Sandbox spb2013

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

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

Class 1

"1. XXXXX. (Level of Evidence: A)"

Class 1

"1. XXXXX. (Level of Evidence: A)"

Class 2

"1. XXXXX.(Level of Evidence: A)"

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

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)"

Antiplatelet Agents

Class 1

"1. We recommend that aspirin therapy should continue perioperatively in most surgical settings, especially cardiac surgery. (Level of Evidence: C)"

"2. Where aspirin withdrawal is considered, we recommend a time interval of 5 days. (Level of Evidence: C)"

"3. Clopidogrel increases perioperative bleeding. In cases of increased bleeding risk, we recommend that it should be withdrawn for no more than 5 days. (Level of Evidence: C)"

"4. Prasugrel increases perioperative bleeding. In cases of increased bleeding risk, we recommend that it should be withdrawn for no more than 7 days. (Level of Evidence: C)"

"5. We recommend that antiplatelet agent therapy should resume as soon as possible postoperatively to prevent platelet activation. (Level of Evidence: C)"

"6. We recommend postponement of elective surgery following coronary stenting (at least 6 to 12 weeks for bare metal stent and one year for drug-eluting stents). (Level of Evidence: C)"

"7. We recommend that a multidisciplinary team meeting should decide on the perioperative use of antiplatelet agents in urgent and semi-urgent surgery. (Level of Evidence: C)"

Sources

• 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding