Post-Cardiac Surgery Bleeding Management (EACTS 2024)

Algorithm Steps

1. ▶

   Start

   Post-Cardiac Surgery Bleeding

   Elevated chest tube output or hemodynamic instability in post-op period

   1. ◆

      Decision

      Assess Bleeding Severity

      Quantify chest tube output and clinical status

      • Measure chest tube output hourly
      • Trend hemoglobin/hematocrit
      • Assess hemodynamic stability
      • Check for signs of tamponade
      1. ⚠

         Warning

         ⚠️ MASSIVE BLEEDING

         >400 mL/hr or hemodynamic collapse

         • Activate massive transfusion protocol
         • Prepare for immediate re-exploration
         • Call cardiac surgery STAT
         1. ●

            Action

            Return to OR

            Surgical re-exploration

            • Median sternotomy re-opening
            • Evacuate clot
            • Identify and control surgical bleeding
            • Irrigate and reclose
            • Continue hemostatic resuscitation
            1. ✓

               Outcome

               Bleeding Controlled

               Continue routine post-op care

         2. ⚠

            Warning

            ⚠️ Rule Out Tamponade

            Sudden drop in chest tube output + hypotension = assume tamponade until proven otherwise

      2. ●

         Action

         Significant Bleeding

         >200 mL/hr for 2+ hours

         • Check chest tubes for patency - milk gently
         • Warm patient to 37°C
         • Correct acidosis
         • Obtain coagulation labs + viscoelastic test
         1. ●

            Action

            Coagulation Assessment

            Use viscoelastic testing if available

            • TEG or ROTEM preferred over conventional tests
            • Check: PT/INR, aPTT, fibrinogen, platelets
            • Consider heparin rebound (protamine re-dose)
            • Assess platelet function if on antiplatelet agents
            1. ●

               Action

               Correct Coagulopathy

               Guided by TEG/ROTEM or conventional labs

               • Fibrinogen <1.5 g/L: Fibrinogen concentrate or cryoprecipitate
               • Platelets <100 × 10⁹/L: Platelet transfusion
               • INR >1.5: PCC or FFP (PCC preferred)
               • Heparin rebound: Protamine 25-50 mg
               • Consider desmopressin (DDAVP) 0.3 mcg/kg
               • Tranexamic acid if ongoing fibrinolysis
               1. ◆

                  Decision

                  Re-exploration Indicated?

                  Assess need for surgical intervention

                  • Indications for re-exploration:
                  • • >400 mL in first hour
                  • • >200 mL/hr for 4 hours despite correction
                  • • Sudden cessation of drainage (clot)
                  • • Hemodynamic instability
                  • • Signs of tamponade
                  1. ●

                     Action

                     Continue Medical Management

                     If bleeding controlled with correction

                     • Serial hemoglobin monitoring (q2-4h)
                     • Continue warming
                     • Maintain Hb >7-8 g/dL (>8-9 if ongoing bleeding)
                     • Watch for delayed tamponade
               2. ●

                  Action

                  Transfusion Targets

                  Restrictive approach when stable

                  • Hemoglobin trigger: 7-8 g/dL (stable)
                  • Higher threshold if active bleeding/ischemia
                  • Avoid over-transfusion (increased complications)
                  • Use cell salvage when available
      3. ●

         Action

         Moderate Bleeding

         100-200 mL/hr

         • Monitor closely
         • Check coagulation status
         • Optimize temperature and pH
         • Review anticoagulation status