Distinguishing surgical from coagulopathic bleeding, a targeted (viscoelastic-guided) correction bundle, when to call for re-exploration, recognising post-operative tamponade, and the cardiac-surgery-specific arrest protocol (CALS/STS: three shocks, pace, resternotomy within 5 minutes).
At the bedside
Timed steps- 1
Measure bleeding
HourlyRecord drain output every hour (more often if heavy); check for clots in tubing, Hb, ACT, platelet count, PT/INR, aPTT, fibrinogen, ionised calcium, temperature and, where available, TEG/ROTEM.
- 2
Basics: warm, calcium, pressure
FirstNormothermia (≥36 °C), ionised calcium >1.1 mmol/L, pH >7.2, avoid hypertension (agree a lower SBP/MAP target with the surgeon), PEEP may be modestly increased only with surgeon agreement.
- 3
Correct coagulopathy
TargetedResidual heparin (ACT prolonged / heparinase test): protamine 25–50 mg slow IV. Fibrinogen <1.5 g/L: cryoprecipitate or fibrinogen concentrate. Platelets <50–100 × 10⁹/L or antiplatelet drugs: platelets ± desmopressin 0.3 mcg/kg. Prolonged clotting times: FFP or prothrombin complex concentrate. Tranexamic acid if hyperfibrinolysis or per protocol.
- 4
Call the surgeon early
EscalateRe-exploration is usually considered for heavy ongoing bleeding (commonly quoted: >400 mL in the first hour, >200 mL/h for 2–4 h, or sudden increase) despite correction, or any haemodynamic compromise/tamponade. Do not 'chase' surgical bleeding with blood products alone.
- 5
Recognise post-operative tamponade
TamponadeHypotension, tachycardia (or loss of pacing response), rising CVP and filling pressures, falling cardiac output/urine, rising lactate, widening mediastinum, sudden drop in drain output (clotted tubes). Can be LOCALISED (clot over right atrium/ventricle) with atypical echo — TOE if transthoracic views are poor.
- 6
Three stacked shocks first
Arrest VF/pVTWitnessed VF/pVT in a monitored post-cardiac-surgery patient: up to 3 rapid successive shocks (within ~1 min) BEFORE external compressions; amiodarone 300 mg after the third failed shock.
- 7
Pace first
Arrest brady/asystoleAsystole or extreme bradycardia: if pacing wires present, pace DDD at 80–100/min at maximum output before starting CPR; atropine 1 mg if no wires.
- 8
Turn off pacing, think tamponade
Arrest PEAPEA: pause pacing to exclude underlying VF; start CPR; hypovolaemia/tamponade/tension pneumothorax are likely. Avoid full-dose adrenaline (1 mg) — consider small doses only on senior advice.
- 9
Emergency resternotomy
≤5 minIf no ROSC after the above, prepare for emergency resternotomy within 5 minutes (within ~10 days of surgery) — the resternotomy kit should be in the ICU; six key roles (compressions, airway, defibrillation, team leader, drugs, ICU coordinator).
Residual heparin effect
Protamine sulfate
- Dose
- 25–50 mg over ≥10 min (1 mg per ~100 units residual heparin)
- Worked example
- ACT 180 s with heparinase-corrected normal: protamine 25 mg (2.5 mL of 10 mg/mL) over 10 min, recheck ACT.
Post-operative bleeding with fibrinolysis
Tranexamic acid
- Dose
- 1 g over 10 min (protocol-dependent)
- Worked example
- 70 kg: 1 g = 2 ampoules of 500 mg/5 mL in 100 mL saline over 10 min.
Platelet dysfunction (antiplatelet drugs, uraemia)
Desmopressin (DDAVP)
- Dose
- 0.3 mcg/kg in 50 mL saline over 20–30 min
- Worked example
- 70 kg: 21 mcg (≈5 ampoules of 4 mcg) over 30 min.
VF/pVT after three failed shocks
Amiodarone
- Dose
- 300 mg bolus
- Worked example
- 300 mg (2 ampoules of 150 mg/3 mL) IV/central bolus.
