Point-of-Care Algorithm for Bleeding Management in Cardiovascular Surgery Guided by Thromboelastometry and Whole-Blood Impedance Aggregometry
Point-of-Care Algorithm for Bleeding Management in Cardiovascular Surgery Guided by Thromboelastometry and Whole-Blood Impedance Aggregometry - Flowchart Point-of-Care Algorithm for Bleeding Management in Cardiovascular Surgery Guided by Thromboelastometry and Whole-Blood Impedance Aggregometry Point-of-Care Algorithm for Bleeding Management in Cardiovascular Surgery Guided by Thromboelastometry and Whole-Blood Impedance Aggregometry
«Flowchart»

Cardiovascular algorithm
Diffuse bleeding after heparin-reversal and blood transfusion considered

Cardiovascular algorithm
Diffuse bleeding after heparin-reversal and blood transfusion considered

Cardiovascular algorithm
Diffuse bleeding after heparin-reversal and blood transfusion considered

Cardiovascular algorithm
and

YES

YES

YES

YES

Tranexamic acid 25 mg/kg as a single bolus (in addition to the local protocol)

Tranexamic acid 25 mg/kg as a single bolus (in addition to the local protocol)

Tranexamic acid 25 mg/kg as a single bolus (in addition to the local protocol)

Tranexamic acid 25 mg/kg as a single bolus

Protamine 25-50 mg (2.5-5 mL) (then recheck ACT and INTEM/HEPTEM)

Protamine 25-50 mg (2.5-5 mL) (then recheck ACT and INTEM/HEPTEM)

Protamine 25-50 mg (2.5-5 mL) (then recheck ACT and INTEM/HEPTEM)

Protamine 25-50 mg (2.5-5 mL)

End

End

End

Cryoprecipitate1 or Fibrinogen concentrate2,3
Target: A10FIB≥12 mm

Cryoprecipitate1 or Fibrinogen concentrate2,3
Target: A10FIB≥12 mm

Cryoprecipitate1 or Fibrinogen concentrate2,3
Target: A10FIB≥12 mm

Cryoprecipitate1 or Fibrinogen concentrate2,3 1 1 2 2 ,3 3
FIB ≥

A10EX <40 mm and A10FIB <10 mm

A10EX <40 mm and A10FIB <10 mm

A10EX <40 mm and A10FIB <10 mm

EX and FIB

YES

YES

YES YES

NO

NO

NO NO

Platelet concentrate
1-2 pooled or apheresis

Platelet concentrate
1-2 pooled or apheresis

Platelet concentrate
1-2 pooled or apheresis

Platelet concentrate

A10EX <40 mm and A10FIB ≥10 mm or platelet dysfunction!

A10EX <40 mm and A10FIB ≥10 mm or platelet dysfunction!

A10EX <40 mm and A10FIB ≥10 mm or platelet dysfunction!

EX and FIB ≥ or

YES

YES

YES YES

NO

NO

NO NO

FFP 10-15 ml/kg bw or 4F-PCC 15-25 IU/kg bw3,4

FFP 10-15 ml/kg bw or 4F-PCC 15-25 IU/kg bw3,4

FFP 10-15 ml/kg bw or 4F-PCC 15-25 IU/kg bw3,4

3 3 ,4 4

Ongoing bleeding

Ongoing bleeding

Ongoing bleeding

FFP 10-15 ml/kg bw

FFP 10-15 ml/kg bw

FFP 10-15 ml/kg bw

CTIN and CTHEP >240 s

CTIN and CTHEP >240 s

CTIN and CTHEP >240 s

IN and HEP

YES

YES

YES YES

NO

NO

NO NO

YES

YES

YES

YES

Recheck after 10-15 min using a new blood sample

Recheck after 10-15 min using a new blood sample

Recheck after 10-15 min using a new blood sample

CTEX >80 s

CTEX >80 s

CTEX >80 s

EX

YES

YES

YES YES

NO

NO

NO NO

A10EX <45 mm or CTFIB >600 s or ML ≥15% (within 60 min)

A10EX <45 mm or CTFIB >600 s or ML ≥15% (within 60 min)

A10EX <45 mm or CTFIB >600 s or ML ≥15% (within 60 min)

EX FIB ≥

YES

YES

YES YES

DONE

DONE

DONE DONE

NO

NO

NO NO

ACTafter Protamine >ACTBaseline and CTIN >>CTHEP

ACTafter Protamine >ACTBaseline and CTIN >>CTHEP

ACTafter Protamine >ACTBaseline and CTIN >>CTHEP

after Protamine Baseline and IN HEP

YES

YES

YES YES

NO

NO

NO NO

1 10 U Cryoprecipitate !!doubleapprox!! 2 g Fibrinogen concentrate

1 10 U Cryoprecipitate !!doubleapprox!! 2 g Fibrinogen concentrate

1 10 U Cryoprecipitate !!doubleapprox!! 2 g Fibrinogen concentrate

1

2 Fibrinogen dose (g) = targeted increase in A10FIB (mm) × body weight (kg)/160

2 Fibrinogen dose (g) = targeted increase in A10FIB (mm) × body weight (kg)/160

2 Fibrinogen dose (g) = targeted increase in A10FIB (mm) × body weight (kg)/160

2 FIB

3 Off-label use in the US

3 Off-label use in the US

3 Off-label use in the US

3

4 45-90 µg rFVIIa/kg bw (if A10EX and A10FIB are ok and 4F-PCC is not available and FFP is not effective)

4 45-90 µg rFVIIa/kg bw (if A10EX and A10FIB are ok and 4F-PCC is not available and FFP is not effective)

4 45-90 µg rFVIIa/kg bw (if A10EX and A10FIB are ok and 4F-PCC is not available and FFP is not effective)

4 EX and FIB and and