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Perioperative coagulopathy in coronary artery bypass surgery

Perioperative coagulopathy in coronary artery bypass surgery. Dr Lelanie Pretorius MBChB, Mmed (Hemat), PG Dip (Transfusion Medicine) Dept of Haematology University of the Free State. content. Normal haemostasis Mechanisms of peri -operative coagulopathy Laboratory monitoring

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Perioperative coagulopathy in coronary artery bypass surgery

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  1. Perioperativecoagulopathyin coronary artery bypass surgery Dr Lelanie Pretorius MBChB, Mmed (Hemat), PG Dip (Transfusion Medicine) Dept of Haematology University of the Free State

  2. content • Normal haemostasis • Mechanisms of peri-operative coagulopathy • Laboratory monitoring • Management

  3. The major role players 3

  4. Endothelial function

  5. Classic coagulation cascade

  6. EXSTRINSIC INTRINSIC XIIa XII Complement and contact XIa XI activation IX IXa VIII, Pl & Ca++ X TISSUE FACTOR PL VII Ca++ X Xa V, Pl & Ca++ II IIa FIBRINOGEN FIBRIN IIa (Thrombin) COMMON PATHWAY

  7. Cell based model of coagulation

  8. Platelet function

  9. Inhibitors of coagulation

  10. Tissue Factor + factor VIIa TFPI Factor IXa (+ factor VIII) Factor Xa (+ factor Va) Anti- thrombin Factor IIa (thrombin) Factor XIa Protein C system Fibrinogen Fibrin

  11. fibrinolysis

  12. EXTRINSIC ACTIVATION INTRINSIC ACTIVATION Tissue Plasminogen Activator Urokinase-like Activator Factor XIIa Kallikrein Fibrin Fragment X Fragment Y + D Fragment E + D Plasminogen Plasmin Streptokinase

  13. Peri-operative coagulopathy Antithrombotic drugs Blood components Antifibrinolytic drugs

  14. Mechanism of coagulopathy in CABG Haemodilution HIGH INTENSITY PREOPERATIVE ANTITHROMBOTIC THERAPY

  15. Activation of coagulation

  16. Impaired haemostasis

  17. Platelets

  18. INCREASED FIBRINOLYSIS

  19. Haemodilution

  20. Identify high risk

  21. Blood conservation strategies

  22. Laboratory monitoring

  23. POC • ACT Prolonged by: Hypothermia Haemodilution Thrombocytopenia • PFA-100 Value proven in blood conservation • TEG

  24. Flow Platelet Plug PFA 100 Injured Blood Vessel PFA-100 Test Cartridge Agonist Collagen The system measures platelet function under high shear conditions similar to the environment of a partially occluded blood vessel

  25. PFA 100

  26. TEG measures What does it measure? • Viscoelastic changes that occur during coagulation • Graphical representation of fibrin polymerization • Thus measuring: • Rate of fibrin polymerization • Overall clot strength • Complete evaluation • Clot initiation • Clot formation and • Clot stability 29

  27. TEG Guided transfusion Clinical case • 57yo female with Marfan syndrome and history of aneurysm presents now with a second aneurysm. Platelet count is approximately 16K.

  28. Delayed clot formation Delayed Clot formation K R α° MA • Heparin Effect • Factor deficiency • Treatment: Protamine or FFP R K Angle MA 2- 8 min 1- 3 min 55 – 78 deg 53 – 69 mm 13 min 3 min 56 deg 60 mm

  29. Weak clot formation Weak Clot formation K R α° MA Treatment: FFP, platelets and possible cryoprecipitate R K Angle MA 2- 8 min 1- 3 min 55 – 78 deg 53 – 69 mm 5 min6 min35 deg 42 mm

  30. management

  31. To reduce of peri-operative bleeding and aim at blood conservation • Pharmacologic agents

  32. Drugs used to reduce blood loss

  33. Drugs ass with ↑ periop blood loss

  34. Blood products

  35. Additional transfusion related methods

  36. Other strategies used

  37. The Society of Thoracic Surgeons Blood Conservation Guideline Task Force, 2007: 83 (5): S27 – S86. • Perioperativecoagulopathy, bleeding and hemostasis during cardiac surgery. Makar et al. ICU Director,

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