Cardiac surgery correlates with multiple risks due to the threats linked to perioperative blood loss. However, it is vital to address the blood management post-intervention as certain risks persist and patients may encounter negative outcomes. Active bleeding, especially when it comes to post-cardiac surgery patients, can lead to the occurrence of strokes, myocardial infarctions, and death. Moreover, such complications can lead to the necessity of further cariad surgical interventions. As a result, bleeding management can minimize the risks and adverse outcomes in case the patient is prescribed adequate pre, peri, and post-surgical therapy. In this article, several bleeding prevention methods will be discussed from the perspective of practical use in post-cardiac surgery patients in intensive care units.
Fresh Frozen Plasma (FFP)
Fresh frozen plasma is the liquid component of blood that has been separated through a centrifuged and frozen. The post-surgical appliance of FFP is linked to the prevention of bleeding and blood clotting. Multiple studies have been examining the effects of the current therapeutical intervention. For example, Dieu et al. (2020) have studied the impact of FFP in pediatric cardiac surgery. The researchers highlight that it is applied for blood clotting prevention. Moreover, the results illustrate positive results in regard to a reduction in postoperative hemorrhages as well as the need for blood transfusions. Such results support the efficacy of the measure since the requirement of allogenic blood products has been linked to risks after cardiac interventions.
Fresh frozen plasma, however, is not the first choice when it comes to blood management during post-operative care for patients in ICUs. For example, studies show that prothrombin complex concentrate (PCC) is more effective when compared with FFP in regard to its effects on postoperative bleeding (Roman et al., 2019). There are several reasons why fresh frozen plasma is challenging in the post-surgery appliance for patients who underwent cardiac surgery. The plasma itself is to be frozen within the first eight hours after collection from a matching donor (Adam & Fischer, 2020). Moreover, the plasma may contain traces of drugs (shown in 12% of the cases), and the risk of transfusion-related conditions is present. Additional research comparing FFP and PPC highlights that FFP does not correlate with similar positive results in the minimization of risks associated with the need for red blood cell transfusions (Roman et al., 2019). Other disadvantages are illustrated as the large necessary volume for administration, inefficient acquisition guidelines, and difficulties in managing administration times.
It is certain that fresh frozen plasma does, indeed, addresses bleeding and is effective in regards to the replacement of coagulation factors in patients who underwent cardiac surgery. By containing procoagulants and anti-fibrinolytic components, FFP replenishes specific elements that are minimized due to intense bleeding. While several adverse effects and unfavorable circumstances linked to the administration of FFP have been highlighted, it is an evidence approach to blood management. Hence, researchers suggest that insufficient studies have been conducted to determine a specific link between FFP and higher morbidity or bleeding risks (Ikić, 2021). Nonetheless, limitations are to be considered in post-surgical cardiac patient care in intensive care units.
Fibrinogen Concentrate
Fibrinogen concentrate, similarly to FFP, is a plasma-derived component administered to patients to address acute hemorrhages. It, however, can also be a recombinant, yet both types are applied to maintain hemostasis. It is essential to highlight that low fibrinogen levels, both pre and post-cardiac surgery, have been linked to extensive bleeding (Ikić, 2021). This, in turn, raises the need for post-surgery blood transfusions, which ultimately have been suggested to correlate with negative outcomes for the patients. According to researchers, despite effective blood conservation techniques, evidence shows blood transfusion to be dangerous even for low-risk patients who have had cardiac surgeries (Arias-Morales et al., 2017). Thus, fibrinogen concentrate is administered with the purpose of maximizing the formation of clots and generating a more effective platelet adherence under the circumstance of vascular injury. One advantage of applying this particular method of blood management is its efficiency. According to researchers, fibrinogen concentrate is a plasma-derived component that is treated through various pathogen-reduction techniques and does not contain ABO blood group antibodies (Bolliger & Tanaka, 2017). Hence, unlike the appliance of other methods, such as interventions with the use of cryoprecipitate, it does not require matching the blood type of the donor and the recipient. As a result, post-cardio surgical patients can access this particular blood conservation technique relatively successfully.
