CARDIAC ANAESTHESIA
Principles of cardiac
anaesthesia
David Alexander
Abstract
Cardiac surgical outcomes in the UK have consistently improved despite
increasing procedure complexity and sicker patients. Numerous anaes-
thetic techniques are employed with no definitive evidence clearly
demonstrating superiority of one particular technique. Patient safety is
paramount and various monitoring techniques used to enhance safety
and ensure effective anaesthesia are outlined. Management of bleeding,
particularly in complex cases, is a major component of cardiac anaes-
thesia and recent developments in this area are briefly described.
Keywords Anti-fibrinolytics; bleeding and haemostasis; cardiac anaes-
thesia; cardiac surgery; cerebral oximetry; monitoring
Royal College of Anaesthetists CPD Matrix: 3G00
Cardiac surgery in the UK
More than 30,000 cardiac surgical operations are performed each
year in the UK. The Society for Cardiothoracic Surgery in Great
Britain & Ireland has led the surgical specialities in audit of
clinical outcomes for several decades. Annual outcome data for
named individual surgeons and institutions are readily available
via the Society of Cardiothoracic Surgery in Great Britain and
Ireland (SCTS).1
The National Adult Cardiac Surgery Audit (NACSA) collects
data regarding all major cardiac surgery in the UK and publishes
an annual report (last published 2014).2 It is managed by the
National Institute for Cardiovascular Outcomes Research
(NICOR) with clinical direction from the SCTS. The latest report
shows that in-hospital mortality has fallen by 20% in the last 10
years, with overall mortality under 3% despite increasing case
complexity. A further valuable resource is the Blue Book (www.
bluebooks.scts.org) which is an up-to-date account of cardiac
surgery, including national trends for mortality and operative
risk.
Data available concerning cardiac anaesthesia or anaesthetists
are limited. The value of effective teamwork is widely recognized
as key to the safe delivery of specialized, invasive and highly
technical healthcare procedures. As part of the cardiac surgical
team, many cardiac anaesthetists encounter an ever more com-
plex case-mix with patients identified to be at increasingly high
risk.
In 2008, the National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) published its report on Death
following a first time, isolated coronary artery bypass graft.3
David Alexander FRCA is Consultant in Cardiothoracic Anaesthesia at
The Royal Brompton and Harefield NHS Foundation Trust, UK. Conflicts
of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Alexander D, Principles of cardiac anaesthesia, Anaesthesia and intensive care medicine (2015), http://
dx.doi.org/10.1016/j.mpaic.2015.07.011
Learning objectives
After reading this article, you should be able to:
C recognize cardiac surgical outcome improvements in an
increasingly complex patient cohort
C understand broad principles of delivery of cardiac anaesthesia
C be aware of monitoring modalities commonly applied to cardiac
surgical patients
C understand approaches to managing bleeding and deranged
haemostasis associated with cardiac surgery
This analysis of 1045 deaths following first-time CABG aimed
to investigate organizational factors impacting on surgical mor-
tality rates. The specific anaesthetic question addressed, ranked
6/13 in importance, was To what extent does variation in the
anaesthetic process affect outcome? Anaesthetic questionnaires/
records were available to anaesthetic assessors in 88% of cases.
This report also highlighted the importance of effective
teamwork and communication amongst team members and the
need for senior clinicians to be readily available throughout the
perioperative period to ensure that complications (which occur
commonly) are recognised without delay and managed appro-
priately.3 The report recognized anaesthesia induction as a
critical time and reported that in 97% of cases a consultant was
the most senior anaesthetist at induction,3 reflecting a
consultant-delivered cardiac anaesthesia service in the UK.
Although elements of individual cases were examined, no com-
ments or recommendations were made concerning the actual
techniques used for cardiac anaesthesia.
Cardiac anaesthesia
Numerous cardiac anaesthetic techniques have been reported in
the literature, often with institutional or favoured personal var-
iations. As far as the author is aware, there is still no definitive
evidence confirming clear superiority of a particular technique
and it remains, as has been suggested in previous articles, that
the choice of anaesthetic technique appears less important than
the manner in which it is applied.
