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
- stop bleeding
- maintain blood pressure
- maintain blood volume
- 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 – Hypertension post-cardiac surgery
- CCC – Hypotension post-cardiac surgery
- CCC – Hypothermia post-cardiac surgery
- CCC – Hypoxaemia post-cardiac surgery
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a 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 three amazing children.
On Twitter, he is @precordialthump.
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