This document discusses guidelines for transfusion therapy and management of postoperative bleeding in cardiac surgery patients. It provides an overview of factors that can influence bleeding, complications of blood transfusions, and tests to assess coagulation status. The document outlines guidelines for transfusion of blood products like platelets, plasma, cryoprecipitate based on results of coagulation tests or thromboelastography. It also provides guidelines for surgical re-exploration based on chest tube output. Management of massive bleeding and tamponade is discussed.

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By- Dr. Arm
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By- Dr. Arm
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2. POSTOPERATIVE BLEEDING AND
GUIDELINES FOR TRANSFUSION
Postoperative blood loss depends on:
•Preoperative anticoagulant or antiplatelet therapy
•Acquired coagulopathy (liver dysfunction, renal failure)
•Von Willebrand disease (inherited, acquired)
•Type of operation
•Duration of CPBP
•Postoperative factors
.

3. MORBIDITY AND MORTALITY ASSOCIATED WITH
REOPERATION FOR BLEEDING IN MATCHED PATIENTS
Risk Factors for Reoperation:
•smaller body size
•higher acuity
•longer cardiopulmonary bypass time
•operations other than isolated CABG
and isolated mitral valve repair

4. MORBIDITY AND MORTALITY ASSOCIATED WITH
REOPERATION FOR BLEEDING IN MATCHED PATIENTS
Probability of major morbidity associated with blood
use with and without reoperation for bleeding:

5. MORBIDITY AND MORTALITY ASSOCIATED WITH
REOPERATION FOR BLEEDING IN MATCHED PATIENTS
Mortality associated with blood use
with and without reoperation for bleeding:
No blood Tx / No Reop 0.1%
Blood Tx / No Reop 2.1%
No blood Tx / Reop 6.6%
Blood Tx / Reop 8.7%
.

6. MORBIDITY AND MORTALITY ASSOCIATED
WITH BLOOD TRANSFUSIONS
Adverse effects of blood transfusions:
•Transfusion transmitted diseases
•Increase the risk of postoperative infection
and mortality following cardiac surgery
•Blood transfusions have immunomodulating effects:
may increase the risk of nosocomial infections
transfusion-associated graft-versus-host
disease
transfusion-related lung injury (TRALI)
.

7. MORBIDITY AND MORTALITY ASSOCIATED
WITH BLOOD TRANSFUSIONS
Complications of blood component therapy:
•Immune-mediated hemolytic transfusion reactions:
acute or subacute hemolysis
•Immune-mediated non-hemolytic reactions:
fever, rigors, rash, TRALI, GVHD
•Non-immune-mediated adverse effects:
volume overload, infection
•Metabolic sequelae:
hypothermia, ↑ K, ↓ Ca, lactic acidosis
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;30:437-460.

8. GUIDELINES FOR TRANSFUSION IN
CRITICALLY ILL PATIENTS
Mean pre-transfusion hemoglobins:
Corwin HL, et al: The CRIT Study: Anemia and blood transfusion in the critically ill. Current clinical practice in
the United States. Crit Care Med 2004; 32:39-52.

9. GUIDELINES FOR TRANSFUSION IN
CRITICALLY ILL PATIENTS
Mortality by transfusion status :

10. MORBIDITY AND MORTALITY ASSOCIATED
WITH BLOOD TRANSFUSIONS
Survival of ICU patients who received blood
transfusions:

11. MORBIDITY AND MORTALITY ASSOCIATED
WITH BLOOD TRANSFUSIONS
Survival of patients with ischemic heart disease
who received blood transfusions:
Hebert PC, et al: Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?
Crit Care Med 2001;29:227-234.

12. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
If significant bleeding is observed
in post-operative cardiac surgery patients:
•Obtain/repeat complete coagulation panel (& TEG)
•Assure patency of chest tubes
•Keep patient intubated & sedated
•Keep MAP 60-75 mmHg
•PEEP 8-10 cm
•Avoid hypothermia
•Transfuse PRC and blood components
Sniecinski RM, Levy JH: Bleeding and management of coagulopathy. J Thorac Cardiovasc Surg
2011;142:662-667.

13. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Coagulation tests:
•Platelet count
•ACT, aPTT, PT/INR
•Fibrinogen level / Thrombin clotting time
•D-Dimer & FDP
•PFA-100 / HemoSTATUS
•Thromboelastography
Sniecinski RM, Levy JH: Bleeding and management of coagulopathy. J Thorac Cardiovasc Surg
2011;142:662-667.

14. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
.

15. THROMBOELASTOGRAPHY AND
THROMBOELASTOMETRY
Standard tests of coagulation are performed
on platelet-poor plasma.
Thromboelastography (TEG) is performed on whole blood
and provides information on the entire clotting process.
TEG measures initiation and speed of clot formation,
clot strength, and fibrinolysis.
Luddington RJ: Thrombelastography/thromboelastometry. Clin Lab Haematol 2005;27:81-90.

16. THROMBOELASTOGRAPHY AND
THROMBOELASTOMETRY
Main advantages of TEG/ROTEM:
• bedside test
• results within 30 min
• measures activity of plasmatic coagulation system
• evaluation of platelet function
• fibrinolytic system
• assess the need for blood component therapy
Luddington RJ: Thrombelastography/thromboelastometry. Clin Lab Haematol 2005;27:81-90.

