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A Cluster of Severe Postoperative Bleeding Following Open Heart Surgery

Published online by Cambridge University Press:  21 June 2016

Margarita E. Villarino*
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia
Steven M. Gordon
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia
Carol Valdon
Affiliation:
Palo Alto Veterans Administration Medical Center, Palo Alto, California
Diana Potts
Affiliation:
Palo Alto Veterans Administration Medical Center, Palo Alto, California
Kevin Fish
Affiliation:
Palo Alto Veterans Administration Medical Center, Palo Alto, California
Charles Uyeda
Affiliation:
Palo Alto Veterans Administration Medical Center, Palo Alto, California
Patrick M. McCarthy
Affiliation:
Palo Alto Veterans Administration Medical Center, Palo Alto, California
Lee A. Bland
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia
Roger L. Anderson
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia
William R. Jarvis
Affiliation:
Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, Georgia
*
A-07, Epidemiology Branch, Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333

Abstract

Objective:

To investigate a cluster of postoperative bleeding following open heart surgery.

Design:

A cohort and case/control study.

Setting:

Palo Alto Veterans Administration Medical Center, Palo Alto, California.

Participants:

Six (21.4%) of 28 patients undergoing open heart surgery who developed severe, nonsurgical, postoperative bleeding from July 1 through August 30, 1988 (outbreak period). All case-patients had chest tube drainage of > 1000 ml within 4 hours of surgery but did not have identifiable bleeding vessel(s) on exploration.

Results:

Upon comparison of the pre-outbreak (January 1986 through June 1988) and the outbreak period, a significant increase was found in the incidence of postoperative nonsurgical bleeding (5/440 versus 6/28, p = .0006), but not of postoperative surgical bleeding (8/440 versus 0/28, p = 1 .0). Of all patients undergoing open heart surgery during the outbreak period, case patients were found to be older (67.8 versus 60.6, p= .02) and to have received a larger volume of hetastarch (HES), a synthetic colloidal plasma-volume expander (mean = 19.4 ml/kg versus 14.1 ml/kg, p= .02).

Conclusions:

We conclude that the use of large volumes of HES during surgery in the elderly open heart surgery patient may increase the risk for severe, nonsurgical postoperative bleeding, probably caused by alterations of the coagulation system. As the incidence of open heart surgery increases among the elderly, surgeons and anesthesiologists should be alert to possible adverse reactions from exposures not associated with adverse reactions in younger patients.

