM has been recommended by the World Health Organization (WHO) since 2011. The aim is to manage anaemia and bleeding in surgical patients with the objective to minimise the need for transfusion. AntiVbrinolytics play a major role in cardiac surgery, where the risk of perioperative bleeding is high and affects most patients. AntiVbrinolytics effectively reduce bleeding, transfusions, re-operations, and associated morbidity and mortality. They represent an essential part of the pharmacological arsenal of PBM. The authors compared the current available European guidelines in PBM and analysed the place of different antiVbrinolytics in cardiac surgery, according to these guidelines. <h3>Methods</h3> A literature search on European PBM guidelines was performed in December 2020 and repeated in January 2021 using PubMed, Cochrane Database and Google Scholar databases. <h3>Results</h3> Thirteen documents were identiVed, from 6 countries (France, Germany, Italy, The Netherlands, Romania, UK), provided by European Commission or European and/or national learned societies. Of these 13 articles, 10 mentioned cardiac surgery, with 1 fully dedicated to it, and 8 were actual PBM guidelines. <h3>Discussion</h3> Despite the trend towards high-level PBM practices, and the implementation of PBM programs actively supported by the European Commission, national or international PBM guidelines for European countries appear to be both few and heterogeneous in form and content. At the European level, guidelines on bleeding management were published in 2017 by the ESAIC and those dedicated to cardiac surgery were published in 2018 jointly by the EACTS and the EACTA. All the current available guidelines follow and agree on the deVnition of PBM as deVned by the WHO, supported by three pillars: optimizing blood volume, minimising blood loss and optimizing the patient's tolerance to anaemia. Most of them were divided according to the three main surgical phases: preoperative, perioperative and post-operative. Anaemia management appears as a cornerstone of PBM in all guidelines, followed by limiting blood loss during surgical procedures to reduce transfusions and limit the risk of reoperation for bleeding. In this context, the European and national PBM guidelines all recommend the prophylactic use of antiVbrinolytics to avoid or reduce perioperative bleeding. However, they differ in the type of antiVbrinolytic recommended, when it should be given and how (bolus or infusion or both), including the dose and timing. Indeed, when mentioned, the dosing to be used generally differs from one guideline to another. Most guidelines recommend only the use of tranexamic acid. Aprotinin is rarely mentioned, partly because of its recent reintroduction in Europe (Table 1). The implementation of PBM practices in Europe is still challenging, as there is a real need for more homogenous guidance in PBM and in the use of antiVbrinolytics, especially in cardiac surgery. New clinical data to promote the use of antiVbrinolytics could be of interest to improve, accelerate and deploy PBM implementation at a large scale.

Minimally invasive versus conventional aortic valve replacement: The network meta-analysis.

Outcome comparisons after surgical aortic valve replacement (SAVR) with minimally invasive approaches including mini-sternotomy (MS) and right mini-thoracotomy (RMT) and full sternotomy (FS) have been conflicting. Furthermore, the synthesis of mid-term mortality has not been performed. MEDLINE and EMBASE were searched through April 2022 to identify propensity score matched (PSM) studies or randomized controlled trial (RCT) which compared outcomes following SAVR among three incisional approaches: FS, MS, or RMT. The network analysis was performed to compare these approaches with random effects model. Mid-term mortality was defined as 1-year mortality. A total of 42 studies met the inclusion criteria enrolling 14,925 patients. RCT and PSM were performed in 13 and 29 studies, respectively. The operative mortality was significantly lower with MS compared to FS (risk ratio [RR]: 0.60, 95% confidence interval [CI]: 0.41-0.90, p = .01, I2 = 25.8%) or RMT (RR: 0.51, 95% CI: 0.27-0.97, p = .03, I2 = 25.8%). RMT had significantly higher risk of reoperation for bleeding compared to MS (RR: 1.65, 95% CI: 1.18-2.30, p = .003, I2 = 0%). Hospital length of stay was significantly shorter with MS compared to FS (mean difference: -0.89 days, 95% CI: -1.58 to -0.2, p = .01, I2 = 95.5%) while it was equivocal between FS and RMT. The mid-term mortality was similar among the three approaches. While mid-term mortality was comparable among approaches, MS may be a safe and potentially more effective approach than FS and RMT for SAVR in the short term.

