Reduced re-exploration and blood product transfusion after the introduction of the Papworth haemostasis checklist†.

OBJECTIVES: Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery. METHODS: The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes. RESULTS: Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102 165 ($134 198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit. CONCLUSIONS: The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.

An Absorbable Hydrogel Spray Reduces Postoperative Mediastinal Adhesions After Congenital Heart Surgery.

BACKGROUND: Adhesions encountered during reoperative cardiac surgery can prolong operative time and increase operative risk. The purpose of this clinical study was to investigate the antiadhesion property of a synthetic bioabsorbable polymer spray after cardiac reoperations in infants. METHODS: A prospective randomized double-blinded study was designed. Forty infants requiring staged cardiac operations were randomly allocated to a study group (n = 20) or a control group (n = 20). The appropriate volume of the polymer was sprayed onto the mediastinal surfaces before chest closure after the first surgical procedure in the study group. At reoperation, adhesions were evaluated by a blinded investigator following a 5-grade scoring system. Five predetermined anatomic areas were scored. Incision to extracorporeal circulation time was also analyzed. RESULTS: In all, 40 subjects were enrolled into the study. Four babies died before the second operation. Three others were missed for reevaluation. The control group (n = 16) had longer incision to extracorporeal circulation time (38 ± 10 minutes) than the study group (n = 17; 23 ± 6 minutes; p < 0.001). The control subjects had significantly more severe adhesions than the study group at all five mediastinal areas: (1) retrosternal (p < 0.001); (2) base of the heart (large vessels [p < 0.05]); (3) right side (p < 0.01); (4) left side (p < 0.02); and (5) diaphragmatic side of the mediastinum (p < 0.001). CONCLUSIONS: The use of synthetic bioabsorbable polymer sealant spray at the end of primary pediatric cardiac surgery reduces the intensity of mediastinal adhesions and the reentry time in infants undergoing repeat median sternotomy.

A successful attempt to prevent postoperative adhesions between the mediastinum and a lung: a canine model.

A bioabsorbable sheet was sutured to cover the right-sided mediastinal pleurectomy defect, whereas not in a control. There was a significant difference in mediastinal adhesions with a lung between the groups. Our findings suggested that the sheet may prevent postoperative adhesions between the mediastinum and a lung.

Prevention of retrosternal adhesion by novel biocompatible glue derived from food additives.

BACKGROUND: Postoperative retrosternal adhesion increases the risk of cardiac injury during cardiac reoperation. We created a novel biodegradable glue called "Lydex" that is derived from food additives. The purpose of this study is to evaluate this new biomaterial's biocompatibility and its preventive effect on retrosternal adhesion. METHODS: We performed a median sternotomy and anterior pericardiectomy on Japanese white rabbits, and then closed the chest (control, group 1; n = 12), implanted an expanded polytetrafluoroethylene membrane (group 2; n = 12), or applied Lydex (group 3; n = 12) before closure. After 4 weeks, we evaluated macroscopic adhesion (each group; n = 6) and microscopic findings for fibrosis and macrophage infiltration (each group; n = 6). RESULTS: In group 3, the retrosternal adhesion score was significantly lower than in group 1 (P = .0022). There was no significant difference between groups 2 and 3. The fibrotic area ratio was significantly lower in group 3 than in groups 1 and 2 (P < .001 vs group 1; P < .001 vs group 2). In group 3, the macrophage count was significantly lower than in group 2 (P < .001) and almost equal to that in group 1. CONCLUSIONS: Our findings indicate that Lydex reduces retrosternal adhesion and attenuates the progression of fibrosis with excellent biocompatibility. Lydex is a next-generation substance for safer cardiac reoperation, with excellent capability for preventing adhesion, biocompatible and biodegradable properties, and lower potential for viral infections related to human plasma or other animal-derived products.

Prevention of postpneumonectomy syndrome in children with prophylactic tissue expander insertion.

INTRODUCTION: Postpneumonectomy syndrome (PPS) is an often life-threatening complication of pneumonectomy that occurs in up to 15% of children. This occurrence is higher than in adults, presumably because of more elastic tissues in younger patients. METHODS: We present a case series of 4 pediatric patients at Memorial Sloan Kettering Cancer Center, in whom prophylactic tissue expanders were inserted immediately after pneumonectomy. RESULTS: Insertion of the tissue expander and prevention of PPS was successful in all patients. The presence of the tissue expander did not result in infection in any patient. Our only complication was rupture of the tissue expander in 1 patient, but by the time of removal, a capsule had already formed within the lung and replacement was unnecessary. CONCLUSION: This case series, although limited in number and follow-up, presents evidence that prophylactic tissue expander insertion appears to be a safe option for children requiring pneumonectomy. Its insertion at the time of pneumonectomy may prevent the devastating complications of PPS. Because it may result in a higher total number of procedures, the benefits must be weighed against the risks of insertion and decisions made for individual patients on a case-by-case basis.

