Thorac Cardiovasc Surg 2018; 66(08): 622-628
DOI: 10.1055/s-0037-1603205
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Low Fibrinogen Is Associated with Increased Bleeding-Related Re-exploration after Cardiac Surgery

Yasin Essa
1   Department of Cardiothoracic Surgery, Friedrich Schiller University of Jena, Jena, Germany
,
Natig Zeynalov
1   Department of Cardiothoracic Surgery, Friedrich Schiller University of Jena, Jena, Germany
,
Tim Sandhaus
1   Department of Cardiothoracic Surgery, Friedrich Schiller University of Jena, Jena, Germany
,
Michael Hofmann
2   Department of Anaesthesiology and Critical Care Medicine, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
,
Thomas Lehmann
3   Institute of Medical Statistics, Computer Sciences and Documentation, Friedrich Schiller University of Jena, Jena, Germany
,
Torsten Doenst
1   Department of Cardiothoracic Surgery, Friedrich Schiller University of Jena, Jena, Germany
› Institutsangaben
Weitere Informationen

Publikationsverlauf

13. November 2016

10. April 2017

Publikationsdatum:
16. Mai 2017 (online)

Abstract

Background Re-exploration after cardiac surgery remains a relatively frequent complication associated with adverse effects on outcome. We aimed to identify risk factors for re-exploration.

Methods We retrospectively reviewed 2,403 patients having undergone cardiac surgical procedure between January 2013 and December 2014. Re-exploration was required in 114 patients (4.7%). Patients with oral anticoagulation, infective endocarditis, or a clearly identified bleeding source were excluded. Therefore, 42 patients remained for analysis. A matched cohort was selected for age, sex, ejection fraction, creatinine, and procedure out of the non–re-explored patients.

Results Demographic data were similar in both groups, except for a higher prevalence of diabetes (45 vs. 21%; p = 0.036) in the non–re-explored patients. Surgery was elective in two-thirds and preoperative plasma fibrinogen concentration was lower in patients requiring re-exploration (2.8 ± 0.9 vs. 3.6 ± 0.9 g/L; p = 0.002). During the initial operation, re-explored patients received more packed red blood cells (1.5 ± 3 vs. 0 ± 1 units; p < 0.001), Postoperatively, re-explored patients had higher lactate levels (1.7 ± 1.4 vs. 1.3 ± 0.6 mmol/L, p = 0.044), more chest tube drainage (1,245 ± 948 vs. 685 ± 413 mL; p < 0.001), higher hospital mortality (19 vs. 7%; p = 0.19), and longer intensive care unit (ICU) stays (8 ± 8 vs. 4 ± 7 days; p = 0.010). In addition, more fibrinogen was administrated during the initial surgery. Plasma fibrinogen concentration upon arrival at the ICU was lower in patients requiring re-exploration (2 ± 0.6 vs. 2.7 ± 0.7 g; p < 0.001). Multivariable linear regression analysis identified fibrinogen upon arrival at the ICU as an independent predictor of postoperative bleeding.

Conclusion Cardiac surgery patients with low perioperative plasma fibrinogen concentration appear to be more susceptible to bleeding and re-exploration. Re-exploration in this group of patients is associated with increased morbidity and mortality.

