Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model

Figures & data

Table 1 Demographic Characteristics of the Survey Sample (n=284)

Specialty
Anesthesiologist	159 (56%)
Perfusionist	86 (30.3%)
Cardiac Surgeon	39 (13.7%)
Type of hospital setting
Metropolitan Public Hospital	183 (64.4%)
Metropolitan Private Hospital	59 (20.8%)
Regional Public Hospital	27 (9.5%)
Regional Private Hospital	15 (5.3%)
Heart/Lung Transplant service
Yes	60 (21.1%)
No	224 (78.9%)
ECMO and/or VAD
Extracorporeal Membrane Oxygenation (ECMO)	165 (58%)
Ventricular Assist Device (VAD)	2 (0.7%)
Both	72 (25.4%)
Participating State the answers refer to
New South Wales	113 (39.8%)
Victoria	73 (25.7%)
Queensland	58 (20.4%)
Western Australia	20 (7%)
South Australia	17 (6%)
Tasmania	3 (1.1%)

Figure 1 Frequency of routinely applied bleeding management strategies in cardiac surgery.

Abbreviations: aFVll, activated factor seven; FFP, fresh frozen plasma; PCC, prothrombin complex concentrate; Cryo, Cryoprecipitate; Fib Conc, Fibrinogen concentrate; ROTEM, Rotational Thromboelastometry; TEG, Thromboelastography; DDAVP, D-Deamino Arginine Vasopressin.

Table 2 Respondent Perceptions of Requirements to Improve Bleeding Management Practice

COM-B	TDF Domains	Themes	Example Quotations	Frequency Out of 99
Capability	Behavioural Regulation	Standardization	“A more structured approach to bleeding” A “Blood product availability should not be unit dependent for institutions within the same state or territory. Every blood bank at every hospital has different process for providing blood products” P “Need consistency in approach between different surgeons and ICU clinicians” A “Our local algorithm included in an app to make it easy to follow” A “Minimise haemodilution in the first place, is the most important strategy” S	16
	Knowledge	Cardiac surgery specific bleeding management education/guidelines	“Online CPD courses specifically looking at bleeding in cardiac surgical patients” A “National guidelines which set a standard for blood product administration based on a single ROTEM algorithm accepted nationally rather than unit based” P “Some evidence-based bleeding management guidelines would be helpful” P “National guidelines would allow us to push past local funding and political problems” A “More and more education” A	13
Opportunity	Environmental Context and Resources	Access to point of care diagnostic assays (ROTEM/TEG & Multiplate)	“Better POCCT availability (i.e. rapid)” P “ROTEM ± Multiplate in MOT” A “I believe we should be using point of care thromboelastography with a panel of tests” A “Easy point of care access to TEG/ROTEM” “ROTEM, Multiplate and vWF assays” S “Better availability of Multiplate analysis” A “Better point of care assessment - rapid response time” A “Need Multiplate, ROTEM” P “The availability of TEG has changed our management” A “ROTEM or equivalent in theatre itself” S	20
		Dedicated blood management support clinicians	“I expect it would not be a viable business model, but it would be novel and helpful to have a separate and properly trained transfusion expert to manage massive bleeding” A “Blood management nurse support” A “Transfusion nurse onsite” A “More blood management nurses” S	15
		Decision support tool for bleeding management (algorithm/app)	“Standardized ROTEM guided algorithm” A “Algorithms” P “Decisions guided by an algorithm/app approved and adopted nationally” A “ROTEM/Multiplate interpretation app” S “An agreed protocol for the bleeding patient would be useful” A “App would be useful, including doses, (on/kg basis)” A	9
		Access to fibrinogen concentrate	“Fibrinogen concentrate” A “Fibrinogen concentrate more readily available” A “Availability of more specific factors such as fibrinogen concentrate” S “Availability of FC” A	6
	Social Influences	Multidisciplinary team contribution	“Combined cardiac surgery, cardiac anaesthesia, intensive care and haematology consensus on management with emphasis on point of care testing” P “An awareness by cardiologists re their impact on potential post op bleeding in acute patients” S “Needs to be multi-disciplinary to work” P “I would like the intensivists to be more interested” A “We have a good response at this hospital, with good advice from Haematology” A “If the various departments (cardiac, surgery, anaesthesia, ICU and blood bank) could actually work together” A “Haematologist with experience in acute bleeding” A “More awareness from everyone involved - ICU, surgeons, hospital administration” S “Need a co-ordinated blood management program” A “A haematologist that answers the phone” S	12
Motivation	Beliefs about capability	Control (or lack of) over ability to effectively manage bleeding	“We have the best available tools and agents available to us for routine use” A “Too many times tests are performed, and the results are either ignored or not considered in the management of post-operative bleeding” P “We have a documented strategy for dealing with bleeding that includes administration of platelets. cryoprecipitate and desmopressin. Factor VII is only used when surgical bleeding continues beyond reasonable use of blood products” P “Better blood bank support for peripheral hospitals” S “It is frequent to have a normal ROTEM in the bleeding post-op patient, but blood products are given anyway as opposed to discussion about surgical intervention” A	8

