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Chapter 21 - Perioperative management of hemostasis

from Section 6 - Hematology

Published online by Cambridge University Press:  05 September 2013

By
Mrinal Dutia ,
Eve Rodler  and
Ted Wun
Edited by
Michael F. Lubin ,
Thomas F. Dodson  and
Neil H. Winawer
Michael F. Lubin
Affiliation:
Emory University, Atlanta
Thomas F. Dodson
Affiliation:
Emory University, Atlanta
Neil H. Winawer
Affiliation:
Emory University, Atlanta
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Summary

There is perhaps more money wasted and blood unnecessarily shed in this setting than in any other in medicine.

Sabiston's Textbook of Surgery

Summary

When patients are evaluated for the potential of abnormal bleeding before surgery, the intensity of screening is determined by the hemostatic challenge of the procedure and the likelihood that the patient has an underlying congenital or acquired disorder that would predispose to bleeding. The risk of bleeding associated with the type of surgical procedure ranges from low risk (lymph node biopsies, dental extractions), to moderate risk (laparotomy, thoracotomy, mastectomy), to high risk (neurosurgical, ophthalmic, plastic, cardiopulmonary bypass, prostatic, and surgery to stop bleeding). A screening history should reveal if the patient has experienced any abnormal bleeding or bruising, if there is a history of an acquired medical disorder which could affect hemostasis, if family members have bled abnormally, or if the patient is taking any drugs which could interfere with hemostasis. Physical examination can also provide important information about a patient's surgical bleeding risk. Ecchymoses, petechiae, or purpura may suggest a systemic hemostatic defect. Stigmata of chronic liver disease include hepatomegaly, splenomegaly, jaundice, spider angiomas, palmar erythema, and dilated abdominal veins.

The preoperative hemostatic screening recommendations by Rapaport, based on levels of concern, provide a reasonable basis for selecting laboratories for individual patients [1]. Nearly 30 years old, these recommendations are not obsolete.

Type
Chapter
Information
Medical Management of the Surgical Patient
A Textbook of Perioperative Medicine
 , pp. 223 - 233
Publisher: Cambridge University Press
Print publication year: 2013

