Universal definition of perioperative bleeding in adult cardiac surgery.

Dyke C, Aronson S, Dietrich W, et al.
J Thorac Cardiovasc Surg 2013; Dec 9 [Epub ahead of print].
NATA Rating :
Review by : D. Faraoni
NATA Review

In this article, an international group of experts in perioperative transfusion and hemostasis (The multidisciplinary International Initiative on Haemostasis Management in Cardiac Surgery) published a multivariable definition of perioperative bleeding. This universal definition of perioperative bleeding (UDPB) represents the consensus opinion of this group, and includes 9 parameters: delayed sternal closure (Yes/No), postoperative chest tube output measured within the first 12 postoperative hours after chest closure (ml), allogeneic blood products transfusion (number of RBCs, FFP, and PLT units), the use of cryoprecipitate (Yes/No), factor concentrates (Yes/No), administration of recombinant factor VIIa (Yes/No), and surgical re-exploration (Yes/No). Using these 9 parameters, the authors defined 5 perioperative bleeding classes: insignificant, mild, moderate, severe, and massive.

The UDPB was tested in a retrospective analysis including 1144 patients who underwent cardiac surgery with cardiopulmonary bypass at a single institution. The authors reported that the 9 items were successful in adjudicating patients to the perioperative bleeding classes. After univariate and multivariate analyses, factors independently associated with the determinants of UDPB were EuroSCORE, preoperative hematocrit, and cardiopulmonary bypass duration. When the 30-day mortality was explored in each bleeding class, the authors reported that higher classification within the UDPB correlated with higher mortality.

Definition of abnormal and excessive bleeding remains a challenge because no consensus exists in the literature. The lack of a universal definition results from the huge heterogeneity in practices between centers with regard to patient management, transfusion policy, and surgical skills. This definition cannot be considered as universal. Indeed, cryoprecipitates are not available in most European countries, and prothrombin complex concentrates and recombinant factor VIIa are not used in most centers. Finally, we need tools that allow early detection of abnormal bleeding. Using the definition proposed by the authors, a patient’s classification is only allowed after 12  hours postoperatively. This definition may probably be used in studies, but not in daily practice to guide patient management.

– David Faraoni