title: Attributable harm of severe bleeding after cardiac surgery in hemodynamically stable patients.
abstract: BACKGROUND
  We sought to quantify the effect of severe postoperative bleeding in hemodynamically stable patients following cardiac surgery.
  
  
  METHODS
  We reviewed the charts of all cardiac surgery patients operated on at our institution between 2010 and 2014. After excluding patients with tamponade or MAP <60, we propensity matched patients having chest tube output >300 mL in the first postoperative hour, >200 mL in the second, and >100 mL in the third ("bleeding" group) with patients having <50 mL/h of chest tube output ("dry" group). The primary outcome was a composite of morbidity or mortality (excluding reexploration).
  
  
  RESULTS
  5016 patients were operated on between 2010 and 2014; of these, we included the records of 84 bleeding and 498 dry patients. Propensity matching resulted in 68 pairs of patients well-matched on baseline and operative variables. As compared to matched dry patients, bleeding patients were more likely to experience the primary outcome of any morbidity/mortality (36.8 vs. 13.2 %, p = 0.002), as well as ventilation >24 h (33.8 vs. 7.4 %, p < 0.001) and 30-day mortality (11.8 vs. 1.5 %, p = 0.02). Of the 84 bleeding patients, 46 underwent reexploration for bleeding within 24 h of surgery. A subgroup analysis propensity matching bleeding patients who were or were not reexplored <24 h demonstrated similarly poor outcomes in each group (primary outcome, 44.7 % reexplored vs. 50.0 % non-reexplored, p = 0.65), though reexplored patients were far less likely to require hematoma evacuation/washout >24 h after surgery (0 vs. 18.4 %, p = 0.005).
  
  
  CONCLUSIONS
  Even among hemodynamically stable patients, severe bleeding is associated with markedly worse outcomes following cardiac surgery.
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: J Trent
authors.initials: JT
authors.lastname: Magruder
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: Stephen
authors.initials: S
authors.lastname: Belmustakov
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: Rika
authors.initials: R
authors.lastname: Ohkuma
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Collica
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: Joshua C
authors.initials: JC
authors.lastname: Grimm
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: Todd
authors.initials: T
authors.lastname: Crawford
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
authors.forename: William A
authors.initials: WA
authors.lastname: Baumgartner
authors.affiliation: Department of Cardiac Surgery, School of Medicine, Vanderbilt University, Nashville, TN, USA.
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.affiliation: Division of Cardiac Surgery, School of Medicine, Johns Hopkins University, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA. gwhitman@jhmi.edu.
authors.forename: Glenn R
authors.identifier: http://orcid.org/0000-0001-6895-7659
authors.initials: GR
authors.lastname: Whitman
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000453:epidemiology*; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
keywords: Anemia; Bleeding; Cardiac surgery; Postoperative hemorrhage; Transfusion