Fibrinogen concentrate is often illustrated as comparable with a similar element, namely, cryoprecipitate. Both components assist in bleeding management and have been examined in studies assessing the similarities and differences between the two. According to researchers, fibrinogen concentrate is not inferior when analyzed alongside the administration of cryoprecipitate in cases of post-cardiac surgery. Specifically, Callum et al. (2019) examined the subsequent transfusions of various blood components, which remains low when one of the two elements is applied in treatment. The exact procedure that was examined was cardiopulmonary bypass with subsequent bleeding and hypofibrinogenemia, yet the results are applicable to an array of post-cardiac blood management procedures. The human blood coagulation factor is widely applied in minimizing bleeding, and research shows the method as successful in reducing risks correlating with the need for transfusion. Nonetheless, it is important to mention certain factors that may suggest other interventions as more efficient.
As mentioned, fibrinogen concentrate is often examined alongside cryoprecipitate, and specific research highlights the second option as potentially efficient in treating extensive bleeding for patients in ICU after undergoing cardiac surgery. Erdoes et al. (2019), while underlining that fibrinogen concentrate is an evidence-based component leading to positive post-surgical results, cryoprecipitate can be similarly applied when it comes to increasing the level of plasma fibrinogen. Moreover, researchers mention the importance of applying the measure to achieve normal levels of physiological fibrinogen that become lower due to extensive hemorrhaging. Thus, the achievement of supranormal levels is not advised when it comes to patient intervention.
Fibrinogen levels are also essential to consider during the pre-surgery preparation. However, as the topic of the current article is managing bleeding during post-surgery ICU stays, pre-intervention measures that will be discussed correlate with the overall outcomes. Researchers mention that efficient pre-intervention maintenance of adequate fibrinogen levels affects the possibility of bleeding during the post-surgical timespan (Ikić, 2021). Based on the aforementioned information, fibrinogen concentrate implemented before surgical interventions can lead to the facilitation of fewer risks later on.
Vitamin K
Similar to the compounds mentioned previously, namely, fresh frozen plasma and fibrinogen concentrate, vitamin K is applied in bleeding management. Thus, patients who have undergone cardiac surgery and are at risk of developing hemorrhages can benefit from being treated with vitamin K compounds as the measure implies assistance to the process of blood clotting. Unlike the previously described elements, the administration of vitamin K may be problematic due to the antagonists correlating with the intervention. Namely, researchers highlight the antagonistic relationship between vitamin K and warfarin, an anticoagulant that is widely applied to prevent the formation of blood clots (Roman et al., 2019). Since warfarin is sometimes applied in the treatment of patients undergoing cardiac problems, researchers highlight additional possibilities that can replace the appliance of warfarin of vitamin K prescribed, specifically, non-vitamin K antagonist oral coagulants. These include compounds such as dabigatran, apixaban, and similar elements (De Caterina et al., 2018). However, such considerations do not contradict the positive effects correlating with the administration of vitamin K for patients who underwent cardiac surgery and are being monitored and treated in intensive care units afterward.
As mentioned previously, pre-surgical consideration reduces the risks of peri and post-interventions. Researchers highlight that individuals whose treatment plan implemented the administration of vitamin K prior to the cardiac surgery procedures are less likely to develop complications during the post-surgical treatment (Bansal et al., 2020). Namely, it has been illustrated that such implementations minimize the need for use of blood components, hence, transfusions. As a result, the risks linked to blood transfusions are minimized, and patients are more likely to encounter beneficial outcomes after the surgery is performed.
Cryoprecipitate
Cryoprecipitate, similarly to fibrinogen concentrate, is a component derived from plasma. Moreover, the two share the characteristic of being applied in case the patient’s fibrinogen levels are below average. Cryoprecipitate can be used in peri and post-surgical interventions to address extensive bleeding. The distinct feature of this particular element is its form, namely, being nonpurified. As a result, fibrinogen is not the only element that it contains. The other components are fibronectin, platelet microparticles, and coagulation factors (Callum et al., 2019). Moreover, if compared with fibrinogen concentrate, cryoprecipitate has a shorter shelf life since the concentrate is to be applied within 24 hours after the thawing compared to approximately 4 hours. Despite the potential wastage risks, cryoprecipitate remains a preferred therapy in the US, which highlights its potential in blood management issues correlating with post-cardiac surgery patients in the ICU.
