Bleeding During Robotic CABG Leads to a Poor

Patient ExperienceRobert Poston, MD

Chair, Dept. of Cardiothoracic SurgerySt. Francis Medical Center

Bleeding and Transfusions after CABG• Periop transfusions• On-pump CABG 63%• OPCAB 50%• Robotic CABG 24-44%

NEJM 2012; 366: 1489-97

Therapeutic misconception

• Inaccurate website marketing• Orthopedics1

• TAVI2

• Robotic cardiac surgery3

• Suboptimal informed consent4

1. RS Labovitch, KJ Bozic, E Hansen. An evaluation of information available on the internet regarding minimally invasive hip arthroplasty. The Journal of Arthroplasty, 2006 2. Kincaid M, Neuman M Presentation on US Hospital Websites of Risks and Benefits of Transcatheter Aortic Valve Replacement Procedures. JAMA 20153. Poston, et al. Marketing of Low Volume Robotic Cardiac Surgery Programs via the Internet and Public Reporting Avenues. Abstract, ISMICS 20144. S Ryan, V Chirumamilla, RA Bello et al., How informed is “informed consent” for robotic cardiac surgery? Innovations 2009

Does bleeding and transfusion after r-CABG increase the risk of unmet expectations and dissatisfaction?

MethodsRobotic CABG – hemostat group

(n=62)

Robotic CABG – control group

(n=131)

Hemostatic into port sites routinely

Hemostatic into port sites as needed

Primary OUTCOMES:• 30 day clinical outcomes• Patient satisfaction

• HCAHPS score: Items #5-7; 22• Unmet expectations:

• Size of the incision• Speed of recovery

Methods: Patient satisfaction

PhysicianCommunication

Clinical outcomes

Outcome Hemostat group (n=62)

Control group (n=131)

p value

RBC transfusion

- % transfused 24.2% 40.8% 0.026

- Units received 0.44 U 1.39 U 0.024

Discharge Hct 32.4±5.7 27.2±6.5 0.001

Chest tube output (cc/24 hr) 529±112 cc 594±133 cc NS

Reoperation 3.2% 3.0% NS

Length of stay (d) 3.5±0.6 3.8±0.9 NS

Composite M&M (O/E) 0.81±0.12 0.95±0.14 NS

Satisfaction outcomes

Outcome Hemostat group (n=62)

Control group (n=131)

p value

HCAHPS survey

- Physician communication (percentile) 98% 85% 0.001

- Willing to recommend (% definitely yes) 91% 83% 0.02

Unmet expectations

- Size of the incisions 3 out of 58 respondents (5.2%)

7 out of 125 respondents (5.6%)

NS

- Recovery time 2* out of 58 respondents (3.4%)

17* out of 125 respondents (13.6%)

0.03

*18 out of 19 respondents with unmet expectations about recovery time received ≥1 U PRCs.

Baseline Port placement

Wound closureSurgeon at robotic console

Baseline

60% of baseline(severe stress)

HEART RATEVARIABILITY

SURGICAL STAGE

SURGEON HEART RATE VARIABILITY DURING ROBOTIC SURGERY

Abstract, SRS 2014

Baseline Port placement

Wound closureSurgeon at robotic console

on bypassmitral repair

LA closure

repair of bleeding

remove cardio-plegia cannula

Baseline

60% of baseline(severe stress)

HEART RATEVARIABILITY

SURGICAL STAGE

SURGEON HEART RATE VARIABILITY DURING ROBOTIC SURGERY

Abstract, SRS 2014

ConclusionBleeding and transfusion after r-CABG

Unmet expectations about recovery time

Dissatisfied patient

ConclusionBleeding and transfusion after r-CABG

Unmet expectations about recovery time

Dissatisfied patient

Topical hemostatics Manage expectations