Perioperative bleeding - NYSORA | NYSORA

Perioperative bleeding

Learning objectives

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


  • 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


  • 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


perioperative bleeding management, cardiovascular surgery, liver resection, TXA, orthopedic surgery, orthotopic liver transplantation, aortic surgery

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

Suggested reading

  • Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. European Journal of Anaesthesiology | EJA. 2023;40(4).
  • Ghadimi K, Levy JH, Welsby IJ. Perioperative management of the bleeding patient. Br J Anaesth. 2016;117(suppl 3):iii18-iii30.

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