postoperative bleeding & guidelines for transfusion

POSTOPERATIVE

POSTOPERATIVE

BLEEDING

BLEEDING

AND GUID

ELINES

AND GUID

ELINES

FOR TRANSFUSIO

N

FOR TRANSFUSIO

N

THERAPY

THERAPY

By- Dr.

Armaan S

ingh

By- Dr.

Armaan S

ingh

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

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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


Probability of major morbidity associated with blood use with and without reoperation for bleeding:


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%

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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)

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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.

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.

GUIDELINES FOR TRANSFUSION IN CRITICALLY ILL PATIENTS

Mortality by transfusion status :


Survival of ICU patients who received 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.

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.


Coagulation tests:

•Platelet count •ACT, aPTT, PT/INR •Fibrinogen level / Thrombin clotting time •D-Dimer & FDP •PFA-100 / HemoSTATUS •Thromboelastography



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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.


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.


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



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



Guidelines for blood component therapy:

Platelet ct < 100,000 or TEG MA <45 mm Platelets 250 mlFibrinogen < 100 mg/dL Cryoprecipitate 2-4 uINR > 1.5 or aPTT > 2x FFP 2-4 uFibrinolysis on TEG Amicar or Tranexamic acid


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


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


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 370C.

•Fluid resuscitation with crystalloids, colloids, and PRBC causes further dilution of platelets and coagulation factors.



•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.



•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.

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.


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


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.

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



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


Imaging studies:

•CXR •ECG •TTE •TEE


Treatment:

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

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postoperative bleeding & guidelines for transfusion

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