Induction of anaesthesia
The NCEPOD report highlighted induction as one of the most
critical times during the cardiac anaesthetic process. Wide fluc-
tuations in arterial blood pressure and heart rate may result in
reduced cardiac output and impaired coronary perfusion,
resulting in myocardial ischaemia and further deterioration in
cardiovascular haemodynamics. Induction should be performed
in a gradual and careful fashion, with knowledge of the likely
adverse effects of agents used and with a view to mitigating these
adverse effects in the patients particular haemodynamic profile.
Small doses of short acting vasoconstrictors (metaraminol 25
e100 mg, phenylephrine 10e50 mg) are frequently administered
at or soon after induction to counteract systemic vasodilatation if
coronary perfusion is at risk, particularly in coronary artery
disease with critical lesions (e.g. high-grade left coronary main
stem) or severe aortic stenosis (with or without coronary
disease).
1 2015 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA

The choice of induction agent appears to be less important left-sided double-lumen endo-bronchial tube, although this usu-
than the speed of injection and overall dose, with the possible ally necessitates a tube change on completion of the case to
exception of ketamine, which is not routinely used for cardiac facilitate postoperative ventilation. Bronchial blockers may also
anaesthesia. Some practitioners advocate a moderate dose of be used, ensuring only one endotracheal intubation is required.
opioid (fentanyl 2.5e5 mg/kg, alfentanil 50e100 mg/kg or remi-
fentanil 1 mg/kg) followed by an induction dose of induction Antibiotic prophylaxis
agent given slowly via large bore peripheral IV access. Others
Antibiotic prophylaxis is recommended for cardiac surgery and
prefer a higher dose opioid (e.g. fentanyl 20e40 mg/kg) supple-
the responsibility for administration usually lies with the
mented with a modest dose of induction agent, titrated to loss of
anaesthetist. The Scottish Intercollegiate Guidelines Network
the lash reflex. Both approaches are appropriate and confer
2008 guidelines are informative, widely used and based on best
cardiac stability with a smooth induction. Very high-dose opioid
available evidence at the time, plus recommended best practice
techniques (e.g. fentanyl 50e100 mg/kg or similar) following pre-
based on the clinical experience of the guideline development
treatment with a benzodiazepine are popular in North America
group.4 These recommend that for cardiac surgery intravenous
and are occasionally employed in the UK.
prophylactic antibiotics should be given 30 minutes or earlier
The main induction agents used are propofol, etomidate and
before the skin is incised and duration should not be more than
thiopentone. Pre-treatment with an opioid and/or benzodiaze-
48 hours. The choice of antibiotic should take into account local
pine should allow reduction of the overall induction dose. The
resistance patterns and if b-lactam antibiotics are first-line
most important effects of each of the drugs are detailed in
agents, an alternative should be recommended for patients with
Table 1.
allergy to penicillins or cephalosporins. Current recommenda-
tions at the authors institution are for CABG IV cefuroxime 1.5 g
Muscle relaxant and intubation
at induction, 750 mg at sternal closure and 8-hourly for a total of
Most non-depolarizing muscle relaxants have been used safely four doses. In addition, for valve surgery, teicoplanin 400 mg IV
and effectively in cardiac surgery. Atracurium is less favoured is added 12-hourly for three doses then daily until major
due to its short duration of action and hypotension that may indwelling catheters are removed. Penicillin/cephalosporin-
result from histamine release. Pancuronium is widely used due to allergic patients receive teicoplanin plus gentamicin 2 mg/kg
long duration of action, and confers some advantage through its ideal body weight as single induction dose (continued for valves
sympathomimetic and vagolytic actions. The resultant tachy- as per aminoglycoside protocol).
cardia may be undesirable in a patient with aortic stenosis or
with coronary artery disease who is intolerant of b-blockers. Maintenance
Patients established on b-blockade rarely develop troublesome
There are three phases in the maintenance of cardiac anaesthesia
tachycardia following pancuronium. Vecuronium and rocuro-
which can each be managed with a single or multiple methods.
