Postoperative Bleeding and Blood Products

Bleeding is considered excessive if:

  • >400mls in the first hours

 
OR after the first hour, it is greater than:

  • 250 ml/30 mins x 1

  • 150 ml/30 mins x 2

  • 100 ml/30 mins x 4

 
Or a marked increase after being acceptable (not after being turned for the first time)

 

The longer a patient bleeds, the worse the coagulopathy becomes.

 

The commonest non-surgical reasons for bleeding are platelet problems (too few or abnormal function), and unreversed heparin effect.  Platelet function is impaired by CPB/heparin and in patients who have been on aspirin pre-operatively.  Long bypass times increase the risk of platelet dysfunction.

 

If a patient is bleeding excessively, the Intensive Care Specialist & the Surgeon must be informed.  However a treatment plan should be formulated prior to discussion with the surgeon to avoid delay in treatment.
 

For the CABG patient who has moderate blood loss on arrival from theatre and an abnormal coagulation profile (usually due to heparin effect).

  • If the bleeding settles, no treatment is required and there is no need to repeat the coagulation profile.

  • If the bleeding does not settle over 2 hours and patient is haemodynamically stable, a treatment plan might include low dose Protamine 25-50 mg, 1 pool of platelets (irrespective of the platelet count) & consider repeat FBC and coagulation profile (INR, APTT & Fibrinogen), (Protamine of no use after 3-4 hours).

  • If haemodynamically unstable, contact Intensive Care Specialist & the surgeon.

 
Ongoing bleeding in the presence of a normal coagulation profile may be indicative of a surgical cause of bleeding.  Inform the Intensive Care Specialist & the Surgeon.

 

Treatment for excessive bleeding

  • Sedation

      • Morphine, midazolam/Propofol

  • Warm to 37°C

  • Shivering

      1. Pethidine 25-50mg

      2. Muscle relaxant

  • Control hypertension

      • Nitro glycerine

  • Platelets, clotting factors

 

There is a standing order with blood bank for any bypass patient who is bleeding excessively to have platelets and cryoprecipitate without consultation with blood bank if appropriate criteria are met (see over). 

 

After this has been given, the need for further platelets or cryoprecipitate must be discussed with the on call blood transfusion specialist.  Plasma should not be used in the first instance.

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Page last reviewed: 13 May 2014
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