Bleeding perioperative bleeding management in specific surgeries: Difference between revisions

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==2013 ESA Guidelines for the Management of Severe Perioperative Bleeding (DO NOT EDIT)<ref name="Kozek-Langenecker-2013">{{Cite journal  | last1 = Kozek-Langenecker | first1 = SA. | last2 = Afshari | first2 = A. | last3 = Albaladejo | first3 = P. | last4 = Santullano | first4 = CA. | last5 = De Robertis | first5 = E. | last6 = Filipescu | first6 = DC. | last7 = Fries | first7 = D. | last8 = Görlinger | first8 = K. | last9 = Haas | first9 = T. | title = Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. | journal = Eur J Anaesthesiol | volume = 30 | issue = 6 | pages = 270-382 | month = Jun | year = 2013 | doi = 10.1097/EJA.0b013e32835f4d5b | PMID = 23656742 }}</ref>==
==2013 ESA Guidelines for the Management of Severe Perioperative Bleeding (DO NOT EDIT)<ref name="Kozek-Langenecker-2013">{{Cite journal  | last1 = Kozek-Langenecker | first1 = SA. | last2 = Afshari | first2 = A. | last3 = Albaladejo | first3 = P. | last4 = Santullano | first4 = CA. | last5 = De Robertis | first5 = E. | last6 = Filipescu | first6 = DC. | last7 = Fries | first7 = D. | last8 = Görlinger | first8 = K. | last9 = Haas | first9 = T. | title = Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. | journal = Eur J Anaesthesiol | volume = 30 | issue = 6 | pages = 270-382 | month = Jun | year = 2013 | doi = 10.1097/EJA.0b013e32835f4d5b | PMID = 23656742 }}</ref>==


===Algorithms in Specific Clinical Fields===


====Cardiovascular Surgery====


{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that a prophylactic dose of [[LMWH|low molecular weight heparin]] should be administered subcutaneously 8–12 h before elective [[CABG|CABG surgery]]. This intervention does not increase the risk of perioperative [[bleeding]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' We recommend that [[tranexamic acid]] or [[Aminocaproic acid]] should be considered before [[CABG|CABG surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend that intraoperative [[tranexamic acid]] or [[Aminocaproic acid]] administration should be considered to reduce perioperative [[bleeding]] in high-, medium- and low-risk cardiovascular [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' We recommend that [[tranexamic acid]] should be applied topically to the [[chest cavity]] to reduce postoperative blood loss following [[CABG|CABG surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' We recommend that [[fibrinogen]] concentrate infusion guided by point-of-care viscoelastic [[coagulation]] monitoring should be used to reduce perioperative [[blood loss]] in complex cardiovascular [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' We recommend the use of standardized hemostatic algorithms with predefined intervention triggers. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|}


