HPE CSL Managing Perioperative Bleeding handbook - Page 11

Concentrates/blood products Coagulation factor concentrates vs allogeneic blood products In light of the current evidence in the management of perioperative bleeding, prompt and goal-directed therapy is the key element in the implementation of haemotherapy for patients with coagulopathies Christian Weber MD Clinic of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt, Germany Bleeding events have a substantial impact on the supply of blood to the organs and tissues and increase morbidity and mortality as well as the length and cost of hospital stay. Its major contributors are haemorrhage resulting from trauma, surgery, anticoagulatory therapy and acquired coagulopathies such as coagulation factor deficiencies or bleeding caused by hypothermia or acidosis. Surgical bleeding must be corrected as soon as possible through damage control measures or interventional therapy in order to prevent catastrophic outcomes for the patients. An adequate assessment and management of perioperative bleeding can be challenging and involves both the identification of patients at increased risk of bleeding and goal- directed haemotherapy to control coagulation function, restore blood circulation, and attain haemodynamic stability. Clinical importance of perioperative bleeding Significant blood loss results in the dilution of coagulation factors and platelets, accompanied by delayed thrombin formation and propagation and low fibrinogen levels. Despite the availability of different strategies to contain blood loss, the management of perioperative bleeding can be complex and is defined by a fine balance between reducing haemorrhage and preventing thromboembolic events at the same time. Disturbances in the coagulation process (coagulopathies) can have a multitude of causes and may result in spontaneous bleeding or bleeding following an injury or medical procedure. 1 Conversely, in the event of major trauma, bleeding can induce an acute coagulopathic state, which comprises several pathological components and can be modified by individual characteristics, including age, ethnicity, presence of comorbidities, use of oral anticoagulants, and fluid intake before hospitalisation. 2 In the specific perioperative context, acquired coagulopathy can develop as a consequence of loss of coagulation factors (for example, caused by a traumatic event) or haemodilution due to excessive fluid replacement, and constitutes a risk factor for progression to severe bleeding. Although fluid restriction during resuscitation efforts following a major trauma or major bleeding event during surgery results in shorter stays in the intensive care unit, reduced blood volumes can lead to acidosis, which in turn worsens the coagulopathy. Alternatively, coagulopathy can be induced by antithrombotic agents. 3 Keeping in mind these distinct scenarios, patients receiving anticoagulation therapy, or those with congenital bleeding disorders, should be evaluated preoperatively by a multidisciplinary team, which will determine their risk of bleeding through a detailed medical history and coagulation tests. 4 Preoperative anaemia, which is common in patients undergoing elective surgery, is known to contribute significantly to increased morbidity and mortality and is a strong predictor of the need for perioperative transfusion of allogeneic blood products. 4 However, a large retrospective study showed that red blood cell transfusion during surgery actually increased morbidity and mortality outcomes for patients presenting with severe anaemia before a general, non- emergent, non-cardiac surgical procedure. Although surgical bleeding could not be ruled out as a culprit for the worse outcomes observed with blood transfusion in this study, the results pointed to the importance of promptly managing perioperative bleeding. 5 Other studies have yielded similar findings for patients undergoing cardiac surgery. 6 hospitalpharmacyeurope.com 11