Perioperative bleeding

Learning objectives

Describe the causes of perioperative bleeding
Optimize patients at risk of perioperative bleeding
Manage perioperative bleeding

Background

Perioperative bleeding is a complex surgical complication with a range of causes
Usually characterized by a site of bleeding and confined exclusively to the operative site
Can evolve into pathologic thrombosis

Causes

Blood loss
Hemodilution
Acquired platelet dysfunction
Coagulation factor consumption in extracorporeal circuits
Activation of fibrinolytic, fibrinogenolytic, and inflammatory pathways
Hypothermia
Anticoagulant use
Platelet inhibitor use
Congenital coagulopathies

Preoperative optimization

perioperative bleeding, ginkgo biloba, desmopressin, hemophilia, fibrinogen level assessment, valproic acid, preoperative anemia, impaired homeostasis

RBC, red blood cell; rFVIIa, recombinant activated factor VII; aPCC, activated prothrombin complex concentrate; DDAVP, desmopressin;

preoperative bleeding, antithrombotic agents, heparin, fondaparinux, vitamin K, oral anticoagulants, platelet transfusion

NSAID, non-steroidal anti-inflammatory drug; LMWH, low molecular weight heparin; INR, international normalized ratio; PCC, prothrombin complex concentrate

COVID-19 coagulopathy

Avoid major elective surgery in patients with COVID-19 coagulopathy
In (semi)urgent surgery in patients with COVID-19 coagulopathy, avoid prophylactic TXA administration
VHA-guided, goal-directed procoagulant treatment of perioperatively acquired coagulopathic bleeding avoiding overcorrection
Perioperative drug monitoring of LMWH used as a standard anticoagulant in COVID-19 critical illness; If anti-Xa activity > 0.3 IU/mL in clinical bleeding, consider reversal with protamine
A restrictive red blood cell transfusion strategy as in non-COVID-19 patients
In patients recovered from COVID-19 and free of post-COVID-19 symptoms, manage severe perioperative bleeding as in non-COVID-19 patients
Administer postoperative thromboprophylaxis as early as possible
A restrictive red blood cell, plasma, and platelet transfusion strategy in the critically ill
Use f a goal-directed coagulation therapy algorithm in the presence of ongoing bleeding, considering altered laboratory tests and VHA in critical illness
If ongoing bleeding is unresponsive to multimodal coagulation therapy or there are wound healing defects in the critically ill, monitor FXIII and correct deficiency
A restrictive systemic administration of TXA in case of fibrinolytic shutdown in critical illness
Initiate thromboprophylaxis after bleeding as soon as the bleeding risk is overbalanced by the risk of thromboembolic complications

Management

LMWH, low molecular weight heparin; TXA, tranexamic acid; EACA, epsilon-aminocaproic acid; CPB, Cardiopulmonary bypass; Hb, hemoglobin; PCC, prothrombin complex concentrate; FFP, fresh frozen plasma; rFVIIa, recombinant activated factor VII; FXIII, factor XIII; VHA, viscoelastic hemostatic assay

perioperative bleeding management, obstetric surgery, gynecological surgery, peripartum hemorrhage, prothrombin complex concentrate, viscoelastic hemostatic assay, PPH, patient blood management

Hb, hemoglobin; EPO; erythropoietin; IDA, iron deficiency anemia; TXA, tranexamic acid; PBM, patient blood management; RBC, red blood cell; PPH, peripartum hemorrhage; VHA, viscoelastic hemostatic assay; rFVIIa, recombinant activated factor VII; PCC, prothrombin complex concentrate; DDAVP, desmopressin

perioperative bleeding management, pediatric surgery, intraoperative transfusion, hemoglobin, hematocrit, isomaltoside, carboxymaltose, sucrose

VHA, viscoelastic hemostatic assay; RBC, red blood cell; Hb, hemoglobin; Hct, hematocrit; ESA, erythropoietin-stimulating agent