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References

Rapaport, SI.Preoperative hemostatic evaluation–which tests, if any?Blood 1983; 61: 229–31.Google Scholar
Katsaros, D, Petricevic, M, Snow, NJ et al. Tranexamic acid reduces postbypass blood use: a double-blinded, prospective, randomized study of 210 patients. Ann Thorac Surg 1996; 61: 1131–5.CrossRefGoogle ScholarPubMed
George, JN, Shattil, SJ.The clinical importance of acquired abnormalities of platelet function. N Engl J Med 1991; 324: 27–39.CrossRefGoogle ScholarPubMed
Cattaneo, M, Harris, AS, Stromberg, U, Mannucci, PM.The effect of desmopressin on reducing blood loss in cardiac surgery – a meta-analysis of double-blind, placebo-controlled trials. Thromb Haemost 1995; 74: 1064–70.Google ScholarPubMed
Sheridan, DP, Card, RT, Pinilla, JC et al. Use of desmopressin acetate to reduce blood transfusion requirements during cardiac surgery in patients with acetylsalicylic-acid-induced platelet dysfunction. Can J Surg 1994; 37: 33–6.Google ScholarPubMed
Dilthey, G, Dietrich, W, Spannagl, M, Richter, JA.Influence of desmopressin acetate on homologous blood requirements in cardiac surgical patients pretreated with aspirin. J Cardiothorac Vasc Anesth 1993; 7: 425–30.CrossRefGoogle Scholar
Menichetti, A, Tritapepe, L, Ruvolo, G. et al. Changes in coagulation patterns, blood loss and blood use after cardio-pulmonary bypass: aprotinin vs tranexamic acid vs epsilon aminocaproic acid. J Cardiovasc Surg (Torino) 1996; 37: 401–7.Google Scholar
Janssens, M, Hartstein, G, David, JL.Reduction in requirements for allogeneic blood products: pharmacologic methods. Ann Thorac Surg 1996; 62: 1944–50.CrossRefGoogle ScholarPubMed
Rich, JB.The efficacy and safety of aprotinin use in cardiac surgery. Ann Thorac Surg 1998; 66 (5 Suppl): S6–11.CrossRefGoogle ScholarPubMed
Mannucci, PM.Desmopressin: a nontransfusional form of treatment for congenital and acquired bleeding disorders. Blood 1988; 72: 1449–55.Google ScholarPubMed
Royston, D, Bidstrup, BP, Taylor, KM, Sapsford, RN.Effect of aprotinin on need for blood transfusion after repeat open-heart surgery. Lancet 1987; 2 (8571): 1289–91.CrossRefGoogle ScholarPubMed
Mannucci, PM.Hemostatic drugs. N Engl J Med 1998; 339: 245–53.CrossRefGoogle ScholarPubMed
Vander Salm, TJ, Kaur, S, Lancey, RA et al. Reduction of bleeding after heart operations through the prophylactic use of epsilon-aminocaproic acid. J Thorac Cardiovasc Surg 1996; 112: 1098–107.CrossRefGoogle ScholarPubMed
Horrow, JC, Van Riper, DF, Strong, MD et al. The dose-response relationship of tranexamic acid. Anesthesiology 1995; 82: 383–92.CrossRefGoogle ScholarPubMed
Whitlock, RP, Chan, S, Devereaux, PJ et al. Clinical benefit of steroid use in patients undergoing cardiopulmonary bypass: a meta-analysis of randomized trials. Eur Heart J 2008; 29: 2592.CrossRefGoogle ScholarPubMed
Karkouti, K, Cohen, MM, McCluskey, SA et al. A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery. Transfusion 2001; 41: 1193.CrossRefGoogle ScholarPubMed
Reece, TB, Maxey, TS, Kron, IL.A prospectus on tissue adhesives. Am J Surg 2001; 182 (2 Suppl): 40S–4S.CrossRefGoogle ScholarPubMed
Carless, PA, Anthony, DM, Henry, DA.Systematic review of the use of fibrin sealant to minimize perioperative allogeneic blood transfusion. Br J Surg 2002; 89: 695–703.CrossRefGoogle ScholarPubMed
Gill, R, Herbertson, M, Vuylsteke, A et al. Safety and efficacy of recombinant activated factor VII: a randomized placebo-controlled trial in the setting of bleeding after cardiac surgery. Circulation 2009; 120: 21.CrossRefGoogle ScholarPubMed
van de Garde, EM, Bras, LJ, Heijmen, RH et al. Low-dose recombinant factor VIIa in the management of uncontrolled postoperative hemorrhage in cardiac surgery patients. J Cardiothorac Vasc Anesth 2006; 20: 573.CrossRefGoogle ScholarPubMed
Vinnicombe, J, Shuttleworth, KE.Aminocaproic acid in the control of haemorrhage after prostatectomy. Safety of aminocaproic acid – a controlled trial. Lancet 1966; 1(7431): 232–4.CrossRefGoogle ScholarPubMed
