Perioperative management of the bleeding patient

Abstract

Perioperative bleeding remains a major complication during and after surgery, resulting in increased morbidity and mortality. The principal causes of non-vascular sources of haemostatic perioperative bleeding are a preexisting undetected bleeding disorder, the nature of the operation itself, or acquired coagulation abnormalities secondary to haemorrhage, haemodilution, or haemostatic factor consumption. In the bleeding patient, standard therapeutic approaches include allogeneic blood product administration, concomitant pharmacologic agents, and increasing application of purified and recombinant haemostatic factors. Multiple haemostatic changes occur perioperatively after trauma and complex surgical procedures including cardiac surgery and liver transplantation. Novel strategies for both prophylaxis and therapy of perioperative bleeding include tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates. Point-of-care patient testing using thromboelastography, rotational thromboelastometry, and platelet function assays has allowed for more detailed assessment of specific targeted therapy for haemostasis. Strategic multimodal management is needed to improve management, reduce allogeneic blood product administration, and minimize associated risks related to transfusion.

An Audit of the Diagnostic Accuracy of Rotational Thromboelastometry for the Identification of Hypofibrinogenaemia and Thrombocytopenia during Cardiopulmonary Bypass

“…We calculated the sensitivity (probability of a positive result given the presence of the target condition) and specificity (probability of a negative result given the absence of the target condition) of ROTEM assessments of hypofibrinogenaemia (FIBTEM A10 ≤8 mm) and thrombocytopenia (PLTEM A10 <35 mm) using laboratory measurements of fibrinogen (<1.5 g/l) and platelet count (<100 x 10 9 /l) as reference standards. The laboratory thresholds were based on the recommended triggers for fibrinogen and platelet transfusion in the presence of diffuse bleeding in published reviews and guidelines [1][2][3][9][10][11] . The ROTEM thresholds were based on the equivalent FIBTEM and PLTEM triggers recommended in previous studies [5][6][7][8] .…”

“…Rotational thromboelastometry (ROTEM®, TEM Innovations, GmbH, Munich, Germany), based on the viscoelastic properties of blood as it clots, provides a method for the rapid assessment of coagulation during a range of surgical procedures, including cardiac surgery [1][2][3] . Like many cardiac surgical centres worldwide, we have used rotational thromboelastometry to guide coagulation factor replacement in cardiac surgical patients for many years.…”

“…In order to assess the validity of this practice, we audited the diagnostic accuracy (sensitivity, specificity, positive and negative predictive values) of ROTEM measurements obtained prior to separation from CPB using laboratory measurements as a reference standard. Our focus was on the identification of hypofibrinogenaemia and thrombocytopenia, being the two most common coagulation disturbances requiring correction in the presence of abnormal bleeding in cardiac surgical patients [1][2][3] .…”

Three‐factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis

“…Furthermore, by first replenishing low fibrinogen and platelets levels, low‐dose PCC administration may be more effective during the management of surgical haemostasis . We therefore hypothesized that the use of low‐dose Profilnine ® (higher prothrombin levels compared with Kcentra ® ), administered for refractory haemorrhage as part of an institutionally derived bleeding algorithm , would be associated with decreased post‐PCC blood product transfusion and minimal postoperative thromboembolic complications.…”

Análise da coagulação sanguínea com a administração profilática da desmopressina em cirurgias cardíacas valvares

“…48,49 . Esta ação pode ter corroborado na atenuação da disfunção plaquetária que observamos, traduzida pela não observância de discrepâncias nos testes laboratoriais utilizados em nosso estudo.…”