Bleeding perioperative bleeding coagulation management

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

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

Coagulation Management

Fibrinogen Concentrate

Class 1

"1. We recommend treatment with fibrinogen concentrate if significant bleeding is accompanied by at least suspected low fibrinogen concentrations or function. (Level of Evidence: C) "

"2. We recommend that a plasma fibrinogen concentration <1.5–2.0 g/L or ROTEM/TEG signs of functional fibrinogen deficit should be triggers for fibrinogen substitution. (Level of Evidence: C) "

"3. We recommend that patients on oral anticoagulant therapy should be given prothrombin complex concentrate (PCC) and vitamin K before any other coagulation management steps for severe perioperative bleeding. (Level of Evidence: B) "

Class 2

"1. We suggest an initial fibrinogen concentrate dose of 25–50 mg/kg. (Level of Evidence: C) "

"2. We suggest that the indication for cryoprecipitate is lack of available fibrinogen concentrate for the treatment of bleeding and hypofibrinogenemia. (Level of Evidence: C) "

"3. In cases of ongoing or diffuse bleeding and low clot strength despite adequate fibrinogen concentrations, it is likely that FXIII activity is critically reduced. In cases of significant FXIII deficiency (i.e. < 60% activity), we suggest that FXIII concentrate (30 IU/kg) can be administered. (Level of Evidence: C) "

"4. We suggest that PCC (20 –30 IU/kg) can also be administered to patients not on oral anticoagulant therapy in the presence of an elevated bleeding tendency and prolonged clotting time. Prolonged INR/PT alone is not an indication for PCC, especially in critically ill patients. (Level of Evidence: C) "

"5. We suggest that off-label administration of recombinant activated factor VII (rFVIIa) can be considered for bleeding which cannot be stopped by conventional, surgical or interventional radiological means and/or when comprehensive coagulation therapy fails. (Level of Evidence: C) "

Antifibrinolytics and Tranexamic Acid

Class 1

"1. We recommend the consideration of tranexamic acid (20 –25 mg/kg). (Level of Evidence: A) "

Class 2

"1. We suggest the use of DDAVP under specific conditions (acquired von Willebrand syndrome). There is no convincing evidence that DDAVP minimises perioperative bleeding or perioperative allogeneic blood transfusion in patients without a congenital bleeding disorder. (Level of Evidence: B) "

Correction of Confounding Factors

Class 1

"1. We recommend maintaining perioperative normothermia because it reduces blood loss and transfusion requirements. (Level of Evidence: B) "

"2. While pH correction alone cannot immediately correct acidosis-induced coagulopathy, we recommend that pH correction should be pursued during treatment of acidotic coagulopathy. (Level of Evidence: C) "

"3. We recommend that rFVIIa should only be considered alongside pH correction. (Level of Evidence: C) "

Class 2

"1. We suggest that rFVIIa may be used in treatment of patients with hypothermic coagulopathy. (Level of Evidence: C) "

"2. We suggest that calcium should be administered during massive transfusion if Ca2+ concentration is low, in order to preserve normocalcaemia (0.9 mmol/l). (Level of Evidence: B) "

Emergency Radiological/Surgical Interventions to Reduce Blood Loss

Class 2

"1. We suggest that endovascular embolization is a safe alternative to open surgical intervention after failed endoscopic treatment for upper gastrointestinal bleeding. (Level of Evidence: C) "

"2. We suggest super-selective embolization as primary therapy for treatment of angiogram positive lower gastrointestinal bleeding. (Level of Evidence: C) "

"3. We suggest embolization as first-line therapy for arterial complications in pancreatitis. (Level of Evidence: C) "

Cost Implications

Class 1

"1. We recommend restricting the use of rFVIIa to its licensed indication because, outside these indications, the effectiveness of rFVIIa to reduce transfusion requirements and mortality remains unproven and the risk of arterial thromboembolic events as well as costs are high. (Level of Evidence: A) "

Sources

• 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding