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Bleeding complications associated with cardiopulmonary bypass
RC Woodman and LA Harker
Department of Molecular and Experimental Medicine, Research Institute of
Scripps Clinic, La Jolla, CA.
Bleeding after CPB has been difficult to characterize and its treatment
equally difficult to standardize. The complexity of this problem is related
to the hemostatic process, the technical variations in the operative
procedures, and the many uncontrolled variables associated with CPB,
including the effects of anesthetic or pharmacologic agents, the nature of
the priming solution, hemodilution, hypothermia, the type of oxygenator,
and the use of transfused blood products. Although there are multiple and
generally predictable complex changes in the hemostatic mechanism during
CPB, the temporary loss of platelet function is the most common and
clinically relevant. This transient platelet dysfunction occurs in all
patients undergoing CPB; however, it only causes excessive bleeding in a
small percentage of patients. Unfortunately, it has not yet been possible
to predict which patients will develop hemorrhagic complications, although
prolonged pump times are a contributing risk factor. Over the past decade
there has been extensive investigation into the management of bleeding
associated with CPB, provoked primarily by the increased awareness of
transfusion- transmitted viral diseases and the inappropriately excessive
use of homologous blood products. Several approaches to autotransfusion of
shed blood and autologus blood donation have been developed to minimize
perioperative homologous blood transfusion. Pharmacologic agents such as
desmopressin, aprotinin, and topical fibrin glues have also been introduced
to improve hemostasis during CPB. The protease inhibitor aprotinin is
particularly promising in the reduction of bleeding associated with CPB
when given prophylactically. Aprotinin may provide new insights into the
mechanism of CPB-induced platelet dysfunction. Desmopressin is indicated
only for the treatment of bleeding after CPB. The management of bleeding
associated with CPB will undoubtedly
Volume 76,
Issue 9,
pp. 1680-1697,
11/01/1990
Copyright © 1990 by The American Society of Hematology
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