Transfusion and haemostasis were for a long time carried out in an empirical way, as there were no objective criteria on which to base a rational strategy for the administration of blood and blood products. The situation has changed in the last decade with the discovery of increased postoperative mortality related to transfusions and the development of coagulation tests that are easily performed in the operating room. This has led to the development of logical strategies based on evidence. As with the management of patients weaning off ECC or the use of catecholamines, a pre-established haemotherapy algorithm, supported by laboratory tests, is superior to improvisation on a case-by-case basis. This algorithm consists of several steps [1,3,4,5].
- Pre-operative assessment of bleeding risk: history of bleeding, congenital or acquired coagulopathy, use of anticoagulants or antiplatelets, hepatic or renal insufficiency, etc. (see above Pre-operative anticoagulation). Investigation and treatment of anaemia 3-4 weeks before the operation.
- In patients on antiplatelet therapy, consider a non-ECC procedure (e.g. beating heart ECC) to reduce the dose of heparin administered and to reduce bleeding risk .
- Correction of physiological alterations: maintenance of pH > 7.3, temperature > 36°C, [Ca2+ ]i > 1 mmol/L, and Ht > 25%.
- Restrictive transfusion thresholds: Hb 70-90 gm/L; use of leukoreduced blood bags and aged < 14 days if possible. Use of Cell-Saver™.
- Prophylactic administration of an antifibrinolytic: tranexamic acid or ε-amino-caproic acid, (aprotinin) (see Antifibrinolytics).
- Heparin reversal (for ACT < 130 sec): protamine according to residual heparin or 0.8 mg per 1 mg.
- Maintenance of coagulation factors (according to thromboelastogram): fibrinogen > 2.0 g/L (fibrinogen concentrate), factors II, VII, IX and X (prothrombin complex concentrate with 3 or 4 factors), factor XIII (see Coagulation Factors)
- Platelet maintenance (according to aggregometry tests): platelet concentrates for levels > 70,000/mcL, possibly desmopressin (DDAVP) (see Platelet normalisation).
- Rescue measure: PCC (prothrombin complex concentrate) with 4 partially activated factors (FEIBA™) and factor rVIIa (NovoSeven™), provided Ht (> 25%), fibrinogen (> 2.0 g/L), blood calcium (> 1 mmol/L) and platelets (> 70,000/mcL) are normalised. Justified only in cases of persistent bleeding despite the use of all haemostatic means, including surgery, endoscopy and interventional radiology.
This approach clearly reduces the number of blood bags and units of FFP used; it also reduces morbidity (repeat surgery for haemostasis, thrombo-embolic events, renal failure). On the other hand, it doubles the use of fibrinogen and PCC [2,4].
© CHASSOT PG, MARCUCCI Carlo, last update November 2019.
References
- BROWN C, JOSHI B, FARADAY N, et al. Emergency cardiac surgery in patients with acute coronary syndromes: a review of the evidence and perioperative implications of medical and mechanical therapeutics. Anesth Analg 2011; 112: 277-99
- GÖRLINGER K, DIRKMANN D, HANKE AA; et al. First-line therapy with coagulation factor concentrates combined with point-of-care coagulation testing is associated with decrease allogeneic blood transfusion in cardiovascular surgery. Anesthesiology 2011; 115: 1179-91
- GRONCHI F, RANUCCI M. Perioperative coagulation in cardiovascular surgery. In: MARCUCCI C, SCHOETKER P, editors. Perioperative hemostasis. Coagulation for anesthesiologists. Heidelberg: Springer Verlag, 2014, 243-66
- WEBER CF, GÖRLINGER K, MEININGER D. Point-of-care testing: a prospective randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology 2012; 117: 531-47
- WEBER CF, KLAGES M, ZACHAROWSKI K. Perioperative coagulation management during cardiac surgery. Curr Opin Anaesthesiol 2013; 26: 60-84