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MEDIASTINAL BLEEDING AND BLOOD TRANSFUSIONS IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS SURGERY PERFORMED WITH OR WITHOUT CRDIOPULMONARY BYPASS.

Byline: Muddasar Noor, Farrah Pervaiz, Muhammad Afsheen Iqbal, Muhammad Waseem, Asif Mahmood Janjua, Kanwal Afreen, Aysha saddiqa and Rehana Javaid

ABSTRACT

Objective: To determine the rate of postoperative bleeding and blood transfusions in patient undergoing coronary artery bypass surgery for coronary artery disease during OPCAB or conventional CABG.

Study Design: Comparative cross-sectional study.

Place and Duration of Study: Adult Cardiac Surgery Departments of Armed Forces Institute of Cardiology and National Institute of Heart Disease (AFIC/NIHD) Rawalpindi, Pakistan from 1 July 2017 to 31 Dec 2017.

Material and Methods: Two hundred patients undergoing coronary artery bypass surgeries performed with (Conventional CABG) or without cardiopulmonary bypass. (Off pump CABG /OPCAB) were enrolled in the study and were divided into two equal groups. All procedures were elective. Careful monitoring was carried out on hourly basis. The rate of postoperative chest drainage and number of blood transfusions received were measured in both groups.

Results: As compared to the OPCAB group, the patients in CPB group required ion tropic support for a longer duration (29.6 +- 65.1 vs 60.9 +- 71.2, p-value <0.02). Similarly, the rate of chest drainage was significantly higher in conventional CABG Vs OPCAB (45% vs 30% p0.15 mmol/L. Institution of CPB was achieved by cannulating the ascending aorta and right atrium.

After cross-clamping, antegrade or retrograde blood cardioplegia was infused for myocardial protection of the arrested heart. Minimum systemic temperatures ranged from 28AdegC to 34AdegC. Perfusionist preference determined whether all or part of the cardiotomy blood was returned to the CPB circuit or collected in a cell-saving device for subsequent processing. After weaning from CPB, the residual blood in the extracorporeal circuit was salvaged and processed either through a cell-saving device or simply bagged before patient reinfusion. At least two chest drains were inserted in the pericardium and pleura if internal mammary arteries were harvested. These drains were connected to a low suction system (-20 cm H2O) after closure of the chest. Total chest drainage was recorded as the volume of blood in the collection receptacle from closure of the chest until removal of the chest drains.

Table-I: Clinical characteristics and demographics (CPB vs OPCAB).

Variables###CPB n=100###OPCAB n=100

AGE

(Mean +- SD)###57.5 +- 8.9###59.1 +- 7.2

Gender n(%)

Male###85 (84.2%)###76 (76%)

Female###16 (15.8%)###24 (24%)

BMI

(Mean +- SD)###27.0 +- 4.1###29.2 +- 5.4

NYHA Class

I###28 (28 %)###23 (23%)

II###29 (29%)###34 (34%)

III###43 (43 %)###43 (43%)

IV###NIL###NIL

Hypertension###54 (54 %)###52 (52%)

Diabetics###46 (46 %)###44 (44%)

Smoking

Ex-Smokers###21 (21 %)###25 (25%)

Current Smokers###11 (11%)###7 (7%)

Table-II: Angiographic data (CPB vs OPCAB).

Variable###CPB n=100###OPCAB n=100

Extent of Coronary artery disease

Single vessel###2 (2%)###5 (5%)

Double vessel###14 (14%)###20 (20%)

Triple vessel###84 (84%)###75 (75%)

Left Main stem disease >70%###17 (17%)###15 (15%)

Postoperative Care

Treatment of patients undergoing on-pump or off-pump coronary surgeries followed a standardized care from operation to discharge irrespective of the type of procedure performed.

Transfusion Protocol

For patients in both groups, the decision to transfuse homologous packed RBCs was based on the patient's clinical assessment like pulse, blood pressure, urine output and/or a haematocrit (Hct) level (<20%). Postoperatively, blood transfusions were given when hemoglobin level fell to 300 mL/h, or >200 mL/h for 2 hours despite correction of any coagulopathies. Re-operations were also indicated if there were clinical signs of cardiac tamponade such as tachycardia, increasing central venous pressures, or decreasing urine output, usually associated with a sudden reduction in chest tube drainage.

Data Collection and Statistical Analysis

Statistical analyses were performed using SPSS version 23 with two tailed tests performed and a p-value<0.05 was considered significant. Data are summarized as the mean +- SD for continuous variables and as frequency and percentages for categorical variables. The two groups (CPB or CABG vs OPCAB) were compared using the Chi-square or Fisher exact test for categorical data and unpaired t tests.

Table-III: Intra operative data (CPB vs OPCAB).