Hedner, U.NovoSeven as a universal haemostatic agent. Blood Coagul Fibrinol 2000; 11 (Suppl 1): S107–11.CrossRefGoogle ScholarPubMed
Friederich, PW, Henny, CP, Messelink, EJ et al. Effect of recombinant activated factor VII on perioperative blood loss in patients undergoing retropubic prostatectomy: a double-blind placebo-controlled randomised trial. Lancet 2003; 361(9353): 201.CrossRefGoogle ScholarPubMed
Porte, RJ.Coagulation and fibrinolysis in orthotopic liver transplantation: current views and insights. Semin Thromb Hemost 1993; 19: 191–6.CrossRefGoogle ScholarPubMed
Morikawa, T.Tissue sealing. Am J Surg 2001; 182 (2 Suppl): 29S–35S.CrossRefGoogle ScholarPubMed
Gerlach, R, Tolle, F, Raabe, A et al. Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity: implications of a prospective study. Stroke 2002; 33: 1618–23.CrossRefGoogle ScholarPubMed
Lundberg, GD.Is there a need for routine preoperative laboratory tests?J Am Med Assoc 1985; 253: 3589.CrossRefGoogle Scholar
Shapiro, MB, Jenkins, DH, Schwab, CW, Rotondo, MF.Damage control: collective review. J Trauma 2000; 49: 969–78.CrossRefGoogle ScholarPubMed
Martin, RR, Byrne, M.Postoperative care and complications of damage control surgery. Surg Clin N Am 1997; 77: 929–42.CrossRefGoogle ScholarPubMed
Harrison, TD, Laskosky, J, Jazaeri, O et al. "Low-dose" recombinant activated factor VII results in less blood and blood product use in traumatic hemorrhage. J Trauma 2005; 59: 150.CrossRefGoogle ScholarPubMed
Bauzá, G, Hirsch, E, Burke, P et al. Low-dose recombinant activated factor VII in massively transfused trauma patients with coagulopathy. Transfusion 2007; 47: 749.CrossRefGoogle ScholarPubMed
Johnson, JW, Gracias, VH, Schwab, CW et al. Evolution in damage control for exsanguinating penetrating abdominal injury. J Trauma 2001; 51: 261–9.CrossRefGoogle ScholarPubMed
Gubler, KD, Gentilello, LM, Hassantash, SA, Maier, RV.The impact of hypothermia on dilutional coagulopathy. J Trauma 1994; 36: 847–51.CrossRefGoogle ScholarPubMed
Martinowitz, U, Kenet, G, Segal, E et al. Recombinant activated factor VII for adjunctive hemorrhage control in trauma. J Trauma 2001; 51: 431–8.Google ScholarPubMed
Holcomb, JB, McClain, JM, Pusateri, AE et al. Fibrin sealant foam sprayed directly on liver injuries decreases blood loss in resuscitated rats. J Trauma 2000; 49: 246–50.CrossRefGoogle ScholarPubMed
Lozier, JN, Lessler, CM.Clinical aspects and therapy of hemophilia. In Hoffman, R, Benz, EJ, Shattil, SJ et al., eds. Hematology: Basic Principles and Practice. Philadelphia, PA: Churchill Livingstone; 2000: 1884–5.Google Scholar
White, GC, Roberts, HR.The treatment of factor VIII inhibitors – a general overview. Vox Sang 1996; 70 (Suppl 1): 19–23.CrossRefGoogle ScholarPubMed
Roberts, HR, Hofmann, M.Hemophilia, A and hemophilia, B. In Beutler, E, Lichtman, MA, Coller, BS et al., eds. Williams Hematology. New York, NY: McGraw-Hill; 2001, pp. 1650–5.Google Scholar
Lusher, JM.Recombinant factor VIIa (NovoSeven) in the treatment of internal bleeding in patients with factor VIII and IX inhibitors. Haemostasis 1996; 26 (Suppl 1): 124–30.Google ScholarPubMed
Monroe, DM, Hoffman, M, Oliver, JA, Roberts, HR.A possible mechanism of action of activated factor VII independent of tissue factor. Blood Coagul Fibrinol 1998; 9: S15–20.Google ScholarPubMed
Kjalke, M, Monroe, DM, Hoffman, M et al. Active site-inactivated factors VIIa, Xa, and IXa inhibit individual steps in a cell-based model of tissue factor-initiated coagulation. Thromb Haemost 1998; 80: 578–84.Google Scholar
Aledort, LM, Green, D, Teitel, JM. Unexpected bleeding disorders. Hematology (Am Soc Hematol Educ Program) 2001; 306–21.
Kenet, G, Walden, R, Eldad, A, Martinowitz, U.Treatment of traumatic bleeding with recombinant factor VIIa. Lancet 1999; 354(9193): 1879.CrossRefGoogle ScholarPubMed