Abbreviations: S, Surgeon; A, Anesthesiologist; P, Perfusionist.

Table 3 Routine Use of Tranexamic Acid by Anesthesiologists and Surgeons

Mode of Delivery (n=181)
	Bolus only	Continuous only during the surgical procedure	Bolus + Continuous	Not sure	Other
Anesthesiologist (n=142)	17.6%	9.2%	67.6%	0%	5.6%
Surgeon (n=39)	43.6%	7.7%	38.4%	10.3%	0%
Dose (n=142)
	Bolus only	Continuous only during surgical procedure		Bolus	+ Continuous
Anesthesiologist	1–2g total or 15–50mg/kg	1g/hr for 2–3 hrs, or over the entire surgical procedure, or 2–15mg/kg/hr		1–2g or 10mg/kg up to 50mg/kg	2–15mg/kg/hr

Table 4 Participant Responses for Diagnosis and Correction of Fibrinogen Deficiency

Diagnosing the cause of fibrinogen deficiency (n=158)
Point of care diagnostic assays	Standard laboratory tests	Combination of point of care diagnostic assays and standard laboratory tests	Empirical diagnosis
68.2%	25.8%	4.5%	1.5%
Correction of fibrinogen deficiency (n=39)
Cryoprecipitate	Combination of cryoprecipitate and fibrinogen concentrate	Fibrinogen concentrate	FFP
64%	26.9%	6.1%	3%

Table 5 Summary of Guideline Recommendations for the Immediate Reversal of VKAs

Guideline	Recommendation	Class/Level of Evidence/Grade
2017 EACTS/EACTA Guidelines on PBM for adult cardiac surgery	The use of PCC or FFP may be considered to reverse the action of VKAs^Citation13	Class llb Level of Evidence B
2016 Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology	In bleeding patients where VKA-induced coagulopathy is considered a contributing factor, we recommend the administration of PCC, If PCC is not available, we recommend the transfusion of plasma^Citation14	Grade 1 B Grade 1C
2013 Australasian Society of Thrombosis and Haemostasis	For immediate reversal, PCCs are preferred over FFP. FFP is not routinely needed in combination with PCC. FFP can be used when PCC is unavailable^Citation35	Grade 2C
2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anaesthesiologists Blood Conservation Clinical Practice Guidelines	For urgent warfarin reversal, administration of PCC is preferred, but FFP is reasonable when adequate levels of Factor VII are not present in PCC^Citation15	Class lla Level of evidence B

Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic S, The European Association of Cardiothoracic A; Boer C, et al. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth. 2018;32(1):88–120. doi:10.1053/j.jvca.2017.06.026

 Web of Science ®Google Scholar

Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur J Anaesthesiol. 2017;34(6):332–395. doi:10.1097/EJA.0000000000000630

 PubMed Web of Science ®Google Scholar

Tran HA, Chunilal SD, Harper PL, Tran H, Wood EM, Gallus AS. An update of consensus guidelines for warfarin reversal. MJA. 2013;198(4):198–199. doi:10.5694/mja12.10614

 PubMed Web of Science ®Google Scholar

Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Ferraris VA, Brown JR, et al. 2011 update to the society of thoracic surgeons and the society of cardiovascular anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011;91(3):944–982. doi:10.1016/j.athoracsur.2010.11.078

 Web of Science ®Google Scholar