{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.'''We suggest considering prophylactic preoperative infusion of 2 g [[fibrinogen]] concentrate in patients with [[fibrinogen]] concentration < 3.8 g/L, because it may reduce [[bleeding]] following elective [[CABG|CABG surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that recombinant [[factor VII|FVIIa]] may be considered for patients with intractable [[bleeding]] during cardiovascular [[surgery]] once conventional [[hemostasis|hemostatic]] options have been exhausted. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest that [[antiplatelet|antiplatelet therapy]] with [[aspirin]] or [[clopidogrel]] may be administered in the early postoperative period without increasing the risk of postoperative [[bleeding]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest that [[Factor VII|rFVIIa]] may be considered for patients with intractable [[bleeding]] after cardiovascular [[surgery]] once conventional [[hemostasis|hemostatic]] options have been exhausted. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
====Gynecological (Non-Pregnant) Bleeding====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest against normovolemic hemodilution because it does not reduce allogeneic [[transfusion]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest using preoperative intravenous [[iron]] to reduce allogeneic [[transfusion]] requirements in gynecological [[cancer]] patients receiving [[chemotherapy]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest using intravenous [[iron]] to correct preoperative [[anemia]] in women with [[menorrhagia]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest against the use of [[tranexamic acid]] in benign gynecological operations such as [[myomectomy]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
====Obstetric Bleeding====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that [[peripartum]] [[hemorrhage]] should be managed by a multidisciplinary team. An escalating management protocol including uterotonic drugs, surgical and/or endovascular interventions, and procoagulant drugs should be available. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' We recommend that moderate (<9.5 g/dl) to sever(<8.5 g/dl) [[postpartum]] [[anemia]] be treated with [[intravenous]] [[iron]] rather than oral therapy. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend the administration of [[tranexamic acid]] in obstetric [[bleeding]] to reduce blood loss, bleeding duration and the number of units transfused. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' We recommend that [[Factor VII|rFVIIa]] should only be considered as last line therapy because of its [[thromboembolism|thromboembolic]] risk. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest that patients with known [[placenta accreta]] are treated by multidisciplinary care teams. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that using perioperative cell salvage during [[caesarean section]] may decrease postoperative homologous [[transfusion]] and reduce hospital stay. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest that treatment with [[erythropoietin]] may correct [[anemia]] more rapidly than treatment with [[folic acid]] and [[iron]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest assessing [[fibrinogen]] concentration in parturients with bleeding, as concentrations <2 g/l may identify those at risk of severe PPH. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In life-threatening PPH, we suggest a transfusion protocol with a fixed product ratio or individualised procoagulant intervention and factor substitution. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' We suggest that [[tranexamic acid]] be considered before [[caesarean section]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''7.''' In antepartum [[bleeding]], we suggest administration of [[tranexamic acid]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''8.''' We suggest that [[fibrinogen]] concentration and number of [[platelets]] should be optimized before administration of [[Factor VII|rFVIIa]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
====Orthopedic Surgery and Neurosurgery====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In elective orthopedic [[surgery]], we recommend the implementation of a blood [[transfusion]] protocol (algorithm), together with staff education. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' We recommend that, for orthopedic [[surgery]], monotherapy with [[aspirin]] does not need to be discontinued. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend discontinuing dual antiplatelet therapy before urgent intracranial neurosurgery. A risk-benefit analysis is required for the continuation of aspirin monotherapy during neurosurgery. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' We recommend against performing orthopedic surgery during the first three months after bare metal stent implantation or during the first twelve months after [[drug-eluting stent]] implantation. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Prophylactic use of [[Factor VII|rFVIIa]] does not reduce perioperative blood loss or transfusion in non-[[hemophilia|hemophiliac]] and non-coagulopathic patients undergoing major orthopedic [[surgery]] or [[neurosurgery]], and it may increase the incidence of [[thromboembolism|thromboembolic]] events. We, therefore, recommend against the prophylactic use of [[factor VII|rFVIIa]] in these clinical settings. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' We recommend restricting off-label use of [[factor VII|rFVIIa]] to patients with severe bleeding who are unresponsive to other [[hemostasis|hemostatic]] interventions. