Planned Versus Unplanned Reexplorations for Bleeding: A Comparison of Morbidity and Mortality

摘要

Background Mediastinal reexplorations for bleeding are associated with significant morbidity and mortality. This study hypothesized that bleeding patients who undergo delayed chest closure after an initial operation experience similar outcomes in comparison with patients who have initial chest closure and later require an unplanned reexploration.;Methods This study included all patients in the Johns Hopkins University School of Medicine (Baltimore, MD) institutional Society of Thoracic Surgeons (STS) database who underwent cardiac surgical procedures or thoracic transplantation from 2011 to June 2014, had an intraoperative red blood cell transfusion requirement of 2?units or more, and required mediastinal reexploration for bleeding. Reexplorations were classified as planned (temporary chest closure for a planned “second look”) or unplanned (initial sternal closure and subsequent reexploration). The two groups were then propensity matched. The primary outcome was 30-day mortality. Secondary outcomes were major complication rates, hospital length of stay, duration of mechanical ventilation, and incidence of postoperative pneumonia and cardiac arrest.;Results Among 3,293 patients, 110 (3.3%) met inclusion criteria and required mediastinal reexploration for bleeding. This group included 62 planned (56%) and 48 unplanned (44%) reexplorations. After propensity matching 30 pairs of patients across 16 variables, operative mortality rates were comparable (37% vs 37%; p?=?1.00) between unplanned and planned reexploration cohorts. There were no differences in rates of deep sternal wound infection, renal failure, postoperative hospital length of stay, pneumonia, or cardiac arrest, with the exception of a higher rate of prolonged intubation (93% vs 53%; p < 0.01) in the planned reexploration group.;Conclusions Delayed sternal closure is a safe alternative to initial definitive chest closure when concern exists for postoperative bleeding.;Mediastinal reexplorations complicate 3% to 5% of cardiac surgical procedures and commonly follow excessive bleeding, cardiac tamponade, or a combination of both [1, 2, 3]. Previous studies identified reoperative cardiac surgical procedures [4][4], older age [5, 6], peripheral vascular disease [5][5], and urgent or emergent need for surgical intervention [5, 6] as risk factors for reexploration for bleeding. Although reexploration represents a potentially lifesaving intervention, it is associated with substantial morbidity, including the risk of deep sternal wound infection (DSWI), and death [3, 5].In the setting of postoperative hemorrhage, the decision to perform surgical reexploration after initial sternal closure is often based on clinical judgment, balancing the likelihood of identifying and eliminating the source of bleeding with the probability of safely controlling hemorrhage and preventing cardiac tamponade without intervention. At our own institution (Johns Hopkins University School of Medicine, Baltimore, MD), surgical sources of bleeding have been identified in only 50% of patients who underwent unplanned reexplorations for bleeding, comparable to previously published rates of 50% to 75% [2, 4, 7, 8].Ott and colleagues [9][9] were the first to describe delayed sternal closure as a measure to combat postoperative bleeding diatheses. Nonetheless, concerns over DSWI and its associated morbidity and mortality have perpetuated surgeons’ reluctance to leave patients with “open” chests (temporary sternal closure), sometimes even in the presence of unresolved hemorrhage [4, 5, 10]. Debate remains about the safest method of managing patients with intraoperative coagulopathy, specifically whether or not to delay definitive sternal closure.No study has compared outcomes among bleeding patients who are intentionally left with an open chest at the time of the index operation with outcomes among bleeding patients who have initial chest closure and who subsequently undergo surgical reexploration for postopera