The management of perioperative bleeding

doi:10.1016/S0268-960X(02)00062-0

Blood Reviews

Volume 17, Issue 3, September 2003, Pages 179-185

https://doi.org/10.1016/S0268-960X(02)00062-0 Get rights and content

Abstract

Excess perioperative bleeding remains a major complication following surgery, resulting in increased morbidity and mortality. The principal causes of non-surgical haemostatic perioperative bleeding are a pre-existing undetected bleeding disorder, related to the nature of the operation itself or from coagulation abnormalities arising from massive blood loss. Very often, it is a combination and coexistence of various pathologies. Identifying patients at risk remains a major component of preventing excessive blood loss. Understanding the haemostatic changes occurring in the perioperative period, especially in complex procedures like cardiopulmonary bypass and orthotopic liver transplantation is crucial in developing new strategies for the management of perioperative bleeding. Pharmacological interventions, especially aprotinin, tranexamic acid, desmopressin and increasingly, recombinant VIIa are being used both in prophylaxis and therapeutically to stop bleeding. The use of near patient testing like thromboelastography and platelet function analyser has allowed for more detailed assessment of the various steps of haemostasis. One of the main goals is to reduce the usage of allogeneic blood transfusion and its attendant risks.

Introduction

It is well recognised that any major surgical procedure poses a challenge to the haemostatic system. Some loss of blood is always inevitable. Excessive perioperative bleeding however remains a major complication following surgery and results in increased morbidity and mortality. Prevailing concerns about the safety and reliability of the blood supply, especially the as yet undetermined risk of variant Creutzfeldt–Jacob disease has made this an even more prescient issue. Concerted efforts are therefore required to use blood products sparingly to reduce exposure to allogeneic blood and hence of transfusion transmitted diseases. Management of perioperative bleeding therefore necessitates prompt evaluation and a methodical approach to the diagnosis and institution of appropriate treatment.

There are two main causes of perioperative bleeding. The first is surgical bleeding which is directly attributable to a failure to surgically control bleeding vessels at the operative site. Surgical bleeding is usually characterised by a single site of bleeding and confined exclusively to the operative site. Meticulous technique, patience and good patient selection all contribute significantly to minimising surgical bleeding in the high-risk patient. Achievement of haemostasis lies with the surgeon and will not be further discussed here.

The second cause of perioperative bleeding – “non-surgical or haemostatic bleeding” is due to a failure of the haemostatic pathways. This is often manifest as generalised oozing. The patient should therefore be examined for signs of superficial bleeding and at multiple sites including petechiae, purpura and oozing from venepuncture sites, urinary catheters and nasogastric tubes.

The principal causes of perioperative haemostatic failure are:

•
a pre-existing previously undetected bleeding disorder;
•
related to the procedure itself inducing altered haemostasis, in particular cardiopulmonary bypass (CPB) and orthotopic liver transplantation (OLT);
•
massive blood loss;
•
the co-existence of more than one pathology.

Current management therefore in perioperative bleeding would consist of

•
identifying those patients at risk (preventive);
•
understanding the haemostatic changes related to the surgical procedure;
•
instituting blood based and/or pharmacological interventions (therapeutic);
•
considering the utility of near patient testing and a better understanding of the roles of various coagulation tests and their limitations (monitoring);
•
reducing allogeneic blood exposure through blood conservation programmes.

At this stage is should be remembered that although perioperative bleeding is a major concern for the surgeon, in fact the risk of venous thromboembolism post-operatively is a far greater. Many surgeons do not give adequate thromboprophylaxis due to a perceived risk of increased bleeding when in fact this results in excess of morbidity and mortality due to venous thromboembolism.

Section snippets

Identifying patients at risk of bleeding (preventive)

It is important that the surgical and anaesthetist teams realise that many pre-existing so called “mild” bleeding disorders, e.g., mild von Willebrand’s disease, are clinically silent from day-to-day and only manifest at times of haemostatic stress such as surgery. It may often also not be reflected in screening clotting tests. One of the key points therefore in minimising perioperative blood loss is an index of suspicion and the identification of patients who are at increased risk of bleeding.