Ingerslev, J.Efficacy and safety of recombinant factor VIIa in the prophylaxis of bleeding in various surgical procedures in hemophilic patients with factor VIII and factor IX inhibitors. Semin Thromb Hemost 2000; 26: 425–32.CrossRefGoogle ScholarPubMed
Hedner, U.Recombinant factor VIIa (NovoSeven (R)) as a hemostatic agent. Semin Hematol 2001; 38: 43–7.CrossRefGoogle Scholar
Schulman, S.Continuous infusion of recombinant factor VIIa in hemophilic patients with inhibitors: safety, monitoring, and cost effectiveness. Semin Thromb Hemost 2000; 26: 421–4.CrossRefGoogle ScholarPubMed
Kasper, CK.Problems with the potency of factor VIII concentrate. N Engl J Med 1981; 305: 50–1.Google ScholarPubMed
Chavin, SI, Siegel, DM, Rocco, TA, Olson, JP.Acute myocardial infarction during treatment with an activated prothrombin complex concentrate in a patient with factor VIII deficiency and a factor VIII inhibitor. Am J Med 1988; 85: 245–9.CrossRefGoogle Scholar
Walsh, PN, Rizza, CR, Matthews, JM et al. Epsilon-aminocaproic acid therapy for dental extractions in haemophilia and Christmas disease: a double blind controlled trial. Br J Haematol 1971; 20: 463–75.CrossRefGoogle ScholarPubMed
Forbes, CD, Barr, RD, Reid, G et al. Tranexamic acid in control of haemorrhage after dental extraction in haemophilia and Christmas disease. Br Med J 1972; 2: 311–13.CrossRefGoogle ScholarPubMed
Martinowitz, U, Saltz, R.Fibrin sealant. Curr Opin Hematol 1996; 3: 395–402.CrossRefGoogle ScholarPubMed
Asakai, R, Chung, DW, Davie, EW, Seligsohn, U.Factor XI deficiency in Ashkenazi Jews in Israel. N Engl J Med 1991; 325: 153–8.CrossRefGoogle ScholarPubMed
Edson, JR, White, JG, Krivit, W.The enigma of severe factor XI deficiency without hemorrhagic symptoms. Distinction from Hageman factor and “Fletcher factor” deficiency; family study; and problems of diagnosis. Thromb Diath Haemorrh 1967; 18: 342–8.Google ScholarPubMed
Castaman, G, Ruggeri, M, Rodeghiero, F.Clinical usefulness of desmopressin for prevention of surgical bleeding in patients with symptomatic heterozygous factor XI deficiency. Br J Haematol 1996; 94: 168–70.CrossRefGoogle ScholarPubMed
Seligsohn, U.Factor XI deficiency. Thromb Haemost 1993; 70: 68–71.Google ScholarPubMed
Mannucci, PM, Bauer, KA, Santagostino, E et al. Activation of the coagulation cascade after infusion of a factor XI concentrate in congenitally deficient patients. Blood 1994; 84: 1314–19.Google ScholarPubMed
Mannucci, PM.Desmopressin (DDAVP) in the treatment of bleeding disorders: the first 20 years. Blood 1997; 90: 2515–21.Google ScholarPubMed
Mannucci, PM, Tenconi, PM, Castaman, G, Rodeghiero, F.Comparison of four virus-inactivated plasma concentrates for treatment of severe von Willebrand disease: a cross-over randomized trial. Blood 1992; 79: 3130–7.Google ScholarPubMed
Platelet transfusion therapy. National Institutes of Health Consensus Conference. Transfus Med Rev 1987; 1: 195–200.Google Scholar
Francis, CW, Kaplan, KL.Hematologic problems in the surgical patient: bleeding and thrombosis. In Hoffman, R, Benz, EJ, Shattil, SJ et al., eds. Hematology: Basic Principles and Practice. Philadelphia, PA: Churchill Livingstone; 2000, pp. 2381–3.Google Scholar
Peters, M, Heijboer, H.Treatment of a patient with Bernard–Soulier syndrome and recurrent nosebleeds with recombinant factor VIIa. Thromb Haemost 1998; 80: 352.Google ScholarPubMed
Final report on the aspirin component of the ongoing Physicians’ Health Study. Steering Committee of the Physicians’ Health Study Research Group. N Engl J Med 1989; 321: 129–35.Google Scholar
Despotis, GJ, Filos, KS, Zoys, TN et al. Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients. Anesth Analg 1996; 82: 13–21.Google ScholarPubMed
Horlocker, TT, Wedel, DJ, Offord, KP.Does preoperative antiplatelet therapy increase the risk of hemorrhagic complications associated with regional anesthesia?Anesth Analg 1990; 70: 631–4.CrossRefGoogle ScholarPubMed
