Newly Published
Perioperative Medicine  |   March 2018
Comparison of Two Major Perioperative Bleeding Scores for Cardiac Surgery Trials: Universal Definition of Perioperative Bleeding in Cardiac Surgery and European Coronary Artery Bypass Grafting Bleeding Severity Grade
Author Notes
  • From the Department of Anesthesia and the Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada (J.B., D.N.W., K.K.); the Department of Anesthesia and Pain Management and the Peter Munk Cardiac Centre (D.N.W., K.K.) and the Toronto General Research Institute (K.K.), Toronto General Hospital, University Health Network, Toronto, Ontario, Canada; and the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Ontario, Canada (D.N.W.)., *Members of the Transfusion Avoidance in Cardiac Surgery Study Investigators are listed in the appendix.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Submitted for publication June 14, 2017. Accepted for publication February 12, 2018.
    Submitted for publication June 14, 2017. Accepted for publication February 12, 2018.×
  • Acknowledgments: The authors thank the Transfusion Avoidance in Cardiac Surgery Investigators for access to the study data.
    Acknowledgments: The authors thank the Transfusion Avoidance in Cardiac Surgery Investigators for access to the study data.×
  • *Members of the Transfusion Avoidance in Cardiac Surgery Study Investigators are listed in the appendix.
    Members of the Transfusion Avoidance in Cardiac Surgery Study Investigators are listed in the appendix.×
  • Research Support: There are no sources of funding to declare for this substudy. The original Transfusion Avoidance in Cardiac Surgery Study was funded by a grant from the Canadian Institutes of Health Research and by unrestricted grants from Octapharma Canada Inc. (Toronto, Ontario, Canada) and Baxter Corp. (Mississauga, Ontario, Canada). In-kind financial support was provided by Tem International GmbH (Munich, Germany) and Helena Laboratories (Beaumont, Texas). The funders did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. Drs. Karkouti and Wijeysundera are supported in part by merit awards from the Department of Anesthesia, University of Toronto. Dr. Wijeysundera is supported in part by the New Investigator Award from the Canadian Institutes of Health Research. Dr. Scales was supported by a Fellowship in Translational Research from Physicians’ Services Incorporated Foundation.
    Research Support: There are no sources of funding to declare for this substudy. The original Transfusion Avoidance in Cardiac Surgery Study was funded by a grant from the Canadian Institutes of Health Research and by unrestricted grants from Octapharma Canada Inc. (Toronto, Ontario, Canada) and Baxter Corp. (Mississauga, Ontario, Canada). In-kind financial support was provided by Tem International GmbH (Munich, Germany) and Helena Laboratories (Beaumont, Texas). The funders did not have a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. Drs. Karkouti and Wijeysundera are supported in part by merit awards from the Department of Anesthesia, University of Toronto. Dr. Wijeysundera is supported in part by the New Investigator Award from the Canadian Institutes of Health Research. Dr. Scales was supported by a Fellowship in Translational Research from Physicians’ Services Incorporated Foundation.×
  • Competing Interests: The authors declare no competing interests.
    Competing Interests: The authors declare no competing interests.×
  • Correspondence: Address correspondence to Dr. Karkouti: Toronto General Hospital, 200 Elizabeth Street, 3EN, Toronto, Ontario M5G 2C4, Canada. keyvan.karkouti@uhn.ca. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Cardiovascular Anesthesia / Coagulation and Transfusion
Perioperative Medicine   |   March 2018
Comparison of Two Major Perioperative Bleeding Scores for Cardiac Surgery Trials: Universal Definition of Perioperative Bleeding in Cardiac Surgery and European Coronary Artery Bypass Grafting Bleeding Severity Grade
Anesthesiology Newly Published on March 14, 2018. doi:10.1097/ALN.0000000000002179
Anesthesiology Newly Published on March 14, 2018. doi:10.1097/ALN.0000000000002179
Abstract

Background: Research into major bleeding during cardiac surgery is challenging due to variability in how it is scored. Two consensus-based clinical scores for major bleeding: the Universal definition of perioperative bleeding and the European Coronary Artery Bypass Graft (E-CABG) bleeding severity grade, were compared in this substudy of the Transfusion Avoidance in Cardiac Surgery (TACS) trial.

Methods: As part of TACS, 7,402 patients underwent cardiac surgery at 12 hospitals from 2014 to 2015. We examined content validity by comparing scored items, construct validity by examining associations with redo and complex procedures, and criterion validity by examining 28-day in-hospital mortality risk across bleeding severity categories. Hierarchical logistic regression models were constructed that incorporated important predictors and categories of bleeding.

Results: E-CABG and Universal scores were correlated (Spearman ρ = 0.78, P < 0.0001), but E-CABG classified 910 (12.4%) patients as having more severe bleeding, whereas the Universal score classified 1,729 (23.8%) as more severe. Higher E-CABG and Universal scores were observed in redo and complex procedures. Increasing E-CABG and Universal scores were associated with increased mortality in unadjusted and adjusted analyses. Regression model discrimination based on predictors of perioperative mortality increased with additional inclusion of the Universal score (c-statistic increase from 0.83 to 0.91) or E-CABG (c-statistic increase from 0.83 to 0.92). When other major postoperative complications were added to these models, the association between Universal or E-CABG bleeding with mortality remained.

Conclusions: Although each offers different advantages, both the Universal score and E-CABG performed well in the validity assessments, supporting their use as outcome measures in clinical trials.