Haemostatic changes occurring in the perioperative period

Surprisingly, perioperative haemostatic changes have not been widely studied except in complex procedures such as cardiac surgery using cardiopulmonary bypass (CPB) and orthotopic liver transplantation (OLT). It is known that haemostatic activation occurs as a result of the hyperadrenagic state induced by the stress of surgical stimulation. Hyperfibrinolysis may also often be a feature and this is largely due to increased levels of free tissue plasminogen activator (t-PA). Some regions, namely

Cardiopulmonary bypass (CPB)

Activation of haemostasis is well recognised in patients undergoing CPB as there is extensive contact between blood and the artificial surfaces of the bypass circuit, therefore necessitating the use of heparin. Another aspect of cardiac operations is the activation of fibrinolysis, attributed to increased levels of tissue plasminogen activator (tPA) and the contact activation of fibrinolysis.⁹ Perioperative fibrinolytic activity however as measured by D-dimers is highly variable between

Massive blood loss

This is arbitrarily defined as blood loss requiring the replacement of the patient’s total blood volume in less than 24 h. Initial management is aimed at prompt resuscitation and correction of metabolic disturbances. A pre-operative group and save specimen would normally be available but in emergency cases, group O RhD negative blood could be used until compatible blood is made available. Coagulation problems can occur due to loss of haemostatic factors and dilution from the infused fluids, in

Blood based and pharmacological interventions

The mainstays of blood based interventions remain that of platelets, fresh frozen plasma and cryoprecipitate. They should be given following the UK Blood Transfusion Services guidelines: platelet counts should be kept above 50–100×10⁹, by the use of platelet transfusions; prolongation of the PT/APTT which is not due to the use of heparin should be maintained below 1.5 by using fresh frozen plasma at a dose of 15ml/kg; and if the fibrinogen is particularly low (e.g., with meningococcal sepsis)

Aprotinin

Aprotinin is a bovine serine protease inhibitor with several possible mechanisms of action to reduce perioperative bleeding. It inhibitory effect on plasmin provides it with its main antifibrinolytic activity. At higher doses (200 kIU/ml), inhibition of other serine proteases like kallikrein results in a reduction in contact factor dependent fibrinolysis and bradykinin production.²¹ Fig. 1 illustrates the various effects of aprotinin on fibrinolysis. Plasma markers of fibrinolytic activity such

Lysine analogues

Episolon amino caproic acid (EACA) and tranexamic acid are both competitive inhibitors of plasmin binding to fibrin with the latter studied more extensively than EACA. Tranexamic acid had mainly been studied in cardiac surgery[27], [28], [29], [30] (see section cardiac surgery) and the dose given as a continuous infusion was 10 mg/kg over 30 min followed by 1 mg/kg for 10 h.³¹ The use of such a continuous infusion of tranexamic acid does reduce red cell transfusion requirements. However the

Desmopressin (DDAVP)

DDAVP is a synthetic vasopressin analogue that is relatively devoid of vasoconstrictor activity. It increases the plasma concentrations and activity of von Willebrand factor (vWF) mainly by inducing the release of vWF from Weibel–Palade bodies in the endothelium.³² Desmopression also improves platelet function. Trials using 0.3 μg/kg have not proven useful in CPB[33], [34] but it has a place in reducing perioperative blood loss in patients with von Willebrand’s disease and functional platelet

Recombinant VIIa

Recombinant Factor VIIa (rFVIIa) has been an exciting new modality in the treatment of severe haemophiliacs with inhibitors. The success demonstrated has generated enormous interest and extended into a possible future role in the management of perioperative bleeding. Preliminary results in a randomised, double blind trial for patients undergoing prostatectomy showed a reduction in perioperative blood loss.³⁵ rFVIIa has also been used in the management of intractable post-surgical