Modified Bentall procedure improves postoperative bleeding and medium-term survival

Background: Bentall procedure is a standard technique for complete aortic root replacements but a huge challenge is postoperative bleeding. This study was to evaluate the perioperative and long-term outcomes of the self-assembled composite graft with cuff formation for the Bentall procedure.&#x0D; Methods: A retrospective study of all patients undergoing Bentall procedure with button technique was performed from 2000-2019. Group 1 included 40 patients with commercial composite graft and group 2 included 45 patients with self-assembled composite graft with cuff. Perioperative outcomes were blood loss, reoperation for bleeding, complications, and operative mortality. Long-term outcomes included overall and reoperation-free survival.&#x0D; Results: Preoperative characteristics were similar in both groups, except mean age was higher in group 2 (48.2 versus 36.8 years). Group 2 significantly reduced blood loss in the first six hours postoperatively (250 versus 370 ml, P &lt;0.001) and the risk of reoperation for bleeding (4.5% versus 17.5%, P = 0.002). Other complications were balanced between groups. Overall surgical mortality was 3. Reoperation was 7 cases. Group 2 also significantly improve the overall and reoperation-free survival: 95% and 95% (group 2) versus 75% and 70% (group 1) at four years respectively.&#x0D; Conclusions: Self-assembled composite graft with cuff formation is safe and effective for Bentall procedure in the treatment of aortic root diseases with the reduction of bleeding and improvement of long-term survival. Further investigations are required to improve the feasibility and effectiveness of the procedure.

Sex-based outcomes in surgical repair of acute type A aortic dissection: A meta-analysis and meta-regression

ObjectiveEpidemiologic variation with respect to sex has been established in aortic dissection. However, current literature on sex-based outcomes in patients with aortic dissection is conflicting. In this study we aimed to compare perioperative outcomes according to sex in patients treated surgically for acute type A aortic dissection. MethodsPubMed/MEDLINE, Embase, and Web of Science were searched for studies that reported sex-based differences in postoperative outcomes among patients with acute type A aortic dissection. The primary outcome was in-hospital/30-day mortality, and secondary outcomes included postoperative stroke, renal failure requiring dialysis, and reoperation for bleeding. Data were aggregated using the random effects model as pooled risk ratio (RR). Meta-regression was applied to identify sources of heterogeneity between studies. ResultsNine of 1022 studies were included for final analysis comprising 3338 female and 5979 male participants. Compared with male sex, female sex was associated with similar in-hospital/30-day mortality (RR, 1.04; 95% CI, 0.85-1.28; P = .67), postoperative stroke risk (RR, 1.07; 95% CI, 0.91-1.25; P = .43), and postoperative risk of acute renal failure requiring dialysis (RR, 0.84; 95% CI, 0.59-1.19; P = .32). A decreased risk of reoperation for bleeding (RR, 0.84; 95% CI, 0.75-0.94; P < .01) was observed in female participants. Meta-regression analysis indicated that differences in preoperative shock were a source of heterogeneity in the sex difference in in-hospital/30-day mortality across studies. ConclusionsAmong patients treated surgically for acute type A aortic dissection, female sex was not associated with increased risk of short-term mortality nor with major postoperative complications. Male sex was associated with a greater risk of postoperative bleeding.

Effect of Remote Ischemic Conditioning on Bleeding Complications in Surgery: A Systematic Review and Meta-Analysis.

Remote ischemic conditioning (RIC) is administered with an inflatable tourniquet by inducing brief, alternating cycles of limb ischemia and reperfusion. RIC possibly impacts the hemostatic system, and the intervention has been tested as protective therapy against ischemia-reperfusion injury and thrombotic complications in cardiac surgery and other surgical procedures. In the present systematic review, we aimed to investigate the effect of RIC on intraoperative and postoperative bleeding complications in meta-analyses of randomized controlled trials including adult patients undergoing surgery. A systematic search was performed on November 7, 2020 in PubMed, Embase, and the Cochrane Central Register of Controlled Trials. Randomized controlled trials comparing RIC versus no RIC in adult patients undergoing surgery that reported bleeding outcomes in English publications were included. Effect estimates with 95% confidence intervals were calculated using the random-effects model for intraoperative and postoperative bleeding outcomes. Thirty-two randomized controlled trials with 3,804 patients were eligible for inclusion. RIC did not affect intraoperative bleeding volume (nine trials; 392 RIC patients, 399 controls) with the effect estimate -0.95 [-9.90; 7.99] mL (p = 0.83). RIC significantly reduced postoperative drainage volume (seven trials; 367 RIC patients, 365 controls) with mean difference -83.6 [-134.9; -32.4] mL (p = 0.001). The risk of re-operation for bleeding was reduced in the RIC group (16 trials; 838 RIC patients, 839 controls), albeit not significantly, with the relative risk 0.65 [0.39; 1.09] (p = 0.10). In conclusion, RIC reduced postoperative bleeding measured by postoperative drainage volume in this meta-analysis of adult patients undergoing surgery.

