Clinical Guidelines

Pre-Cardiopulmonary Bypass Transfusion Guideline for Cardiac Surgery

Department of Anesthesiology and Perioperative Medicine
Date: 11-03-2012


INR: International Normalized Ratio; aPTT: act ivated Partial Thromboplastin Time; Plts: Platelets; TEG: Thromboelastograph; FFP:
Fresh Frozen Plas ma; CPB: Cardiopulmonary Bypass; Fib: Fibrinogen; FC: Fibrinogen Concentrate; cryo: cryoprecipitate; R:
Reaction time; MA: Maximum Amplitude
Normal
Cardiac Surgery
related procedure?
No Yes
Avoid
these
Guidelines

Preoperative Central Lab & TEG
Baseline Coagulation Studies
Abnormal
INR 1.9
2 to hepatic
dysfunction or
coumadin
consider
adding 2-4
units FFP to
CPB circuit
1-3
MA < 54 mm
have 1-2
doses of Plts
available
Post-CPB

1.3<INR<1.9
2 to hepatic
dysfunction
or coumadin
consider
adding 2 units
FFP to CPB
circuit
1-3
aPTT 59
2 to hepatic
dysfunction
consider
adding 2-4
units FFP to
CPB circuit
1-3
Plts < 125 x10
3
have 1-2
doses of
Plts
available
Post-CPB
No transfusion indicated
Have 2
units of
FFP
available
Post-
CPB
2
Bewarehypocalcemia Bewarehypocalcemia Bewarehypocalcemia
CPB
R > 9 min
Consider
adding 2
units of
FFP to
CPB
circuit
1-3
Have 2-4
units of
FFP
available
Post-CPB

Have 2-4
units of
FFP
available
Post-CPB

Have 2-4
units of
FFP
available
Post-CPB


Bewarehypocalcemia

45<aPTT<59
2 to hepatic
dysfunction
consider
adding 2 units
FFP to CPB
circuit
1-3
Angle < 59
or
Fi b<150 mg/dL
have 1-2 vials
FC
4
, or 5-10
units cryo
available Post-
CPB
Beware hypocalcemia
Have 2-4
units of
FFP
available
Post-CPB




Clinical guidelines are based on the best and most recent available data and are made available to promote best
clinical practices and to an extent to standardize our approach to managing various clinical issues that are
encountered by all CASECAG staff. Standardizing our approach to some of our practices is expected to reduce
medical errors in the clinical environment and increase work flow for the trainees.

These clinical guidelines are intended to reduce the risk of excessive microvascular bleeding following CPB
related cardiac surgery and to reduce the over transfusion of non-red blood cell allogeneic blood components
that is routinely associated with the management of bleeding without the use of transfusion algorithms.
5-8


1: The rapid administration of any citrate containing blood products can precipitate an acute hypocalcemia that
may present clinically as seizures, bronchospasm, congestive heart failure and prolonged QT interval.
Therefore, if a substantial amount of FFP (i.e. > 2 units) is going to be added to the CPB prime then caution
should be taken to transfuse the FFP slowly to avoid the clinical symptoms associated with acute
hypocalcemia. One suggested technique is to administer 2 units of FFP into the CPB prime and then
following initiation of CPB check the ionized Ca
++
concentration. If it remains within the normal range then
slowly transfuse the other FFP units with frequent checks of the ionized calcium concentration. IV
supplementation of calcium may be indicated but take caution not to infuse the CaCl too rapidly if the heart is
arrested as the Ca
++
acts like a positive inotrope and can increase MVO
2
and thus threaten myocardial
protection.

2: The elevated INR, aPTT and R-time may indicate significant depletion of soluble coagulation factors, a
problem which should be anticipated to worsen following initiation of CPB. Therefore, it is prudent to thaw
2-4 units of FFP and have it available for immediate transfusion following separation from CPB and
protamine administration. No FFP should be transfused until a post-protamine TEG and/or central labs are
available unless severe microvascular bleeding is apparent.

3: The optimal timing of when one should add the FFP to the CPB circuit has not been established. Points to
consider when determining when to add FFP to the CPB circuit are as follows:
a. Adding the FFP early (i.e. in the CPB prime fluid) will prevent further consumption of the already
depleted soluble coagulation proteins as even with optimal heparinization there will be consumption
of these proteins as heparin only effectively blocks factor X and to a lesser extent II. This means that
all of the serine proteases before and in between these steps in the coagulation cascade will be
activated to some extent and factors will be consumed despite the fact that visible clot is not being
formed.
b. Adding the FFP to the CPB circuit prime will leave it vulnerable not only to consumption but also to
hemodilution when and if additional fluids are added to the CPB circuit.
c. Adding the FFP to the CPB circuit later in the pump run mitigates both consumption and
hemodilution of the soluble coagulation proteins and may make more of these factors available to
participate in coagulation following separation from CPB and heparin neutralization.
d. Adding the FFP to the CPB circuit later in the pump run may result in suboptimal heparinization as
the serine protease, Antithrombin III, is required as a cofactor to heparin and may very likely be
depleted also if the aPTT, R time and/or INR are elevated. Suboptimal heparinization would
potentially result in more consumption of existing coagulation proteins and more microvascular
bleeding post-CPB. A clue to AT III depletion is heparin resistance pre-CPB.
e. Regardless of when the FFP is added to the CPB circuit it will not completely obviate the need for
transfusion of FFP following CPB separation and heparin neutralization so additional FFP should be
immediately available following CPB separation for patients with abnormal INR, aPTT and R values.



4: As a general rule one vial of fibrinogen concentrate contains approximately 1100 mg of fibrinogen which is
roughly equivalent to the amount of fibrinogen contained in 5 units of cryoprecipitate or 5 units of FFP.
Using the formula below a specific target blood fibrinogen concentration can be calculated if desired. Limited
data exist to suggest that any one fibrinogen level is optimal, thus TEG Angle guided administration of
fibrinogen appears clinically prudent.









References:
5. Shore-Lesserson L, Manpeizer HE, DePerio M, et al. Thromboelastography guided transfusion
algorithms reduces transfusions in complex cardiac surgery. Anesth Analg 1999;88: 312-9
6. Nuttall GA, Oliver WC, Santrach PJ, et al. Efficacy of simple intraoperative transfusion algorithm for
nonerythrocyte component utilization after cardiopulmonary bypass. Anesthesiology 2001;94:773-81
7. Royston D, Von Kier S. Reduced haemostatic factor transfusion using heparinase- modified
thromboelastography during cardiopulmonary bypass. Brit J Anaesth 2001;86(4):575-8
8. Avidan MS, Alcock EL, Da Fonseca J, et al. Comparison of structured use of routine laboratory tests or
near patient assessment with clinical judgment in the management of bleeding after cardiac surgery. Brit
J Anaesth 2004;92(2);178-86