Incidência de sangramento excessivo e preditores no pós-operatório imediato de cirurgia cardíaca
Arquivos
Data
2015-04-30
Autores
Lopes, Camila Takao 
Orientadores
Barros, Alba Lucia Bottura Leite de
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Sangramento excessivo, necessidade de transfusão de concentrado de hemácias (TCH) ou de reabordagem cirúrgica de emergência (RCE) por sangramento são complicações pós-operatórias de cirurgia cardíaca associadas a significativa morbimortalidade. Conhecer os preditores dessas complicações pode instrumentalizar os enfermeiros na priorização de vigilância para reconhecê-las precocemente ou diminuir sua ocorrência. Objetivos: Avaliar os preditores de sangramento excessivo, de TCH e de RCE por sangramento no pós-operatório imediato (POI) de cirurgia cardíaca. Método: Estudo de coorte prospectivo realizado em um hospital de referência em cardiologia. Incluíram-se adultos submetidos a correção cirúrgica de cardiopatias adquiridas via esternotomia mediana. Os desfechos sangramento excessivo, necessidade de TCH ou de RCE foram avaliados 24h após admissão na unidade de terapia intensiva (UTI) pós-operatória. As variáveis independentes investigadas incluíram fatores pré, intra e pós-operatórios identificados na literatura. As variáveis pré-operatórias foram coletadas até 24h antes da cirurgia; as variáveis intraoperatórias foram coletadas à admissão na UTI e as variáveis pós-operatórias foram coletadas 24h após admissão na UTI. A relação entre as variáveis independentes e os desfechos foi avaliada em análise univariada (Teste exato de Fisher para variáveis categóricas ou Mann-Whitney para contínuas). Variáveis com p?0,05 na análise univariada e outras clinicamente relevantes foram submetidas a análise múltipla por meio regressão logística, com p?0,05 considerado significativo. O odds ratio foi utilizado como medida de associação entre as variáveis independentes e os desfechos. Calculou-se a área sob a curva ROC como medida de acurácia da relação entre as variáveis independentes e os desfechos. Resultados: Incluíram-se 323 pacientes. Desses, 105 (32,5%) apresentaram sangramento excessivo. Na análise univariada, as variáveis significativamente associadas ao sangramento incluíram: Pré-operatórias: sexo masculino, hipertensão arterial, maior altura, porém menor índice de massa corpórea, menor contagem plaquetária e maior hematócrito. Na análise múltipla, os preditores independentes de sangramento excessivo incluíram sexo masculino, IMC<26,34 Kg/m2, contagem plaquetária<214,000/mm3, volume de heparina>6,25mL (acurácia=77,5%). Vinte (6,20%) pacientes receberam TCH. Na análise univariada, as variáveis significativamente associadas à TCH foram: Pré-operatórias: maior idade, menor peso e altura, menor contagem de plaquetas, menor nível de hemoglobina, maior prevalência de contagem plaquetária<150x103/mm3; Intraoperatórias: menor volume de protamina, maior duração da anestesia, maior prevalência de TCH; Pós-operatórias: menor temperatura axilar, maior frequência cardíaca e maior pressão positiva expiratória final (PEEP). Na análise múltipla, o preditor independente de TCH foi peso<66,5Kg (acurácia=68%). Dezoito (5,60%) pacientes foram submetidos a RCE, Na análise univariada, as variáveis significativamente associadas à RCE foram: Pré-operatória: menor contagem plaquetária; Intraoperatória: menor número de pontes na revascularização do miocárdio; Pós-operatória: menor temperatura axilar, infusão endovenosa de menor volume, maior PEEP e transfusão de hemocomponentes. Na análise múltipla, o preditor independente de RCE foi transfusão pós-operatória de hemocomponentes (acurácia=97,93%). As fontes de sangramento na RCE foram lesões aórticas pela canulação da CEC (n=6), ferida esternal (n=4), átrio direito (n=3), e ponte lesionada pelo dreno ou fio de aço (n=2). Em três casos, a fonte de sangramento não era visível. Conclusões: Identificaram-se preditores perioperatórios de sangramento excessivo, de TCH e de RCE no POI de cirurgia cardíaca.