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' In patients with [[INR]] >1.5, with life-threatening [[bleeding]] or [[ICH]], we recommend that four-factor [[Prothrombin complex concentrate|PCCs]] (20–40 IU/kg), supplemented with [[vitamin K]] (10 mg by slow [[intravenous]] infusion), should be used for rapid reversal of [[VKA|vitamin K-antagonists (VKA)]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest the use of viscoelastic tests (ROTEM/TEG) for monitoring perioperative [[hemostasis]] in major orthopedic [[surgery]] and [[neurosurgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest administering [[tranexamic acid]] in total hip arthroplasty, total knee [[arthroplasty]], and major [[spine]] [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Tranexamic acid]] may promote a hypercoagulable state for some patients (with pre-existing thromboembolic events, hip fracture surgery, [[cancer]] [[surgery]], age over 60 years, women). Therefore, we suggest an individual risk-benefit analysis instead of its routine use in these clinical settings. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest the use of [[factor VII|rFVIIa]] in patients with neutralising antibodies to [[Factor VIII|FVIII]] undergoing major orthopedic [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In patients with neutralizing antibodies to [[Factor VIII|FVIII]] undergoing major orthopedic [[surgery]], we suggest using activated PCCs (e.g. FEIBA, [[Factor VIII|FVIII]] inhibitor bypassing agents). ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' New oral anticoagulants, such as [[rivaroxaban]] and [[dabigatran]], may increase surgical [[bleeding]] and [[ICH]] growth.  We suggest that [[Prothrombin complex concentrate|PCCs]], FEIBA or [[factor VII}|rFVIIa]] may be used as non-specific antagonists in life threatening bleeding or [[ICH]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
====Visceral and Transplant Surgery====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend against the use of [[FFP]] for pre-procedural correction of mild to moderately elevated [[INR]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' We recommend that, in [[acute liver failure]], moderately elevated [[INR]] should not be corrected before invasive procedures, with the exception of [[ICP|intracranial pressure]] monitor insertion. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend the use of perioperative coagulation monitoring using ROTEM/TEG for targeted management of coagulopathy. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' We recommend antifibrinolytic drugs for treatment of [[fibrinolysis]] (evident from microvascular oozing or TEG/ROTEM clot lysis measurement) and not for routine [[prophylaxis]]. Marginal grafts (e.g. donation after cardiac death) increase the risk of [[fibrinolysis]] post-[[reperfusion]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' We recommend against [[factor VII|rFVIIa]] for [[prophylaxis]]; [[factor VII|rFVIIa]] should be used only as rescue therapy for uncontrolled [[bleeding]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest a [[platelet]] count of 50,000/ml as a threshold for [[platelet]] [[transfusion]] before liver [[biopsy]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that antifibrinolytic drugs should be considered in [[cirrhosis|cirrhotic]] patients undergoing [[liver]] resection. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}
====Acute Upper Gastrointestinal Bleeding====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend that acute [[variceal bleeding]] should be managed by a multidisciplinary team. A specific multimodal protocol for [[upper gastrointestinal hemorrhage]] should be available. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' We recommend that early treatment involves immediate use of [[vasopressor]]s ([[somatostatin]] or [[terlipressin]]) to reduce [[bleeding]] and early interventional [[endoscopy]]. [[Antibiotic]]s must be started on admission. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[Factor VII|rFVIIa]] should be used only as rescue therapy; we recommend against its routine use. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====Coagulopathy and Renal Disease====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest that conjugated [[estrogen]] therapy should be used in [[uremia]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that [[desmopressin]] should be considered for reducing [[bleeding]] during [[surgery]] and for managing acute [[bleeding]] in [[uremic]] patients. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====Pediatric Surgery====
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 1]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' We recommend against the use of [[Factor VII|rFVIIa]] in children. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable" style="width: 80%;"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ESA guidelines classification scheme#Classification of Recommendations|Class 2]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' We suggest the use of perioperative [[coagulation]] analysis using viscoelastic point-of-care monitoring (ROTEM/TEG) for timely detection of [[coagulation]] defects including dilutional [[coagulopathy]] and [[fibrinolysis|hyperfibrinolysis]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that a critical [[hemoglobin]] threshold of 8 g/dl for [[RBC]] [[transfusion]] may be safe in severe [[pediatric]] [[perioperative bleeding]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' We suggest that [[transfusion]] of [[platelet]] concentrates may be considered if [[platelet]] count is <50,000–100,000/µl. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' We suggest that [[fibrinogen]] concentrate (30–50 mg/kg) or [[cryoprecipitate]] (5 ml/kg) may be used to increase plasma [[fibrinogen]] concentrations above trigger values of 1.5–2.0 g/l or FIBTEM MCF > 7 mm in [[bleeding]] children. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' We suggest that [[FFP]] may be used if no other [[fibrinogen]] source is available. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' We suggest against the routine use of [[desmopressin]] in the absence of [[hemophilia A]] or mild [[von Willebrand disease]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''7.''' We suggest that perioperative [[fibrinolytic|antifibrinolytic therapy]] should be used to reduce [[blood loss]] and [[transfusion]] requirements in cardiac and non-cardiac pediatric [[surgery]]. ''([[ESA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|}


