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Published on: May 19, 2022
Bleeding and management of coagulopathy
Roman M Sniecinski1, Jerrold H Levy
1Department of Anesthesiology, Emory University School of Medicine, Cardiothoracic Anesthesiology and Critical Care, Emory Healthcare, Atlanta, GA 30322, USA.
Insights
Managing bleeding after cardiac surgery is crucial. Point-of-care testing and multimodal strategies, including antifibrinolytics and specific coagulation products, can improve outcomes and reduce transfusions.
Area of Science:
- Cardiology
- Hematology
- Anesthesiology
Background:
- Post-cardiac surgery bleeding is a major complication, increasing hospital stay and mortality.
- Coagulopathy evaluation is hindered by slow standard coagulation tests.
- Factors include dilutional coagulopathy, fibrinolysis, and platelet dysfunction.
Purpose of the Study:
- To review current strategies for managing bleeding and coagulopathy in cardiac surgery.
- To highlight the utility of point-of-care testing and transfusion protocols.
- To discuss the role of pharmacologic agents and novel coagulation products.
Main Methods:
- Review of literature on bleeding management in cardiac surgery.
- Discussion of point-of-care testing modalities like thromboelastography.
- Analysis of transfusion protocols and pharmacologic interventions.
Main Results:
- Point-of-care testing algorithms can potentially reduce transfusion needs.
- Massive transfusion protocols are relevant for complex aortic surgery.
- Multimodal management incorporating antifibrinolytics and specific coagulation products is essential.
Conclusions:
- Effective management requires a multimodal approach tailored to the patient.
- Early recognition and treatment of coagulopathy are key.
- Emerging recombinant and purified coagulation products offer targeted therapeutic options.
Abstract:
Bleeding after cardiac surgery remains a significant problem, increasing both length of stay and mortality, and is caused by multiple factors including dilutional changes, ongoing fibrinolysis, and platelet dysfunction. The evaluation of coagulopathy is problematic because of the long turnaround time of standard coagulation tests. Algorithms involving point of care testing, including thromboelastography and thromboelastometry, have been published; all have the potential to reduce transfusion requirements. Massive transfusion coagulopathy that occurs in trauma can also be seen in complex aortic surgery and other massive bleeding patients and should prompt consideration of a transfusion protocol involving fixed ratios of fresh frozen plasma, platelets, and red blood cells. Pharmacologic agents such as antifibrinolytics are commonly administered, but a multimodal approach to management is important. Recombinant and purified coagulation products are being studied and provide clinicians specific agents to treat targeted deficiencies. A general multi-modal approach is required and recommendations are made for the management of bleeding and coagulopathy in cardiac surgical patients.
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