Post Op Bleeding after heart surgery: Better out than in!

 

shutterstock_101194774All patients bleed in the early hours after heart surgery. The post-operative blood shed into the chest is drained through chest tubes and collected in drainage canisters. For some this is just a few hundred cc’s and then it stops. For others it can be more than a liter. In these early hours after surgery great efforts are taken to support the patient until coagulation is restored and bleeding subsides. In the recent era, the potential for bleeding has increased because of more liberal use of antiplatelet medications like Plavix, as well as more complex and often redo procedures. Some patients bleed more because the operation is urgent and the patient is in shock, while others bleed quite unexpectedly when coagulation problems ensue without apparent cause. And occasionally, patients bleed because of a surgical source that needs re-suturing for reinforcement.1 Whatever the cause, worse outcomes and costs are directly tied to the volume of bleeding, and even what are seemingly small volumes can cause problems.2,3

Where the post-operative blood ends up, however, can make a drastic difference in outcomes. Cardiac caregivers have long recognized the importance of bleeding OUT, versus bleeding IN. This is why surgeons put in chest tubes to drain the blood OUT from around the heart and lungs while coagulation is restored in the early hours after cardiothoracic surgery. During this time the blood undergoes a phase change from liquid to solid as the coagulation system kicks back in. Keeping the shed blood flowing OUT through the chest tubes during that phase can be a challenge as chest tubes are prone to clog and obstruct. Nurses often strip and tap chest tubes to try to break up the clots that block the tubes to help the blood get OUT. But even with the best efforts, studies show that chest tubes clog in 36% of patients, preventing adequate evacuation of the shed blood. In these patients, the shed blood can stay IN rather than draining OUT. When blood stays IN, it can manifest as Retained Blood Syndrome (RBS).4

This is why caregivers take so many efforts to make sure the patient shed blood is evacuated by draining it OUT. When the bleeding comes OUT of the drains, the caregiver can measure the amount and know when the patient is beginning to coagulate. When the bleeding comes OUT, the caregiver knows when it stops. When the bleeding comes OUT, the patient can avoid the cardiac and respiratory compromise that comes with blood accumulating around the heart and lungs in the early hours after surgery. When the shed blood comes OUT, clot does not form around the heart and lungs and develop into pleural and pericardial effusions.  When the bleeding comes OUT, complications from retained blood can be minimized and perhaps even readmissions avoided.

Studies have shown that the key to helping the patient maximally drain shed blood in the early hours after surgery is having patent chest drainage catheters that are free of clot occlusion.5,6 PleuraFlow ACT is the only regulatory-cleared device that enables clinicians to proactively maintain chest drainage catheter patency during this critical time. PleuraFlow ACT has been shown to reduce retained blood by 43% and even POAF by 33% in propensity matched studies.7

As a surgeon, you may not be able to always control when or why patients bleed, but you can significantly influence if they bleed OUT rather than IN.

 

  1. Loor, G, Vivacqua, A, Sabik, J.F., Li, L, Hixson, E.D., Blackstone, E.H., Koch, C.G. 2013. Process improvement in cardiac surgery: Development and implementation of a reoperation for bleeding checklist. J of Thorac and Cardiovasc Surg. 146(5): 1028-1032.
  2. Dixon, B., Santamaria, J.D., Reid, D., Collins, M., Rechnitzer, T., Newcomb, A.E., Nixon, I., Yii, M., Rosalion, A., and Campbell, D.J. 2012. The association of blood transfusion with mortality after cardiac surgery: cause or confounding? Transfusion.
  3. Christensen, M.C., Dziewior, F., Kempel, A., and von Heymann, C. 2012. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth 26:46-51.
  4. Boyle EM, Gillinov AM, Cohn WE, Ley SJ, Fischlein T, Perrault LP.  Retained Blood Syndrome after Cardiac Surgery:  A new look at an old problem. Innovations 2015; In Press.
  5. Shiose, A.; Takaseya, T.; Fumoto, H.; Arakawa, Y.; Horai, T.; Boyle, E. M.; Gillinov, A. M.; Fukamachi, K. “Improved drainage with active chest tube clearance.” Interactive CardioVascular and Thoracic Surgery 10 (5): 685–688.
  6. Arakawa, Yoko; Shiose, Akira; Takaseya, Tohru; Fumoto, Hideyuki; Kim, Hyun-Il; Boyle, Edward M.; Gillinov, A. Marc; Fukamachi, Kiyotaka. “Superior Chest Drainage With an Active Tube Clearance System: Evaluation of a Downsized Chest Tube.” The Annals of Thoracic Surgery 91 (2): 580–583
  7. Sirch J, Ledwon M, Puski T, Boyle EM, Pfeiffer S, Fischlein T.  Active Clearance of Chest Drainage Catheters Reduces Retained Blood. Journal of Thoracic and Cardiovascular Surgery.   DOI: 10.1016/j.jtcvs.2015.10.015