Excellent, **Pasindu** — this is **core CTICU practice**. I’ll give you a **clear, stepwise bleeding algorithm** with **exact blood product doses**, tailored to **post–cardiac surgery bleeding**, aligned with **EACTA / EACTS / NICE / BSH / STS** principles.
I’ll keep it **short, structured, and bedside-ready**.
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# 🩸 **BLEEDING IN CARDIAC ICU — BLOOD PRODUCT REPLACEMENT ALGORITHM**
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## 🔴 STEP 1 — CONFIRM SIGNIFICANT BLEEDING
### **Post-cardiac surgery bleeding = concerning if:**
* Chest drain **>200 mL/hour for 2 consecutive hours**
* OR **>400 mL in 1 hour**
* OR haemodynamic instability
* OR rising lactate / falling Hb
* OR re-exploration concern
👉 **Parallel actions:**
* Call surgeon early
* Warm patient (target ≥36 °C)
* Correct acidosis, hypocalcaemia
* Stop heparin / anticoagulants
* Send **urgent labs**
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## 🔬 STEP 2 — SEND BLOOD TESTS (DO NOT GUESS)
Send immediately:
* **Hb**
* **Platelet count**
* **PT / INR**
* **aPTT**
* **Fibrinogen**
* **ABG + ionised calcium**
* **ROTEM / TEG** (if available)
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## 🧠 STEP 3 — TRANSFUSION TARGETS (MEMORISE THIS)
| Parameter | Target in Active Bleeding |
| ------------ | --------------------------------------------------- |
| Hb | **≥8 g/dL** (≥9–10 if ongoing bleeding / ischaemia) |
| Platelets | **>100 ×10⁹/L** |
| INR | **<1.5** |
| aPTT | **<1.5 × control** |
| Fibrinogen | **>2.0 g/L** |
| Ionised Ca²⁺ | **>1.1 mmol/L** |
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# 🩸 STEP 4 — BLOOD PRODUCT REPLACEMENT (EXACT DOSES)
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## 🟥 **PACKED RED BLOOD CELLS (PRBC)**
### **Indication**
* Hb <8 g/dL **with bleeding**
* Or signs of inadequate oxygen delivery
### **Dose**
* **1 unit PRBC → ↑ Hb ~1 g/dL**
### **CTICU Practice**
* Transfuse **one unit at a time**
* Recheck Hb and clinical response
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## 🟨 **FRESH FROZEN PLASMA (FFP)**
### **Indication**
* INR >1.5 or prolonged PT/aPTT **with bleeding**
* Dilutional coagulopathy
* Massive transfusion
### **Dose**
* **15–20 mL/kg**
* Adult ≈ **4 units (800–1000 mL)**
### **Effect**
* Corrects clotting factor deficiency
* INR reduction modest unless adequate dose given
⚠️ **Do NOT give FFP prophylactically** — only if coagulopathy present.
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## 🟦 **PLATELETS**
### **Indication**
* Platelets <100 ×10⁹/L **with bleeding**
* Platelet dysfunction (post-CPB), even with normal count
### **Dose**
* **1 adult dose** (≈ 4–6 pooled units or 1 apheresis unit)
### **Expected rise**
* ↑ platelets by **30–50 ×10⁹/L**
👉 Platelets are **first-line post-CPB** due to platelet dysfunction.
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## 🟪 **CRYOPRECIPITATE / FIBRINOGEN CONCENTRATE**
### **Indication**
* Fibrinogen <2.0 g/L
* Persistent bleeding with normal INR/platelets
### **Dose**
* **Cryoprecipitate:**
* **2 pools (≈10 units)** → ↑ fibrinogen ~1 g/L
* **Fibrinogen concentrate:**
* **3–4 g IV**
👉 Low fibrinogen is a **common, under-recognised cause** of post-CPB bleeding.
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## 🟩 **CALCIUM (VERY IMPORTANT)**
### **Why**
* Citrate in blood products binds calcium → worsens bleeding
### **Target**
* Ionised Ca²⁺ **>1.1 mmol/L**
### **Dose**
* **Calcium chloride 10% – 10 mL IV**
(preferred via central line)
* OR **Calcium gluconate 10% – 30 mL IV**
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# 🔁 STEP 5 — REASSESS AFTER EACH INTERVENTION
After every product:
* Check chest drain output
* Check BP, lactate, urine output
* Repeat labs (or ROTEM)
👉 **Bleeding improving? Continue targeted therapy**
👉 **Bleeding ongoing? Escalate**
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# 🚨 STEP 6 — MASSIVE BLEEDING PROTOCOL (IF REQUIRED)
### **Trigger if:**
* > 50% blood volume loss in 3 h
* Or ≥4 units PRBC in 1 hour
* Or haemodynamic collapse
### **Empirical ratio (if labs delayed):**
**PRBC : FFP : Platelets = 1 : 1 : 1**
Add:
* Tranexamic acid (if not already given)
* Early fibrinogen
* Aggressive calcium replacement
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# 🧠 ROTEM-BASED QUICK GUIDE (IF AVAILABLE)
| ROTEM Finding | Likely Problem | Treatment |
| ------------------------- | -------------------- | ----------------- |
| Prolonged CT | Factor deficiency | FFP |
| Low MCF (EXTEM) | Platelet dysfunction | Platelets |
| Low FIBTEM | Low fibrinogen | Cryo / fibrinogen |
| Normal ROTEM but bleeding | Surgical cause | Re-explore |
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# 🩺 WHEN TO CALL FOR RE-EXPLORATION
* Bleeding persists despite corrected labs
* ROTEM normal but drain output high
* Sudden increase in output
* Suspected graft/surgical source
* Tamponade physiology
👉 **Surgical bleeding does NOT respond to blood products**
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# 🧠 ULTRA-SHORT MEMORY TABLE (SAVE THIS)
| Product | When | Dose |
| --------- | ----------------- | --------------- |
| PRBC | Hb <8 | 1 unit = ↑ Hb 1 |
| FFP | INR >1.5 | 15–20 mL/kg |
| Platelets | <100 ×10⁹/L | 1 adult dose |
| Cryo | Fibrinogen <2 | 2 pools |
| Calcium | Ionised Ca²⁺ <1.1 | CaCl₂ 10 mL |
---
# 🔑 CTICU PEARLS (VERY IMPORTANT)
* **Platelets + fibrinogen are the most common deficiencies post-CPB**
* **FFP alone rarely stops bleeding**
* **Correct calcium early**
* **ROTEM-guided therapy reduces transfusion & re-exploration**
* **If bleeding doesn’t respond → think surgical source**
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## 🎯 TAKE-HOME
> **Bleeding management = TARGETED replacement, not blind transfusion.**
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If you want next, I can give you:
* 🔹 **ROTEM-based bleeding algorithm poster**
* 🔹 **Massive transfusion pocket card**
* 🔹 **Drug reversal guide (heparin, warfarin, DOACs)**
Just tell me 👍