17. THROMBOELASTOGRAPHY AND
THROMBOELASTOMETRY

18. THROMBOELASTOGRAPHY AND
THROMBOELASTOMETRY

19. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
If significant bleeding is observed:
•Obtain/repeat complete coagulation panel (& TEG)
•Assure patency of chest tubes
•Keep patient intubated & sedated
•Keep MAP 60-75 mmHg
•PEEP 8-10 cm
•Avoid hypothermia
•Transfuse PRC and blood components
Sniecinski RM, Levy JH: Bleeding and management of coagulopathy. J Thorac Cardiovasc Surg
2011;142:662-667.

20. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Guidelines for transfusion of PRBC:
Sidebotham UNM
Major bleeding Hgb <9 Hgb 9-10
Patient hemodynamically unstable Hgb <9 Hgb 9-10
Acidosis, SVO2 <55% Hgb <9 Hgb 9-10
Patient bleeding but stable Hgb 7-8 Hgb 8-9
Patient not bleeding and stable Hgb <7 Hgb 7-8
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;17:243-254.

21. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Guidelines for blood component therapy:
Platelet ct < 100,000 or TEG MA <45 mm Platelets 250 ml
Fibrinogen < 100 mg/dL Cryoprecipitate 2-4 u
INR > 1.5 or aPTT > 2x FFP 2-4 u
Fibrinolysis on TEG Amicar or Tranexamic acid

22. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Additional therapeutic agents:
Protamine 15-50 mg
Desmopressin (DDAVP) 0.3 mg/kg over 15 to 30 min
Antifibrinolytic agents (Amicar 20mg/ml) 4-5 grams IV during the first hour
f/b cont. infusion: 1 g/hour

23. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Coagulation factors:
Fibrinogen concentrate (RiaSTAP 1300 mg/50 ml) 70 mg/kg (will ↑ fibr 120
mg/dL)
Recombinant Factor VIIa (NovoSeven) 50 mcg/kg (1-2% TE complic)
90 mcg/kg (4%TE complic)
Prothrombin Complex Concentrates
(Bebulin VH) [factors II,IX,X] 70-95 units/kg
(Beriplex P/N) [factors II,VII,IX,X] 25-50 units/kg

24. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Massive Transfusion therapy:
•Massive transfusion can cause or exacerbate coagulopathy (hypothermia,
platelet dysfunction, ↓ fibrinogen, fibrinolysis).
•These effects may not be apparent on coagulation tests, because blood samples are
warmed to 370
C.
•Fluid resuscitation with crystalloids, colloids, and PRBC causes further dilution of
platelets and coagulation factors.

25. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Massive Transfusion therapy:
•Transfusion of PRBC is recommended when acute blood loss exceeds 1500 mL,
irrespective of Hgb level.
•Blood component therapy.
•Repeat coagulation tests every 1-2 hours.
•Treatment of associated hemodynamic instability, respiratory insufficiency.
•Treatment of associated hypothermia & hypocalcemia.
•Surgical reexploration if bleeding exceeds 300 mL/hr x 3 hr.

26. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Massive Transfusion therapy:
•Severe bleeding requires FFP, platelets, cryoprecipitate, and factor concentrates
to restore circulating levels of hemostasis factors.
•Massive bleeding should prompt consideration of a transfusion protocol involving
fixed ratios of fresh frozen plasma, platelets, and red blood cells.
•A multimodal approach is important to include antifibrinolytics
and recombinant and purified coagulation factors.

27. MASSIVE TRANSFUSION PROTOCOLS
IN TRAUMA PATIENTS
Massive Transfusion protocols:
Fixed transfusion ratios improve survival in
trauma.
Massive transfusion practice guidelines should aim for
a
1:1:1 ratio of plasma:platelets:RBCs.
Early use of rFVIIa was associated with
decreased 30-day mortality
in severely injured combat casualties
requiring massive transfusion,
but was not associated with increased
risk of thrombotic events.

28. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
Guidelines for surgical reexploration:
•More than 500 ml in 1 hour
•400 ml/hr x 2 hours
•300 ml/hr x 3 hours
•Signs of tamponade

29. POSTOPERATIVE BLEEDING
IN CARDIAC SURGERY PATIENTS
UNM Guidelines for surgical reexploration:
•More than 400 ml in 1 hour
•300 ml/hr x 2-3 hours
•200 ml/hr x 4 hours
•Signs of tamponade
Khalpey ZI, et al. Mediastinal reexploration. In: Cohn LH, Ed. Cardiac surgery in the adult. McGraw Hill,
New York. 3rd
Ed. 2008;16:471.

30. PERICARDIAL TAMPONADE
•Usually occurs in patients who bleed excessively
•Usually develops rapidly
•May develop following correction of coagulopathy
•Clotted blood may cause regional tamponade
•May occur as result of edema of thoracic structures
Sidebotham D, et al: Cardiothoracic critical care. Butterworth-Heinemann, Philadelphia 2007;20:304-306.

31. PERICARDIAL TAMPONADE
Clinical diagnosis:
•Peripheral vasoconstriction with delayed capillary
refill and cool extremities
•MAP <60 mmHg
•Rising CVP (equalization of RAP and LAP)
•Low cardiac output
•Oliguria
•Pulsus paradoxus

32. PERICARDIAL TAMPONADE
Imaging studies:
•CXR
•ECG
•TTE
•TEE

33. PERICARDIAL TAMPONADE
Treatment:
•Supportive medical treatment
•Minimize PEEP
•Patient should be sedated & paralyzed
•Stripping and/or suctioning mediastinal drains
•Reopening of sternotomy (in ICU or OR)
.