Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost

Objective: Crash back on bypass (crash-BOB) is occasionally required in the resuscitation of patients developing life-threatening complications follow ing cardiac surgery. This study aims to determine the incidence, aetiology and cost-effectiveness of such intervention. Methods: Retrospective review of all crash-BOB patients over 5.5 years at one hospital. Results: The inci dence of crash-BOB was 0.8% and occurred at a mean of 7 h post-operatively (range 1 h-20 days). Pre-operative Parsonnet scores were similar to the ove rall population of patients undergoing surgery in our institution (mean sco re 10; range 0-45). The original cardiac operations were coronary revascula rization (39), valve surgery (12) and others (4). Indications for crash-BOB were cardiac arrest (23), bleeding (20), hypotension (7), ischaemia (Z) an d others (4). Of the 55 patients, 20 died on the operating table. Of the re maining 35, a further 12 died in hospital. Overall survival was therefore 4 2%. Where crash-BOB was for bleeding, 17 of 20 patients (85%) survived to l eave theatre, of whom 11 patients (55%) left hospital alive. In the 35 non- bleeders, only 18 (51%) survived crash-BOB and 12 (34%) left hospital alive . Sixteen patients required a second period of aortic cross-clamping of who m 13 (81%) survived to leave theatre, and 11 (69%) left hospital alive. Con versely, of nine patients in whom no specific diagnosis was found during cr ash-BOB, only two (22%) survived the procedure and none survived to hospita l discharge. Multiple logistic regression identified pre-operative Parsonne t score (P = 0.045) and the need for aortic cross-clamping to deal with an identified surgical problem (P = 0.03) as significant predictors of hospita l survival. Indication for crash-BOB (bleeder/non-bleeder) failed to reach significance (P = 0.08). Age, sex, intra-aortic balloon pump use at the pri mary procedure, and time following the primary procedure to crash-BOB were not identified as predictors of hospital survival. Of the 23 hospital survi vors, three patients suffered a stroke post-operatively and made a good fun ctional recovery prior to discharge. Two patients developed sternal wound d ehiscence requiring surgical rewiring. At followup (mean 3 years, range 1-6 years), 19 patients were in NYHA class I and four were in class II. Crash- BOB patients required an average of g extra intensive care days and 2 extra ward days. The total cost of these resources was pound 164 900 (including theatre time, cardiopulmonary bypass and intra-aortic balloon pump use). Th is was equivalent to pound 7170 per life saved. Conclusions: Crash-BOB occu rred in 0.8% of cases and was associated with a survival to discharge of 42 %, and a justifiable cost of only pound 7170 per life saved. Establishing a n accurate diagnosis for the cause of clinical deterioration resulting in c rash-BOB intervention was important, and the need for a further period of a ortic crossclamping did not preclude a favourable outcome. (C) 2000 Elsevie r Science B.V. All rights reserved.