Excessive bleeding, requirement for red blood cell transfusion (RBCT) or emergency bleeding-related re-exploration (BLR) are postoperative cardiac surgery complications associated with significant morbidity and mortality. Awareness of the predictors of these complications can support nurses on surveillance prioritizing for early recognition or reduction. Objective: To evaluate the predictors of excessive bleeding, RBCT and BLR in the immediate postoperative period of cardiac surgery. Method: A prospective cohort study was performed in a Cardiology-specialized hospital. Adults undergoing surgical correction of acquired cardiac disease via median sternotomy were included. The outcomes, excessive bleeding RBCT and BLR were assessed 24 hours after admission to the postoperative intensive care unit (ICU). The independent variables investigated were pre-, intra- and postoperative factors identified in the literature. The preoperative variables were collected up to 24 hours before surgery; intraoperative variables were collected at the moment of ICU admission and postoperative variables were collected 24 hours after ICU admission. The relation between the independent variables and the outcome was assessed by means of an univariate analysis (either Fisher's exact test for categorical variables or Mann-Whitney test for continuous variables). Variables with a p? 0.05 in the univariate analysis and other clinically relevant variables were submitted to a multivariate logistic regression, with p?0.05 considered significant. The odds ratio was used as a measure of association between the independent variables and outcomes. The area under the ROC curve was calculated as a measure of accuracy of the relations between the independent variables and outcomes. Results: 323 patients were included. Of these, 105 (32.5%) had excessive bleeding. In the univariate analysis, the variables significantly associated with bleeding included: Pre-operative: male gender, hypertension, greater height, but lower body mass index, lower platelet count and higher hematocrit. In the multivariate analysis, the independent predictors of excessive bleeding included male gender, BMI<26.34Kg/m2, platelet count<214,000/mm3, heparin volume>6,25mL (accuracy =77.5%). Twenty (6.20%) patients received RBCT. In the univariate analysis, the variables significantly associated with RBCT were: Pre- operative: older age, lower weight and height, lower platelet count, lower hemoglobin level, higher prevalence of platelet count <150x103/mm3; Intraoperative: smaller protamine volume, longer duration of anesthesia, higher prevalence of RBCT; Postoperative: lower axillary temperature, higher heart rate and higher positive end-expiratory pressure (PEEP). In the multivariate analysis, the independent predictor of RBCT was weight<66,5Kg (accuracy=68%). Eighteen (5.60%) patients underwent BLR. In the univariate analysis, the variables significantly associated with BLR were: Preoperative: lower platelet count; Intraoperative: fewer bypasses in coronary artery bypass grafting; Postoperative: lower axillary temperature, intravenous infusion of lower volume, higher PEEP and transfusion of blood products. In the multivariate analysis, the independent predictor of BLR were postoperative transfusion of blood components (accuracy=97.93%). The bleeding sources found during BLR were aortic lesions by CPB cannulation (n=6), sternal wound (n=4), right atrium (n=3), and injured bypass by either the drain or the steel wire (n=2). In three cases, the source of bleeding was not visible. Conclusions: Perioperative predictors of excessive bleeding, RBCT and BLR were identified in the immediate postoperative period of cardiac surgery.
Excessive bleeding, requirement for red blood cell transfusion (RBCT) or emergency bleeding-related re-exploration (BLR) are postoperative cardiac surgery complications associated with significant morbidity and mortality. Awareness of the predictors of these complications can support nurses on surveillance prioritizing for early recognition or reduction. Objective: To evaluate the predictors of excessive bleeding, RBCT and BLR in the immediate postoperative period of cardiac surgery. Method: A prospective cohort study was performed in a Cardiology-specialized hospital. Adults undergoing surgical correction of acquired cardiac disease via median sternotomy were included. The outcomes, excessive bleeding RBCT and BLR were assessed 24 hours after admission to the postoperative intensive care unit (ICU). The independent variables investigated were pre-, intra- and postoperative factors identified in the literature. The preoperative variables were collected up to 24 hours before surgery; intraoperative variables were collected at the moment of ICU admission and postoperative variables were collected 24 hours after ICU admission. The relation between the independent variables and the outcome was assessed by means of an univariate analysis (either Fisher's exact test for categorical variables or Mann-Whitney test for continuous variables). Variables with a p? 0.05 in the univariate analysis and other clinically relevant variables were submitted to a multivariate logistic regression, with p?0.05 considered significant. The odds ratio was used as a measure of association between the independent variables and outcomes. The area under the ROC curve was calculated as a measure of accuracy of the relations between the independent variables and outcomes. Results: 323 patients were included. Of these, 105 (32.5%) had excessive bleeding. In the univariate analysis, the variables significantly associated with bleeding included: Pre-operative: male gender, hypertension, greater height, but lower body mass index, lower platelet count and higher hematocrit. In the multivariate analysis, the independent predictors of excessive bleeding included male gender, BMI<26.34Kg/m2, platelet count<214,000/mm3, heparin volume>6,25mL (accuracy =77.5%). Twenty (6.20%) patients received RBCT. In the univariate analysis, the variables significantly associated with RBCT were: Pre- operative: older age, lower weight and height, lower platelet count, lower hemoglobin level, higher prevalence of platelet count <150x103/mm3; Intraoperative: smaller protamine volume, longer duration of anesthesia, higher prevalence of RBCT; Postoperative: lower axillary temperature, higher heart rate and higher positive end-expiratory pressure (PEEP). In the multivariate analysis, the independent predictor of RBCT was weight<66,5Kg (accuracy=68%). Eighteen (5.60%) patients underwent BLR. In the univariate analysis, the variables significantly associated with BLR were: Preoperative: lower platelet count; Intraoperative: fewer bypasses in coronary artery bypass grafting; Postoperative: lower axillary temperature, intravenous infusion of lower volume, higher PEEP and transfusion of blood products. In the multivariate analysis, the independent predictor of BLR were postoperative transfusion of blood components (accuracy=97.93%). The bleeding sources found during BLR were aortic lesions by CPB cannulation (n=6), sternal wound (n=4), right atrium (n=3), and injured bypass by either the drain or the steel wire (n=2). In three cases, the source of bleeding was not visible. Conclusions: Perioperative predictors of excessive bleeding, RBCT and BLR were identified in the immediate postoperative period of cardiac surgery.
Descrição
Citação
LOPES, Camila Takao. Incidência de sangramento excessivo e preditores no pós-operatório imediato de cirurgia cardíaca. 2015. 172 f. Tese (Doutorado em Enfermagem) - Escola Paulista de Enfermagem, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2015.