Dr.Hadil Magdi

Bleeding after

Congenital Heart Surgery

A bleeding diathesis has been recognized in pt. with CCHD, a variety of coagulation abnormalities has been postulated:

1- Polycythemia 2- Hyper viscosity.3- DIC 4- Platelet

function abnormalities.5- Decreased production of coagulation

factors.6- Vitamin K deficiency.7- Primary fibrinolysis.

Pathophysiology

Arterial hypoxia Erythropoietin

RBC Blood viscosity

Decompensated erythrocytosis.( as

increased blood viscosity limiting factor in

tissue oxygenation.)

Polycythemia

#Headache.#Fatigue.#Dizziness.#Visual disturbance.#Paresthesia.#myalgia.#Irritability.

Hyper viscosity (C/P)

Hyper viscosity

Hyper viscosity symptoms occur

usually at the level of packed

cell volume much lower than that

known to produce, it due to the

associated iron deficiency anemia

which is common in cyanotic

infants (dietary).

Iron Deficiency Anemia

+Polycythemia

=Tissue perfusion

(viscosity)

Thrombocytopenia

Polycythemia

Thrombocytopenia

Polycythemia increased

viscosity

Decrease blood flow & tissue

perfusion (Vascular stasis)

Intravascular deposition of fibrin

and platelet Consumption

of platelet coagulation factors

(DIC) Increase Risk of

bleeding

DIC

Primary fibrinolysis due to coagulation abnormalities usually occur in cyanotic infants.

Fibrinolysis

Laboratory Tests for hemotatic abnormalities PT,

PTT are commonly longer in patients with

haematocrit value >60%, However >50% of

neonates had abnormal coagulation profile

even in the absence of Polycythemia (Due to

impaired synthesis and activation of factor II, vII,

IX, X, because of Vit.K deficiency).

Impaired production of coagulation factor

*Haemodilution resulting from high priming volume.

*Delayed hepatic maturation secondary to poor organ perfusion.

*Complex operative Procedures requiring long duration of CPB.

*Multiple extracardiac lesions.

Other causes of bleeding

in CCHD

Preoperative

preparation

of the patient

-Preoperative Phlebotomy was first suggested

for CCHD Patients in 1964.

-In older children (>5years old) 500 ml of blood

over 30 to 45 min followed by an equivalent

volume of isotonic saline, this may be followed

every 24hrs by an additional 500ml

phlebotomy until HB level of <65% is

achieved.

Phlebotomy

Phlebotomy*Is recommended with symptomatic

hyper- viscosity when dehydration is

not the cause (Hb>65%).

*The red blood cell reduction in CCHD

improved platelet aggregation & lessen

the risk of perioperative bleeding.

Phlebotomy

RBC mass risk of

cerebrovascular events (as a result of

reduced CBF, secondary to hyper

viscosity) therefore Phlebotomy reduce

the risk of cerebral infarction.

If Symptom of hyperviscosity does not improve

after phlebotomy

Possibility of

concomitant iron deficiency anemia.

(as iron deficient red blood cells are less

deformable than normal RBC and does not

pass through the microcirculation).

NB:

A-Pharmacological approach:

Aprotinin:

Is a non specific serine protease inhibitors that

inhibits fibrinolysis and complement

activation due to its effect on the

kallikrein/kinin system.

Strategies to decrease blood loss postoperatively

1-Expensive.

2-Thrombus formation.

3-severe hemodynamic instability.

4-Impaired renal function.

5-Risk of anaphylaxis(due to IgG, IgE antibodies).

Disadvantage:

(EACA) is a synthetic agent that inhibit the

fibrinolytic system by inhibiting activation of

plasminogen (EACA) is used in a dose of

100mg /kg after anesthetic induction,

100mg /kg after in the CPB pump prime and

100mg / on weaning from CPB over 3 hrs.

Aminocaproic acid

Aminocaproic acid

EACA has advantage over aprotinin :

*Lower cost.

*Less risk of anaphylactic.

*Synthetic antifibrinolytic it act by

effectively inhibiting fibrinolysis.

*Is used in a single dose of 50mg/kg

after skin incision.

Tranexanmic acid

Repeated median sternotomy techniqueit is a major challenge because it can be

associated with ventricular or vascular surgery injury to overcome this problem precaution should be taken as:

1-Avoid sudden separation of sternum.

2-Avoid sharp dissection.

3-Elimination of electrocautary during lysis of adhesions.

4-Avilability of fresh blood.

5-Alternative approach to the femorofemoral bypass before sternotomy

B-Surgical technique modification

Ultrafiltration of the extracorporeal

circuit volume after separation from

CPB with reinfusion of the salvage

concentrate.

C-CPB Modification(ultrafiltration during CPB)

1-Means of blood conservation.

2-Can attenuate the inflammatory response to CPB that lead to tissue edema and multiple organ dysfunction.

3-It lead to decrease interleukin I, interleukin 6, interleukin 8 and myloperoxidase this lead to decrease postoperative blood loss, time to extubation, postoperative alveolar arterial oxygen gradient.

Advantage of ultrafiltration

Despite taking necessary precautions

excessive bleeding can occur after

surgery and treatment needs to be

initiated after proper surgical hemostasis

and adequate heparin neutralization have

been achieved.

Management of excessive bleeding after surgery

Laboratory tests may be required to identify the

haemostatic abnormality to guide proper

therapy while waiting for the laboratory

results, Fresh blood <48hrs should be

transfused in children <2yrs old, in children

>2yrs old platelet concentrate followed by

FFP should be used and give better results

than fresh whole blood.

NB:

Laboratory Results

Thank you