Universal definition of perioperative bleeding in adult cardiac surgery.

OBJECTIVES: Perioperative bleeding is common among patients undergoing cardiac surgery; however, the definition of perioperative bleeding is variable and lacks standardization. We propose a universal definition for perioperative bleeding (UDPB) in adult cardiac surgery in an attempt to precisely describe and quantify bleeding and to facilitate future investigation into this difficult clinical problem. METHODS: The multidisciplinary International Initiative on Haemostasis Management in Cardiac Surgery identified a common definition of perioperative bleeding as an unmet need. The functionality and usefulness of the UDPB for clinical research was then tested using a large single-center, nonselected, cardiac surgical database. RESULTS: A multistaged definition for perioperative bleeding was created based on easily measured clinical end points, including total blood loss from chest tubes within 12 hours, allogeneic blood products transfused, surgical reexploration including cardiac tamponade, delayed sternal closure, and the need for salvage treatment. Depending on these components, bleeding is graded as insignificant, mild, moderate, severe, or massive. When applied to an established cardiac surgery dataset, the UDPB provided insight into the incidence and outcome of bleeding after cardiac surgery. CONCLUSIONS: The proposed UDPB in adult cardiac surgery provides a precise classification of bleeding that is useful in everyday practice as well as in clinical research. Once fully validated, the UDPB may be useful as an institutional quality measure and serve as an important end point in future cardiac surgical research.

Has the clinical presentation and clinician's index of suspicion of cardiac tamponade changed over the past decade?

It remains unclear whether advances in the understanding of the pathophysiology and improvements in cardiovascular imaging over the years have impacted the clinician's recognition of cardiac tamponade (CT). We sought to evaluate signs and symptoms of CT in a present-day population and compare it to a similar group from a decade prior. We performed a retrospective analysis of two cohorts of patients presenting to a tertiary hospital with CT, all of whom underwent pericardial drainage (PD). Group 1 (Gp1) included subjects presenting from 1988 to 1991 and Group 2 (Gp2) included subjects from 2002 to 2005. Fifty-five patients comprised each group, with an average age of 55 years. Seventy-one percent of patients in Gp1 had identifiable cardiovascular symptoms 1 week prior to presentation, compared to 33% in Gp2. Dyspnea was the most common symptom in both groups, and was less frequent in Gp2. Compared with Gp1, chest pain, cough, and lethargy were also less frequent in Gp2. One day prior to PD, tachypnea and pulsus paradoxus were detected more frequently in Gp1 compared to Gp2. Large, circumferential pericardial effusions were the most frequent echocardiographic findings in both groups and the most common etiology of CT was malignancy in Gp1and postoperative bleeding in Gp2. Thus, the recognition of symptoms and physical signs in patients presenting with CT has changed over the past decade, as has etiology of pericardial effusions. However, the diagnosis of CT still remains delayed, and the present data emphasize the need for a heightened index of suspicion for recognizing this hemodynamically-important process.

Pericardial tamponade type injury: a 17-year study in an urban trauma center in Japan.

We defined injuries to the heart and the pericardium together with hemopericardium as pericardial tamponade type injury regardless of symptoms or signs due to pericardial tamponade. The aim of the study is to examine the important factors related to the diagnosis and treatment of this type of injury. A retrospective chart review was conducted of traumatized patients admitted with hemopericardium to our institution between 1978 and 1995. Ten out of the 19 consecutive patients with pericardial tamponade type injury demonstrated shock and showed a higher Injury Severity Score and mortality (7/11) than the remaining 9 without shock. The majority of our cases received an emergency room thoracotomy or a surgical fenestration and thereafter some of them needed a (re-)thoracotomy in the operating room. We consider a fenestration through the pericardium to be the first choice for the relief of acute hemopericardium due to trauma, while surgeons should not perform pericardiocentesis for the either diagnosis or relief of this type of injury.

Effect of alcohol intoxication on hemodynamic physiology and outcome in patients with traumatic cardiac tamponade.

BACKGROUND: Alcohol intoxication has a detrimental effect on hypovolemic shock. Our aim, was to study its effects on "pure" cardiac tamponade (i.e., without hypovolemia) in patients with penetrating chest injuries. METHODS: Thirty-five intoxicated and 15 nonintoxicated patients (blood alcohol > and < 17 mmol/L) were studied. Initial vital signs (trauma scores), special investigations (hematologic profiles, blood gases, glucose, lactate, and catecholamines), clinical progress (24- and 72-hour acute physiology and chronic health evaluation II scores) and outcome were compared. RESULTS: Intoxicated patients were older (p = 0.02) and more tachypneic on admission (p = 0.006), but no other differences were noted. Mortality was proportional to the degree of shock and was greater in patients who had "front-room" thoracotomies (p < 0.001). Despite the higher percentage of intoxicated patients who were "lifeless" or "in extremis" on admission, they fared no worse than nonintoxicated patients. CONCLUSION: Alcohol intoxication does not have an adverse affect on traumatic cardiac tamponade.

Cardiac causes of shock early after open heart surgery: etiologic classification by radionuclide ventriculography.

Early after open heart surgery, cardiac shock due to tamponade is easily misdiagnosed as ventricular dysfunction. The distinction is critical to successful therapy. We assessed the utility of 99mTc-red blood cell, gated equilibrium radionuclide ventriculography in 50 patients with early postoperative cardiac shock after historical, clinical, and invasive hemodynamic evaluation failed to identify either tamponade or ventricular dysfunction as the specific cause of their shock. The cause was established by radionuclide ventriculography in 45 of 50 patients and led to a change in therapy in 21 patients. A single cause was found in 35 patients: 13 had severe global dysfunction of the left ventricle (three patients), right ventricle (seven patients), or both ventricles (three patients); three had severe segmental left ventricular dysfunction; and 19 had an exaggerated region of photon deficiency (nine patients) or an abnormal and accumulating blood pool (10 patients) surrounding small hyperdynamic ventricles. Sixteen of these 19 patients with scintigraphic evidence of tamponade underwent aspiration with a pericardial needle or reoperation early after radionuclide ventriculography, resulting in confirmation of scintigraphic findings and improved hemodynamics. Ten additional patients had combined ventricular dysfunction and a pericardial abnormality, and five of these underwent reoperation resulting in improved hemodynamics. Radionuclide ventriculography provided no explanation for the cause of cardiac shock in five patients. Thus, the various causes of cardiac shock early after open heart surgery can be distinguished by 99mTc-red blood cell, gated equilibrium radionuclide ventriculography, eliminating diagnostic uncertainty that can occur with traditional evaluation.