McTavish, D, Faulds, D, Goa, KL.Ticlopidine. An updated review of its pharmacology and therapeutic use in platelet-dependent disorders. Drugs 1990; 40: 238–59.CrossRefGoogle ScholarPubMed
Castillo, R, Lozano, T, Escolar, G et al. Defective platelet adhesion on vessel subendothelium in uremic patients. Blood 1986; 68: 337–42.Google ScholarPubMed
Diaz-Buxo, JA, Donadio, JV. Complications of percutaneous renal biopsy: an analysis of 1,000 consecutive biopsies. Clin Nephrol 1975; 4: 223–7.Google ScholarPubMed
Castaldi, PA, Rozenberg, MC, Stewart, JH.The bleeding disorder of uraemia. A qualitative platelet defect. Lancet 1966; 2(7454): 66–9.CrossRefGoogle ScholarPubMed
Hutton, RA, O'Shea, MJ.Haemostatic mechanism in uraemia. J Clin Pathol 1968; 21: 406–11.CrossRefGoogle ScholarPubMed
Bolan, CD, Alving, BM.Pharmacologic agents in the management of bleeding disorders. Transfusion 1990; 30: 541–51.CrossRefGoogle ScholarPubMed
Shattil, SJ, Abrams, CS, Bennett, JS.Acquired qualitative platelet disorders due to diseases, drugs, and foods. In Beutler, E, Lichtman, MA, Coller, BS et al., eds. Williams Hematology. New York, NY: McGraw-Hill; 2001, p. 1585.Google Scholar
Livio, M, Benigni, A, Vigano, G et al. Moderate doses of aspirin and risk of bleeding in renal failure. Lancet 1986; 1 (8478): 414–16.CrossRefGoogle ScholarPubMed
Heistinger, M, Stockenhuber, F, Schneider, B et al. Effect of conjugated estrogens on platelet function and prostacyclin generation in CRF. Kidney Int 1990; 38: 1181–6.CrossRefGoogle ScholarPubMed
Fellin, F, Murphy, S.Hematologic problems in the pre-operative patient. Med Clin North Am 1987; 71: 477–87.CrossRefGoogle Scholar
van Genderen, PJ, Mulder, PG, Waleboer, M et al. Prevention and treatment of thrombotic complications in essential thrombocythaemia: efficacy and safety of aspirin. Br J Haematol 1997; 97: 179–84.CrossRefGoogle ScholarPubMed
Marassi, A, Manzullo, V, di Carlo, V, Mannucci, PM.Thromboembolism following prothrombin complex concentrates and major surgery in severe liver disease. Thromb Haemost 1978; 39: 787–8.Google ScholarPubMed
Spence, RK, Carson, JA, Poses, R et al. Elective surgery without transfusion: influence of preoperative hemoglobin level and blood loss on mortality. Am J Surg 1990; 159(3): 320–4.CrossRefGoogle ScholarPubMed
Hebert, PC, Wells, G, Martin, C et al. A Canadian survey of transfusion practices in critically ill patients. Crit Care Med 1998; 26: 482–7.CrossRefGoogle ScholarPubMed
Hebert, PC, Wells, G, Martin, C et al. Variation in red cell transfusion practice in the intensive care unit: a multicentre cohort study. Crit Care 1999; 3: 57–63.CrossRefGoogle ScholarPubMed
Hebert, PC, Wells, G, Blajchman, MA et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340: 409–17.CrossRefGoogle ScholarPubMed
Karkouti, K, Cohen, MM, McCluskey, SA et al. A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery. Transfusion 2001; 41: 1193.CrossRefGoogle ScholarPubMed
van de Watering, LM, Hermans, J, Houbiers, JG et al. Beneficial effects of leukocyte depletion of transfused blood on postoperative complications in patients undergoing cardiac surgery: a randomized clinical trial. Circulation 1998; 97: 562.CrossRefGoogle ScholarPubMed
Goodnough, LT, Brecher, ME, Kanter, MH, AuBuchon, JP.Transfusion medicine. Second of two parts – blood conservation. N Engl J Med 1999; 340: 525–33.CrossRefGoogle ScholarPubMed
Cazzola, M, Mercuriali, F, Brugnara, C.Use of recombinant human erythropoietin outside the setting of uremia. Blood 1997; 89: 4248–67.Google ScholarPubMed
Kitchens, CS.Are transfusions overrated? Surgical outcome of Jehovah's Witnesses. Am J Med 1993; 94: 117–19.CrossRefGoogle ScholarPubMed
Viele, MK, Weiskopf, RB.What can we learn about the need for transfusion from patients who refuse blood? The experience with Jehovah's Witnesses. Transfusion 1994; 34: 396–401.CrossRefGoogle ScholarPubMed
Bauer, KA.New anticoagulants. Curr Opin Hematol. 2008; 15: 509–15.CrossRefGoogle ScholarPubMed

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