Topical agent: fibrin glues

These usually consist of a thrombin source added to fibrinogen concentrates in the presence of calcium. These may occasionally help to stop bleeding at suture sites with low blood flow rates but are relatively ineffective in areas with higher flow rates. Efficacy of these agents has been reported but is largely anecdotal or involving small series of patients. Postoperative bleeding has been reported previously when bovine thrombin was used. This was due to the formation of anti-bovine thrombin

Pharmacological interventions in CPD

As mentioned above, several prospective trials have found significant decreases in bleeding and transfusion requirements in CPB using and comparing the various anti-fibrinolytic agents (aprotonin, EACA, tranexamic acid).[26], [27], [28], [29], [30]

A double blind, prospective randomised trial in 70 patients undergoing CPD demonstrated reduced perioperative bleeding using DDAVP compared to placebo due to an increase in vWF levels.³² Other studies however have shown conflicting results.[33], [39],

Pharmacological interventions in orthopaedic surgery

A single dose of 10 mg/kg of tranexamic acid administered to patients undergoing total knee arthroplasty prior to the release of the torniquet was associated with significantly decreased perioperative mean blood loss.⁴⁵

Aprotinin, used widely in cardiac surgery has not demonstrated similar efficacy in orthopaedic surgery, albeit used in lower doses.⁴⁶

Spinal surgery

Intraoperative EACA was found to significantly decrease the perioperative blood loss in patients undergoing posterior spinal fusion.⁴⁷

Near patient testing

As discussed above, near patient testing has evolved due to the limitations of the initial coagulation screening tests as well as the time involved in obtaining results in the face of continued bleeding. The goal in near patient testing would be a test that was cheap, reliable, produces quick results and is able to measure all components in the haemostatic pathway. Unlike other traditional clotting assays which measure a component of the coagulation process, thromboelastography (TEG) provides a

Conservative methods to reduce allogeneic blood use

An important consideration in any comprehensive blood conservation programme in the management of perioperative bleeding would be a reduction in allogeneic blood exposure.

The commonly used methods are:

preoperative autologous transfusion;
intraoperative red cell salvage;
acute normovolaemic dilution;
controlled hypotension;
pre-op erythropoietin;
transfusion trigger.

However, there is still considerable debate as to the extent to which these measures, like acute normovolaemic dilution could reduce

Concluding remarks

In summary the management of perioperative bleeding requires a multidisciplinary approach. There is increasing emphasis on using near patient testing in complex surgical procedures and more widespread recognition of the value of various pharmacological agents in elective surgery. In particular, rFVIIa looks promising, especially in intractable bleeding. Ultimately, careful attention to preventative measures would go a long way to minimising the incidence of severe perioperative bleeding and the

Practice points

1.
Identifying the patient at risk of excessive perioperative bleeding through careful history, clinical examination and appropriate investigations even if baseline screening tests are normal.
2.
Understanding the haemostatic changes that occur in the perioperative period including complex surgical procedures like cardiopulmonary bypass and orthotopic liver transplantation.
3.
Near patient testing is increasingly recognised as an important tool in addition to other coagulation tests in elucidating the

References (55)

N.M. Gibbs et al.
Postoperative changes in coagulant and anticoagulant factors following abdominal aortic surgery
J. Cardiothorac. Vasc. Anesth.
(1992)
B.J. Hunt et al.
Activation of coagulation
Ann. Thorac. Surg.
(1998)
R.C. Woodman et al.
Bleeding complications associated with cardiopulmonary bypass
Blood
(1990)
P. Zilla et al.
Blood platelets in cardiopulmonary bypass operations. Recovery occurs after initial stimulation, rather than continual activation
J. Thorac. Cardiovas. Surg.
(1989)
W.H. Dzik et al.
Fibrinolysis during liver transplantation in humans: role of tissue type plasminogen activator
Blood
(1988)
H. Segal et al.
Aprotinin: pharmacological reduction of perioperative bleeding
Lancet
(2000)
D. Royston et al.
Effects of aprotinin on need for blood transfusion after repeat open heart surgery
Lancet
(1987)
L. Garcia Huete et al.
The prophylactic effect of aprotinin on intraoperative bleeding in liver transplantation
Hepatology
(1997)
D. Katsaros et al.
Tranexamic acid reduces post bypass blood loss: a double blinded, prospective, randomised study of 210 patients
Ann. Thorac. Surg.
(1996)
M. Janssens et al.
Reductions in requirements of allogeneic blood products: pharmacologic methods
Ann. Thorac. Surg.
(1996)