nium are equally effective and do not cause tachycardia but may
These are the pre-bypass, bypass and post-bypass phases of the
require repeated dosing, especially after separation from cardio-
case. Anaesthesia for cardiac surgery without cardiopulmonary
pulmonary bypass. They may result in bradycardia, especially
bypass is considered in another article in this issue. The aim
when given shortly after fentanyl or remifentanil. Common
throughout is to maintain anaesthesia whilst balancing myocar-
agents used for muscle relaxation are detailed in Table 2.
dial oxygen delivery and demand and minimizing ischaemic risk.
Intubation with an oral, cuffed endotracheal tube is the usual
Volatile agents and intravenous agents have both been used
method of securing the airway. Lung isolation may be required
effectively to maintain anaesthesia throughout the phases. Total
for some cases where thoracoscopic surgery is employed e
intravenous anaesthesia affords cardiovascular stability and re-
usually minimally invasive techniques which may proceed to
duces the risk of awareness by maintaining reasonably constant
cardiopulmonary bypass if required. This can be achieved with a

Induction agents in cardiac anaesthesia

Drug Cardiovascular effects Pharmacokinetics special considerations

Thiopentone Cardiac depression / reduced cardiac output preserved Slow hepatic metabolism
or increased SVR and HR
Propofol Reduced cardiac output as MAP reduced from significant Rapid metabolism through redistribution. Suitable for infusion
fall in SVR
Etomidate Minimal cardiac output change with minor changes to Rapid metabolism via esterases. Adrenal suppression even after
HR (increase) and SVR (decrease) single dose. Pain on injection
Ketamine Increase in cardiac output with increased HR and SVR Not suitable in ischaemic heart disease but may maintain cardiac
stability in tamponade/pericardial restrictive disease

HR, heart rate; MAP, mean arterial pressure; SVR, systemic vascular resistance.

Table 1

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 2 2015 Published by Elsevier Ltd.

Please cite this article in press as: Alexander D, Principles of cardiac anaesthesia, Anaesthesia and intensive care medicine (2015), http://
dx.doi.org/10.1016/j.mpaic.2015.07.011

Muscle relaxants in cardiac anaesthesia
Drug Cardiovascular effects
HR SVR CO MAP
Pancuronium All parameters increased
Vecuronium All parameters unchanged
Rocuronium All parameters unchanged
CO, cardiac output; HR, heart rate; MAP, mean arterial pressure; SVR, systemic vascular resistance.
Table 2
plasma levels of anaesthetic drugs. Volatile agents (most usually
isoflurane) are safe and effective pre-bypass, but may reach sub-
anaesthetic levels on bypass when they are delivered into the
circulation via the bypass circuit oxygenator and are flow
dependent. There is growing evidence that volatile agents may
cause myocardial depression when used post-bypass.
The gas mixture usually employed for ventilation (and for the
bypass circuit) is an oxygeneair mixture, with or without a
volatile agent. The use of nitrous oxide may be associated with
marked depression of myocardial function and the advantages
conferred by supplementing anaesthesia with nitrous oxide that
may be seen in other arenas are not realised during cardiac
surgery.
One common approach is to use a volatile agent (isoflurane)
pre-bypass and switch to an intravenous agent by infusion
(propofol) during bypass and post-bypass, which can then be
continued into the immediate postoperative period. Isoflurane
(and other volatile agents) has been shown to protect against the
ischaemia-reperfusion injury of the myocardium often seen in
cardiac surgery that may result in myocardial stunning,
arrhythmia and even infarction. Supplemental doses of a non-
depolarizing muscle relaxant may be required during re-
warming or following bypass as the large change in circulating
volume seen with cardiopulmonary bypass may alter the phar-
macokinetics of the drug. Supplemental doses of opioids are also
used routinely on re-warming, when the cerebral metabolic re-
quirements rise and the risk of awareness increases.
