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CPB time and aortic cross-clamp time

Treatment of “Medical” Bleeding

  1. Correct hypothermia.
  2. Control BP if elevated.
  3. Protamine 25 – 50 mg iv if ACT elevated. Note that an idiopathic “protamine reaction ” (i.e., pulmonary hypertension, hypoxia, and systemic hypotension) can occur with any dose, even if previous doses of protamine were well tolerated. In excessive quantities protamine is itself an anticoagulant.
  4. DDAVP 20 mcg iv. This has been shown to improve platelet function and decrease active bleeding in uremia or vonWillebrand’s disease. It is given post-cardiac surgery because it is felt it might improve platelet function although the data are mixed in this setting.
  5. Platelet transfusion; usually 5 units for bleeding in the face of suspected or confirmed defects in platelet function or number. Five units of platelets should raise the platelet count by 25,000 to 50,000 and will also provide clotting factors equivalent to 1 unit of FFP. In a patient who is bleeding significantly, the goal is to keep the platelet count greater than 100,000 of functional platelets.
  6. Fresh Frozen Plasma – normally 2 to 6 units with each unit 200 to 250 ml. Giving a total of 20 cc/kg will replace factor levels to at least 50% of normal if you are starting at levels of 0. In a bleeding patient the goal is to return the PT and PTT close to normal values.
  7. Cryoprecipitate; contains fibrinogen and factor VIII. 1 unit is 20 to 25cc. Usually given pooled as 8 to 10 units for suspected or confirmed hypofibrinogenemia.
  8. Antifibrinolytic agents; Episilon-aminocaproic acid (AMICAR), tranexemic acid, or aprotinin. Inhibit conversion of plasminogen to plasmin thus preventing activation of fibrinolysis. Ideally should confirm fibrinolysis before use ( elevated D-dimers, low fibrinogen). Risk of thrombosis including acute graft thrombosis, DVT, PE.
  9. Raising the head of the bed or increasing the level of PEEP on the ventilator are also used on occasion. The proposed mechanism of action for these therapies are to decrease mediastinal venous pressure or increase pleural and mediastinal pressure thus stopping small venous bleeding. Definitive studies are lacking.
  10. PRBC; it is of utmost importance to maintain a hemoglobin level high enough to maintain adequate oxygen delivery during the period of significant bleeding.

Ideally, the choice of therapy should be guided by hematological laboratory tests including a CBC, PT, PTT, ACT, fibrinogen, and d-dimers. Practically speaking, one does not always have the luxury of time with patients bleeding significantly and one may have to resort to empiric or “shotgun” therapy.