Achieving efficient anti-adhesion in re-mediastinoscopy: an experimental study in rats.

OBJECTIVE: Re-mediastinoscopy can be a difficult procedure due to fibrosis in the mediastinum. We have investigated the effect of an anti-adhesive barrier agent "hylan B gel" on the formation of adhesions after dissection in the superior mediastinum in a rat model. METHODS: The study was conducted in 70 male Sprague-Dawley rats weighing 300 g. The strap muscles were divided by a midline cervical incision. The anterior and lateral aspects of the trachea were dissected to the level of the carina. Hylan B gel (Sepragel Sinus, Genzyme Company, Redgefield, NJ, USA) was used to create an anti-adhesive barrier. The rats who were subjected to surgery were sacrificed on postoperative days 14 and 28. All rats were previously divided into 5 groups: Sham group (n = 10); Group 1 (n = 15) surgery alone, sacrificed on day 14; Group 2 (n = 15) surgery and Sepragel, sacrificed on day 14; Group 3 (n = 15) surgery alone, sacrificed on day 28; Group 4 (n = 15) surgery and Sepragel, sacrificed on day 28. Histopathological analysis was performed to study the effect of the anti-adhesive agent. Scores were calculated based on collagen fibrosis, fibroblasts, granulation tissue, muscle alterations/inflammation, histiocytes, mononuclear giant cells, inflammation and vascular proliferation. RESULTS: Collagen fibrosis and fibroblast scores, which represent adhesions, were significantly higher in Groups 1, 2, 3, 4 than in the Sham group ( P < 0.01). The degree of adhesions on day 14 was found to be higher in Group 1 compared to Group 2 ( P < 0.01). Adhesions on day 28 were higher in Group 3 compared to Group 4 ( P < 0.01). There were no differences between groups with regard to foreign body reactions ( P > 0.05). CONCLUSION: Adhesions causing technical difficulty during re-mediastinoscopy can be reduced by the application of anti-adhesive agents during the primary procedure.

Mediastinal irrigation with superoxidized water after open-heart surgery: the safety and pitfalls of cardiovascular surgical application.

Postoperative mediastinal infection after open-heart surgery via median sternotomy is a devastating complication. In this paper, we describe a simple method of irrigating the mediastinum using superoxidized water to prevent perioperative contamination. After mediastinal hemostasis was done, warm superoxidized water of more than 21 was uninterruptedly irrigated for 5 min immediately prior to sternal closure. We have used this method in 25 patients undergoing cardiac surgery, and noted significant perioperative electrocardiographic changes, including ST elevation, without hemodynamic compromise in 15 of these patients.

Preventing mediastinal shift after pneumonectomy does not abolish physiological compensation.

To determine the role of mediastinal shift after pneumonectomy (PNX) on compensatory responses, we performed right PNX in adult dogs and replaced the resected lung with a custom-shaped inflatable silicone prosthesis. Prosthesis was inflated (Inf) to prevent mediastinal shift, or deflated (Def), allowing mediastinal shift to occur. Thoracic, lung air, and tissue volumes were measured by computerized tomography scan. Lung diffusing capacities for carbon monoxide (DL(CO)) and its components, membrane diffusing capacity for carbon monoxide (Dm(CO)) and capillary blood volume (Vc), were measured at rest and during exercise by a rebreathing technique. In the Inf group, lung air volume was significantly smaller than in Def group; however, the lung became elongated and expanded by 20% via caudal displacement of the left hemidiaphragm. Consequently, rib cage volume was similar, but total thoracic volume was higher in the Inf group. Extravascular septal tissue volume was not different between groups. At a given pulmonary blood flow, DL(CO) and Dm(CO) were significantly lower in the Inf group, but Vc was similar. In one dog, delayed mediastinal shift occurred 9 mo after PNX; both lung volume and DL(CO) progressively increased over the subsequent 3 mo. We conclude that preventing mediastinal shift after PNX impairs recruitment of diffusing capacity but does not abolish expansion of the remaining lung or the compensatory increase in extravascular septal tissue volume.