Quite separate from the requirements for anaesthesia is the
management of intra-operative events such as tachycardia,
bradycardia, hypotension and hypertension which all contribute
to cardiac instability and may be deleterious. These may neces-
sitate the use of opioids, vasodilators (usually nitroglycerine, less
frequently sodium nitroprusside or phentolamine), vasocon-
strictors (metaraminol, phenylephrine or norepinephrine by
infusion 0.02e0.1 mg/kg/minute) and inotropes (see related
chapter in this issue). Troublesome bradycardia or less than ideal
cardiac rate may be best managed by placing epicardial pacing
wires and commencing atrial pacing at rate 70e90/minute
depending on phase of procedure (ventricular pacing if in com-
plete heart block or slow atrial fibrillation/flutter with a low
ventricular rate).
Monitoring
The minimal monitoring standards should be met, with all pa-
tients undergoing ECG, oxygen saturation, central temperature
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Alexander D, Principles of cardiac anaesthesia, Anaesthesia and intensive care medicine (2015), http://
dx.doi.org/10.1016/j.mpaic.2015.07.011
CARDIAC ANAESTHESIA
Pharmacokinetics special considerations
Long duration of action (60 minutes). Active metabolites accumulate if given by infusion
Bradycardia may occur if used with high-dose opioids
May occasionally cause tachycardia through vagolytic activity
(vital for cooling and re-warming phases), invasive arterial
pressure and central venous pressure monitoring. As all patients
will require endotracheal intubation and ventilation, the fraction
of inspired oxygen (FiO2) and end-tidal CO2 (ETCO2) must also
be monitored. If an inhalational agent is used, the inspired and
expired volatile concentrations should be recorded. Some pa-
tients will require further specialized monitoring.
Arterial cannulation
Arterial cannulation is essential, with some practitioners advo-
cating pre-induction monitoring, especially in high-risk cases
such as left main stem stenosis, aortic stenosis or those with
severe impairment of left ventricular function. Invasive arterial
pressure monitoring is commonly established via the radial ar-
tery of the non-dominant hand using a 20G cannula. In surgery
for repair of aortic coarctation and acute aortic dissection, the
right radial is preferred as the left radial artery may be excluded
from the circulation or supply misleading pressures. In patients
undergoing radial artery harvest for coronary artery graft
conduit, the left radial artery is usually harvested by one surgeon
while another performs sternotomy from the right side. The
choice of radial artery for harvest might be influenced by hand
dominance or other issues and should be confirmed with the
surgeon before cannulating the other radial artery for moni-
toring. Femoral, brachial and even dorsalis pedis arterial can-
nulation may be undertaken if indicated, but much less
frequently than the radial route.
Central venous access
Central venous cannulation affords direct pressure measurement
of right sided filling pressures and a reliable route for adminis-
tering drugs into the central circulation. It is not usually required
prior to induction of anaesthesia. A variety of central venous
catheters are available, with a variable number of lumens and of
different lengths. The right internal jugular vein is most
commonly cannulated as this provides the most direct route to
the central circulation, is anatomically consistent and cannula-
tion carries a low risk of complications. Current NICE guidance
dictates that cannulation should be undertaken with ultrasound
guidance available. The internal jugular vein may be used for
multiple cannulae, and some practitioners insert a large sheath
into the same vessel to allow later passage of a pulmonary artery
catheter. Cannulation with single-lumen devices to allow volume
administration confers no advantage over peripheral cannula-
tion. Large-bore (e.g. 10 French) dual-lumen catheters may be
inserted if massive bleeding is expected.
