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The Epidemiology of Hemorrhage Related to Cardiothoracic Operations

Published online by Cambridge University Press:  02 January 2015

Loreen A. Herwaldt ,
Sheri K. Swartzendruber ,
Michael B. Edmond ,
Richard P. Embrey ,
Kim R. Wilkerson ,
Richard P. Wenzel  and
Trish M. Perl
Loreen A. Herwaldt*
Affiliation:
University of Iowa College of Medicine, Departments of Internal Medicine, Iowa City, Iowa University of Iowa Hospitals and Clinics, Iowa City, Iowa Veterans' Administration Medical Center, Iowa City, Iowa
Sheri K. Swartzendruber
Affiliation:
University of Iowa Hospitals and Clinics, Iowa City, Iowa
Michael B. Edmond
Affiliation:
University of Iowa College of Medicine, Departments of Internal Medicine, Iowa City, Iowa
Richard P. Embrey
Affiliation:
University of Iowa College of Medicine, Department of Surgery, Iowa City, Iowa
Kim R. Wilkerson
Affiliation:
University of Iowa Hospitals and Clinics, Iowa City, Iowa
Richard P. Wenzel
Affiliation:
University of Iowa College of Medicine, Departments of Internal Medicine, Iowa City, Iowa University of Iowa Hospitals and Clinics, Iowa City, Iowa
Trish M. Perl
Affiliation:
University of Iowa College of Medicine, Departments of Internal Medicine, Iowa City, Iowa Veterans' Administration Medical Center, Iowa City, Iowa
*
Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242-1081
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Abstract

Objective:

To define the epidemiology, risk factors, and unadjusted cost of hemorrhages related to cardiothoracic operations.

Study Design:

We conducted two case-control studies to evaluate the risk of hemorrhage following cardiothoracic operations. The definition of hemorrhage required one of the following: reoperation for bleeding, postoperative loss of greater than 800 mL of blood over 4 hours, or surgeon-diagnosed excessive intraoperative bleeding.

Setting:

The cardiothoracic surgery service of a university hospital.

Results:

Of 511 patients undergoing cardiothoracic operations, 93 (18%) met the definition of hemorrhage. In the first case-control study, 3 (14%) of 21 cases and 0 of 42 controls died (odds ratio [OR], 15.0; 95% confidence interval [CI95], 1.18-191.55). Compared with controls, cases received significantly more packed red blood cells intraoperatively (OR, 1.18/100 mL; CI95, 1.01-1.38), and significantly more platelets (OR, 3.26/100 mL; CI95, 1.47-7.26) and fresh frozen plasma (OR, 1.73/100 mL; CI95, 1.05-.84) in the intensive-care unit. Cases were more likely than controls to receive protamine postoperatively (OR, 3.74; CI95, 1.27-11.02). Previous sternotomy, preoperative aspirin or heparin, and preoperative laboratory values did not predict bleeding. The median unadjusted hospital cost was $3,458 higher for patients who suffered hemorrhage than for controls.

To decrease costs, hetastarch (acquisition cost $45/500 mL) was substituted for albumin (acquisition cost $76/100 mL) in the pump priming solution (estimated possible cost savings, $7,000-$53,000/year). Because hemorrhage rates increased subsequently, we conducted a second case-control study that identified patient age (P=.02) and use of greater than 5 mL/kg of hetastarch (OR, 1.82) as risk factors for hemorrhage. The cost of treating hemorrhages exceeded all estimates of possible cost savings ($7,000-$53,000 per year).

Conclusions:

Our definition of hemorrhage identified patients who required increased volumes of blood products and who had an increased crude mortality rate and a higher unadjusted cost of hospitalization. Patient age and hetastarch use were risk factors for hemorrhage. Efforts to save money by substituting less expensive products inadvertently may increase costs by increasing the probability of perioperative adverse events.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 19 , Issue 1 , January 1998 , pp. 9 - 16
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1998

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