Prothrombin Complex Concentrate for Coagulopathy and Bleeding After Cardiopulmonary Bypass

Introduction

Post-cardiopulmonary bypass or CPB coagulopathy and bleeding are some of the most common blood transfusion causes during surgical procedures. All the latest retrospective findings suggest that a lower transfusion rate, as well as a drastic blood loss in patients who are receiving PCC or prothrombin complex, concentrate PCC as compared to plasma post cardiac surgery are seen. PCC or prothrombin complex concentrates are, at times, used for excessive bleeding post-CPB cardiopulmonary bypass. An excessive amount of bleeding after a serious cardiac surgery is one of the major reasons linked with increased morbidity as well as the rate of mortality. Transfusion of several blood products, along with surgical re-exploration, must be frequently done. Bleedings may be related to an altered state of hemostasis chiefly because of the dilution of blood components, called factors. This may additionally occur due to any kind of surgical trauma.

Prothrombin complex concentrate, or PCC, was initially indicated for the accurate treatment of hemophilia B. The usage of prothrombin complex concentrates, or PCC has been directed for the rapid treatment of coagulation defects. Prothrombin complex concentrates are not yet recommended by healthcare professionals all around the globe. On the flip side, in a few nations, prothrombin complex concentrates are widely used in the form of fresh frozen plasma, referred to as FFP. Prothrombin complex concentrates also provide a vast number of advantages over fresh frozen plasma. A few of the positives of prothrombin complex concentrates are mentioned below.

• A lower infusion volume.

• An ambient storage availability.

• Rapid reconstitution.

• An immediate availability.

• A lack of blood group specificity.

• An enhanced safety profile.

It should be acknowledged that the administration of prothrombin complex concentrate for the management of massive bleeding disorders and conditions is fairly based on a low level of data and evidence. Nevertheless, prothrombin complex concentrate has demonstrated some extent of efficacy in animal data and research. Several reports of using prothrombin complex concentrate or PCC after CPB or cardiopulmonary bypass are too sparse. In recent times, the first-line treatment of administration of fibrinogen concentrate and prothrombin complex concentrate, along with the point-of-care testing, was linked with a reduced intraoperative incidence of blood transfusions. Furthermore, the incidences of huge blood transfusions and thrombotic events along with thromboembolic events are additionally decreased.

What Is the Anesthetic Management for Prothrombin Complex Concentrate for Coagulopathy and Bleeding After Cardiopulmonary Bypass?

A cardiopulmonary bypass is a machine and terminology that is used to refer to the overtaking of the heart and lungs as well as their respective functions artificially via a machine during surgeries. This maintains the blood flow along with the oxygen supply throughout the body. Cardiopulmonary bypass behaves as an artificial heart and lung during serious surgeries that require operations in the heart as well as the lung and thus may need to be stopped to work for a brief amount of time. There are several ways to induce anesthesia in patients who are undergoing surgeries that require the aid of a cardiopulmonary bypass. Mentioned below are a few of the anesthetic management for prothrombin complex concentrate for coagulopathy as well as bleeding in patients who have completed a successful surgery that required cardiopulmonary bypass.

• Anesthesia can be induced with Etomidate, Sufentanyl, and Atracurium.

• For maintenance of the induced anesthesia, Sevoflurane is titrated to an end-tidal concentration of approximately one to two percent until the institution of cardiopulmonary bypass.

• During CPB or cardiopulmonary bypass, the induced anesthesia is to be maintained along with the infusion of Propofol or Midazolam.

• Sufentanyl may also be used for the same.

• Boluses of Atracurium can be administered whenever indicated.

• Red blood cells, or RBCs, are generally administered for the maintenance of hematocrit values above 28 % to 30 % in those patients suffering from coronary artery bypass graft, called CABG.

• Fresh frozen plasma or FFP, as well as the platelet concentrate, can be administered in accordance with the amount of bleeding and coagulopathy that the patient is suffering from.

• Bleeding time and blood sample results must be taken into consideration as well.

• Administration of certain drugs like Tranexamic acid, as well as prothrombin complex concentrate, is generally left to the discretion of the attending anesthetist.

• Aspirin may not be discontinued before any surgery.

• Clopidogrel can be discontinued five days before the scheduled surgery.

What Are the Complications for Prothrombin Complex Concentrate for Coagulopathy and Bleeding After Cardiopulmonary Bypass?

There are several complications during the administration of kind of anesthetic drug, even after management and careful analysis. This risk increases when the patient is suffering from coagulopathy and bleeding. On the other hand, sound knowledge of these complications is vital in order to precisely and immediately correct them. Mentioned below are a few of the complications of prothrombin complex concentrate for coagulopathy and bleeding after cardiopulmonary bypass.

• Acute myocardial infarction.

• Left bundle-branch block.

• A new pathological R waves.

• A significant elevation of troponine Ic.

• A clinical picture of hemodynamic instability.

• A suspicion of myocardial infarction.

• Graft occlusion.

• Cerebral infarction.

• Anew focal neurological defect.

• Pulmonary embolism which can be documented by a pulmonary arteriogram or an autopsy.

• A ventilation or perfusion radioisotope scan that shows a high probability of pulmonary embolism.

• Several symptomatic thrombotic reactions.

• Pericardial effusion which can be diagnosed by echocardiography.

• A thoracic computerized tomography scan.

• Mediastinitis, which can be understood as a deep wound infection linked with sternal osteomyelitis that may or may not present with an infected retrosternal space.

• Other infections in the body.

• ARDS or acute respiratory distress syndrome.

• No clinical evidence of left atrial hypertension.

Conclusion

Cardiopulmonary bypass can be understood to be an artificial mechanism that helps and works as a replacement of the functioning of the heart and the lungs before, during, or after a surgery that involves the heart and the lungs and requires these two vital organs to be temporarily stopped from performing their respective function. There is a particular management strategy that should be followed by anesthetists with respect to sedating the patient, especially those who are going through conditions that are linked with coagulopathy and bleeding post-completion of a successful surgery. It is necessary for the entire team of anesthetists to be well aware of the advances in this particular aspect.