3 2015 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
Cardiac output monitoring
Pulmonary artery pressure monitoring and its derived variables,
including cardiac output measurement and vascular resistances
may be indicated in high-risk cases. An introducer sheath may be
inserted post-induction and the catheter positioned if required,
either pre-surgery, following separation from cardiopulmonary
bypass or in the intensive care unit. The measurement of cardiac
output by thermodilution remains the most reliable method,
though other devices may be used, including oesophageal
Doppler, trans-oesophageal echocardiography and pulse contour
analysis. Pulmonary artery catheter insertion is associated with
arrhythmias and with a very low incidence of kinking/knotting,
thrombo-embolism, and pulmonary artery rupture. Routine use
of pulmonary artery catheters remains a point of contention with
some proponents, but other sources accepting that their routine
use confers no advantage to outcome or management. Direct left
atrial pressure measurement can be provided by surgically
placed fine-calibre left atrial catheters, and while these do not
provide the derived haemodynamic variables, the direct mea-
surement of left atrial filling pressure can usefully guide therapy,
especially in left ventricular failure and pulmonary vascular
disease.
Echocardiography
Intraoperative echocardiography is increasingly applied, most
commonly as trans-oesophageal echocardiography but also with
epicardial and intracardiac echo probes. This expanding arena is
the subject of another chapter in this issue.
Depth and delivery of anaesthesia monitoring
Awareness remains a risk during cardiac surgery and depth of
anaesthesia monitoring or cerebral function monitoring have
both been advocated to reduce the incidence of awareness. Bis-
pectral index monitoring is currently the most widely applied of
these with probe placement and interpretation being dependent
on the make and model of the monitor chosen. Delivery of
intravenous anaesthetic agents must be regularly checked and
delivery to the circulation must be visually confirmable
throughout the case. Respiratory gas analysis including volatile
concentration is mandatory as for any anaesthetic case. If
anaesthesia during cardiopulmonary bypass is partially or fully
provided with volatile agents, the concentration should ideally be
monitored via the oxygenator exhaust outlet, confirming delivery
of the agent to the oxygenator. Exhaust gas monitoring provides
additional safety information e the oxygen concentration in-
dicates that oxygen is being delivered to the oxygenator and CO2
elimination can infer adequate oxygenator function.
Cerebral oximetry
Cerebral oxygenation and perfusion are important parameters
during cardiac surgery, particularly in specialized situations such
as deep hypothermic circulatory arrest. Direct measurement is
difficult and near infrared spectroscopy (NIRS) is a surrogate
measure via tissue oxygenation. Though widely advocated in
paediatric cardiac surgery, NIRS is gaining popularity in adult
cardiac surgery. Patients with known cerebrovascular disease,
those with poor cardiac function and those undergoing major
aortic root or arch reconstructions are thought most likely to
benefit from cerebral tissue oximetry, though at the time of
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Alexander D, Principles of cardiac anaesthesia, Anaesthesia and intensive care medicine (2015), http://
dx.doi.org/10.1016/j.mpaic.2015.07.011
writing, evidence of efficacy from large studies in any group is
lacking. Comparative visceral oximetry, usually by placement of
a second NIRS probe positioned to provide renal tissue oximetry,
is gaining popularity in monitoring of major aortic surgery (dis-
sections, aneurysms and arch replacement). Responses to
adverse cerebral (or visceral) oximetry values might include i)
surgical manipulation/release of vessel constriction or manipu-
lation of surgical bypass cannulae; ii) increasing oxygen delivery
by increasing cerebral perfusion pressures, haemoglobin values,
PaCO2 (cerebral vasodilatation) or acid base manipulation; and
iii) a further reduction in brain and body temperature. The
currently most widely used NIRS cerebral oximetry technology in
the UK provides qualitative information as cerebral oximetry
values changed from baseline e hence this device should really
be applied pre-induction of anaesthesia to obtain true baseline
values. New and under-development tissue oximetry devices aim
to provide quantitative and target cerebral oximetry values
which may render easier both clinical decision-making and
clinical trial design.
Analgesia
When opioids are used for induction and maintenance, these
should provide adequate analgesia throughout the case. Anal-
gesic drugs are also used to dampen sympathetic responses to
stimulation during intubation and sternotomy. If a short-acting
opioid (e.g. remifentanil) is used during surgery it should be
replaced or continued into the postoperative period to ensure
adequate postoperative analgesia. Commonly, opioids are
delivered by continuous infusion in the immediate postoperative
period and converted to patient-controlled analgesia or regular
oral analgesia following extubation. In patients who are extu-
bated within 6 hours (fast-track), effective analgesia must be
established prior to extubation to prevent deleterious surges in
blood pressure or heart rate.