Post-thyroidectomy bleeding: analysis of risk factors from a national registry.

Post-thyroidectomy haemorrhage occurs in 1-2 per cent of patients, one-quarter requiring bedside clot evacuation. Owing to the risk of life-threatening haemorrhage, previous British Association of Endocrine and Thyroid Surgeons (BAETS) guidance has been that day-case thyroidectomy could not be endorsed. This study aimed to review the best currently available UK data to evaluate a recent change in this recommendation. The UK Registry of Endocrine and Thyroid Surgery was analysed to determine the incidence of and risk factors for post-thyroidectomy haemorrhage from 2004 to 2018. Reoperation for bleeding occurred in 1.2 per cent (449 of 39 014) of all thyroidectomies. In multivariable analysis male sex, increasing age, redo surgery, retrosternal goitre and total thyroidectomy were significantly correlated with an increased risk of reoperation for bleeding, and surgeon monthly thyroidectomy rate correlated with a decreased risk. Estimation of variation in bleeding risk from these predictors gave low pseudo-R2 values, suggesting that bleeding is unpredictable. Reoperation for bleeding occurred in 0.9 per cent (217 of 24 700) of hemithyroidectomies, with male sex, increasing age, decreasing surgeon volume and redo surgery being risk factors. The mortality rate following thyroidectomy was 0.1 per cent (23 of 38 740). In a multivariable model including reoperation for bleeding node dissection and age were significant risk factors for mortality. The highest risk for bleeding occurred following total thyroidectomy in men, but overall bleeding was unpredictable. In hemithyroidectomy increasing surgeon thyroidectomy volume reduces bleeding risk. This analysis supports the revised BAETS recommendation to restrict day-case thyroid surgery to hemithyroidectomy performed by high-volume surgeons, with caution in the elderly, men, patients with retrosternal goitres, and those undergoing redo surgery.

Editor's Choice – Protamine Reduces Serious Bleeding Complications Associated with Carotid Endarterectomy in Asymptomatic Patients without Increasing the Risk of Stroke, Myocardial Infarction, or Death in a Large National Analysis

Controversy persists regarding the use of protamine during carotid endarterectomy (CEA), despite real world evidence to support its use. The purpose of this study was to determine the impact of protamine reversal of heparin anticoagulation on the outcome of CEA in the USA. A prospective national registry (Society for Vascular Surgery Vascular Quality Initiative) of 72787 patients undergoing elective asymptomatic CEA by 1879 surgeons from 316 centres in the USA and Canada from 2012 to 2018 was reviewed. Protamine use varied by both surgeon (20% rare use [< 10%], 30% variable use [11%-79%], 50% routine use [> 80% cases]) and geographical region (44% vs. 96%). Temporal trends in protamine use were also determined. End points included post-operative re-operation for bleeding, as well as potential protamine related thrombotic complications, including stroke, death, and myocardial infarction (MI). Predictors of end points were determined by multivariable logistic regression. Propensity matching was additionally used to control for differences between groups. Of the 72787 patients who underwent CEA, 69% received protamine, while 31% did not. Protamine use increased over time from 60% (2012) to 73% (2018). In total, 378 patients (0.7%) in the protamine treated group underwent re-operation for bleeding vs. 342 patients (1.4%) in the untreated cohort (p<.001). Protamine use did not affect the rate of MI (0.7% vs. 0.8%; p=.023), stroke (1.1% vs. 1.0%; p=.20), or in hospital death (0.2% vs. 0.2%; p=0.70) between treated and untreated patients, respectively. On multivariable analysis, protamine use was independently associated with reduced risk of re-operation for bleeding (odds ratio 0.5, 95% confidence interval 0.39-0.55; p<.001). Independent of protamine exposure, the consequences of a return to the operating room (RTOR) for bleeding were statistically significant, with a sevenfold increase in MI (RTOR 4.9% vs. no RTOR 0.7%; p<.001), an eightfold increase in stroke (RTOR 7.2% vs. no RTOR 0.9%; p<.001), and a 13 fold increase in death (RTOR 2.4% vs. no RTOR 0.2%; p<.001). Protamine reduces serious bleeding complications at the time of CEA without increasing the risk of MI, stroke, or death, in this large North American analysis. Based on this and previous regional work regarding protamine use in CEA, it is believed that there is now sufficient evidence to support its routine use, and it should be considered as a benchmark for quality during CEA.

The effect of levosimendan on postoperative bleeding and blood transfusion in cardiac surgical patients: a PRISMA-compliant systematic review and meta-analysis.