Besides the relatively short time span cryoprecipitate can be applied after thawing is performed, another factor that minimized its practical appliance is the aforementioned non-purification factor. The circumstance is linked to both adverse and positive effects. On the one hand, cryoprecipitate contains additional elements that may benefit the patient, hence, improving potential positive outcomes. On the other hand, since it is non-purified, it is not treated in relation to the potential pathogens it may contain (Bolliger & Tanaka, 2017). Moreover, this characteristic implies that the blood type is to be a consideration when it is administered to avoid incompatibilities. As a result, the short life stage after thawing and the need for consideration for blood type compatibilities create circumstances in which cryoprecipitate is not a preferred measure. However, the administration difficulties, while present, do not illustrate the lack of beneficial bleeding interventions correlating with the appliance of this method.
Prothrombin Complex Concentrate
Prothrombin complex concentrate (PCC) is a compound constructed from blood clotting factors II, IX, and X. It is administered when the patient is bleeding profusely, as well as if warfarin is administered and its effects are to be minimized. Thus, similarly to the aforementioned fresh frozen plasma, fibrinogen concentrate, vitamin K and cryoprecipitate, prothrombin is administered for bleeding management which is necessary when it comes to post-cardiac surgery patients in the ICU. Moreover, it is a compound of human plasma, yet it is known as a reliable substitute for fresh frozen plasma. Thus, it is widely used in post-surgical risks for bleeding are present and constitute a major problem for the patients (Katz et al., 2021). As PCC is a plasma compound, it is often compared with FFP when it comes to relevant research determining the efficacy of both elements.
There are significant benefits correlating with the administration of prothrombin complex concentrate over its less efficient analog, fresh frozen plasma. According to researchers, it has an advantage in regards to the reduced need for transfusions. Thus, it minimized potential adverse outcomes for patients in the ICU (Santana & Brovman, 2021). The safety profile is also evidence for the prothrombin complex concentrate administration being a preferred method. Moreover, its administration is much more efficient if compared to the compound that PCC partially emulates, fresh frozen plasma. As previously discussed, FFP’s administration and storage processes create circumstances in which it is more challenging to practical implementation.
On the other hand, researchers highlight that PCC is required in lower quantities. Hence, a smaller volume is more efficient in regard to frequent administration (Santana & Brovman, 2021). Furthermore, another benefit is the concentration of coagulation factors, a measure higher than one found when examining fresh frozen plasma. Last but not least, it is essential to mention the acquisition and administration time which is more adequate when contrasted to that of FFP. Based on the aforementioned information, it is evidence that prothrombin complex concentrate is not only effective in bleeding management for patients post-cardiac surgery but also less challenging in administration and acquisition management.
Desmopressin
Desmopressin, which is commonly known based on the tradename DDAVP, is an agent that is administered under various circumstances, including bleedings. However, it is essential to mention that desmopressin is commonly applied in the treatment of minor hemorrhages. As a synthetic derivative of vasopressin, an antidiuretic hormone, it can also be prescribed when addressing bed wetting and a variety of blood clotting disorders. However, in the case of extensive bleeding experienced by patients in ICU units recovering and being treated after cardiac surgery, the agent is less effective. Nonetheless, specific studies show the effectiveness of the measure when patients encounter platelet dysfunctions. Thus, the authors mention that desmopressin, if administered alongside platelet concentrate transfusions, generates the efficient operation of the blood fragments that facilitate the formation of clots (Ranucci et al., 2018). By advancing in platelet dysfunction mitigation, the blood is more prone to coagulation, and the risks for extensive bleeding are minimized as clots are formed accordingly. While the effect of DDAVP is commonly studied in regard to patients with inherited chronic blood conditions, evidence shows its potential effectiveness in post-surgical treatments and bleeding prevention measures.