Regional neuraxial blockade, usually with thoracic epidural
anaesthesia (TEA) may confer some advantage by blocking car-
diac accelerator fibres in the thoracic cord (reducing myocardial
work load) and providing analgesia within the surgical field. The
timing of any central blockade must be such that it avoids con-
flict with anticoagulants administered preoperatively or intra-
operatively. With many more patients presenting for surgery
still taking aspirin and or long-acting platelet inhibitors, the risk
of haematoma following regional anaesthesia is problematic.
Though the incidence is small, the consequences of epidural or
spinal haematoma may be devastating. TEA is not practised for
cardiac anaesthesia in the authors institution and it is our
impression that, save for a small number of enthusiasts, interest
in this technique has waned in the UK. Cardiac anaesthesia
performed solely with regional blockade is novel but has not
gained widespread application.
Bleeding and cardiac surgery
One of the greatest challenges to the cardiac anaesthetist is the
assessment and management of bleeding and deranged haemo-
stasis. In some cases, severe haemorrhage may be expected
(complex redo aortic surgery, infective endocarditis) but
approximately 5% of patients have significant bleeding post-
4 2015 Published by Elsevier Ltd.
 CARDIAC ANAESTHESIA
cardiac surgery. Reoperation for bleeding, and even allogeneic
transfusion, increases mortality and morbidity.
Whilst the conduct of anaesthesia is unlikely to influence
bleeding, the conduct of the anaesthetist certainly can! Many
blood conservation strategies are recommended and cell salvage
is now routine. Patients at increased risk of bleeding (e.g. redo
surgery, endocarditis) may require anti-fibrinolytic agents. Tra-
nexamic acid is most widely used, though dose and administra-
tion remain uncertain. Some advocate a single bolus dose (4000
e5000 mg), whilst others prefer a smaller loading dose and
ongoing infusion (16 mg/kg/hour). Infusions may be associated
with an increased incidence of post-operative seizures. Which-
ever practice is adopted, it is important to establish the anti-
fibrinolytic therapy before fibrinolysis is triggered, preferably
before surgery and certainly before cardiopulmonary bypass.
Aprotinin (a serine protease inhibitor anti-fibrinolytic with
additional potentially attractive anti-inflammatory effects) was
previously widely used but received much adverse publicity due
to the 2007 BART study5 (approx. 3000 cardiac surgical patients)
which suggested higher mortality at 30 days in the aprotinin
group. The European Medicines Agency (EMA) suspended its
marketing in 2008, though it has remained available in the UK on
a named patient basis only. The EMA has recently lifted this
suspension, with clarification in June 2012,6 after further infor-
mation has come to light concerning the BART study, though it is
not known if its manufacturer will support its widespread re-
introduction. Desmopressin (DDAVP) has not been shown to
reduce the incidence of bleeding if used prophylactically, except
in patients with specific platelet dysfunction (e.g. uraemia, CPB
induced platelet dysfunction and type 1 von Willebrands
disease).
A large number of patients presenting for cardiac surgery are
receiving or have recently stopped receiving anti-platelet drugs.
A battery of tests are available to assess platelet function, the
most widely applied being the P2Y12 (platelet receptor) inhibi-
tion test. In those patients whose surgery is not electively post-
poned, results of platelet function tests may influence the
administration of platelets in the perioperative period. Throm-
boelastograms (TEG) provide a useful point-of-care overall
assessment of clotting components including platelet function,
but caveats in interpretation may require the assistance of hae-
matologists. Formal clotting studies may help to direct therapy
but are not as immediately available as TEG testing. Empirical
therapy of blood products should be avoided except in the most
extreme circumstances e all should be directed by relevant and
recent assessment of platelets and clotting factor assay.