Variable###CPB n=100###OPCAB n=100###p-value

Ionotropic support

(in Hrs)###0.02

(Mean +- SD)###60.9 +- 71.2###29.6 +- 65.1

Chest Drain N (%)

Less than 800 ml###51 (51%)###70 (70%)###0.02

More than 800 mI###49 (49%)###30 (30%)

Blood###Transfusion

(RCC) Requirement###0.04

(Mean +- SD)###1.6 +- 1.6###1.0 +- 1.2

Ventilation Time

(in hrs)

(Mean +- SD)###12.9 +- 25.2 (6)###10.6 +- 23.4 (6)###0.07

Table-IV: Post-operative complication (CPB vs OPCAB).

Variable###CPB n=100###OPCAB n=100###p-value

Re-exploration###for

###12 (12%)###2 (2%)###0.02

bleeding N (%)

ICU Stay Time

(in hrs)

(Mean +- SD)###67.6 +- 74.0###51.0 +- 78.5###0.04

Mortality N (%)###6 (5.9%)###5 (5%)###0.93

RESULTS

Of the total 200 patients, 100 cases were included in each CABG or CPB group. Patients in both groups were similar in terms of demographic features, pre-operative characteristics, re-do operations and incidence of comorbid conditions. In OPCAB group, there were 76 males (76%) and 24 females (24%) with a mean age of 59.1 +- 7.2 years, whereas, in CPB group, there were 85 males (85%) and 16 females (16%), with a mean age of 57.5 +- 8.9 years. Fifty two patients (52%) had hypertension in OPCAB group, while 54 (54%) patients were hypertensive in the CPB group. In OPCAB group, 44 patients (44%) were known to be diabetic and the number was 46 (46%) in CPB group. 7 (7%) were smokers in OPCAB patients and there were 11 (11%) smokers in group-2. In OPCAB group, 23 patients (23%) had NYHA class I, 34 patients (34%) had NYHA class II, and 43 (43%) patients were having NYHA class III symptoms.

While in CABG group, 28 patients (28%) had NYHA class I, 29 patients (29%) had NYHA class II, and 43 (43%) cases were in NYHA class III (table-I). The patients in CPB group had tendency to have multi-vessel disease than those in OPCAB (off pump) group. In CPB group, there were 85 patients (85%) who had triple vessel disease vs 75 (75%) patients in OPCAB group, 20 patients (20%) had double vessel disease in OPCAB vs 14 patients (14%) in CPB; however, there were only 5 patients (5%) who had single vessel disease in OPCAB vs 2 patients (2%) in CPB group. In addition, the left main disease was almost same among the off pump group 15 (15%) and 17(17%) patients in group-1. Results are shown in table-II.

As compared to the OPCAB group, the patients in the CPB group required ionotropic support for a longer duration (29.6 +- 65.1 vs 60.9 +- 71.2, p-value<0.02). Similarly, the rate of postoperative chest drainage was significantly higher in CPB Vs OPCAB (49% vs 30% p<0.026). Requirement of blood transfusion product (RCC) was significantly higher in CPB group as compared to OPCAB patients (1.6 +- 1.6 vs 1.0 +- 1.2, p-value 0.04). Mechanical ventilation time was almost same in both groups with median value of 6 hours. Results are shown in table-III and figure.

There was significantly high incidence of early postoperative complications among patients in CPB compared to those in OPCAB as regards to incidence of complete revascularization (12% vs 2%, p<0.02). Similarly, hospital stay was higher in CPB group as compared to OPCAB group (67.6 +- 74.0 vs 51.0 +- 78.5 hours < p<0.04), respectively. Mortality in both groups was found to be statistically insignificant (5.9% vs 5%, p 5). Heart Lung Circ 2015; 24(12): 1216-24.

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17. Yousuf-ul-Islam M, Ahmed MU, Khan MS, Bawany FI, Khan A, Arshad MH et al. On Pump coronary artery bypass graft surgery versus Off pump coronary artery bypass graft surgery: A Review. Global J Health Sci 2014; 6(3): 186-93.

18. Rogers CA, Pike K, Campbell H, Reeves BC, Angelini GD, Gray A, et al. Coronary artery bypass grafting in high-Risk patients randomized to off-or on-Pump surgery: A randomized controlled trial (the CRISP trial). Health Technol Assess 2014; 18(44): 1-157.

19. Hlavicka J, Straka Z, Jelinek S, Budera P, Vanek T, Maly M, et al. Off-pump versus on-pump coronary artery bypass grafting surgery in high-risk patients: PRAGUE-6 trial at 30 days and 1 year. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2016; 160: 263-70.

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Publication:Pakistan Armed Forces Medical Journal
Date:Feb 28, 2018
Words:1705
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