Bleeding perioperative bleeding management in specific surgeries

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

2013 ESA Guidelines for the Management of Severe Perioperative Bleeding (DO NOT EDIT)[1]

Cardiovascular Surgery

Class 1
"1. We recommend that a prophylactic dose of low molecular weight heparin should be administered subcutaneously 8–12 h before elective CABG surgery. This intervention does not increase the risk of perioperative bleeding. (Level of Evidence: B) "
"2. We recommend that tranexamic acid or Aminocaproic acid should be considered before CABG surgery. (Level of Evidence: A) "
"3. We recommend that intraoperative tranexamic acid or Aminocaproic acid administration should be considered to reduce perioperative bleeding in high-, medium- and low-risk cardiovascular surgery. (Level of Evidence: A) "
"4. We recommend that tranexamic acid should be applied topically to the chest cavity to reduce postoperative blood loss following CABG surgery. (Level of Evidence: C) "
"5. We recommend that fibrinogen concentrate infusion guided by point-of-care viscoelastic coagulation monitoring should be used to reduce perioperative blood loss in complex cardiovascular surgery. (Level of Evidence: B) "
"6. We recommend the use of standardized hemostatic algorithms with predefined intervention triggers. (Level of Evidence: A) "
Class 2
"1.We suggest considering prophylactic preoperative infusion of 2 g fibrinogen concentrate in patients with fibrinogen concentration < 3.8 g/L, because it may reduce bleeding following elective CABG surgery. (Level of Evidence: C) "
"2. We suggest that recombinant FVIIa may be considered for patients with intractable bleeding during cardiovascular surgery once conventional hemostatic options have been exhausted. (Level of Evidence: B) "
"3. We suggest that antiplatelet therapy with aspirin or clopidogrel may be administered in the early postoperative period without increasing the risk of postoperative bleeding. (Level of Evidence: C) "
"4. We suggest that rFVIIa may be considered for patients with intractable bleeding after cardiovascular surgery once conventional hemostatic options have been exhausted. (Level of Evidence: B) "

Gynecological (Non-Pregnant) Bleeding

Class 2
"1. We suggest against normovolemic hemodilution because it does not reduce allogeneic transfusion. (Level of Evidence: A) "
"2. We suggest using preoperative intravenous iron to reduce allogeneic transfusion requirements in gynecological cancer patients receiving chemotherapy. (Level of Evidence: B) "
"3. We suggest using intravenous iron to correct preoperative anemia in women with menorrhagia. (Level of Evidence: B) "
"4. We suggest against the use of tranexamic acid in benign gynecological operations such as myomectomy. (Level of Evidence: B) "

Obstetric Bleeding

Class 1
"1. We recommend that peripartum hemorrhage should be managed by a multidisciplinary team. An escalating management protocol including uterotonic drugs, surgical and/or endovascular interventions, and procoagulant drugs should be available. (Level of Evidence: C) "
"2. We recommend that moderate (<9.5 g/dl) to sever(<8.5 g/dl) postpartum anemia be treated with intravenous iron rather than oral therapy. (Level of Evidence: B) "
"3. We recommend the administration of tranexamic acid in obstetric bleeding to reduce blood loss, bleeding duration and the number of units transfused. (Level of Evidence: B) "
"4. We recommend that rFVIIa should only be considered as last line therapy because of its thromboembolic risk. (Level of Evidence: B) "
Class 2
"1. We suggest that patients with known placenta accreta are treated by multidisciplinary care teams. (Level of Evidence: C) "
"2. We suggest that using perioperative cell salvage during caesarean section may decrease postoperative homologous transfusion and reduce hospital stay. (Level of Evidence: B) "
"3. We suggest that treatment with erythropoietin may correct anemia more rapidly than treatment with folic acid and iron. (Level of Evidence: C) "
"4. We suggest assessing fibrinogen concentration in parturients with bleeding, as concentrations <2 g/l may identify those at risk of severe PPH. (Level of Evidence: C) "
"5. In life-threatening PPH, we suggest a transfusion protocol with a fixed product ratio or individualised procoagulant intervention and factor substitution. (Level of Evidence: C) "
"6. We suggest that tranexamic acid be considered before caesarean section. (Level of Evidence: C) "
"7. In antepartum bleeding, we suggest administration of tranexamic acid. (Level of Evidence: B) "
"8. We suggest that fibrinogen concentration and number of platelets should be optimized before administration of rFVIIa. (Level of Evidence: C) "

