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II.
III.
l. Allergies to heparin are rare; more commonly, patients may present with a history
of heparin-induced thrombocytopenia (HIT).
i. There are 2 subtypes:
ii. The 1st is generally mild and consists of a transient decrease in platelet count
following the administration of heparin a few days following surgery.
iii. The 2nd type is more severe, characterized by autoimmune-mediated
decreasein the platelet count due to the formation of antigenic heparin
compounds (Anti-PF4) that activate platelets in the face of endothelial injury.
This predisposes toe platelet clumping and microvascular thrombosis. This
thrombosis may occur anywhere in the body and cause bowel or limb
ischemia to name a fe.
iv. In patients with HIT who require systemic anticoagulation, heparin
alternative should be used instead. Ex: defibrinogenating agents, hirudin,
bivalirudin, and factor 10 inhibitors.
Blood conservation in cardiac surgery
a. Intraoperative autologous hemodilution is a well-described method of removing
whole blood from a patient prior to systemic heparinization and CPB.
i. Returning this blood following the separation from CPB returns RBS, active
platelets, and functional coagulation factors that may mitigate surgical
bleeding.
ii. CI to intraoperative autologous blood donation include preoperative anemia,
unstable angina/ high grade left main coronary artery disease, and AS.
b. Blood salvage is another key method of intraoperative blood conservation in
cardiac surgery.
i. Following processing, units of shed blood may have hematrocrits of 70%.
ii. As PLTs and coagualation factors are removed in the washing process,
reinfusion of shed blood may worsen the CPB-associated coagulopathy by
promting a dilutional thrombocytopenia and reduction of clotting factors.
iii. CI to the use of intraoperative cell salvage incude infection, malignancy, and
the use of topical hemostatic agetns
c. Antifibrinolytic use in cardiac surgery is the standard in most cardiac centers, with
E-aminocaproic acid being the primary agent used in the US. The lsine analogueseaminocaproic and tranexamic acid bind to plasminiogen and block it ability to bind
at lysine resideues of fibrinogen. This prevents the lysis of firbin clots.
i. Administration of these antibirbinolytics decreases bleeding after CPB and
reduces the risk of blood transfusion.
d. Aprotinin, a naturally occurring fibrinolytic , inhibits kallekrein, preserves platelet
glycoprotein receoptros, inhibits the proinflammatory cytokine release associated
with CPB, as well as the inhibition of plasmin and protein C. until recelntly it was
used in repoperation, aortic srurgyer, and whenever major bleeding was expected.
Questions regarding safety are raised. Can cause RF, increase patient mortality. No
longer used. Higher 30 day mortality when compared to aminocaproic
e. Hemodilution is due to the CPB prime is one undesired byproduct of extracorporeal
circulation. One method that has been ued with success to avoid excess
hemodilution and reduce the need for blood transfusion is retrograde autologous
priming. (RAP). In RAP, the cruystalloid prime contained within the CPB circuit is
drained prior to the initiation of CPB and replaced by blood drained retrogreade via
the arterial cannula. RAP reduces hemodilution and diminishes the drop in
systemic vascular resistance associated with the initiation of CPB.
f. Ultrafiltration is another technique used in conjuction with CPB to reduce
postoperative bleeding and transfusion needs.
IV.