Levosimendan (LEVO), is an inotropic agent which has been shown to be associated with better myocardial performance, and higher survival rate in cardiac surgical patients. However, preliminary clinical evidence suggested that LEVO increased the risk of post-operative bleeding in patients undergoing valve surgery. Currently, there has been no randomized controlled trials (RCTs) designed specifically on this issue. Therefore, we performed present systemic review and meta-analysis. Electronic databases were searched to identify all RCTs comparing LEVO with Control (placebo, blank, dobutamine, milrinone, etc). Primary outcomes include post-operative blood loss and re-operation for bleeding. Secondary outcomes included post-operative transfusion of red blood cells (RBC), fresh frozen plasma (FFP) and platelet concentrates (PC). For continuous variables, treatment effects were calculated as weighted mean difference (WMD) and 95% confidential interval (CI). For dichotomous data, treatment effects were calculated as odds ratio (OR) and 95% CI. Search yielded 15 studies including 1,528 patients. Meta-analysis suggested that, LEVO administration was not associated with increased risk of reoperation for bleeding post-operatively (OR = 1.01; 95%CI: 0.57 to 1.79; p = 0.97) and more blood loss volume (WMD = 28.25; 95%CI: -19.21 to 75.72; p = 0.24). Meta-analysis also demonstrated that, LEVO administration did not increase post-operative transfusion requirement for RBC (rate: OR = 0.97; 95%CI: 0.72 to 1.30; p = 0.83 and volume: WMD = 0.34; 95%CI: -0.55 to 1.22; p = 0.46), FFP (volume: WMD = 0.00; 95%CI: -0.10 to 0.10; p = 1.00) and PC (rate: OR = 1.01; 95%CI: 0.41 to 2.50; p = 0.98 and volume: WMD = 0.00; 95%CI: -0.05 to 0.04; p = 0.95). This meta-analysis suggested that, peri-operative administration of LEVO was not associated with increased risks of post-operative bleeding and blood transfusion requirement in cardiac surgical patients.

Preoperative Heparin for Lung Cancer Resection Increases Risk of Reoperation for Bleeding

Lung cancer patients are at risk for venous thromboembolism (VTE). Preoperative heparin administration may increase the risk of bleeding requiring reoperation. The purpose of this study was to evaluate preoperative heparin's effect on reoperation for bleeding. A retrospective review compared outcomes for patients undergoing pulmonary resection for primary lung cancer from January 2006 to April 2018. Preoperative heparin was administered at the discretion of the attending surgeon. Comparisons were performed between preoperative subcutaneous heparin (5000 U) and no heparin groups. A total of 3325 lung resections were reviewed, 1.4% (n = 48) required reoperation for bleeding. VTE occurred in 1.1% (n = 38). Four hundred sixty-four patients (14.0%) did not receive preoperative heparin. The preoperative heparin group had increased rates of prior thoracic surgery (5.1% [n = 146] vs 1.7% [n = 8], P < 0.001), minimally invasive approach (40.2% [n = 1150] vs 10.6% [n = 49], P < 0.001), and sublobar resections (17.7% [n = 506] vs 10.6% [n = 49], P < 0.001). There were no differences in blood loss/transfusions. Reoperation for bleeding was significantly increased in the preoperative heparin group (1.6% [n = 47] vs 0.2% [n = 1], P = 0.017). There were no differences in VTE (1.5% [n = 7] vs 1.1% [n = 31], P = 0.424). On logistic regression, preoperative heparin was independently associated with increased reoperation for bleeding (odds ratio 8.13, P = 0.039); however, preoperative heparin was not independently associated with VTE. Preoperative heparin was associated with increased reoperation for bleeding. VTE rates are low after pulmonary resection for lung cancer and are not decreased by preoperative heparin. Preoperative heparin use should be determined by risk factor stratification for VTE and reoperation for bleeding in patients undergoing lung cancer resection.

The Effects of Preoperative Aspirin on Coronary Artery Bypass Surgery: a Systematic Meta-Analysis.