V. Casati et al.

Tranexamic acid compared to high dose aprotinin in primary elective heart operations: effect of perioperative bleeding and allogeneic transfusions

J. Thorac. Cardiovasc Surg.

(2000)

M. Weinstein et al.

Changes in von Willebrand factor during cardiac surgery: effect of desmopressin acetate

Blood

(1988)

M. Levi et al.

Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant outcomes

Lancet

(1999)

J.I. Casas et al.

Aprotinin versus desmopressin for patients undergoing operations with cardiopulmonary bypass. A double blind placebo controlled study

J. Thorac. Cardiovasc. Surg.

(1995)

C.W. Francis et al.

Haematologic problems in the surgical patient: Bleeding and Thrombosis

Blood Transfusion Task Force. Transfusion for massive blood loss. Clin Lab Haematol 1988;10:...

K.A. Jorgensen et al.

Alterations in plasma anti-thrombin III following total hip replacement and elective cholecystectomy

Scand. J. Haematol.

(1980)

J. Vinnicombe et al.

Aminocaproic acid in the control of haemorrhage after prostatectomy: a controlled trial

Lancet

(1996)

A.E. Seyfer et al.

Coagulation changes in elective surgery and trauma

Ann. Surg.

(1981)

T.E. Brothers et al.

Coagulation status during aortic aneurysm surgery: comparison of thromboelastography with standard tests

J. Invest. Surg.

(1993)

K.A. Illig et al.

Primary fibrinolysis during supraceliac aortic clamping

J. Vasc. Surg.

(1997)

E.F. Mammen et al.

Haemostasis changes during cardiopulmonary bypass surgery

Semin. Thromb. Hemost.

(1985)

A.B. Gelb et al.

Changes in blood coagulation during and following cardiopulmanry bypass: lack of correlation with clinical bleeding

Am. J. Clin. Pathol.

(1996)

R.W. Colman

Haemostatic complications of cardiopulmanry bypass

Am. J. Haematol.

(1995)

M.D. Boisclar et al.

Mechanisms of thrombin generation during surgery and cardiopulmanry bypass

Blood

(1993)

G. Bertolino et al.

Platelet composition and function in patients undergoing CPB for heart surgery

Haematologica

(1996)

J.H. Lewis et al.

Liver transplantation: intraoperative changes in coagulation factors in 100 first transplants

Hepatology

(1989)

