OR Algorithm for Adult Cardiac Surgery with Microvascular Bleeding
S. Kogan, L. Campbell, J. Ramsey, C.Clary-Macy. Draft: 19 Nov 2015
OR Algorithm for Adult Cardiac Surgery with Microvascular Bleeding:
Initial Assessment and Plan
- When patient temperature reaches 33-34 degrees C (or approx. 30 min before coming off bypass): Draw ROTEM (HEPTEM & FIBTEM)
- After Protamine reversal (ACT used to assess heparin reversal): Assess for abnormal bleeding.
- If abnormal bleeding is present: Follow ROTEM algorithm for PLT/CRYO/FFP.
Subsequent Assessment and Plan
- Following initial product infusion: Re-assess for abnormal bleeding.
- If bleeding is sufficiently limited: Repeat ROTEM (HEPTEM & FIBTEM) Follow ROTEM algorithm for PLT/CRYO/FFP.
- If bleeding is brisk (or for patients identified as high risk*) and it is not possible to wait for repeat ROTEM results: Follow BRISK BLEED algorithm for PLT/CRYO/FFP.
ICU Assessment and Plan
- Assess for abnormal bleeding.
- If bleeding is sufficiently limited: Order STAT Platelet Count, Fibrinogen, PT/INR. Follow ICU algorithm for PLT/CRYO/FFP.
- If bleeding is “brisk” (or for patients identified as high risk*) and it is not possible to wait for laboratory results: Follow BRISK BLEED algorithm for PLT/CRYO/FFP.
RBC Transfusion Assessment and Plan
See RBC algorithm for coming off bypass vs. coming out of OR or in ICU
(*h/o Coagulopathy or recent anticoagulants, Aortic root or dissection, Endocarditis, Long pump run or clamp time, LVAD/Heart transplant, Re-do valve or CABG or any bleed after protamine has been given )
ROTEM Algorithm for PLT/CRYO/FFP
BRISK BLEED Algorithm for PLT/CRYO/FFP
Recommended order of product use and dosing*:
- 1 unit of platelets
Reassess: continue or switch to ROTEM algorithm? - 10 units of cryoprecipitate
Reassess: continue or switch to ROTEM algorithm? - 2 units of FFP
Reassess: continue or switch to ROTEM algorithm? - 1 unit of platelets
Reassess: continue or switch to ROTEM algorithm? - 10 units of cryoprecipitate
Reassess: continue or switch to ROTEM algorithm? - 2 units of FFP
Reassess: continue or switch to ROTEM algorithm?
*Note: if a product was given on basis of initial ROTEM, then omit additional dose at steps 1, 2 and/or 3.
Consider recombinant activated Factor VII if the algorithm for management of massive refractory blood loss has failed to control severe bleeding.
Recombinant activated Factor VII dosing guidelines.
Available in 1 mg, 2 mg, and 5 mg vials. Round dose to nearest vial size.
Recommended dosing based on weight (~30 mcg/kg per dose):
- If patient <100 kg, give 2 mg IV bolus
- If patient >100 kg, give 3 mg IV bolus
If bleeding remains uncontrolled with one dose of recombinant activated Factor VII, may consider repeating the same dose.
ICU Algorithm for PLT/CRYO/FFP
ICU Algorithm for Adult Cardiac Surgery with Microvascular Bleeding:
BRISK BLEED Algorithm for PLT/CRYO/FFP
Recommended order of product use and dosing*:
- 1 unit of platelets
Reassess: continue or switch to lab guided algorithm? - 10 units of cryoprecipitate
Reassess: continue or switch to lab guided algorithm? - 2 units of FFP
Reassess: continue or switch to lab guided algorithm? - 1 unit of platelets
Reassess: continue or switch lab guided algorithm? - 10 units of cryoprecipitate
Reassess: continue or switch to lab guided algorithm? - 2 units of FFP
Reassess: continue or switch to lab guided algorithm?
*Note: if a product was given on basis of initial lab guided, then omit additional dose at steps 1, 2 and/or 3.
Consider recombinant activated Factor VII if the algorithm for management of massive refractory blood loss has failed to control severe bleeding.
Recombinant activated Factor VII dosing guidelines.
Available in 1 mg, 2 mg, and 5 mg vials. Round dose to nearest vial size.
Recommended dosing based on weight (~30 mcg/kg per dose):
- If patient <100 kg, give 2 mg IV bolus
- If patient >100 kg, give 3 mg IV bolus
If bleeding remains uncontrolled with one dose of recombinant activated Factor VII, may consider repeating the same dose.
Algorithm for Adult Cardiac Surgery:
Red Cell Transfusion
*In limited circumstances, clinical judgment may determine that RBC transfusion is indicated.
This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.