Background and ObjectivesAspirin plays an important role in the maintenance of graft patency and the prevention of thrombotic event after coronary artery bypass graft surgery (CABG). However, the use of preoperative aspirin is still under debate due to the risk of bleeding.MethodsFrom PubMed, EMBASE, and Cochrane Central Register of Controlled Trials, data were extracted by 2 independent reviewers. Meta-analysis using random effect model was performed.ResultsWe performed a systemic meta-analysis of 17 studies (12 randomized controlled studies and 5 non-randomized registries) which compared clinical outcomes of 9,101 patients who underwent CABG with or without preoperative aspirin administration. Preoperative aspirin increased chest tube drainage (weighted mean difference 177.4 mL, 95% confidence interval [CI], 41.3–313.4; p=0.011). However, the risk of re-operation for bleeding was not different between the preoperative aspirin group and the control group (3.2% vs. 2.4%; odds ratio [OR], 1.23; 95% CI, 0.94–1.60; p=0.102). There was no difference in the rates of all-cause mortality (1.6% vs. 1.5%; OR, 0.98; 95% CI, 0.64–1.49; p=0.920) and myocardial infarction (MI) (8.7% vs. 10.4%; OR, 0.83; 95% CI, 0.66–1.04; p=0.102) between patients with and without preoperative aspirin administration.ConclusionsAlthough aspirin increased the amount of chest tube drainage, it was not associated with increased risk of re-operation for bleeding. In addition, the risks of early postoperative all-cause mortality and MI were not reduced by using preoperative aspirin.

Readmission after Adult Uvulopalatopharyngoplasty: A Population-Based Inpatient Cohort Study in Taiwan.

To investigate readmissions among adult inpatients who underwent uvulopalatopharyngoplasty (UPPP) in Taiwan. Population-based survey. Retrospective study with the National Health Insurance Database. All cases of inpatient adult UPPP (age >20 years) from 1997 to 2012 were identified through International Classification of Diseases, Ninth Revision, Clinical Modification. Factors associated with readmission within 30 days after surgery were analyzed. A total of 38,839 adults with UPPP were identified (mean age, 39.3 years; men, 73.7%). The incidence of UPPP was 14.6 per 100 000 adults, which increased from 1997 to 2012 (6.7 to 16.7 per 100,000, Ptrend < .001). The rates of readmission for any reason, readmission for bleeding, reoperation for bleeding, and 30-day mortality were 4.2%, 1.7%, 1.0%, and 0.14%, respectively. Young age increased the risk of reoperation for bleeding, and old age increased the risk of readmission for any reason and mortality. Men had an increased risk of readmission and reoperation. Hypertension was associated with an increased risk of readmission for any reason (odds ratio [OR], 1.29; 95% CI, 1.10-1.51), bleeding-related readmission (OR, 1.89; 95% CI, 1.52-2.36), and reoperation (OR, 2.47; 95% CI, 1.84-3.30). Concurrent hypopharyngeal surgery was associated with an increased risk of readmission for any reason (OR, 1.34; 95% CI, 1.07-1.66) and bleeding-related readmission (OR, 1.69; 95% CI, 1.25-2.27). Finally, the use of steroids was associated with an increased risk of bleeding-related readmission and reoperation. The incidence of adult UPPP increased from 1997 to 2012 in Taiwan. Age, sex, comorbidity, concurrent hypopharyngeal surgery, and drug administration were associated with readmission after inpatient UPPP.

Long-term survival and related outcomes for hybrid versus traditional arch repair-a meta-analysis.

Surgical interventions for aortic aneurysm and dissection remain associated with high risk of mortality and morbidity. Advances in operative techniques have led to a variety of options for the cardiac surgeon, including endovascular and hybrid approaches. Debate remains over which of these techniques provide optimal outcomes for the patient. The present systematic review and meta-analysis aims to evaluate long term patient survival and identify short-term outcomes for conventional (open) aortic arch repair and hybrid aortic arch repair (HAR). An electronic literature search was conducted according to predefined inclusion criteria for hybrid and conventional aortic arch repair surgery. Digitized survival data was extracted from identified studies' Kaplan-Meier curves and used to re-create individual patient data for aggregated survival analysis. Post-operative morbidity and mortality were analyzed using random-effects model meta-analysis. Nine studies were included, containing 841 hybrid arch repair and 1,182 conventional arch repair patients. Pooled Kaplan-Meier analysis of all patients demonstrated higher survival in hybrid arch repair patients than conventional arch repair patients, however, this was noted to be sensitive to results from a particular study. Overall results showed for the hybrid repair cohort, survival at 1, 2, 3, 5 and 7 years was 87%, 85%, 83%, 78% and 75%, respectively. Survival in the conventional repair cohort at 1, 2, 3, 5 and 7 years was 84%, 82%, 80%, 75% and 71%, respectively. Statistically significant findings from meta-analysis showed hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with reduced risk of spinal cord injury. Pooled Kaplan-Meier analysis of all studies showed long-term survival outcomes for hybrid and conventional aortic arch repair patients are heterogeneous and sensitive to the results of particular studies. Superior results from particular centres and the low number of comparative studies mean that more data is required to make definitive findings with regards to the long-term survival outcomes of either procedure. Hybrid arch repair was associated with lower risk of re-operation for bleeding, while conventional arch repair was associated with lower risk of spinal cord injury. Surgeons should consider their own center's experience and patient suitability when deciding between hybrid or conventional aortic repair techniques.

