Cardiovascular Algorithm © Klaus Görlinger 2015 [email protected] Diffuse bleeding after heparinreversal and blood transfusion considered 1,2, 8 YES YES A5EX < 35 mm or CTFIB > 600 s or ML ≥ 15% (within 60 min) (in addition to the local protocol) DONE NO ACTafter Protamine > ACTBaseline and CTIN >> CTHEP 4 Tranexamic acid 3 25 mg/kg as a single bolus 4 YES Protamine 25-50 mg (2.5-5 mL) (then re-check ACT and INTEM/HEPTEM) NO A5EX < 30 mm and A5FIB < 9 mm YES Fibrinogen concentrate or Cryoprecipitate (dose cal.) 5 Target: A5FIB ≥ 12 mm NO A5EX < 30 mm and A5FIB ≥ 9 mm or platelet dysfunction! YES Platelet concentrate 1-2 pooled or apheresis 6 NO YES CTEX > 80 s PCC 15-25 IU / kg bw 7 or FFP 10-15 mL / kg bw NO YES CTIN and CTHEP > 280 s FFP 10-15 mL / kg bw NO YES Ongoing bleeding Re-check after 10-15 min using a new blood sample Cardiovascular A5 Algorithm - Footnotes • 1 Timing of ROTEM-analysis: – – – • 2 Check basic conditions before weaning from CPB: – – • 3 4 5 6 – – – – 7 8 Fibrinogen dose (mg/ kg bw) Fibrinogen concentr. (mL / kg bw) Cryoprecipitate (mL / kg bw) 2 12.5 0.6 [1 g per 80 kg] 1 [ 5 U per 80 kg] 4 25 1.2 [2 g per 80 kg] 2 [10 U per 80 kg] 6 37.5 1.9 [3 g per 80 kg] 3 [15 U per 80 kg] 8 50 2.5 [4 g per 80 kg] 4 [20 U per 80 kg] 10 62.5 3.1 [5 g per 80 kg] 5 [25 U per 80 kg] 12 75 3.8 [6 g per 80 kg] 6 [30 U per 80 kg] Fibrinogen dose (g) = targeted increase in A5FIB (mm) x body weight (kg) / 160 Correction factor (140-160 mm kg g-1) depends on the actual plasma volume Reached increase can be lower than calculated increase in severe bleeding 10 U Cryoprecipitate ≈ 2 g Fibrinogen concentrate Check platelet function with ROTEM platelet (ADPtem and TRAPtem) or Multiplate Consider tranexamic acid (25 mg/kg) and/or desmopressin (DDAVP; 0.3µg/kg) in patients with dual antiplatelet therapy and/or ADPtem < 40 Ω·min Expected increase per pooled/apheresis PC per 80 kg: 8-10 mm in A5EX → A5EX < 30 mm or ADPtem ≤ 30 Ω·min: 1 pooled or apheresis PC A5EX < 20 mm or ADPtem ≤ 30 Ω·min (and TRAPtem ≤ 50Ω·min): 2 pooled or apheresis PC A5EX ≤ 10 mm: 2 platelet concentrates + fibrinogen substitution (≥ 4 g) If Prothrombin-Complex-Concentrate (PCC) is not available: – – • Targeted increase in A5FIB (mm) Platelet concentrate (PC) transfusion: – – • Prophylaxis according to the local protocol of the hospital EACA can be used instead of TXA (based on local practice) Dirkmann et al. Anesth Analg. 2014 CTFIB > 600 s represents a flat-line in FIBTEM Delta ACT(baseline vs. after protamine) and delta CT(INTEM vs. HEPTEM) > 10-20% of baseline Fibrinogen dose calculation (stepwise approach): – – – – • Temp. > 36oC; pH > 7.2; Cai++ > 1 mmol/L Hb > 8 g/dL Antifibrinolytic therapy: – – – – • • Consider ROTEM platelet (and ROTEM delta) baseline testing in patients with dual antiplatelet therapy (or other known hemostatic dysfunction) Consider ROTEM delta and ROTEM platelet analysis before weaning from CPB (declamping of the aorta) in patients with a high bleeding risk Perform ROTEM delta and ROTEM platelet analysis in case of diffuse bleeding after weaning from CPB and heparin-reversal with protamine (if not already done before weaning from CPB) 10-15 mL FFP /kg bw or 45-90 µg rFVIIa /kg bw (if A5EX and A5FIB are ok but FFP is not effective) Simultaneous interventions: – – – Maximal three interventions at the same time (in first analysis and severe bleeding) Maximal two interventions at the same time (in second analysis and moderate to severe bleeding) Only one intervention at the same time (in second or later analysis and mild to moderate bleeding) Cardiovascular Algorithm - References – – – – – – – – – – – – – – – – Reinhöfer M, Brauer M, Franke U, et al. The value of rotation thromboelastometry to monitor disturbed perioperative haemostasis and bleeding risk in patients with cardiopulmonary bypass. Blood Coagul Fibrinolysis 2008;19:212–9. Christensen MC, Krapf S, Kempel A, von Heymann C. Costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg. 2009;138:687-93. Bolliger D, Görlinger K, Tanaka KA. Pathophysiology and treatment of coagulopathy in massive hemorrhage and hemodilution. Anesthesiology 2010;113:1205-19. Görlinger K, Dirkmann D, Weber CF, et al. Algorithms for transfusion and coagulation management in massive haemorrhage. Anästh Intensivmed 2011 Feb; 52(2): 145-59. 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 decreased allogeneic blood transfusion in cardiovascular surgery: A retrospective, single-center cohort study. Anesthesiology 2011;115:1179-91. Ranucci M, Baryshnikova E, Soro G, et al. Multiple electrode whole-blood aggregometry and bleeding in cardiac surgery patients receiving thienopyridines. Ann Thorac Surg 2011;91:123– 30. Görlinger K, Bergmann L, Dirkmann D. Coagulation management in patients undergoing mechanical circulatory support. Best Pract Res Clin Anaesthesiol 2012;26:179-98. Görlinger K, Fries D, Dirkmann D, et al. Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal-directed therapy. Transfus Med Hemother 2012;39:104-13. Hanke AA, Herold U, Dirkmann D, et al. Thromboelastometry based early goal-directed coagulation management reduces blood transfusion requirements, adverse events, and costs in acute type A aortic dissection: A pilot study. Transfus Med Hemother 2012;39:121-8. Weber CF, Görlinger K, Meininger D, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology. 2012 Sep;117(3):531-47. Rahe-Meyer N, Solomon C, Hanke A, et al. Effects of fibrinogen concentrate as first-line therapy during major aortic replacement surgery. A randomized, placebo-controlled trial. Anesthesiology 2013;118:40-50. Dirkmann D, Görlinger K, Dusse F, et al. Early thromboelastometric variables reliably predict maximum clot firmness in patients undergoing cardiac surgery: A step towards earlier decision making. Acta Anaesthesiol Scand 2013;57:594-603. Hanke AA, Joch C, Görlinger K. Long-term safety and efficacy of a pasteurized nanofiltrated prothrombin complex concentrate (Beriplex P/N): a pharmacovigilance study. Br J Anaesth. 2013 May;110(5):764-72. Görlinger K, Dirkmann D, Hanke AA. Potential value of transfusion protocols in cardiac surgery. Curr Opin Anaesthesiol 2013;26:230-43. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding. Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30:270-382. Ranucci M, Baryshnikova E, Castelvecchio S, et al. Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thorac Surg. 2013;96:478-85. Cardiovascular Algorithm - References – – – – Görlinger K, Shore-Lesserson L, Dirkmann D, et al. Management of hemorrhage in cardiothoracic surgery. J Cardiothorac Vasc Anesth. 2013;27:S20-34. Tanaka KA, Bader SO, Görlinger K. Novel approaches in management of perioperative coagulopathy. Curr Opin Anaesthesiol. 2014 Feb;27(1):72-80. Olde Engberink RH, Kuiper GJ, Wetzels RJ, et al. Rapid and correct prediction of thrombocytopenia and hypofibrinogenemia with rotational thromboelastometry in cardiac surgery. J Cardiothorac Vasc Anesth. 2014 Apr;28(2):210-6. Dirkmann D, Görlinger K, Peters J. Assessment of early thromboelastometric variables from extrinsically activated assays with and without aprotinin to rapidly detect hyperfibrinolysis. Anesth Analg. 2014 Sep;119(3):533-42. – – – – – – – – – – – – Haas T, Görlinger K, Grassetto A, et al. Thromboelastometry for guiding bleeding management of the critically ill patient: A systematic review of the literature. Minerva Anestesiol. 2014 Dec;80(12):1320-35. Nakayama Y, Nakajima Y, Tanaka KA, et al. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery. Br J Anaesth. 2015 Jan;114(1):91-102. American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology. 2015 Feb;122(2):241-75. Karkouti K, McCluskey SA, Callum J, et al. Evaluation of a novel transfusion algorithm employing point-of-care coagulation assays in cardiac surgery: a retrospective cohort study with interrupted time-series analysis. Anesthesiology. 2015 Mar;122(3):560-70. Schmidt DE, Holmström M, Majeed A, et al. Detection of elevated INR by thromboelastometry and thromboelastography in warfarin treated patients and healthy controls. Thromb Res. 2015 May;135(5):1007-11. Corredor C, Wasowicz M, Karkouti K, Sharma V. The role of point-of-care platelet function testing in predicting postoperative bleeding following cardiac surgery: a systematic review and meta-analysis. Anaesthesia. 2015 Jun;70(6):715-31. Ji SM, Kim SH, Nam JS, et al. Predictive value of rotational thromboelastometry during cardiopulmonary bypass for thrombocytopenia and hypofibrinogenemia after weaning of cardiopulmonary bypass. Korean J Anesthesiol. 2015 Jun;68(3):241-8. Ranucci M, Baryshnikova E1, Crapelli GB, et al. Randomized, double-blinded, placebocontrolled trial of fibrinogen concentrate supplementation after complex cardiac surgery. J Am Heart Assoc. 2015 Jun 2;4(6):e002066. Blasi A, Muñoz G, de Soto I, et al. Reliability of thromboelastometry for detecting the safe coagulation threshold in patients taking acenocoumarol after elective heart valve replacement. Thromb Res. 2015 Sep;136(3):669-72. Pearse BL, Smith I, Faulke D, et al. Protocol guided bleeding management improves cardiac surgery patient outcomes. Vox Sang. 2015 Oct;109(3):267-79. Mace H, Lightfoot N, McCluskey S, et al. Validity of thromboelastometry for rapid Assessment of fibrinogen levels in heparinized samples during cardiac surgery: A retrospective, singlecenter, observational study. J Cardiothorac Vasc Anesth. 2015 May 5. pii: S10530770(15)00282-7. [Epub ahead of print] Petricevic M, Konosic S, Biocina B, et al. Bleeding risk assessment in patients undergoing elective cardiac surgery using ROTEM® platelet and Multiplate® impedance aggregometry (NCT02277379). Anaesthesia. 2015. [Accepted for Publication]