==Sources==
==Sources==

Revision as of 18:49, 21 April 2014

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Main article: Bleeding

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

2013 ESA Guidelines for the Management of Severe Perioperative Bleeding (DO NOT EDIT)[1]

Algorithms in Specific Clinical Fields

Cardiovascular Surgery

Class 1
"1. We recommend that a prophylactic dose of low molecular weight heparin should be administered subcutaneously 8–12 h before elective CABG surgery. This intervention does not increase the risk of perioperative bleeding. (Level of Evidence: B) "
"2. We recommend that tranexamic acid or Aminocaproic acid should be considered before CABG surgery. (Level of Evidence: A) "
"3. We recommend that intraoperative tranexamic acid or Aminocaproic acid administration should be considered to reduce perioperative bleeding in high-, medium- and low-risk cardiovascular surgery. (Level of Evidence: A) "
"4. We recommend that tranexamic acid should be applied topically to the chest cavity to reduce postoperative blood loss following CABG surgery. (Level of Evidence: C) "
"5. We recommend that fibrinogen concentrate infusion guided by point-of-care viscoelastic coagulation monitoring should be used to reduce perioperative blood loss in complex cardiovascular surgery. (Level of Evidence: B) "
"6. We recommend the use of standardized hemostatic algorithms with predefined intervention triggers. (Level of Evidence: A) "
Class 2
"1.We suggest considering prophylactic preoperative infusion of 2 g fibrinogen concentrate in patients with fibrinogen concentration < 3.8 g/L, because it may reduce bleeding following elective CABG surgery. (Level of Evidence: C) "
"2. We suggest that recombinant FVIIa may be considered for patients with intractable bleeding during cardiovascular surgery once conventional hemostatic options have been exhausted. (Level of Evidence: B) "
"3. We suggest that antiplatelet therapy with aspirin or clopidogrel may be administered in the early postoperative period without increasing the risk of postoperative bleeding. (Level of Evidence: C) "
"4. We suggest that rFVIIa may be considered for patients with intractable bleeding after cardiovascular surgery once conventional hemostatic options have been exhausted. (Level of Evidence: B) "

Gynecological (Non-Pregnant) Bleeding

Class 2
"1. We suggest against normovolemic hemodilution because it does not reduce allogeneic transfusion. (Level of Evidence: A) "
"2. We suggest using preoperative intravenous iron to reduce allogeneic transfusion requirements in gynecological cancer patients receiving chemotherapy. (Level of Evidence: B) "
"3. We suggest using intravenous iron to correct preoperative anemia in women with menorrhagia. (Level of Evidence: B) "
"4. We suggest against the use of tranexamic acid in benign gynecological operations such as myomectomy. (Level of Evidence: B) "