Perioperative Steroid Use for Tonsillectomy and Its Association With Reoperation for Posttonsillectomy Hemorrhage: A Retrospective Cohort Study.

Steroids reduce postoperative complications after tonsillectomy such as nausea and vomiting, pain, and delayed recovery. However, steroids may also increase the risk of severe posttonsillectomy bleeding requiring reoperation. To evaluate the risk of postoperative bleeding requiring reoperation related to perioperative steroid use, we conducted a retrospective cohort study of 6149 patients treated at 68 hospitals using a hospital-based claims database. The primary outcome was reoperation for bleeding within 14 postoperative days. We estimated odds ratios (ORs) between perioperative steroid use and reoperation by multivariable logistic regression analysis adjusted for confounders. We also estimated differences in the adjusted risk. Subgroup analyses after dividing patients into adults and children were also performed. The incidence of reoperation did not differ significantly between patients who received steroids on the day of tonsillectomy and those who did not (1.8%, n = 15 vs 1.5%, n = 79; adjusted OR 0.81, 95% confidence interval [CI], 0.45-1.43; P = .46). We also found nonsignificant associations in both adults (OR, 0.73; 95% CI, 0.38-1.38; P = .33) and children (OR, 1.18; 95% CI, 0.34-4.11; P = .80). The adjusted risk differences estimated by the logistic regression model were -0.30% (95% CI, -1.05 to 0.45) in all patients, -0.64% (95% CI, -1.82 to 0.54) in adults, and 0.13% (95% CI, -0.93 to 1.19) in children. Steroid use on the day of tonsillectomy was not associated with an increased risk of reoperation for bleeding. Although the wide range of CIs for the ORs could not eliminate the possibility of increased risk, especially in children, the incremental risks of reoperation for steroid use were within an acceptable range for both adults and children. Our results support the safety of perioperative steroid use for tonsillectomy, considering the magnitude of risk of reoperation because of bleeding.

Stopping versus continuing acetylsalicylic acid before coronary artery bypass surgery: A systematic review and meta-analysis of 14 randomized controlled trials with 4499 patients.

This study aimed to evaluate the efficacy and safety of continuing versus stopping aspirin [acetylsalicylic acid (ASA)] preoperatively in patients undergoing coronary artery bypass graft surgery. MEDLINE, EMBASE, CENTRAL/Cochrane Controlled Trials Register (CCTR), ClinicalTrials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino Americana em Ciências da Saúde (LILACS), Google Scholar and reference lists of relevant articles were searched for randomized controlled trials that reported efficacy outcomes of myocardial infarction and mortality, and safety outcomes of blood loss, packed red blood cell transfusion and surgical re-exploration were compared between groups. Fourteen studies fulfilled our eligibility criteria and included a total of 4499 patients (2329 for 'continuing ASA' and 2170 for 'stopping ASA'). In the pooled analysis, continuing aspirin therapy did not reduce the risk of myocardial infarction [risk ratio 0.834, 95% confidence interval (CI) 0.688-1.010; P = 0.063] or operative mortality (risk ratio 1.384, 95% CI 0.727-2.636; P = 0.323). Preoperative ASA increased postoperative chest tube drainage (mean difference 143 ml, 95% CI 39-248 ml; P = 0.007) and packed red blood cell transfusion (mean difference 142 ml, 95% CI 55-228; P = 0.001) but did not increase the risk of surgical re-exploration (risk ratio 1.316, 95% CI 0.910-1.905; P = 0.145). This meta-analysis found no statistically significant difference regarding the risk of operative mortality and myocardial infarction between the 'continuing ASA' and 'stopping ASA' strategies. On the other hand, the mean volume of blood loss and packed red blood cell transfusion was higher in the 'continuing ASA' group, but this finding did not translate into higher risk of reoperation for bleeding.

PO-132: Risk of re-operation for bleeding in head and neck surgery.

PO-132: Risk of re-operation for bleeding in head and neck surgery.

