Hostname: page-component-cd9895bd7-gbm5v Total loading time: 0 Render date: 2024-12-26T23:02:57.407Z Has data issue: false hasContentIssue false
  • English
  • Français

Preventing and managing postoperative bleeding in cardiac surgery by controlling disseminated intravascular coagulation

Published online by Cambridge University Press:  01 June 2007

J. Szefner
J. Szefner*
Affiliation:
Haemostasis Cardiovascular Surgery Department, La Pitié Hospital, Paris, France
*
Correspondence to: Jacques Szefner, MD., Haemostasis Cardiovascular Surgery Department, La Pitie Hospital, Paris, France.
Get access

Summary

Background and objectives

Bleeding in cardiac surgery is still one of the major concerns for cardiac surgeons and anaesthesiologists. The present review addresses the main pathophysiological mechanisms underlying bleeding after cardiac operations, and analyzes possible therapeutic strategies.

Methods

Overview of different bleeding mechanisms and related diagnostic and therapeutic approaches, with specific respect to disseminated intravascular coagulopathy.

Results

Biological bleeding after cardiac operations depends on the interaction of platelet activity, the procoagulant system, and the fibrinolytic system. A diagnostic and therapeutic approach based on a four-phase model of disseminated intravascular coagulation and haemostasis imbalance is presented. At each step, adequate diagnostic tools (thromboelastography and antithrombin activity) are required to make a diagnosis and guide the appropriate treatment.

Conclusions

Bleeding is not a fatality. Quite the contrary, it must be treated through a multi-system approach, and as early as possible, preferably at a biological phase before clinical bleeding. In addition, early monitoring and treatment adapted to each patient makes it possible to better follow a patient’s evolution and helps reduce the occurrence of later thromboembolic events.

Keywords

Bleeding; Cardiac surgery; DIC; Assist Devices; Thromboelastography; Antithrombin III
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue S40 , June 2007 , pp. 59 - 66
Copyright
Copyright © European Society of Anaesthesiology 2007