[Relatively long time use of percutaneous cardiopulmonary support after unsuccessful weaning from intra-operative extracorporeal circulation--clinical considerations from an experience of 5 patients].

Percutaneous cardiopulmonary support (PCPS) was used in 5 patients (4 males and 1 female); 70.2 +/- 10.8 years old) who underwent open heart surgery and failed to wean from the extracorporeal circuit because of profound heart failure unresponsive to maximal doses of catecholamines and intra-aortic balloon pump support. Duration of PCPS was 6975 +/- 5516 min, and the average flow was 1.51 +/- 0.26 l/min/m2. Heparin-coated circuit including the oxygenator was used to minimize the necessary dose of heparin, and activated clotting time (Celite ACT) was maintained between the range of 130 and 200 seconds. Despite this low-dose heparinization, mediastinal hematoma formation and subsequent cardiac tamponade occurred in 4 patients. Weaning from PCPS was successful in 3 patients for whom reexploration to remove hematoma was performed, and 2 of these 3 achieved long-term survival. During the use of PCPS, ipsilateral femoral artery, through which part of the pump flow was actively perfused. Owing to this maneuvering, limb ischemia did not occur in any case. From these findings, we could conclude that reexploration for mediastinal hematoma should be performed in weaning from PCPS for postoperative patients, even when low-dose heparinization was employed, and that active perfusion through the 18g catheter downstream to the ipsilateral lower limb is effective in preventing limb ischemia during relatively long time PCPS.

The use of tranexamic acid to reduce postoperative bleeding following cardiac surgery: a double-blind randomized trial.

Bleeding during the first 24 hours following cardiac surgery using cardio-pulmonary bypass (CPB) is a serious complication. Attempts to modify the degree of postoperative bleeding with pharmacologic therapy have met with limited success. Tranexamic acid, a potent inhibitor of plasminogen, may decrease the amount of mediastinal bleeding following surgery utilizing CPB. We assigned 30 patients who were about to undergo cardiac surgery to a double-blind randomized trial. The treatment group received tranexamic acid, given intravenously as 10 mg/kg over 30 minutes, at the time of skin incision, followed by a 1 mg/kg/hr infusion for 12 hours. The control group received a placebo (saline) of equal volume. Measurements of shed mediastinal blood and transfused homologous blood were made at 6, 12, and 24 hours postoperatively. Mediastinal blood loss in the treatment and control groups was 382 mL versus 594 mL at 6 hours (P = 0.08), 502 mL versus 848 mL at 12 hours (P = 0.04), and 711 mL versus 1160 mL at 24 hours (P = 0.02). The mean transfusion volumes after 24 hours were 356 mL in the treatment group and 528 mL in the placebo group (P = NS). Prophylactic tranexamic acid infusion decreases mediastinal blood loss following cardiopulmonary assisted cardiac surgery.

Mediastinal drainage after open heart surgery: comparison of infectious complications with two different systems.

Over the last years disposable systems have replaced in many hospitals the glass bottle drainage equipment used after cardiac surgery. The present study was designed to evaluate the incidence of postoperative infections and technical problems with 2 types of drainage systems. Positive microbial cultures and infectious complication as well as technical incidents were lower with the disposable equipment. The costs of the material alone, when infections are not taken into consideration, are slightly lower for the glass drainage system. We conclude from this survey that the incidence of superinfection of a closed, disposable system for mediastinal drainage is rare and smaller than with conventional glass bottles. When costs of different systems are compared, this consideration may be important.

Pneumonectomy in infants and children: the use of a prosthesis to prevent mediastinal shift and its complications.

Twenty cases of pneumonectomy in infants and children performed over a 35-yr period have been reviewed. Pneumonectomy may be necessary for inflammatory, congenital, neoplastic, and traumatic conditions. The postoperative complications of progressive mediastinal shift can be minimized by the use of a pleural prosthesis.

Postoperative chest wound infections in patients requiring coronary bypass. A controlled study evaluating prophylactic antibiotics.

A controlled study investigating clean chest wound infections in 904 patients undergoing myocardial revascularization was performed. Four hundred fifty-one patients received systemic antibiotics before and after the operation, and 453 patients received no prophylactic systemic antibiotics. The infection rate was 1.10 per cent and 1.76 per cent, respectively, indicating no statistical difference between the two groups. Preoperative skin preparation and subsequent local antibiotic wound irrigation may be the most important factors in preventing clean wound infection.