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy

Controversy persists regarding the perioperative management of clopidogrel among patients undergoing carotid endarterectomy (CEA). This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes. Patients undergoing CEA in the Vascular Quality Initiative were analyzed (2003-2014). Patients on clopidogrel and aspirin (dual therapy) were compared with patients taking aspirin alone preoperatively. Study outcomes included reoperation for bleeding and thrombotic complications defined as transient ischemic attack (TIA), stroke, or myocardial infarction. Secondary outcomes were in-hospital death and composite stroke/death. Univariate and multivariable analyses assessed differences in demographics and operative factors. Propensity score-matched cohorts were derived to control for subgroup heterogeneity. Of 28,683 CEAs, 21,624 patients (75%) were on aspirin and 7059 (25%) were on dual therapy. Patients on dual therapy were more likely to have multiple comorbidities, including coronary artery disease (P< .001), congestive heart failure (P< .001), and diabetes (P< .001). Patients on dual therapy were also more likely to have a drain placed (P< .001) and receive protamine during CEA (P< .001). Multivariable analysis showed that dual therapy was independently associated with increased reoperation for bleeding (odds ratio [OR], 1.71; 95% confidence interval [CI], 1.20-2.42; P=.003) but was protective against TIA or stroke (OR, 0.61; 95% CI, 0.43-0.87; P= .007), stroke (OR, 0.63; 95% CI, 0.41-0.97; P= .03), and stroke/death (OR, 0.66; 95% CI, 0.44-0.98; P= .04). Propensity score matching yielded two groups of 4548 patients and showed that patients on dual therapy were more likely to require reoperation for bleeding (1.3% vs 0.7%; P= .004) but less likely to suffer TIA or stroke (0.9% vs 1.6%; P= .002), stroke (0.6% vs 1.0%; P= .04), or stroke/death (0.7% vs 1.2%; P= .03). Within the propensity score-matched groups, patients on dual therapy had increased rates of reoperation for bleeding regardless of carotid symptom status. However, asymptomatic patients on dual therapy demonstrated reduced rates of TIA or stroke (0.6% vs 1.5%; P< .001), stroke (0.4% vs 0.9%; P= .01), and composite stroke/death (0.5% vs 1.0%; P= .02). Among propensity score-matched patients with symptomatic carotid disease, these differences were not statistically significant. Preoperative dual antiplatelet therapy was associated with a 40% risk reduction for neurologic events but also incurred a significant increased risk of reoperation for bleeding after CEA. Given its observed overall neurologic protective effect, continued dual antiplatelet therapy throughout the perioperative period is justified. Initiating dual therapy in all patients undergoing CEA may lead to decreased neurologic complication rates.

Impact of preoperative use of P2Y12 receptor inhibitors on clinical outcomes in cardiac and non-cardiac surgery: A systematic review and meta-analysis

To review systematically the evidence and perform a meta-analysis of benefits and risks associated with use of P2Y12 receptor inhibitors in coronary artery bypass graft-, non-cardiac- and device surgery. Data selection and analysis: We performed a meta-analysis of published studies. Patients with preoperative use of clopidogrel, ticagrelor or prasugrel (late discontinuation: <5 days before surgery or no discontinuation) were compared with patients without preoperative use of the respective drug (early discontinuation: ⩾5 days before surgery or no users of P2Y12 receptor inhibitors). Outcomes evaluated were re-operation for major bleeding, death, myocardial infarction, combined major adverse cardiac events (MACEs) and major haematoma. Using a random effect model, relative risks (RRs) and 95% confidence intervals (CI) were calculated for each outcome. Fifty-four studies met the selection criteria and included 50,048 patients. Preoperative use of clopidogrel on top of aspirin in patients undergoing coronary artery bypass graft was associated with a 2.5-fold increased risk of re-operation for bleeding (95% CI: 1.92-3.25; p<0.001) and a 1.47-fold increased risk of death (95% CI: 1.25-1.72; p<0.001), but did not diminish the risk for myocardial infarction (RR: 0.96; 95% CI: 0.75-1.25; p=0.18) or MACE (RR: 1.16; 95% CI: 0.90--1.50; p=0.30). In patients undergoing non-cardiac surgery, preoperative use of clopidogrel increased the RR of re-operation for major bleeding by 2.05-fold (95% CI: 1.13-3.73; p=0.002) but did not reduce the RR for MACE or death. Clopidogrel use during cardiac device implantation raised the RR for procedure-related haematoma by 3.0-fold (95% CI: 1.30--6.94; p=0.001). Whereas preoperative ticagrelor use did not increase the risk for mortality (RR: 1.03; 95% CI: 0.49-2.14), preoperative prasugrel use tended to increase the risk for death (RR: 5.06; 95% CI: 0.54-47.65). Preoperative exposure to clopidogrel on top of aspirin did not reduce the risk of MACE but was associated with increased risk of bleeding and mortality.