Fresh frozen plasma (FFP) is usually the first line of therapy in
treating clotting factor deficiencies, though replacement of spe-
cific, individual, factors is becoming more commonplace in car-
diac surgery. The first of these therapies was recombinant factor
VIIa (rVIIa). Originally licensed for the treatment of haemophilia,
rVIIa has been extensively studied in bleeding associated with
cardiac surgery.7 Though the terms of that licence are unchanged
it is now used for treatment of intractable haemorrhage without
an identifiable surgical source that is unresponsive to conven-
tional therapy. The doses used initially matched those for hae-
mophiliacs (90 mg/kg), but much lower doses are now
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Please cite this article in press as: Alexander D, Principles of cardiac anaesthesia, Anaesthesia and intensive care medicine (2015), http://
dx.doi.org/10.1016/j.mpaic.2015.07.011
recommended (30 mg/kg), with cessation of therapy if two doses
do not control the bleeding. A variety of protocols have been
recommended but the principle is to maintain a haemostatic
environment, that is, normothermic, adequate platelet numbers,
fibrinogen more than 1, correction of base deficit and mainte-
nance of calcium levels. Thrombotic events remain the single
most serious limitation in use of rVIIa.
Other factor concentrates are now available. Prothrombin
complex concentrates (Octaplex, Beriplex) contain factors II, VII,
IX and X as well as protein C and S. This allows administration of
higher doses of clotting factors in smaller volumes than pooled
plasma. Their primary role is in the treatment of acquired de-
ficiencies of vitamin K dependent clotting factors, including
bleeding!
In addition, to the therapies available, it is also important to
ensure that inappropriate fluid administration does not
contribute to a dilutional coagulopathy. Blood conservation
protocols are appropriate and should be agreed in all cardiac
surgical units. Crystalloid and colloid therapy should be judged
according to the likely clinical requirements and when bleeding
is ongoing and a sensible transfusion trigger is encountered, or
clearly will be, blood should be administered. In the bleeding
patient, rapid assessment and re-assessment with laboratory and
near patient testing should direct therapy. A
REFERENCES
1 Rates of survival after heart surgery in the UK. http://www.scts.org.
2 National Institute for Cardiovascular Outcomes Research: Audit data
2014. http://www.ucl.ac.uk/nicor/audits/adultcardiac/about.
3 A report of the National Confidential Enquiry into Patient Outcome and
Death. Death following a first time, isolated coronary artery bypass
graft. The heart of the matter. 2008, http://www.ncepod.org.uk/
2008report2/Downloads/CABG_report.pdf.
4 Antibiotic prophylaxis in surgery. A national clinical guideline. Scottish
Intercollegiate Guidelines Network. http://www.sign.ac.uk/pdf/
sign104.pdf.
5 Fergusson DA, Hebert PC, Mazer CD, et al. A comparison of aprotinin
and lysine analogues in high-risk cardiac surgery. N Engl J Med 2008;
358: 2319e3233.
6 European Medicines Agency. Questions and answers on the review of
antifibrinolytic medicines (aprotinin, aminocaproic acid and tranexa-
mic acid). 21 June 2012 http://www.ema.europa.eu/docs/en_GB/
document_library/Referrals_document/Antifibrinolytic_medicines/
WC500129106.pdf (accessed 13 July, 2012).
7 Gill R, Herbertson M, Vuylsteke A, et al. Safety and efficacy of rVIIa: a
randomised placebo-controlled trial in the setting of bleeding after
cardiac surgery. Circulation 2009; 120: 21e7.
FURTHER READING
Association of Cardiothoracic Anaesthetists UK. Clinical guidelines. http://
www.acta.org.uk/home/guidelines.asp.
Barnard M, Martin B, eds. Cardiac anaesthesia (Oxford Specialist Hand-
books in Anaesthesia). Oxford University Press, 2010.
Despotis G, Avidan M, Eby C. Prediction and management of bleeding in
cardiac surgery (review). J Thrombosis Haemostasis 2009; 7(suppl):
111e7.
5 2015 Published by Elsevier Ltd.