Obstetric Bleeding

Class 1
"1. We recommend that peripartum hemorrhage should be managed by a multidisciplinary team. An escalating management protocol including uterotonic drugs, surgical and/or endovascular interventions, and procoagulant drugs should be available. (Level of Evidence: C) "
"2. We recommend that moderate (<9.5 g/dl) to sever(<8.5 g/dl) postpartum anemia be treated with intravenous iron rather than oral therapy. (Level of Evidence: B) "
"3. We recommend the administration of tranexamic acid in obstetric bleeding to reduce blood loss, bleeding duration and the number of units transfused. (Level of Evidence: B) "
"4. We recommend that rFVIIa should only be considered as last line therapy because of its thromboembolic risk. (Level of Evidence: B) "
Class 2
"1. We suggest that patients with known placenta accreta are treated by multidisciplinary care teams. (Level of Evidence: C) "
"2. We suggest that using perioperative cell salvage during caesarean section may decrease postoperative homologous transfusion and reduce hospital stay. (Level of Evidence: B) "
"3. We suggest that treatment with erythropoietin may correct anemia more rapidly than treatment with folic acid and iron. (Level of Evidence: C) "
"4. We suggest assessing fibrinogen concentration in parturients with bleeding, as concentrations <2 g/l may identify those at risk of severe PPH. (Level of Evidence: C) "
"5. In life-threatening PPH, we suggest a transfusion protocol with a fixed product ratio or individualised procoagulant intervention and factor substitution. (Level of Evidence: C) "
"6. We suggest that tranexamic acid be considered before caesarean section. (Level of Evidence: C) "
"7. In antepartum bleeding, we suggest administration of tranexamic acid. (Level of Evidence: B) "
"8. We suggest that fibrinogen concentration and number of platelets should be optimized before administration of rFVIIa. (Level of Evidence: C) "

Orthopedic Surgery and Neurosurgery

Class 1
"1. In elective orthopedic surgery, we recommend the implementation of a blood transfusion protocol (algorithm), together with staff education. (Level of Evidence: B) "
"2. We recommend that, for orthopedic surgery, monotherapy with aspirin does not need to be discontinued. (Level of Evidence: B) "
"3. We recommend discontinuing dual antiplatelet therapy before urgent intracranial neurosurgery. A risk-benefit analysis is required for the continuation of aspirin monotherapy during neurosurgery. (Level of Evidence: B) "
"4. We recommend against performing orthopedic surgery during the first three months after bare metal stent implantation or during the first twelve months after drug-eluting stent implantation. (Level of Evidence: C) "
"5. Prophylactic use of rFVIIa does not reduce perioperative blood loss or transfusion in non-hemophiliac and non-coagulopathic patients undergoing major orthopedic surgery or neurosurgery, and it may increase the incidence of thromboembolic events. We, therefore, recommend against the prophylactic use of rFVIIa in these clinical settings. (Level of Evidence: B) "
"6. We recommend restricting off-label use of rFVIIa to patients with severe bleeding who are unresponsive to other hemostatic interventions. (Level of Evidence: C) "
"6. In patients with INR >1.5, with life-threatening bleeding or ICH, we recommend that four-factor PCCs (20–40 IU/kg), supplemented with vitamin K (10 mg by slow intravenous infusion), should be used for rapid reversal of vitamin K-antagonists (VKA). (Level of Evidence: C) "
Class 2
"1. We suggest the use of viscoelastic tests (ROTEM/TEG) for monitoring perioperative hemostasis in major orthopedic surgery and neurosurgery. (Level of Evidence: C) "
"2. We suggest administering tranexamic acid in total hip arthroplasty, total knee arthroplasty, and major spine surgery. (Level of Evidence: A) "
"3. Tranexamic acid may promote a hypercoagulable state for some patients (with pre-existing thromboembolic events, hip fracture surgery, cancer surgery, age over 60 years, women). Therefore, we suggest an individual risk-benefit analysis instead of its routine use in these clinical settings. (Level of Evidence: A) "
"4. We suggest the use of rFVIIa in patients with neutralising antibodies to FVIII undergoing major orthopedic surgery. (Level of Evidence: C) "
"5. In patients with neutralizing antibodies to FVIII undergoing major orthopedic surgery, we suggest using activated PCCs (e.g. FEIBA, FVIII inhibitor bypassing agents). (Level of Evidence: C) "
"6. New oral anticoagulants, such as rivaroxaban and dabigatran, may increase surgical bleeding and ICH growth. We suggest that PCCs, FEIBA or [[factor VII}|rFVIIa]] may be used as non-specific antagonists in life threatening bleeding or ICH. (Level of Evidence: C) "

