Practice Guidelines for Perioperative Blood Management

doi:10.1097/aln.0000000000000463

Cited by 602 publications

(105 citation statements)

References 241 publications

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“…36,42–52 KCentra® (CSL Behring, Germany) is the only 4-Factor formulation approved for this indication in the United States. Vitamin K antagonists, such as warfarin, effectively prevent essential post-translational gamma-carboxylation of the hepatically synthesized coagulation factors (II, VII, IX, and X) (Figure 2) and anticoagulants (proteins C, S and Z).…”

Section: Approved and Off-label Uses For Pccsmentioning

confidence: 99%

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Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

Ghadimi

Levy²,

Welsby³

2016

Anesthesia &Amp; Analgesia

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Prothrombin complex concentrates (PCCs) contain vitamin K-dependent clotting factors (II, VII, IX and X) and are marketed as 3 or 4 factor-PCC formulations dependent on the concentrations of Factor VII. PCCs rapidly restore deficient coagulation factor concentrations to achieve hemostasis, but as with all procoagulants, the effect is balanced against thromboembolic risk. The latter is dependent on both the dose of PCCs and individual patient prothrombotic predisposition. PCCs are Food and Drug Administration approved for the reversal of vitamin K antagonists in the setting of coagulopathy or bleeding and therefore can be administered in these patients when urgent surgery is required. There is, however, a growing experience with the off-label use of PCCs to treat patients with surgical coagulopathic bleeding. Despite their increasing use, there are limited prospective data related to the safety, efficacy, and dosing of PCCs for this indication. PCC administration in the perioperative setting may be tailored to the individual patient based on laboratory and clinical variables, including point-of-care coagulation testing, in order to balance hemostatic benefits while minimizing prothrombotic risk. Importantly, in patients with perioperative bleeding, other considerations should include treating additional sources of coagulopathy such as hypofibrinogenemia, thrombocytopenia and platelet disorders, or surgical sources of bleeding. Thromboembolic risk from excessive PCC dosing may be present well into the postoperative period after hemostasis is achieved owing to the relatively long half-life of prothrombin (Factor II, 60 – 72 hours). The integration of PCCs into comprehensive perioperative coagulation treatment algorithms for refractory bleeding is increasingly reported, but further studies are needed to better evaluate the safe and effective administration of these factor concentrates.

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Section: Approved and Off-label Uses For Pccsmentioning

confidence: 99%

“…54 Guidelines and consensus statements now recommend PCCs equally or in preference to FFP for urgent vitamin K antagonist reversal (Table 2). 36,42–52 …”

Section: Approved and Off-label Uses For Pccsmentioning

confidence: 99%

Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

Ghadimi

Levy²,

Welsby³

2016

Anesthesia &Amp; Analgesia

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“…TEG® and ROTEM® can be considered for rapid hemostatic assessment during PPH and these technologies have been endorsed in guidelines from the Obstetric Anaesthetists Association (UK)[70], the European Society of Anaesthesiology[71] and the American Society of Anesthesiologists[72]. …”

Section: Point-of-care Devices For Assessing Coagulopathymentioning

confidence: 99%

Transfusion and coagulation management in major obstetric hemorrhage

Butwick¹,

Goodnough

2015

Current Opinion in Anaesthesiology

107

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Purpose of Review Major obstetric hemorrhage is a leading cause of maternal morbidity and mortality. We will review transfusion strategies and the value of monitoring the maternal coagulation profile during severe obstetric hemorrhage. Recent Findings Epidemiologic studies indicate that rates of severe postpartum hemorrhage (PPH) in well-resourced countries are increasing. Despite these increases, rates of transfusion in obstetrics are low (0.9% - 2.3%), and investigators have questioned whether a pre-delivery ‘type and screen’ is cost-effective for all obstetric patients. Instead, blood ordering protocols specific to obstetric patients can reduce unnecessary antibody testing. When severe PPH occurs, a massive transfusion protocol (MTP) has attracted interest as a key therapeutic resource by ensuring sustained availability of blood products to the labor and delivery unit. During early postpartum bleeding, recent studies have shown that hypofibrinogenemia is an important predictor for the later development of severe PPH. Point-of-care technologies, such as thromboelastography and rotational thromboelastometry, can identify decreased fibrin-clot quality during PPH, which correlate with low fibrinogen levels. Summary A MTP provides a key resource in the management of severe PPH. However, future studies are needed to assess whether formula driven vs. goal-directed transfusion therapy improves maternal outcomes in women with severe PPH.

