Bleeding related to cardiac surgery

Cardiac surgery has now been performed for over a hundred years. Research in the heart-lung machine by Dr. Gibbon made cardiopulmonary bypass (CPB) a reality, and advancements in the field in the 1950s and 1960s have made cardiac surgery what we know today. However, with these innovations came the realization of major bleeding complications in this subpopulation of patients, accounting for nearly 25% of transfused products in the United States. The risk factors for bleeding in cardiac surgery patients manifest intraoperatively, primarily due to the effects of CPB, including hypothermia and hyperfibrinolysis, and secondarily due to massive transfusion and dilutional coagulopathy. Furthermore, some of these effects may persist into the immediate postoperative period. Additionally, there are also preoperative risk factors to consider such as medication effect (anticoagulants, antiplatelet medications), previous sternal surgeries, and history of liver disease and/or renal insufficiency. Management can include evaluation by a qualified physician for bleeding risk assessment to determine the severity of bleeding complications that may occur in the perioperative period, and if appropriate, delay surgery if the risks of bleeding outweigh the benefits. However, in many situations, these patients are critical and require immediate surgery. In these cases, management of coagulopathy can include not only blood product support but also consideration of reversal of anticoagulation with appropriate reversal agents, management of massive transfusion, and in cases of severe bleeding, consideration of hemostatic agents such as prothrombin complex concentrates, fibrinogen concentrate, and recombinant activated factor VII.