Cardiovascular Algorithm © Klaus Görlinger 2015 klaus@goerlinger.net 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. 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