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“…Though these indications for plasma transfusion have been broadly endorsed (28), the more controversial issue of prophylactic plasma transfusion for nonbleeding patients with abnormal preprocedural coagulation screening tests is a matter of much debate (13,28). Indeed, plasma administration is still common in this clinical setting despite the dearth of data suggesting clinical benefit (12,13,28–30).…”

Section: Discussionmentioning

confidence: 99%

“…Indeed, plasma administration is still common in this clinical setting despite the dearth of data suggesting clinical benefit (12,13,28–30). To further complicate matters, international guidelines are conflicting on this point as well (28,31,32). Thus, providers are left with unclear guidance and frequently err on the side of providing a therapy with unclear benefit and thereby exposing patients to the potential harms of plasma transfusion, as well as the substantial costs.…”

Section: Discussionmentioning

confidence: 99%

Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single-institution propensity-adjusted cohort study

Jia

Brown

Clifford

et al. 2016

The Lancet Haematology

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Background Perioperative hemorrhage negatively impacts patient outcomes and results in substantial health care resource consumption. Plasma transfusions are frequently administered to address abnormal preoperative coagulation tests, with the hope of mitigating bleeding complications. This study aimed to evaluate the associations between preoperative plasma transfusion and bleeding complications in patients with elevated international normalized ratios undergoing noncardiac surgery. Methods An observational comparative effectiveness research study evaluating a consecutive sample of adult patients undergoing noncardiac surgery (N=14,743) with preoperative international normalized ratios ≥ 1.5 between January 1, 2008, and December 31, 2011. Among the patients, 1,234 (8.4%) had an international normalized ratio ≥ 1.5 and were included in this investigation. Exposure of interest was transfusion of preoperative plasma for an elevated international normalized ratio. Primary outcome was World Health Organization grade 3 bleeding in the early perioperative period. Secondary outcomes included blood loss, reoperation for bleeding, and additional patient-important outcomes including death and lengths of stay. Hypotheses were tested with univariate and propensity-matched analyses. Multiple sensitivity analyses were performed to further evaluate the robustness of study findings. Findings Of 1,234 study participants, 139 (11.3%) received a preoperative plasma transfusion. Those who received plasma had a higher rate of perioperative (52.5% vs 32.0%; P < .0001) and intraoperative (40.3% vs 24.5%; P < .0001) red blood cell transfusion, as well as an increased rate of reoperation for bleeding (11.5% vs 4.5%; P = .0005). The increased rate of perioperative red blood cell transfusion stayed in the propensity-matched analyses (OR, 1.75 [95% CI, 1.09–2.81]; P= .0210). Results from multiple sensitivity analyses were qualitatively similar. Interpretation Preoperative plasma transfusion for elevated international normalized ratios was associated with an increased rate of perioperative bleeding complications. Findings were robust in the sensitivity analyses, suggestive that more conservative management of abnormal preoperative international normalized ratios is warranted. Funding Department of Anesthesiology and Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, Minnesota; National Institutes of Health, Grant Number: R01 HL121232-01.

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Practice Guidelines for Perioperative Blood Management

Abstract: The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Blood Management presents an updated report of the Practice Guidelines for Perioperative Blood Management. Supplemental Digital Content is available in the text.

Cited by 602 publications

References 241 publications

Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

Transfusion and coagulation management in major obstetric hemorrhage

Prophylactic plasma transfusion for surgical patients with abnormal preoperative coagulation tests: a single-institution propensity-adjusted cohort study

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