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)"

Class 2

"1. For intra- or postoperative bleeding clearly related to aspirin, we suggest that platelet transfusion be considered (dose: 0.7 × 1011 [i.e. two standard concentrates] per 7 kg body weight in adults). (Level of Evidence: C)"

"2. We suggest that the first postoperative dose of clopidogrel or prasugrel should be given no later than 24 h after skin closure. We also suggest that this first dose should not be a loading dose. (Level of Evidence: C)"

"3. We suggest that urgent or semi-urgent surgery should be performed under aspirin/clopidogrel or aspirin/prasugrel combination therapy if possible, or at least under aspirin alone. (Level of Evidence: C)"

"4. We suggest that platelet transfusion should be considered (dose: 0.7 × 1011 [i.e. two standard concentrates] per 7 kg body weight in adults) in cases of intra- or postoperative bleeding clearly related to clopidogrel or prasugrel. (Level of Evidence: C)"

"5. According to pharmacological characteristics, we suggest that the management of ticagrelor may be comparable to clopidogrel (i.e. withdrawal interval of 5 days). (Level of Evidence: C)"

"6. Platelet transfusion may be ineffective for treating bleeding clearly related to ticagrelor when given 12 h before. (Level of Evidence: C)"

Heparin

Class 1

"1. We recommend that severe bleeding associated with intravenous unfractionated heparin (UFH) should be treated with intravenous protamine at a dose of 1 mg per 100 IU UFH given in the preceding 2–3 h. (Level of Evidence: A)"

Class 2

"1. We suggest that severe bleeding associated with subcutaneous UFH unresponsive to intravenous protamine at a dose of 1 mg per 100 IU UFH could be treated by continuous administration of intravenous protamine, with dose guided by aPTT. (Level of Evidence: C)"

"2. We suggest that severe bleeding related to subcutaneous low molecular weight heparin (LMWH) should be treated with intravenous protamine at a dose of 1 mg per 100 anti-Xa units of LMWH administered. (Level of Evidence: C)"

"3. We suggest that severe bleeding associated with subcutaneous LMWH and unresponsive to initial administration of protamine could be treated with a second dose of protamine (0.5 mg per 100 anti-FXa units of LMWH administered). (Level of Evidence: C)"

Fondaparinux

Class 2

"1. We suggest that the administration of rFVIIa could be considered to treat severe bleeding associated with subcutaneous administration of fondaparinux (off-label treatment). (Level of Evidence: C)"

Sources

• 2013 ESA Guidelines for the Management of Severe Perioperative Bleeding