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Ann Thorac Surg 2006;81:191-194
© 2006 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Chest Reexploration in the Intensive Care Unit After Cardiac Surgery: A Safe Alternative to Returning to the Operating Theater

Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Manchester, United Kingdom

Accepted for publication June 8, 2005.

^_* Address correspondence to Dr Charalambous, F204, 159 Hathersage Rd, Manchester M13 0HX, UK (Email: bcharalambos{at}hotmail.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: The aim of this study was to determine the outcome of patients who had chest reexploration in the intensive care unit (ICU) for bleeding or cardiovascular instability after heart surgery.

METHODS: This was a retrospective analysis of medical records of patients who had a chest reexploration in the ICU for bleeding or possible cardiac tamponade over a 9-year period (1991 to 2000), at the Cardiothoracic Centre of Manchester Royal Infirmary, England.

RESULTS: Between 1991 and 2000, 240 patients (3.4% of the total heart operations) who fitted the above criteria were identified. Two hundred and seven (86%) were reexplored for bleeding, 22 (9%) for possible tamponade, and 11 (5%) for both. Ninety-five percent were reexplored within 24 hours (median, 5 to 6 hours). Two hundred and twenty-six patients were found to have bleeding on reexploration. Of these, 125 (55%) were found to have focal bleeding, 74 (33%) diffuse bleeding, and 11 (5%) both. Two hundred and twelve (88%) had their chest closed, 25 (12%) packed, and 13 (10%) had further chest openings while in ICU. Sixteen (6.7%) of the patients died. Seven (2.9%) had sternal wound infection. For the survivors, ICU stay ranged from 1 to 60 days (median, 1) and their hospital stay ranged from 2 to 90 days (median, 8).

CONCLUSIONS: Chest reexploration in ICU for bleeding or tamponade after heart surgery can be a safe alternative to return to the operating theater.

	Introduction

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As many as 5% of patients undergoing open-heart surgery may have chest reexploration in the immediate postoperative period [1–3]. The main indications for this are bleeding, hemodynamic instability (clinical suspicion of cardiac tamponade) or cardiac arrest. Cardiac arrest patients are reexplored immediately in the intensive care unit (ICU) or in the ward where the arrest occurs. However, patients who present with bleeding or possible tamponade have traditionally been returned to the operating theater and reexplored, as often time allows for this.

During the last 9 years in our institution, patients have mainly been reexplored for bleeding or hemodynamic instability in the ICU rather than being returned to theater. Such a policy could, in theory at least, allow a more immediate reexploration and save theater costs and time. However, as ICU does not provide a sterile environment, reexplorations there might confer greater morbidity and mortality. The data in the literature supporting or disputing the safety of chest reexploration in ICU are limited. The aim of this study was to determine the outcome of patients undergoing chest reexploration in ICU for bleeding or hemodynamic instability after heart surgery.

	Patients and Methods

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Between April 1991 and April 2000, 6,890 open-heart operations were performed at the Cardiac Surgical Centre of the Manchester Royal Infirmary, England. Two hundred and forty of these patients (3.4% of the total heart operations) were reexplored in the ICU for bleeding or hemodynamic instability (clinical suspicion of cardiac tamponade). They included only first-time reexplorations. Patients who were explored for cardiac arrest were excluded, but these formed only a small minority of the total number of reexplorations. The medical records of these patients were retrospectively reviewed by one of the authors. Demographic data, operation characteristics, indication for reexploration, timing and findings of the reexploration, and patient outcomes were recorded.

The technique used for reexploration in our ICU is standardized. General theater routine is followed except the patient remains in the ICU bed with all the monitoring equipment attached. The surgical technique is identical to that in theater. Our ICU is a single room with patients' beds next to each other. Curtains can be drawn to isolate individual bed spaces. The reexploration was done without transferring the patients anywhere else. The reexploration team consisted of the surgeon and a theater nurse and on occasions a surgeon's assistant, all of whom were scrubbed and dressed in sterile gowns, masks, and theater hats. The operating site was prepared with povidone-iodine solution and sterile drapes were used to isolate the operating field.

The procedure was done under general anesthetic performed by the duty anesthetist who was present throughout the procedure. The soft tissues and the sternal edges are inspected for any bleeding points. Any clots within the chest cavity are evacuated and systematic inspection of all operative sites is undertaken. Bleeding sites are controlled by sutures, stainless-steel clips, electrodiathermy, or application of thrombostatic material as required. The drainage tubes are cleared of any clotted blood. Provided hemostasis has been achieved, the wound is closed in the standard manner. Stainless steel wire is used to close the sternum while the subcutaneous tissues and skin are closed with absorbable suture material. For cases in which there is continuous diffuse bleeding that cannot be controlled surgically, the chest is packed with swaps, the sternum is left open, and only the skin is closed. Such patients have their packing removed once they are stable by further reexploration in the ICU.

The decision to reexplore the patient is normally undertaken by the consultant cardiac surgeon who performed the primary heart operation and is performed either by the same consultant or by the senior trainee who is on-duty during that time. Theater nursing personnel and ICU personnel trained in basic theater technique assist in the reexplorations. Reexplorations in ICU are not restricted to any particular bed or area. Traffic in ICU is not restricted during reexplorations. Antibiotic treatment consisted of flucloxacillin or other equivalent intravenous antibiotics, but the duration varied according to the consultant's decision and patients' comorbid conditions.