 
  • References

  • 1 Hall TS, Brevetti GR, Skoultchi AJ, Sines JC, Gregory P, Spotnitz AJ. Re-exploration for hemorrhage following open heart surgery differentiation on the causes of bleeding and the impact on patient outcomes. Ann Thorac Cardiovasc Surg 2001; 7 (06) 352-357
  • 2 Moulton MJ, Creswell LL, Mackey ME, Cox JL, Rosenbloom M. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg 1996; 111 (05) 1037-1046
  • 3 Ranucci M, Bozzetti G, Ditta A, Cotza M, Carboni G, Ballotta A. Surgical reexploration after cardiac operations: why a worse outcome?. Ann Thorac Surg 2008; 86 (05) 1557-1562
  • 4 Dacey LJ, Munoz JJ, Baribeau YR. , et al; Northern New England Cardiovascular Disease Study Group. Reexploration for hemorrhage following coronary artery bypass grafting: incidence and risk factors. Arch Surg 1998; 133 (04) 442-447
  • 5 Despotis G, Avidan M, Eby C. Prediction and management of bleeding in cardiac surgery. J Thromb Haemost 2009; 7 (Suppl. 01) 111-117
  • 6 Scheraga HA. The thrombin-fibrinogen interaction. Biophys Chem 2004; 112 (2-3): 117-130
  • 7 Blome M, Isgro F, Kiessling AH. , et al. Relationship between factor XIII activity, fibrinogen, haemostasis screening tests and postoperative bleeding in cardiopulmonary bypass surgery. Thromb Haemost 2005; 93 (06) 1101-1107
  • 8 Momeni M, Carlier C, Baele P. , et al. Fibrinogen concentration significantly decreases after on-pump versus off-pump coronary artery bypass surgery: a systematic point-of-care ROTEM analysis. J Cardiothorac Vasc Anesth 2013; 27 (01) 5-11
  • 9 Bolliger D, Szlam F, Molinaro RJ, Rahe-Meyer N, Levy JH, Tanaka KA. Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model. Br J Anaesth 2009; 102 (06) 793-799
  • 10 Kozek-Langenecker SA, Afshari A, Albaladejo P. , et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2013; 30 (06) 270-382
  • 11 Essa Y, Amorim P, Färber G. , et al. Cardiac surgery and phenprocoumon therapy—is preoperative normalization of the international normalized ratio necessary?. Cardiovasc Thorac Open 2016; 2: 1-7
  • 12 Karlsson M, Ternström L, Hyllner M, Baghaei F, Nilsson S, Jeppsson A. Plasma fibrinogen level, bleeding, and transfusion after on-pump coronary artery bypass grafting surgery: a prospective observational study. Transfusion 2008; 48 (10) 2152-2158
  • 13 Azevedo Maranhão Cardoso TA, Nigro Neto C, Santos Silva CG, Lobo da Rocha P, Iosto HH. Use of lyophilized fibrinogen concentrate in cardiac surgery: a systematic review. Heart Lung Vessel 2015; 7 (01) 47-53
  • 14 Levy JH, Szlam F, Tanaka KA, Sniecienski RM. Fibrinogen and hemostasis: a primary hemostatic target for the management of acquired bleeding. Anesth Analg 2012; 114 (02) 261-274
  • 15 Whicher J, Dieppe P. Acute phase proteins. Ann Rheum Dis 1985; 5 (03) 425-446
  • 16 Biancari F, Mikkola R, Heikkinen J, Lahtinen J, Airaksinen KE, Juvonen T. Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2012; 41 (01) 50-55
  • 17 Christensen MC, Dziewior F, Kempel A, von Heymann C. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth 2012; 26 (01) 46-51
  • 18 Unsworth-White MJ, Herriot A, Valencia O. , et al. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Ann Thorac Surg 1995; 59 (03) 664-667
  • 19 Choong CK, Gerrard C, Goldsmith KA, Dunningham H, Vuylsteke A. Delayed re-exploration for bleeding after coronary artery bypass surgery results in adverse outcomes. Eur J Cardiothorac Surg 2007; 31 (05) 834-838
  • 20 Ranucci M. Fibrinogen supplementation in cardiac surgery: where are we now and where are we going?. J Cardiothorac Vasc Anesth 2013; 27 (01) 1-4
  • 21 Ucar HI, Oc M, Tok M. , et al. Preoperative fibrinogen levels as a predictor of postoperative bleeding after open heart surgery. Heart Surg Forum 2007; 10 (05) E392-E396
  • 22 Waldén K, Jeppsson A, Nasic S, Backlund E, Karlsson M. Low preoperative fibrinogen plasma concentration is associated with excessive bleeding after cardiac operations. Ann Thorac Surg 2014; 97 (04) 1199-1206
  • 23 Yang L, Vuylsteke A, Gerrard C, Besser M, Baglin T. Postoperative fibrinogen level is associated with postoperative bleeding following cardiothoracic surgery and the effect of fibrinogen replacement therapy remains uncertain. J Thromb Haemost 2013; 11 (08) 1519-1526
  • 24 Lunde J, Stensballe J, Wikkelsø A, Johansen M, Afshari A. Fibrinogen concentrate for bleeding--a systematic review. Acta Anaesthesiol Scand 2014; 58 (09) 1061-1074
  • 25 Rahe-Meyer N, Pichlmaier M, Haverich A. , et al. Bleeding management with fibrinogen concentrate targeting a high-normal plasma fibrinogen level: a pilot study. Br J Anaesth 2009; 102 (06) 785-792
  • 26 Kindo M, Hoang Minh T, Gerelli S. , et al. Plasma fibrinogen level on admission to the intensive care unit is a powerful predictor of postoperative bleeding after cardiac surgery with cardiopulmonary bypass. Thromb Res 2014; 134 (02) 360-368
  • 27 Ternström L, Radulovic V, Karlsson M. , et al. Plasma activity of individual coagulation factors, hemodilution and blood loss after cardiac surgery: a prospective observational study. Thromb Res 2010; 126 (02) e128-e133
  • 28 Ranucci M, Pistuddi V, Baryshnikova E, Colella D, Bianchi P. Fibrinogen levels after cardiac surgical procedures: association with postoperative bleeding, trigger values, and target values. Ann Thorac Surg 2016; 102 (01) 78-85
  • 29 Gielen C, Dekkers O, Stijnen T. , et al. The effects of pre- and postoperative fibrinogen levels on blood loss after cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2014; 18 (03) 292-298