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Selected Bibliography

1.Bellon, JL, Szefner, J, Cabrol, C. Coagulation et coeur artificiel, 1st ed. Paris: Masson, 1989.Google Scholar
2.Bonaros, N, Mueller, MR, Salat, A et al. . Extensive coagulation monitoring in patients after implantation of the MicroMed DeBakey continuous flow axial pump. ASAIO Journal 2004; 50: 424–431.CrossRefGoogle ScholarPubMed
3.Bukhari, EA, Krukenkamp, IB, Burns, PG et al. . Does Aprotinin increase the myocardial damage in the setting of ischemia and preconditioning? Ann Thorac Surg 1995; 60: 307–310.CrossRefGoogle ScholarPubMed
4.Cabrol, C, Pavie, A, Szefner, J et al. . Management of surgical bleeding in cardiopulmonary bypass surgery In: Pifarré, R (ed). Management of bleeding in cardiovascular surgery. Philadelphia: Hanley & Belfus, 2000: pp 469–474.Google Scholar
5.Copeland, J, Arabia, F, Tsau, P et al. . Total artificial hearts bridge to transplantation. Cardiol Clin 2003; 21: 105–117.CrossRefGoogle ScholarPubMed
6.Copeland, J, Szefner, J. Anticoagulants and the artificial heart In: Lewis, T, Graham, TR (eds). Mechanical circulatory support. London: Edward Arnold, 1995: pp 306–311.Google Scholar
7.Dewald, O, Fischlein, T, Vetter, HO et al. . Platelet morphology in patients with mechanical circulatory support. Eur J Cardiothorac Surg 1997; 12: 634–641.CrossRefGoogle ScholarPubMed
8.Drews, T, Loebe, M, Szefner, J et al. . Assistance biventriculaire de longue durée avec le système d’assistance pneumatique biventriculaire externe Berlin-Heart. J Chir Thorac Cardiovasc 2000; 3: 129–136.Google Scholar
9.Gando, S, Kameue, T, Nanzaki, S, Nakanishi, Y. Disseminated intravascular coagulation is a frequent complication of systemic inflammatory response syndrome. Thromb Haemost 1996; 75: 224–228.Google ScholarPubMed
10.Glauber, M, Szefner, J, Senni, M et al. . Reduction of haemorrhagic complications during mechanically assisted circulation with the use of a multi-system anticoagulation protocol. Int J Artif Organs 1995; 18: 649–655.CrossRefGoogle ScholarPubMed
11.Harker, L. Bleeding after cardiopulmonary bypass. N Engl J Med 1986; 314: 1446–1448.CrossRefGoogle ScholarPubMed
12.Hathaway, WE, JrGoodnight, SH. Disseminated intravascular coagulation In: Hathaway, WE, JrGoodnight, SH (eds). Disorders of hemostasis and thrombosis: a clinical guide. New York: McGraw-Hill Inc., 1993: pp 219–229.Google Scholar
13.Koster, A, Loebe, M, Hansen, R et al. . Alterations in coagulation after implantation of a pulsatile Novacor LVAD and the axial flow MicroMed DeBakey LVAD. Ann Thorac Surg 2000; 70: 533–537.CrossRefGoogle ScholarPubMed
14.JrLemmer, JH, Despotis, GJ. Antithrombin III concentrate to treat heparin resistance in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2002; 123: 213–217.CrossRefGoogle ScholarPubMed
15.Leprince, P, Pavie, A, Szefner, J et al. . Le cœur artificiel total Cardiowest, à propos de 29 cas. Arch Mal Cœur et Vx 1998; 91: 397–404.Google Scholar
16.Livingston, ER, Fischer, CA, Bibidakis, EJ et al. . Increased activation of the coagulation and fibrinolytic systems leads to hemorrhagic complications during left ventricular assist implantation. Circulation 1996; 94 (suppl II): 227–234.Google ScholarPubMed
17.Mohr, R, Goor, DA, Lavee, J. Fresh whole blood In: Mohr, R, Goor, DA, Lavee, J (eds). Management of bleeding after open heart surgery. Heidelberg: Springer, 1997: pp 111–121.Google Scholar
18.Murphy, PJ, Connery, C, Hicks, GL et al. . Homologous blood transfusion as a risk factor for postoperative infection after coronary artery bypass graft operations. J Thorac Cardiovasc Surg 1992; 104: 1092–1099.CrossRefGoogle ScholarPubMed
19.Pavie, A, Szefner, J, Leger, P et al. . Preventing, minimizing and managing postoperative bleeding. Ann Thorac Surg 1999; 68: 705–710.CrossRefGoogle ScholarPubMed
20.Quaini, E, Pavie, A, Chieco, S, Mambrito, B, and the Registry Committee. The Concerted Action “Heart” European registry on clinical application of mechanical circulatory support systems: bridge to transplant. Eur J Cardiothorac Surg 1997; 11: 182–188.CrossRefGoogle ScholarPubMed
21.Raby, C. Coagulations intravasculaires disséminées et localisées, 2nd ed. Paris: Masson, 1974.Google Scholar
22.Ranucci, M, Ditta, A, Boncilli, A et al. . Determinants of antithrombin consumption in cardiac operations requiring cardiopulmonary bypass. Perfusion 2004; 19: 47–52.CrossRefGoogle ScholarPubMed
23.Ranucci, M, Frigiola, A Menicanti L et al. . Postoperative antithrombin levels and outcome in cardiac operations. Crit Care Med 2005; 33: 355–360.CrossRefGoogle ScholarPubMed
24.Salsberg, S, Lachat, M, Zünd, G et al. . Left ventricular assist device as bridge to heart transplantation – lessons learned with the MicroMed DeBakey axial blood flow pump. Eur J Cardiothorac Surg 2003; 24: 113–118.CrossRefGoogle Scholar
25.Spanier, T, Oz, M, Levin, H et al. . Activation of coagulation and fibrinolytic pathways in patients with left ventricular assist devices. J Thorac Cardiovasc Surg 1996; 112: 1090–1097.CrossRefGoogle ScholarPubMed
26.Szefner, J, Cabrol, C. Control and treatment of hemostasis in patients with a total artificial heart: The experience of La Pitié In: Pifarre, R (ed). Anticoagulation, Hemostasis, and Blood Preservation in Cardiovascular Surgery. Philadelphia: Hanley & Belfus, 1993: pp 237–264.Google Scholar
27.Szefner, J, Pavie, A, Leger, P et al. . Supervision and treatment of hemostasis in 82 patients implanted with a total artificial heart at La Pitié hospital. Thromb Haemost 1995; 73: 1043.Google Scholar
28.Szefner, J. Apport de l’étude de la fonction plaquettaire et de la cinétique coagulo-lytique dans le contrôle et le traitement des transplantés cardiaques In: Laboratoires, Sandoz (ed). Transplantation Cardiaque. France: Rueil-Malmaison, 1989: pp 80–87.Google Scholar
29.Szefner, J. Control and treatment of hemostasis in cardiovascular surgery. The experience of La Pitié Hospital with patients on total artificial heart. Int J Artif Organs 1995; 18: 633–648.CrossRefGoogle ScholarPubMed
30.Teoh, KH, Christakis, GT, Weisel, RD et al. . Dipyridamole preserved platelet and reduced blood loss after cardiopulmonary bypass. J Thorac Cardiovasc Surg 1988; 96: 332–341.CrossRefGoogle ScholarPubMed
31.Vinazzer, HA. Antithrombin III in shock and disseminated intravascular coagulation. Clin Appl Thrombosis/Hemostasis 1995; 1: 62–65.CrossRefGoogle Scholar
32.Vitali, E, Lanfranconi, M, Ribera, E et al. . Successful experience in bridging patients to heart transplantation with the MicroMed DeBakey ventricular assist device. Ann Thorac Surg 2003; 75: 1200–1204.CrossRefGoogle ScholarPubMed
33.Wahba, A, Black, G, Koksch, M et al. . Aprotinin has no effect on platelet activation and adhesion during cardiopulmonary bypass. Thromb Haemost 1996; 5: 844–848.Google Scholar
34.Wegner, J, DiNardo, J, Arabia, F et al. . Blood loss and transfusion requirements in patients implanted with a mechanical circulatory support device undergoing cardiac transplantation. J Heart Lung Transplant 2000; 19: 504–506.CrossRefGoogle ScholarPubMed