Targeted correction of post-cardiac-surgery bleeding
| Test result | Treatment |
|---|---|
| ACT prolonged (corrects with heparinase) | Protamine 25–50 mg |
| Fibrinogen <1.5 g/L (or low FIBTEM/functional fibrinogen) | Cryoprecipitate (≈10 units) or fibrinogen concentrate 2–4 g |
| Platelets <50–100 × 10⁹/L, or recent antiplatelet drugs | Platelet transfusion; desmopressin 0.3 mcg/kg |
| PT/INR prolonged, low factor activity (EXTEM CT prolonged) | FFP 15 mL/kg or prothrombin complex concentrate |
| Hyperfibrinolysis on ROTEM/TEG | Tranexamic acid |
| Ionised calcium <1.1 mmol/L | Calcium chloride/gluconate |
| Temperature <36 °C | Active warming |
Values and products per local blood bank; viscoelastic testing reduces unnecessary transfusion (EACTS/EACTA PBM).
Cardiac surgery arrest: six key roles
| Role | Task |
|---|---|
| 1. External compressions | Start after shocks/pacing if no ROSC |
| 2. Airway and breathing | 100% O₂; check tube, exclude tension pneumothorax; disconnect PEEP |
| 3. Defibrillation | Three stacked shocks for VF/pVT |
| 4. Team leader | Runs the protocol, calls resternotomy |
| 5. Drugs and syringe drivers | Stop non-essential infusions; amiodarone; avoid 1 mg adrenaline |
| 6. ICU coordinator | Calls surgeon, prepares resternotomy kit and sterile field |
References
- 1
- 2
- 3
- 4
Arrest after cardiac surgery (CALS/STS)
Step 1 of ~5
Modified ALS for monitored patients after cardiac surgery.
Decision: Rhythm?
Based on Dunning J, Levine A, Ley J, et al; Dunning J, Fabbri A, Kolh PH, et al. Educational use; follow local protocol.
Pathophysiology
Tamponade after cardiac surgery is often caused by clot rather than free fluid; the open pericardium allows localised compression of a single chamber (commonly the right atrium or right ventricle), so classical signs (equalisation of pressures, pulsus paradoxus) may be absent. Coagulopathy after bypass reflects heparin, haemodilution, platelet activation/consumption on the circuit and fibrinolysis.
Evidence
- EACTS/EACTA 2017 Patient Blood Management guideline: pre-operative anaemia management, antifibrinolytics, viscoelastic-guided transfusion algorithms (IIa), fibrinogen/PCC use, restrictive thresholds, and protamine dosing.
- STS 2017 expert consensus (building on EACTS 2009 guideline): for arrest after cardiac surgery, three sequential shocks before compressions for VF/VT, immediate pacing for asystole/bradycardia, early emergency resternotomy (within 5 min) and avoidance of routine 1 mg adrenaline; resuscitation teams train with CALS (Cardiac Surgical Advanced Life Support).
- Survival after arrest following cardiac surgery is much higher than in other in-hospital arrests (often quoted around 50%) because causes are frequently reversible (tamponade, bleeding, graft occlusion, arrhythmia).
Controversies
- Fixed volume thresholds vs clinical judgment for re-exploration.
- Fibrinogen concentrate vs cryoprecipitate (FIBRES trial: non-inferior).
- Prophylactic tranexamic acid dose (OPTIMAL trial: high vs low dose — high dose reduced transfusion, seizure risk similar in that trial).
🇮🇳 India notes
- Fibrinogen concentrate and PCC are costly and not universally stocked in India — cryoprecipitate is the usual source of fibrinogen; know your blood bank's turnaround time.
- TEG/ROTEM is available mostly in large cardiac centres; standard lab coagulation tests and clinical judgment are used elsewhere.
- Every cardiac surgical ICU should have a sterile resternotomy pack and a CALS-trained team at the bedside 24/7.
References
- 1
- 2
- 3
- 4
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.