Protocol Adherence When Managing Massive Bleeding Following Complex Cardiac Surgery: A Study Design Pilot

Greilich, Philip E.; Edson, E. F.; Rutland, Lindsey; Jessen, Michael E.; Key, Nigel S.; Levy, Jerrold H.; Faraday, Nauder; Steiner, Marie

doi:10.1053/j.jvca.2014.08.009

Cited by 12 publications

(9 citation statements)

References 26 publications

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“…Hemodilution during pediatric cardiopulmonary bypass (CPB) universally affects all components of the coagulation cascade in unpredictable proportions resulting in a significant coagulopathy . Neonates and infants have relatively high concentrations of plasma fibrinogen and the large hemodilution consequent to bypass in this age group makes fibrinogen the first clotting factor to decrease to critically low levels .…”

Section: Introductionmentioning

confidence: 99%

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery

Gautam

Cai

Pawelek

et al. 2016

Pediatric Anesthesia

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In pediatric patients undergoing cardiac surgery, FLEV derived from Functional Fibrinogen correlated linearly with plasma fibrinogen levels (Clauss) both before and after CPB. FLEV estimation of plasma fibrinogen was improved after CPB in neonates, infants, and small children. After CPB, FFTEG can be used to predict laboratory diagnosis of critical hypofibrinogenemia (≤200 mg·dl ) during pediatric cardiac surgery. Further studies are required to assess the impact of predictability of FFTEG on component transfusion during pediatric cardiac surgery.

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Section: Introductionmentioning

confidence: 99%

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery

Gautam

Cai

Pawelek

et al. 2016

Pediatric Anesthesia

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“…Nevertheless, administration of these products is plagued with thrombotic risks, which could be life-threatening following intricate cardiac surgery. 9 Based on this case study, experience and the aforementioned literature, two modifications to institutional protocols are recommended. The first is the use of CVVH in theatre to eliminate bivalirudin in renal failure patients or in patients where bivalirudin elimination is prolonged.…”

Section: Discussionmentioning

confidence: 99%

“…This report also highlights the need for the development of bivalirudin protocols to include sections for management of post-CPB refractory bleeding. As refractory bleeding post cardiac surgery occurs in 10%-15% of patients 9 and one of the major concerns when using bivalirudin is the increased risk of post-cardiac surgery bleeding due to the lack of a reversal agent. With this knowledge, no study or trial has outlined a protocol for the management of refractory bleeding post-CPB with bivalirudin anticoagulation.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, in addition to the absence of robust management of refractory bleeding post-CPB, Greilich et al proposed that, through adherence to well-structured protocols, swift identification and management of refractory bleeding can reduce the risk of morbidity and mortality associated with it. 9 The conventional management of bleeding post cardiac surgery entails the administration of anti-fibrinolytic agents and transfusion of allogeneic blood products. If haemostasis is not achieved and severe bleeding continues, more blood products are administered and a rescue therapy is sought.…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, administration of these products is plagued with thrombotic risks, which could be life-threatening following intricate cardiac surgery. 9…”

Section: Discussionmentioning

confidence: 99%

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Management of refractory bleeding post-cardiopulmonary bypass in an acute heparin-induced thrombocytopenia type II renal failure patient who underwent urgent cardiac surgery with bivalirudin (Angiox^®) anticoagulation

et al. 2017

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Acute heparin-induced thrombocytopenia (HIT) patients present a myriad of anticoagulation management challenges, in clinical settings where unfractionated heparin (UFH) is the traditional drug of choice. UFH use in cardiac surgery is a known entity that has been subject to rigorous research. Research has, thus, led to its unparalleled use and the development of well-established protocols for cardiac surgery. In comparison to UFH, bivalirudin use for acute HIT patients requiring urgent cardiac surgery with cardiopulmonary bypass (CPB) is still in its infancy. We describe the tailored post-CPB management of refractory bleeding in a 65-year-old infective endocarditis, acute HIT patient with renal failure who underwent urgent aortic valve replacement and mitral valve repair with bivalirudin anticoagulation. A management approach that entailed a combination of continuous venovenous haemofiltration (CVVH), 4-Factor prothrombin complex concentrate (PCC) (Beriplex), recombinant factor VIIa (rFactor VIIa) and desmopressin (DDAVP) were consecutively used post-operatively in theatre. Based on this case study experience, two modifications to institutional protocols are recommended. The first is the use of CVVH in theatre to eliminate bivalirudin in renal failure patients or in patients where bivalirudin elimination is prolonged. Secondly, a 'rescue therapy/intervention' algorithm for the swift identification of refractory bleeding post-CPB is also recommended. Rescue therapy agents, such as a 4-Factor PCCs and rFactor VIIa, should be incorporated into the protocol after a robust evidence-based search and agreement with the haematologist. The aim of these recommendations is to reduce the risk of bleeding associated with bivalirudin use for inexperienced institutions and experienced institutions alike, until larger randomized, controlled studies provide more in-depth knowledge to expand our clinical practice.

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Effects of Fibrinogen Concentrate Supplementation on Postoperative Bleeding in Infants Undergoing Complex Cardiac Surgery

Rizza,

Pergolizzi,

Benegni

et al. 2024

Pediatr Cardiol

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Protocol Adherence When Managing Massive Bleeding Following Complex Cardiac Surgery: A Study Design Pilot

Cited by 12 publications

References 26 publications

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery

Management of refractory bleeding post-cardiopulmonary bypass in an acute heparin-induced thrombocytopenia type II renal failure patient who underwent urgent cardiac surgery with bivalirudin (Angiox^®) anticoagulation

Effects of Fibrinogen Concentrate Supplementation on Postoperative Bleeding in Infants Undergoing Complex Cardiac Surgery

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Protocol Adherence When Managing Massive Bleeding Following Complex Cardiac Surgery: A Study Design Pilot

Cited by 12 publications

References 26 publications

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery

Performance of functional fibrinogen thromboelastography in children undergoing congenital heart surgery

Management of refractory bleeding post-cardiopulmonary bypass in an acute heparin-induced thrombocytopenia type II renal failure patient who underwent urgent cardiac surgery with bivalirudin (Angiox®) anticoagulation

Effects of Fibrinogen Concentrate Supplementation on Postoperative Bleeding in Infants Undergoing Complex Cardiac Surgery

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Management of refractory bleeding post-cardiopulmonary bypass in an acute heparin-induced thrombocytopenia type II renal failure patient who underwent urgent cardiac surgery with bivalirudin (Angiox^®) anticoagulation