With regard to the criteria used for reexploration, these were not preset and were a combination of the amount of drainage as well as the hemodynamic status of the patient and always relied on the decision of the consultant in charge of the patient care. We believe that clinical judgement rather than strict criteria should be used in the management of these patients.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Two hundred and forty cardiac first-time reexplorations in the ICU were identified between April 1991 and April 2000. This was equivalent to 3.5% of the total cardiac open-heart operations performed during this time. The distribution of the rates of reexploration during this period is shown in Figure 1. One hundred and ninety-one (80%) of patients were male and 49 (20%) were females. The patients' ages ranged from 19 to 84 years (median, 62). One hundred and ninety (79%) of the original operations were done electively, 43 (18.5%) were done urgently (within the same admission for uncontrolled cardiac symptoms), and 7 (3%) as emergency (within 24 hours of hospital admission with cardiac symptoms). The characteristics of the heart operations are shown in Table 1. Two hundred and seven (86%) were reexplored for bleeding, 22 (9%) because there was a clinical suspicion of cardiac tamponade, and 11 (5%) for a combination of both. The amount of blood drained from the chest drains from initial chest closure to reexploration ranged from 120 to 2,925 mL (median, 980 mL). Sixty-one percent of the patients reexplored had blood transfusion before reopening; this ranged from 1 to 8 units (median, 2 units). Ninety patients (63%) had fresh frozen plasma, 93 (84%) had platelets, 20 (11%) had protamine, and 24 (14%) approtinin, in order to correct coagulation abnormalities before reexploration. The use of blood products was based on platelet count, clotting times, and the patients' overall clinical picture rather than a preset protocol. Seventy-one percent of the patients had inotrope support before reopening. Two hundred and twenty reexplorations were carried out within 24 hours of the primary operation whereas 5 were carried out after more than 24 hours. In 7 cases there was no recorded data for the exact time of the operation. The distribution of the timing of reexploration for those performed within 24 hours is shown in Figure 2.

View larger version (32K): [in this window] [in a new window]   Fig 1. Reexplorations (percent of total open-heart operations) for bleeding and cardiac tamponade in yearly intervals.

View larger version (27K): [in this window] [in a new window]   Fig 2. Distribution of reexplorations performed within 24 hours of primary operation. (post-op = postoperative).

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Chest reexploration after open-heart surgery has traditionally been performed in the operating theater unless this has to be done immediately, as in cases of cardiac arrest. Returning patients to theater delays reexploration, carries high economic costs, and imposes a great demand on emergency theater time. In our institution we have been reexploring patients for bleeding and possible cardiac tamponade in the ICU. However, the safety of such a policy has not been previously extensively evaluated. Thus the current study was performed in order to determine whether the outcome of patients undergoing reexploration in the ICU was acceptable.

Over a 9-year period, 3.4% of our patients undergoing cardiac surgery were reexplored for bleeding or suspicion of cardiac tamponade. This is equivalent to that reported previously by others [1–3].

Sternal wound infections develop in 1% to 5% of patients undergoing heart operations [4–9]. Postoperative hemorrhage, lengthy operations, long cardiopulmonary bypass times, lengthy hospital stay before operation, internal mammary artery harvesting, immunocompromised states, and diabetes mellitus are considered as predisposing factors. Early postoperative reexploration has been listed as a predisposing factor in some reports [4–6], but its statistical significance has not been proven [10, 11]. The main worry in relation to reexploration in the ICU is the fear of sternal wound infections. However, our 2.9% observed rate is comparable to that reported for reexplorations in theater [3, 12]. That is not surprising, however, as the same aseptic techniques as the ones in theater in terms of preparation of the operative field, the equipment used, and the clothing of the personnel are employed. Furthermore, only consultant surgeons or senior trainees carried out the reexploration, always with the assistance of theater trained nursing staff. The main difference between theater and ICU environment is that the former is in theory maintained cleaner by the use of positive pressure ventilation systems, laminar air flow, and the restriction of entry only to theater-dressed personnel.

Our mortality rates and other postoperative complications are also comparable with that reported previously for reexplorations in theater [3, 12]. Although morbidity and mortality in our reexplored patients are higher than those in uncomplicated cardiac surgery, that would be most likely attributed to the hemodynamic consequences of excessive bleeding or cardiac tamponade rather than to the reexploration itself.

Kaiser and colleagues [13] and McKowen and associates [14] looked at 49 and 64 primary reexplorations, respectively, in the ICU. The former reported a zero incidence of sternal wound infections and 10 deaths, whereas the latter reported 2 sternal wound infections (3.1%) and 34 deaths. Their low incidence of sternal wound infections is in accord with our observations and is reassuring. Their relatively higher mortality rates can be attributed to the inclusion of cardiac arrest patients in their studies.

In conclusion, our study has documented that reexploration in ICU for patients with bleeding or possible cardiac tamponade after open cardiac surgery is a safe alternative to return to the operating theater. Our study is the largest to date to explore this issue and the first one outside North America.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We acknowledge the Cardiothoracic Surgeons at the Manchester Royal Infirmary for their permission to include their patients in this study.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Charalambous, C. P. Articles by Keenan, D. J. Search for Related Content PubMed PubMed Citation Articles by Charalambous, C. P. Articles by Keenan, D. J. Related Collections Cardiac - other