Orthopedic Surgery and Neurosurgery

Class 1
"1. In elective orthopedic surgery, we recommend the implementation of a blood transfusion protocol (algorithm), together with staff education. (Level of Evidence: B) "
"2. We recommend that, for orthopedic surgery, monotherapy with aspirin does not need to be discontinued. (Level of Evidence: B) "
"3. We recommend discontinuing dual antiplatelet therapy before urgent intracranial neurosurgery. A risk-benefit analysis is required for the continuation of aspirin monotherapy during neurosurgery. (Level of Evidence: B) "
"4. We recommend against performing orthopedic surgery during the first three months after bare metal stent implantation or during the first twelve months after drug-eluting stent implantation. (Level of Evidence: C) "
"5. Prophylactic use of rFVIIa does not reduce perioperative blood loss or transfusion in non-hemophiliac and non-coagulopathic patients undergoing major orthopedic surgery or neurosurgery, and it may increase the incidence of thromboembolic events. We, therefore, recommend against the prophylactic use of rFVIIa in these clinical settings. (Level of Evidence: B) "
"6. We recommend restricting off-label use of rFVIIa to patients with severe bleeding who are unresponsive to other hemostatic interventions. (Level of Evidence: C) "
"6. In patients with INR >1.5, with life-threatening bleeding or ICH, we recommend that four-factor PCCs (20–40 IU/kg), supplemented with vitamin K (10 mg by slow intravenous infusion), should be used for rapid reversal of vitamin K-antagonists (VKA). (Level of Evidence: C) "
Class 2
"1. We suggest the use of viscoelastic tests (ROTEM/TEG) for monitoring perioperative hemostasis in major orthopedic surgery and neurosurgery. (Level of Evidence: C) "
"2. We suggest administering tranexamic acid in total hip arthroplasty, total knee arthroplasty, and major spine surgery. (Level of Evidence: A) "
"3. Tranexamic acid may promote a hypercoagulable state for some patients (with pre-existing thromboembolic events, hip fracture surgery, cancer surgery, age over 60 years, women). Therefore, we suggest an individual risk-benefit analysis instead of its routine use in these clinical settings. (Level of Evidence: A) "
"4. We suggest the use of rFVIIa in patients with neutralising antibodies to FVIII undergoing major orthopedic surgery. (Level of Evidence: C) "
"5. In patients with neutralizing antibodies to FVIII undergoing major orthopedic surgery, we suggest using activated PCCs (e.g. FEIBA, FVIII inhibitor bypassing agents). (Level of Evidence: C) "
"6. New oral anticoagulants, such as rivaroxaban and dabigatran, may increase surgical bleeding and ICH growth. We suggest that PCCs, FEIBA or [[factor VII}|rFVIIa]] may be used as non-specific antagonists in life threatening bleeding or ICH. (Level of Evidence: C) "

Visceral and Transplant Surgery

Class 1
"1. We recommend against the use of FFP for pre-procedural correction of mild to moderately elevated INR. (Level of Evidence: C) "
"2. We recommend that, in acute liver failure, moderately elevated INR should not be corrected before invasive procedures, with the exception of intracranial pressure monitor insertion. (Level of Evidence: C) "
"3. We recommend the use of perioperative coagulation monitoring using ROTEM/TEG for targeted management of coagulopathy. (Level of Evidence: C) "
"4. We recommend antifibrinolytic drugs for treatment of fibrinolysis (evident from microvascular oozing or TEG/ROTEM clot lysis measurement) and not for routine prophylaxis. Marginal grafts (e.g. donation after cardiac death) increase the risk of fibrinolysis post-reperfusion. (Level of Evidence: C) "
"5. We recommend against rFVIIa for prophylaxis; rFVIIa should be used only as rescue therapy for uncontrolled bleeding. (Level of Evidence: C) "
Class 2
"1. We suggest a platelet count of 50,000/ml as a threshold for platelet transfusion before liver biopsy. (Level of Evidence: C) "
"2. We suggest that antifibrinolytic drugs should be considered in cirrhotic patients undergoing liver resection. (Level of Evidence: C) "

Pediatric Surgery

Class 1
"1. We recommend against the use of rFVIIa in children. (Level of Evidence: C)"
Class 2
"1. We suggest the use of perioperative coagulation analysis using viscoelastic point-of-care monitoring (ROTEM/TEG) for timely detection of coagulation defects including dilutional coagulopathy and hyperfibrinolysis. (Level of Evidence: C)"
"2. We suggest that a critical hemoglobin threshold of 8 g/dl for RBC transfusion may be safe in severe pediatric perioperative bleeding. (Level of Evidence: C)"
"3. We suggest that transfusion of platelet concentrates may be considered if platelet count is <50,000–100,000/µl. (Level of Evidence: C)"
"4. We suggest that fibrinogen concentrate (30–50 mg/kg) or cryoprecipitate (5 ml/kg) may be used to increase plasma fibrinogen concentrations above trigger values of 1.5–2.0 g/l or FIBTEM MCF > 7 mm in bleeding children. (Level of Evidence: C)"
"5. We suggest that FFP may be used if no other fibrinogen source is available. (Level of Evidence: C)"
"6. We suggest against the routine use of desmopressin in the absence of hemophilia A or mild von Willebrand disease. (Level of Evidence: C)"
"7. We suggest that perioperative antifibrinolytic therapy should be used to reduce blood loss and transfusion requirements in cardiac and non-cardiac pediatric surgery. (Level of Evidence: A)"

Sources

  • 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding[1]

References

  1. 1.0 1.1 Kozek-Langenecker, SA.; Afshari, A.; Albaladejo, P.; Santullano, CA.; De Robertis, E.; Filipescu, DC.; Fries, D.; Görlinger, K.; Haas, T. (2013). "Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology.". Eur J Anaesthesiol. 30 (6): 270–382. PMID 23656742. doi:10.1097/EJA.0b013e32835f4d5b. 

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