Haemorrhage Post Cardiac Surgery

OVERVIEW

  • common
  • mild/moderate -> medically managed
  • severe -> re-exploration thus requires close liaison with surgeon
  • complications: hypovolaemia, anaemia, pericardial tamponade

GOALS

  1. stop bleeding
  2. maintain blood pressure
  3. maintain blood volume
  4. maintain blood constituents

SPECIFIC CAUSES + MANAGEMENT

Surgical Bleeding – graft site, bone, skin, soft tissue

  • optimise coagulation (TEG, lab)
  • replace volume (isotonic fluid, blood products)
  • involve surgeon early

Anticoagulation Pre-OT

  • aspirin, heparin, LMWH, clopidogrel, warfarin, pre-existing coagulopathy
  • obtain history + drug history
  • correct coagulopathy
  • DDAVP may be helpful

Anticoagulation in OT

  • heparin effect, rebound or overdose of protamine
  • history from anaesthetist
  • review TEG
  • small aliquots of protamine (25mg)

Platelet dysfunction post CPB

  • activation of coagulation by contact with foreign surface, trauma bypass, fibrinolysis
  • replace platelets
  • DDAVP may be helpful

Consumption of clotting factors/loss due to bleeding

  • replace according to TEG/lab work
  • replace fluid

Hypothermia/Acidosis

  • active warming
  • FAW
  • fluid warmer
  • correct acidosis

CCDHB Post Cardiac Surgical Bleeding Protocol

  • decide whether there is significant bleeding or high risk procedure

Significant bleeding =

> 150mL in 1st 30 minutes
> 250mL in 1st hour (call surgeon and intensivist)
> 150mL in 2nd hour
> 100mL in subsequent hours

High risk procedure:

  • aortic root replacement
  • aortic arch surgery
  • bilateral mammary harvest
  • MVR + CABG
  • double valve
  • re-do surgery

TEG

  • R > 10min
    – 11-14 -> 1U FFP
    – 14-20 -> 2U FFP
    – >20 -> 4U FFP
  • if difference between K TEG and KH TEG is >3 minutes then give 0.5mg/kg of protamine
  • MA < 49mm
    – < 41 -> 2 PLT
    – 41-49 -> 1 PLAT
  • Alpha angle < 45 degrees
    – 1U of Cyro for every 30kg of body weight

Laboratory results

  • Hb
    – transfusion threshold 80g/L
  • INR > 1.5
    – 1.5-2.0 -> 2U FFP
    – > 2.0 -> 4U FFP
  • Fibrinogen < 1.5
    – 1U Cryo for every 30kg of body weight
  • Platelets: give 2U if
    – bleeding and haven’t been given platelets yet!
    – < 50 – aspirin within 5 days
    – clopidogrel within 5 days

If NOT Significant Bleeding Or Not High Risk Procedure

  • don’t worry about TEG
  • RBC transfusion threshold = 70g/L
  • INR > 2.0 -> 2U FFP
  • fibrinogen < 1.0 -> 1U Cryo per 30kg of body weight
  • no platelets indicated

References and Links

LITFL


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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