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Six information sources were screened until 25-June-2022. The Cochrane Collaboration tool and Newcastle–Ottawa Scale were used to evaluate the risk of bias. Data were summarized as mean difference or risk ratio with 95% confidence interval in a random-effects model.
Eleven studies, comprising 1067 patients (vasopressin=567 and control=500) were analyzed. For RCTs (n = 8), the overall quality included ‘high risk’ (n = 4), ‘low risk’ (n = 2), and ‘some concerns’ (n = 2). For NCTs (n = 3), the overall quality included ‘good’ (n = 2) and ‘fair’ (n = 1). The mean intraoperative blood loss, mean difference in hemoglobin level, mean difference in hematocrit level, rate of perioperative blood transfusion, and mean operative time were significantly reduced in favor of the vasopressin group compared with the control group. However, there was no significant difference between both groups regarding the mean hospital stay. Pertaining to safety endpoints, after omission of an outlier study, the rate of drug-related cardiovascular adverse events did not significantly differ between both groups. There was no quantitative evidence of publication bias for the endpoint of intraoperative blood loss.
Among patients undergoing myomectomy, prophylactic administration of vasopressin was largely safe and correlated with significant reductions in intraoperative blood loss and associated morbidities compared with a passive control intervention. Nonetheless, the conclusions should be cautiously interpreted owing to the low-evidence quality and the used doses varied greatly between studies.
Prophylactic tranexamic acid during myomectomy: A systematic review and meta-analysis of randomized controlled trials
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To conduct a systematic review and meta-analysis of randomized controlled trials on the clinical efficacy and safety of prophylactic tranexamic acid (TXA) versus control (normal saline/no treatment) during myomectomy.
Six databases were screened from inception until 21-February-2022. The eligible studies were assessed for risk of bias. The outcomes were summarized as mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CI) in a random-effects model.
Seven studies, comprising eight arms and 571 patients (TXA = 304 patients, control = 267 patients) were analyzed. The included studies had an overall low risk of bias. The mean intraoperative blood loss (MD = −224.34 ml, 95% CI [−303.06, −145.61], p < 0.001), mean postoperative blood loss, and mean total blood loss were significantly reduced in favor of the prophylactic TXA group. Additionally, the mean postoperative hemoglobin (MD = 0.4 mg/dl, 95% CI [0.11, 0.68], p = 0.006) and mean postoperative hematocrit levels were significantly higher in favor of the prophylactic TXA group. While the mean hospital stay was significantly reduced in favor of the prophylactic TXA group (MD = −0.39 d, 95% [−0.74, −0.04], p = 0.03), there was no significant difference between both groups regarding the mean operation time and rate of blood transfusion. None of the participants in both groups developed any incidence of thromboembolic events. The rate of nausea was significantly higher in disfavor of the prophylactic TXA group (RR = 2.68, 95% CI [1.11, 6.43], p = 0.03).
Among patients undergoing myomectomy, prophylactic TXA was largely safe and linked to substantial reductions in perioperative blood loss and related morbidities.
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Citation Excerpt :
The persistence of surgical bleeding, despite currently available hemostasis methods, represents a continued risk of unfavorable clinical outcomes, an unmet need requiring advanced hemostats, and a more critical, substantiated understanding of comparative performance [1]. Several individual clinical factors have been linked to a higher risk of surgical bleeding including coagulopathies, renal and liver diseases, and various medications such as chronic antiplatelet therapies, non-steroidal anti-inflammatory drugs, and anticoagulants which have been recently associated with an increased number of users [6,35]. These factors can complicate surgeries as well as increase the likelihood of transfusion, reoperation, and associated complications.
Evidence comparing fibrin sealants (FSs) in surgery are limited. This study evaluated the efficacy and safety of FSs, and manual compression in peripheral vascular surgery.
A systematic review of randomized trials was conducted in Medline, Embase, and Cochrane databases within the last 15 years. Data were available to conduct a network meta-analysis (NMA) in peripheral vascular surgery. Fibrin sealant treatment arms were further broken-down and assessed by clotting time (i.e., 2-min [2C] or 1-min [1C]). The primary efficacy outcome was the proportion of patients achieving hemostasis by 4 min (T4). Treatment-related serious and non-serious adverse events (AEs) were qualitatively assessed.
Five studies (n = 693), were included in the NMA. Results predicted VISTASEAL 2C, followed by EVICEL 1C, had the highest probability of achieving T4. Compared with manual compression, significant improvements in T4 were found with VISTASEAL 2C (relative risk [RR] = 2.67, 95% CrI: 2.13–3.34), EVICEL 1C (RR = 2.58, 95% CrI: 2.04–3.23), VISTASEAL 1C (RR = 2.00, 95% CrI: 1.45–2.65), and TISSEEL 2C (RR = 1.99, 95% CrI: 1.48–2.60). TISSEEL 1C was not significantly different than manual compression (RR = 1.40, 95% CrI: 0.70–2.33). Among FSs, VISTASEAL 2C was associated with a significant improvements in T4 compared with VISTASEAL 1C (RR = 1.33, 95% CrI: 1.02–1.82), TISSEEL 2C (RR = 1.34, 95% CrI: 1.05–1.77), and TISSEEL 1C (RR = 1.90, 95% CrI: 1.18–3.74). Treatment-related serious and non-serious AE rates were typically lower than 2%.
In peripheral vascular surgeries, VISTASEAL 2C and EVICEL 1C were shown to have the highest probabilities for achieving rapid hemostasis among the treatments compared. Future studies should expand networks across surgery types as data become available.
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The baseline demographic features and characteristics of leiomyomas were comparable in both groups. The mean (±standard deviation) blood loss in Group I was 139 ± 96.7 ml, which was significantly less than that for Group II (206 ± 101.2 ml) (p = 0.008). The mean postoperative haemoglobin was 11.6 ± 1.3 g/dl in Group I and 10.0 ± 1.2 g/dl in Group II (p = 0.001). Although blood loss was not clinically significant in either group, the decrease in haemoglobin was significantly higher in Group II. The mean score for ease of enucleation (surgeon-rated measure) was significantly lower in Group I (2.6 ± 1.1) compared with Group II (3.4 ± 1.1) (p = 0.029). Intra- and postoperative vital signs, duration of surgery, need for blood transfusion and postoperative morbidity were comparable in both groups.
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Conventional coagulation tests (CCTs) in patients with cirrhosis only assess procoagulant factors and are poor predictors of bleeding risk. In spite of this knowledge, they are routinely used prior to invasive procedures, and attempts are made to correct these abnormalities before invasive procedures. These practices are not supported by the evidence and are harmful to the patients.
This prospective study included 150 patients of cirrhosis undergoing invasive procedures. CCTs [bleeding time (BT), clotting time (CT), international normalized ratio (INR), activated partial thromboplastin time (aPTT) and platelet count], thromboplastin generation time (TGT) and thromboelastography (TEG) were done in all patients, and they were observed for post procedural bleeding. None of the patients received prophylactic transfusion before the procedure.
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The management of perioperative bleeding

