Free Download: Management of Post Op Bleeding in Cardiac Surgery Patients.
Management of post-operative bleeding in cardiac surgery (and cheat sheet, swipe): Many factors contribute to bleeding in cardiac surgery that do not necessarily entail a surgical etiology. The cardiopulmonary bypass pump (CPB) pump itself is thrombogenic, thus high dose heparin is administered to prevent clotting. Although heparin is reversed at the end of the surgery, remnants still linger. Other coagulopathy factors include platelet activation and consumption, hypothermia, and dilutional issues with crystalloid and pump priming.
The definition of a “bleeding” patient varies by institution and surgeon, but is often dictated by the chest tube output. The surgery team should be notified if total chest tube output for 1 hour is > 200ml and typically 150ml for robotic surgeries. It is also important to note if the output abruptly stops indicating a clot, setting the patient up for tamponade.
Controlling the patient’s blood pressure should be a first line intervention (higher bp = more bleeding). Crystalloid administration should be limited to prevent hemodilution and hypothermia. And finally, when it’s time to transfuse, a restrictive strategy is best. Using a ratio of PRBC:FFP:Platelets of 2:2:1 is an appropriate strategy. Fibrinogen replacement with cryoprecipitate is effective for levels <200.
In my clinical practice, when a patient comes out of the OR hemorrhaging, sometimes I don’t even wait for coags to result before repletion. It is fair to begin with FFP and PRBC repletion in effort to stay ahead of the bleeding. After all coags have been corrected, heparin reversed with protamine, and the patient is still bleeding, it’s time to consider surgical bleeding. On the flip side, if the patient isn’t bleeding and the coags have minor abnormalities, I often don’t replace anything.
Finally, for nurses, knowing your policies on transfusions and monitoring for reactions is imperative, especially when given multiple blood products very fast. Doing two nurse checks on every product is also imperative. Once again, blood products are so far from benign, but we use them so often, it’s easy to forget.