Preoperative Aspirin Use and Its Effect on Adverse Events in Patients Undergoing Cardiac Operations

Preoperative aspirin use within 5 days of cardiac operations is controversial. Aspirin could reduce cardiovascular complications and yet might increase risk of bleeding. Recent reports showed conflicting results, and whether aspirin has variable effects for different cardiac surgical procedures is unclear. A single-center retrospective cohort analysis was performed. After propensity score matching (PSM) for identified confounders, the relationship between preoperative aspirin use and 30-day all-cause mortality, postoperative renal failure, major adverse cardiocerebral events (MACE), blood transfusion, reoperation for bleeding, and postoperative infection were estimated with separate logistic regression models. Preoperative aspirin therapy was associated with a 49% (p= 0.04) increased risk of reoperation for bleeding among 868 matched pairs of patients undergoing valve operations. Among 725 matched patients undergoing coronary artery bypass grafting (CABG), preoperative aspirin therapy was not associated with a statistically significant higher risk of reoperation for bleeding. However, preoperative aspirin use, compared with nonuse, was not associated with risks of MACE, 30-day mortality, postoperative renal failure, blood transfusion, or postoperative infection in the entire cohort, in patients undergoing valve operations only, and in patients undergoing CABG only after PSM. Preoperative aspirin use in all patients undergoing cardiac operations was not associated with risks of major cardiac, cerebral, or renal complications and infections and death; however, the risk of reoperation for bleeding was elevated among preoperative aspirin users compared with nonusers in a subpopulation of patients undergoing valve operations only.

Levosimendan increases bleeding risk after heart valve surgery: a retrospective analysis of a randomized trial.

To investigate whether levosimendan, an inotrope with cardioprotective properties, increases postoperative bleeding after cardiac surgery. Retrospective analysis of a randomized, prospective clinical study. Post-anesthesia care unit (PACU) and surgical ward in a university hospital. Two hundred heart valve surgery patients. The patients were randomized to receive either a 24-hour intravenous infusion of levosimendan or placebo. Infusion was administered as a 24 µg/kg bolus over 30 minutes and then continued at a dose of 0.2 µg/kg/min. Postoperative bleeding was approximately 31% greater in the levosimendan group (1050 mL) compared to the placebo group (880 mL, p = 0.008). Serious bleeding exceeding 1000 mL was more common in the levosimendan group than the placebo group (51 v 38 patients, p = 0.044, risk ratio (RR) 1.37, 95% CI 1.00-1.87). However, the risk of reoperation for bleeding did not increase if patients received levosimendan (RR 1.52, 95% CI 0.77-2.97, p = 0.309). This result did not change after excluding patients who received clopidogrel preoperatively (RR 2.13, 95% CI 0.98-4.65, p = 0.145). The groups did not differ regarding transfused blood products. Eight patients, including seven from the levosimendan group, had delayed (diagnosed>48 hours after the surgery) cardiac tamponade and underwent re-exploration (7 v 1, p = 0.031). Levosimendan increased the risk of postoperative bleeding after cardiac valve surgery. In addition, the risk of postoperative cardiac tamponade was increased in patients who received levosimendan compared to placebo.

Managing Port-Site Bleeding during Less Invasive Coronary Artery Bypass Grafting

Robotic-assisted coronary artery bypass grafting (r-CABG) requires the placement of ports bluntly through the chest wall. When removed, these ports create bleeding sites that can be difficult to detect and treat. This study evaluated whether a topical hemostatic agent placed locally within these sites helps to reduce bleeding and blood product requirements. We retrospectively analyzed outcomes for r-CABG cases where 5 mL of a flowable hemostatic agent was injected locally within all port sites (hemostat group, n = 62) compared with patients whose port sites were untreated (controls, n = 131). Outcomes included chest tube output, red blood cell (RBC) transfusions, length of hospital stay, and the risk of reoperation for bleeding. Analyses were adjusted for risk factors known to influence bleeding and Society of Thoracic Surgeons (STS) risk score as a weighted composite of variables, which controls for patient and clinical variables. The 2 study groups had similar baseline characteristics and underwent the same r-CABG procedure. The hemostat group had significant reductions in RBC transfusion (24.2% versus 40.8% receiving blood; P = .026; 0.44 versus 1.39 U transfused postoperatively, P = .024). After adjustment for bleeding risks (using STS risk score), differences in transfusions remained significant. Reoperation rates for bleeding, length of stay, chest tube drainage, and intraoperative transfusions were not significantly different in the 2 groups. There was significantly reduced postoperative bleeding and less exposure to blood products in the hemostat group. These findings suggest that undetected bleeding from sites used for port access serves as an underappreciated source of morbidity after r-CABG.