Abstract

Introduction

Section snippets

Identifying patients at risk of bleeding (preventive)

Haemostatic changes occurring in the perioperative period

Cardiopulmonary bypass (CPB)

Massive blood loss

Blood based and pharmacological interventions

Aprotinin

Lysine analogues

Desmopressin (DDAVP)

Recombinant VIIa

Topical agent: fibrin glues

Pharmacological interventions in CPD

Pharmacological interventions in orthopaedic surgery

Spinal surgery

Near patient testing

Conservative methods to reduce allogeneic blood use

Concluding remarks

Practice points

J. Cardiothorac. Vasc. Anesth.

Ann. Thorac. Surg.

Blood

J. Thorac. Cardiovas. Surg.

Blood

Lancet

Lancet

Hepatology

Ann. Thorac. Surg.

Ann. Thorac. Surg.

J. Thorac. Cardiovasc Surg.

Blood

Lancet

J. Thorac. Cardiovasc. Surg.

Haematologic problems in the surgical patient: Bleeding and Thrombosis

Alterations in plasma anti-thrombin III following total hip replacement and elective cholecystectomy

Scand. J. Haematol.

Aminocaproic acid in the control of haemorrhage after prostatectomy: a controlled trial

Lancet

Coagulation changes in elective surgery and trauma

Ann. Surg.

Coagulation status during aortic aneurysm surgery: comparison of thromboelastography with standard tests

J. Invest. Surg.

Primary fibrinolysis during supraceliac aortic clamping

J. Vasc. Surg.

Haemostasis changes during cardiopulmonary bypass surgery

Semin. Thromb. Hemost.

Changes in blood coagulation during and following cardiopulmanry bypass: lack of correlation with clinical bleeding

Am. J. Clin. Pathol.

Haemostatic complications of cardiopulmanry bypass

Am. J. Haematol.

Mechanisms of thrombin generation during surgery and cardiopulmanry bypass

Blood

Platelet composition and function in patients undergoing CPB for heart surgery

Haematologica

Liver transplantation: intraoperative changes in coagulation factors in 100 first transplants

Hepatology