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1992

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References

1. Belcher, P, Lennox, SC. Avoidance of blood transfusion in coronary artery surgery: a trial of hydroxyethyl starch. Ann Thorac Surg. 1984;37:365370.CrossRefGoogle ScholarPubMed
2. McCarthy, PM, Popovsky, MA, Schaff, HV, et al. Effect of blood conservation efforts in cardiac operations at the Mayo Clinic. Mayo Clin Proc. 1988;63:225229.CrossRefGoogle ScholarPubMed
3. Munsch, CM, MacIntyre, E, Machin, SJ, Mackie, IJ, Treasure, T. Hydroxyethyl starch: an alternative to plasma for postoperative volume expansion after cardiac surgery. Br J Surg. 1988;75:675678.CrossRefGoogle ScholarPubMed
4. Hicks, GL, Jensen, LA, Norsen, LH, Quinn, JR, Stewart, SS, DeWeese, JA. Platelet inhibitors and hydroxyethyl starch: safe and cost-effective interventions in coronary artery surgery. Ann Thorac Surg. 1985;39:422425.CrossRefGoogle ScholarPubMed
5. Symington, BE. Hetastarch and bleeding complications. Ann Intern Med. 1986;105:627628.Google ScholarPubMed
6. Cully, MD, Larson, CP, Silverberg, GD. Hetastarch coagulopathy in a neurosurgical patient. Anesthesiology 1987;66:706707.CrossRefGoogle Scholar
7. Lockwood, DN, Bullen, C, Machin, SJ. A severe coagulopathy following volume replacement with hydroxyethyl starch in a Jehovah's Witness. Anaesthesia. 1988;43:391393.CrossRefGoogle Scholar
8. Siegel, S. Nonparametric Statistics for Behavioral Sciences. New York, NY: John Wiley & Sons; 1981.Google Scholar
9. APHA. Standard Methods for the Examination of Water and Wastewater. New York, NY: APHA; 1960.Google Scholar
10. Booth, C. The limulus amoebocyte lysate (LAL) assay-a replacement for the rabbit pyrogen test. Dev Biol Stand. 1986;64:271273.Google ScholarPubMed
11. Harker, LA. Bleeding after cardiopulmonary bypass. N Engl J Med. 1986;314:14461447.CrossRefGoogle ScholarPubMed
12. Salzman, EW, Weinstein, MJ, Weintraub, RM, et al. Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. N Engl J Med. 1986;314: 14021406.CrossRefGoogle ScholarPubMed
13. Strauss, RG, Stump, DC, Henriksen, A, Saunders, R. Effects of hydroxyethyl starch on fibrinogen. fibrin clot formation, and fibrinolysis. Transfusion. 1984;25:230234.CrossRefGoogle Scholar
14. Macintyre, E, Mackie, IJ, Ho, D, Tinker, J, Bullen, C, Machin, SJ. The haemostatic effects of hydroxyethyl starch (HES) used as a volume expander. Intensive Care Med. 1985;11:300303.CrossRefGoogle ScholarPubMed
15. Kirklin, JK, Lell, WA, Kouchoukos, NT. Hydroxyethyl starch versus albumin for colloid infusion following cardiopulmonary bypass in patients undergoing myocardial revascularization. Ann Thorac Surg. 1984;37:4046.CrossRefGoogle ScholarPubMed
16. Stump, DC, Strauss, RG, Henriksen, RA, Petersen, RE, Saunders, R. Effects of hydroxyethyl starch on blood coagulation, particularly factor VIII. Transfusion. 1985;25:349354.CrossRefGoogle ScholarPubMed
17. Bick, RL. Hemostasis defects associated with cardiac surgery, prosthetic devices, and other extracorporeal circuits. Semin Thromb Hemost. 1985;11:249280.CrossRefGoogle ScholarPubMed
18. Strauss, RG. Review of the effects of hydroxyethyl starch on the blood coagulation system. Transfusion. 1981;21:299302.CrossRefGoogle ScholarPubMed
19. Gonzalez-Santos, JM, Ennabli, K, Pelletier, LC. Coronary artery bypass surgery in the eighth decade of life: experience with 101 patients. Thorac Cardiovasc Surg. 1984;32:341345.CrossRefGoogle ScholarPubMed
20. Mullany, CJ, Clarebrough, JK, White, AL, Wilson, AC. Open heart surgery in the elderly. Aust NZ J Surg. 1987;57:733737.CrossRefGoogle ScholarPubMed
21. Silvay, G, Bodner, N, Koffsky, B, Mindich, BP, Litwak, RS, Kaplan, JA. Open heart surgery in patients in the eighth and ninth decades of life. J Am Geriatr Soc. 1988;36:11231124.CrossRefGoogle ScholarPubMed
22. Hughes, CF, Grant, AF, Leckie, BD, Baird, DK. Cardioplegic solution: a contamination crisis. J Thorac Cardiovasc Surg. 1986;91:296302.CrossRefGoogle ScholarPubMed
23. Andersen, LW, Baek, L, Degn, H, Lehd, J, Krasnik, M, Rasmussen, JP. Presence of circulating endotoxins during cardiac operations. J Thorac Cardiovasc Surg. 1987;93:115119.CrossRefGoogle ScholarPubMed
24. Bland, LE, Villarino, ME, Arduino, MJ, et al. Bacteriologic and endotoxin analysis of salvaged blood used in autologous transfusions during open heart surgery procedures. J Thorac Cardiovasc Surg. [in press].Google Scholar
25. National Center for Health Statistics. National Hospital Discharge Survey. Hyattsville, MD: US Department of Health and Human Services; 1987.Google Scholar