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 – Hypertension post-cardiac surgery
• CCC – Hypotension post-cardiac surgery
• CCC – Hypothermia post-cardiac surgery
• CCC – Hypoxaemia post-cardiac surgery