Presenter: Dr Shingo Kunioka. Dr Victor A. Ferraris (Lexington, Ky). The title of my commentary should be “patience is a virtue, but who said cardiothoracic surgeons are virtuous or patient.” Please excuse the provocative rhetoric, but I suspect that the audience understands the need for action. A necessary prerequisite for the vast majority of cardiothoracic surgeons is an urgency to do good by doing something, usually this implies doing something active in the operating room or in the perioperative care. We are not passive observers whose main job is to sit back and think about medical problems. We are trained to act since the very first time we appear in the operating room and the chief resident says “don't just stand there! Do something, get busy, prep the patient, then scrub your hands, and get your gown and gloves on.” We have all been there. The presentation by Kunioka and colleagues is hard to swallow. They suggest that we take some time at the end of a long and difficult operation to place packs around the heart and wait 5 minutes. Really, wait 5 minutes! Yes, and then continue to do that until the sponges are not blood-soaked. Wow! I suspect that no one in this audience finds that 5-minute wait to be a simple chore. It comes at a time when the surgeon has spent several hours in the operating room performing a difficult, complex task. I remember almost 50 years ago when the attending surgeon turned to me near the end of an operation and said “dry up and close the chest. I'll see you in the recovery room.” Those days are gone forever, for at least 3 reasons:•Operative complexity has changed.•Care standards demand constant engagement by the responsible surgeon.•Perhaps most importantly, no one is more knowledgeable about where the bleeding might be coming from and what can and needs to be done to control bleeding than the attending surgeon. The presentation by Professor Kunioka provides convincing evidence that a few minutes spent at the end of a difficult cardiac operation, employing a simple matter of placing packs around the heart and weighing sponges, can provide a meaningful improvement in bleeding complications. I have 4 questions for the presenters:1.First, have the authors considered any refinements or modifications of their techniques? Have they thought about adding some topical hemostatic agents to the pericardial surface? Topical hemostatic agents may speed up the process.2.Are the authors' results impacted by the addition of intravenous agents that enhance hemostasis, such as Aprotinin or Amicar? How would they manage intravenous hemostatic agents?3.Have the authors thought of other intraoperative techniques that may supplement this process? Are there refinements in the bypass circuit or the anesthetic management that can impact bleeding?4.Are there certain operations that do not respond well to the authors' protocol. I'm thinking about operations for endocarditis or other complex procedures with increased bleeding risk from intrinsic patient coagulation or clotting defects. In other words, how would the authors modify their practice in patients with the highest bleeding risk? Is there a role for prophylactic clotting factors or other hemostatic agents? Honestly, I'm surprised that a more rigorous, standardized assessment of bleeding before chest closure has not surfaced up until this presentation. Sometimes beneficial interventions are simple, and simple is better! Congratulations Dr Kunioka on a very provocative presentation. Dr Percy Boateng (New York, NY). I'm sorry to interrupt you there, but we only have 1 minute for him to answer questions. Maybe we should jump to him to answer. Dr Ferraris. Yes, of course. Dr Shingo Kunioka (Asahikawa, Japan). Thank you for your questions. For the first question, that's a great question, thank you for asking. We sometimes use topical hemostatic agents. The most common ones are fibrin sealant patch and fibrin glue. The present study did not examine that; however, those topical hemostatic agents may speed up the process. As for your second question, we usually use drugs that enhance hemostasis, for example, fresh-frozen plasma, fibrinogen, recombinant factor VIIa in many cases. In many cases, anesthesiologist coordinates these use. We need to consider that impact of these factors. For the next question, so far no interpretive techniques have been identified that would complement this process. But we always try to perform the surgery carefully to avoid bleeding in the first place. For the final question, we recently had a case of resternotomy for bleeding caused by serious coagulopathy due to infectious endocarditis. In this case, 5 minutes was too short. However, postcardiotomy bleeding increased after return to the ICU. So I think the test cannot detect such cases. Thank you very much.
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Nov 1, 2024
Jeong-Yeol Park + 2
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Open Access