Bleeding at Removal of Nuss Bar: Rare But Sometimes Significant

Background: Hemorrhage during Nuss bar removal is an uncommon but feared complication that can be life threatening if not controlled rapidly. This study aims to identify the incidence and sources of large volume hemorrhage, discuss successful management strategies, and provide patient care recommendations. Methods: An IRB approved (#15-11-WC-0214), single institution retrospective chart review was performed on patients who underwent Nuss bar removal over a 15-year interval. Estimated blood loss (EBL), source of hemorrhage, management, and outcomes are reported. Results: One thousand six hundred twenty-eight Nuss bar removal procedures were reviewed. EBL >150mL occurred in 7 patients (0.43%), of whom 2 patients (0.12%) had EBL >2000mL. Bleeding sources included: lateral soft tissue, lateral ectopic calcium, medial ectopic calcification, and an intercostal vessel. Most bleeding could be controlled with pressure and electrocautery. Only 2 patients (0.12%) required transfusion. One of these had bleeding from an intercostal vessel, and the other bled from a large vein in the medial calcified substernal tract. No patients sustained heart injury or died. Conclusion: Large volume hemorrhage after Nuss bar removal is rare, but may require blood transfusion, thoracoscopic exploration, or open exploration through thoracotomy or sternotomy. Nuss bar removal should be performed in centers capable of these interventions. After bar removal, a chest X-ray and a period of postoperative observation up to 6 hours may be beneficial to detect occult hemorrhage.