Prior to surgery, including cardiac interventions, patients are administered various antiplatelet therapy measures. As a result, blood clots are not being generated, and risks are mitigated. However, the development of such interventions usually correlates with potential bleeding during the peri and post-surgical stages. According to researchers, despite patients receiving antiplatelet therapy, the administration of DDAVP was positive in regard to effects on bleeding time (Andersen et al., 2020). However, the results cannot be applied to the cardiac surgery framework as bleeding is more extensive. Thus, as mentioned prior, DVVAP, while beneficial in being administered to patients with hemophilic conditions and minor bleedings, is not effective in complex cardiac surgery. Since the opportunity of extensive bleeding development is much higher and blood management is a more prominent aim, other measures are to be considered that can address the risk-inducing challenges.
Tranexamic Acid
Tranexamic acid is a synthetic acid that, compared to the application of DDAVP, is prescribed when treating extensive bleeding. It works as an inhibitor of fibrinolysis. Hence, it is effective in generating the advancement in blood clotting processes. Its implementation has been researched from the perspective of poor blood management under various conditions. However, the efficacy of tranexamic acid in relation to the outcomes of cardiac surgery has also been proved. Thus, researchers mention that low doses of tranexamic acid correlate with positive outcomes for patients during the post-cardiac surgery phase (Zufferey et al., 2020). Based on the aforementioned circumstance, the synthetic compound effectively aggressive extensive bleeding by generating processes in which the blood clots more efficiently.
Moreover, the risks correlating with the need for blood transfusions are minimized, and patients are less likely to encounter complications linked to such measures. Tranexamic acid has also been described as being safe in functional appliances. Namely, researchers highlight that studies do not exemplify major side effects and risks despite certain patients being prescribed high doses of tranexamic acid (TXA) for a long period of time (Pabinger et al., 2017). As a result, it can be formulated that the measure is safe, relatively complication-free, and effective in addressing major bleeding in patients who underwent cardiac surgery and are being treated in intensive care units post-intervention.
The efficiency of TXA has been assessed through its application under various circumstances and in different demographics. While children are not the most common demographic linked to the need for cardiac surgery and subsequent treatment in ICUs, tranexamic acid has been analyzed from this particular perspective. Namely, researchers have determined that the implementation of bleeding management measures, including the administration of TXA in pediatric cardiac surgery, correlates with beneficial outcomes (Zhang et al., 2019). As a result, it became the most commonly used antifibrinolytic agent in cardiac surgery in 2008. By preventing the fibrin protein from breaking down, the agent facilitates the generation of circumstances in which the protein is able to address blood clotting problems, hence, minimizing bleeding.
Activated FVII
Activated factor VII is a protein applied to generate a more effective activation of blood clotting problems. The measure has become a widespread agent in addressing surgical and non-surgical bleeding. Hence, it can be applied in cases in which ICU patients are being prescribed blood management therapy after undergoing cardiac surgery. According to research, FVII works by generating the binding of tissue factors (Castaman, 2017). However, in contrast with the aforementioned compounds, the dosage of activated factor VII can be increased for a more efficient recovery required as a result of cardiac surgical interventions. Namely, researchers suggest that high-dose and sustained interventions with rFVIIa facilitate a more time-efficient and productive wound healing process (Castaman, 2017). This is applicable under the circumstances that the patient experiences intense bleeding, which is a common occurrence during the post-surgical treatment of patients undergoing cardiac surgeries.
The synthetic derivative is often compared with PCC due to the fact that both elements are factor concentrates. Moreover, studies show their efficiency as high and similar, yet mention that they are not as widely used after cardiac interventions compared to other measures. Namely, researchers highlight that the implementation is activated factor VII treatment minimizes the need for blood transfusions as evidence shows risks to be diminished under this particular framework (Katz et al., 2021). As a result, the patient is more likely to experience an efficient post-surgical recovery and not encounter negative outcomes during ICU stays.
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