Bleeding and Re-exploration After Cardiac Surgery

A unique constellation of preoperative and intraoperative factors place cardiac surgical patients at an increased risk of postoperative bleeding. A comprehensive strategy is required to minimize the morbidity and mortality associated with bleeding in cardiac surgery. Preoperative measures include correction of preexisting coagulopathies and ensuring platelet quantity and function whenever possible. Medical management of postoperative bleeding requires timely recognition of coagulopathies to allow for focused and directed treatment, potentially with transfusion of blood products, antifibrinolytics, or coagulation factor concentrates. The administration of blood products should be protocolized and evidence-based, given the well-recognized risks associated with inappropriate transfusion. A restrictive transfusion threshold should be employed for patients with asymptomatic anemia. Balanced transfusion with packed red blood cells, plasma, and platelets should be considered in patients with significant bleeding requiring a massive transfusion protocol. Surgical re-exploration should be considered when bleeding persists despite optimal medical management. While re-exploration is associated with increased risk of complications, it can potentially avoid the morbidity and long-term sequelae of multiple blood transfusions. A discrete source of bleeding is only identified in as few as 67% of patients who are re-explored. However, the use of fibrin sealants and other hemostatic agents can greatly improve the likelihood of successfully controlling bleeding.