Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Abstract

BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Early Goal-Directed Hemostatic Therapy for Severe Acute Bleeding Management in the Intensive Care Unit: A Narrative Review

“…Early Goal-Directed Therapy coagulation disorders and may be complemented by platelet function testing (PFT). 69…”

Peripartum Haemorrhage: Haemostatic Aspects of the Updated Peripartum Haemorrhage Guideline of the German-Speaking Countries

“…Fibrinogen is the first and most common coagulation factor to fall in PPH [66]. One of the few therapeutic options with international consensus might be the threshold for fibrinogen replacement of <2 g/L [41, 67, 68]. For a prior non-anaemic woman at term, this is rarely the case with a BL of 1,000 mL (2.4% [63]) but almost always, if bleeding volume is >4,000 mL [66, 67].…”

Management of severe peri-operative bleeding

“…In this issue of the Journal, Kietaibl et al 10 publish the second update of these guidelines. These updated guidelines are elaborate and contain all you ever wanted to know about peri-operative bleeding management.…”

“…Patients undergoing obstetric surgery (Recommendation 12): the ESAIC guidelines suggest that ‘dynamic platelet count decrease or a level <150 × 10 −9 l −1 at the onset of labour, particularly if combined with plasma fibrinogen level <2.0 g l −1 , may indicate an increased risk of postpartum haemorrhage (grade C)’ 10 . However, in a prospective cohort study of 1300 women, prepartum factor XIII activity had the strongest correlation with postpartum blood loss 17 .…”