“Achieving Hemostasis in the Surgical Field: Some Views of a Cardiothoracic Anesthesiologist and a Health-System Pharmacist”

"Achieving Hemostasis in the Surgical Field: Some Views of a Cardiothoracic Anesthesiologist and a Health-System Pharmacist"

Bradley A. Boucher, PharmD, FCCP, FCCM, BCPS, and Jerrold H. Levy, MD,

June 22, 2013


Maintaining hemostasis is a balancing act involving multiple intravascular systems—vessel wall, platelets, coagulation and fibrinolytic systems—to ensure the arrest of bleeding following injury.1-4 Disruption of the balance between procoagulant and anticoagulant forces may result in severe bleeding or thrombotic complications,2 with the challenge for clinicians becoming one of maintaining patient physiology between these 2 forces so that patients do not bleed or clot to death.1,3

Surgical Bleeding and Hemostasis

Bleeding is a complication of many types of surgery and the most common cause of major blood loss in a medical setting.2,5 Patients often present for surgery with an acquired hemostatic imbalance due to preoperative antithrombotic therapy.6-8 Moreover, patients are increasingly receiving anticoagulants, including heparin and thrombin inhibitors, for perioperative thromboprophylaxis and as therapy for ischemic cardiovascular disease, which may exacerbate bleeding.6,9,10 As a result, it is not uncommon for clinicians to manage patients who are receiving one or more anticoagulant therapies.6 The novel anticoagulants dabigatran and rivaroxaban pose an additional challenge to clinicians because there is no antidote to reverse their effects in the event of uncontrolled bleeding.11,12

Knowing what to do when is key to surgical success. For optimal patient outcomes, intraoperative control of bleeding is essential.13 Various methods are employed to maintain perioperative hemostasis—a multimodal approach that includes the use of systemic and topical agents.13 By way of a cardiac case example (up to 5% of cardiac surgery patients require reexploration for bleeding13), a cardiothoracic anesthesiologist and a health-system pharmacist provide differing perspectives on a shared goal: achieving hemostasis in the surgical field.


Clinical Profile
Louis B. is a 68-year-old white man with unstable angina who presents for urgent repeat on-pump coronary artery bypass grafting (CABG). He has a history of myocardial infarctions, which resulted in a CABG with saphenous vein grafts 15 years earlier. Comorbidities include heart failure, non-insulin-dependent diabetes, and hypertension. His medications include lisinopril for the heart failure and clopidogrel 75 mg qd.

Cardiac catheterization revealed proximal 3-vessel disease, with occlusion of both grafts. The ejection fraction (EF) was 25%. Low-molecular-weight heparin was administered. The patient's vital signs at this time included the following: BP, 120/70 mm Hg; HR, 76 BPM; HCT, 42%; and platelet count, 220,000.


The patient had global hypokinesis and anterior wall dyskinesis. Transesophageal echocardiography (TEE) probe revealed a low EF and a 2+ mitral regurgitation. At this point, his BP was 110/75 mm Hg; HR, 72 BPM; pulmonary artery pressure, 45/26 mm Hg; and pulmonary artery occlusion pressure, 15 mm Hg. Blood conservation technique consisted of administration of tranexamic acid 1 g given postintubation, followed by infusion of 200 mg/min. Heparin 400 U/kg was administered after the left internal mammary artery (LIMA) was taken down.

The patient underwent a LIMA to LAD (left anterior descending artery) graft, as well as several vein grafts. He came off bypass relatively easily, and TEE revealed resolution of anterior dyskinesis; there were no new wall motion abnormalities but persistent global hypokinesis.

Due to subsequent biventricular dysfunction, placement of an intra-aortic balloon pump (IABP) to his femoral artery was needed. He was separated from cardiopulmonary bypass with infusions of norepinephrine 6 mcg/min and milrinone 0.5 mcg/kg/min. Protamine 200 mg was also administered to reverse the activated clotting time (ACT) back to a baseline of approximately 125 seconds. Following protamine administration, the patient appeared oozy.

Expert Q&A with Jerrold H. Levy, MD, FAHA, FCCM

The patient continues to bleed in the ICU. Protamine is administered ≈200 mL/h for the first hour.

Postoperative Days 1 and 2

The patient was extubated and weaned from IV norepinephrine. He continued to receive milrinone infused at a rate of 0.25 mcg/kg/min. A transthoracic echocardiogram on postop day 2 demonstrated persistent evidence of systolic and diastolic dysfunction, with an EF of approximately 30% on IV milrinone with IABP in place.

Postoperative Day 3

The IABP was weaned and removed, and oral clopidogrel was restarted at 75 mg once daily. The right foot/extremity was noted to be cold and pulseless in the area where the IABP had been placed. A consult with a vascular surgeon determined that a femoral embolectomy was necessary, so the patient was returned to the OR. The pulse was temporarily restored to the right foot, and the extremity regained blood flow.

Expert Q&A with Jerrold H. Levy, MD, FAHA, FCCM and
Bradley A. Boucher, PharmD, FCCP, FCCM, BCPS
Pharmacologic agents are an important component of the multimodal approach to achieving perioperative hemostasis. Systemic agents represent a mainstay therapeutic option for the management of bleeding
(Table 1).9,10,14-22
Dr. Levy discuss several systemic hemostatic agents

Humankind's attempts to arrest bleeding date back many thousands of years, beginning with the ancient Egyptians and Greeks, who used such topical "agents" as wax, grease, and barley mixtures, as well as hemostatic herbs, to manage bleeds.23 It has only been within the past decade that advances in biotechnology have resulted in an abundance of topical hemostatic agents available to modern-day surgeons (Table 2).23-30

Expert Q&A with Bradley A. Boucher,

A multimodal approach involving the use of systemic and topical hemostatic agents is integral to maintaining perioperative hemostasis and achieving positive patient outcomes.

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