Visceral and Transplant Surgery

Class 1
"1. We recommend against the use of FFP for pre-procedural correction of mild to moderately elevated INR. (Level of Evidence: C) "
"2. We recommend that, in acute liver failure, moderately elevated INR should not be corrected before invasive procedures, with the exception of intracranial pressure monitor insertion. (Level of Evidence: C) "
"3. We recommend the use of perioperative coagulation monitoring using ROTEM/TEG for targeted management of coagulopathy. (Level of Evidence: C) "
"4. We recommend antifibrinolytic drugs for treatment of fibrinolysis (evident from microvascular oozing or TEG/ROTEM clot lysis measurement) and not for routine prophylaxis. Marginal grafts (e.g. donation after cardiac death) increase the risk of fibrinolysis post-reperfusion. (Level of Evidence: C) "
"5. We recommend against rFVIIa for prophylaxis; rFVIIa should be used only as rescue therapy for uncontrolled bleeding. (Level of Evidence: C) "
Class 2
"1. We suggest a platelet count of 50,000/ml as a threshold for platelet transfusion before liver biopsy. (Level of Evidence: C) "
"2. We suggest that antifibrinolytic drugs should be considered in cirrhotic patients undergoing liver resection. (Level of Evidence: C) "

Acute Upper Gastrointestinal Bleeding

Class 1
"1. We recommend that acute variceal bleeding should be managed by a multidisciplinary team. A specific multimodal protocol for upper gastrointestinal hemorrhage should be available. (Level of Evidence: C)"
"2. We recommend that early treatment involves immediate use of vasopressors (somatostatin or terlipressin) to reduce bleeding and early interventional endoscopy. Antibiotics must be started on admission. (Level of Evidence: A)"
"3. rFVIIa should be used only as rescue therapy; we recommend against its routine use. (Level of Evidence: C)"

Coagulopathy and Renal Disease

Class 2
"1. We suggest that conjugated estrogen therapy should be used in uremia. (Level of Evidence: C)"
"2. We suggest that desmopressin should be considered for reducing bleeding during surgery and for managing acute bleeding in uremic patients. (Level of Evidence: C)"

Pediatric Surgery

Class 1
"1. We recommend against the use of rFVIIa in children. (Level of Evidence: C)"
Class 2
"1. We suggest the use of perioperative coagulation analysis using viscoelastic point-of-care monitoring (ROTEM/TEG) for timely detection of coagulation defects including dilutional coagulopathy and hyperfibrinolysis. (Level of Evidence: C)"
"2. We suggest that a critical hemoglobin threshold of 8 g/dl for RBC transfusion may be safe in severe pediatric perioperative bleeding. (Level of Evidence: C)"
"3. We suggest that transfusion of platelet concentrates may be considered if platelet count is <50,000–100,000/µl. (Level of Evidence: C)"
"4. We suggest that fibrinogen concentrate (30–50 mg/kg) or cryoprecipitate (5 ml/kg) may be used to increase plasma fibrinogen concentrations above trigger values of 1.5–2.0 g/l or FIBTEM MCF > 7 mm in bleeding children. (Level of Evidence: C)"
"5. We suggest that FFP may be used if no other fibrinogen source is available. (Level of Evidence: C)"
"6. We suggest against the routine use of desmopressin in the absence of hemophilia A or mild von Willebrand disease. (Level of Evidence: C)"
"7. We suggest that perioperative antifibrinolytic therapy should be used to reduce blood loss and transfusion requirements in cardiac and non-cardiac pediatric surgery. (Level of Evidence: A)"

Sources

  • 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding[1]

References

  1. ↑ 1.0 1.1 Kozek-Langenecker, SA.; Afshari, A.; Albaladejo, P.; Santullano, CA.; De Robertis, E.; Filipescu, DC.; Fries, D.; Görlinger, K.; Haas, T. (2013). "Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology". Eur J Anaesthesiol. 30 (6): 270–382. doi:10.1097/EJA.0b013e32835f4d5b. PMID 23656742. Unknown parameter |month= ignored (help)
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