Excessive Bleeding in the Surgical Patient

Jeffrey H. Lawson, MD, PhDDirector, Vascular Surgery Research LabDirector of Clinical Trials in Vascular SurgeryDuke University Medical CenterDurham, North Carolina

Learning Objectives

• Develop strategies for patient risk stratification during the preoperative examination

• Assess emergency surgical maneuvers to achieve operative hemostasis

• Review challenges in balancing hemorrhage and thrombosis

The Preoperative Patient Evaluation

We’ve discussed previously in this initiative about certain risk factors to determine who might bleed perioperatively. Can you walk us through a proper “preoperative” patient evaluation?

The Preoperative Patient Evaluation

• Conduct biochemical tests PT PTT Bleeding time

Drawback: Not sophisticated enough to identify patients with subtle, undetectable polymorphisms

• Conduct good clinical patient history Question patient on: Multiple miscarriages Bleeding from minor procedures Easy bruising Problems with previous surgeries Family members having had difficult surgeries

• Goal: Develop more appropriate screening measures that address coagulation polymorphisms not otherwise detected by abnormalities in PT, PTT

PT = prothrombin time; PTT = partial thromboplastin time.

Stratifying Patients for Bleeding Risk

Would you suggest using a formal risk stratification system in real practice?

Stratifying Patients for Bleeding Risk

• Use general stratification system

• Formal stratification with delineated levels of risk works in theory

• In practice, consider a continuum of risk Patient placement on continuum based on medical history, family medical history, surgery type

• Don’t pigeon-hole patients according to risk level

• Inform patient and family of possible surgical risks for postoperative bleeding and thrombosis

• For high-risk patients, modify surgical plan accordingly:

Anesthesia requirements

Cardiology clearance

Availability of blood, other clotting factors

Continuum of Patient Types

Although there may not be an awful lot of data to this end, is it rare to see patients on the more risky side of the continuum?

Continuum of Patient Types

• General surgery

Primarily low-risk patient cohorts

• Vascular surgery; complex, targeted surgery

High-risk patient cohorts Elderly patients Patients with prior surgeries Patients with kidney failure Patients with heart failure

• All surgeries associated with bleeding and clotting issues

Surgical Hemostasis

Outside of vascular surgery, for example in oncology, urology, orthopedic surgery … is this issue of hemostasis as critical as it is in vascular surgery?

Surgical Hemostasis

• Bleeding and clotting are the most underappreciated problems in surgery

As common as breathing air

Like gravity that existed before Newton described it

• At Duke University Medical Center, >50%-70% of surgical complications seen weekly are associated with bleeding and clotting

• Bleeding and clotting are the leading cause of morbidity and mortality in surgery today

Prevention and Management of Perioperative Bleeding and Clotting

What are some of the things that can be done perioperatively to manage bleeding and clotting issues when they occur?

Prevention and Management of Perioperative Bleeding and Clotting

• Prevention of perioperative bleeding and clotting = good physiology and good surgery

Good anesthesia support

Patients kept warm

Patients well resuscitated

Management of calcium and acidemia

• Management of perioperative bleeding and clotting:

“Don’t get caught . . . behind the 8-ball”

Ensure anesthesia is available

Role for topical hemostatic agents

Role for systemic therapies Fresh frozen plasma Cryoprecipitate Platelets Recombinant factor VIIa (rVIIa) Antifibrinolytic molecules

Transfusion Issues

It seems the threshold for initiating transfusion when bleeding occurs has been creeping lower. Can you discuss the use of blood and blood products?

Transfusion Issues

• Still a role for blood and transfusion therapies

• Blood management community more comfortable using lower transfusion threshold for patients

• All blood is not created equal

Fresher blood has healthier red cells than older blood

Older, nearly expired red cells can be deleterious to patients

• Transfusion trigger lower than it was 10-15 years ago

• Quality of red blood cells and of transfused products is critical and still an area of important research

Practicing Bloodless Medicine

What is the concept of “bloodless medicine”?

Practicing Bloodless Medicine

• Possible for medical institutions to become completely bloodless

• Respect religious beliefs and ethical systems of patients who do not advocate transfusion

• Acknowledge risks associated with practice of bloodless medicine and possible adverse effects of hemorrhage

• Balance inherent in transfusion; possible to practice bloodless medicine Accept some risk Derive some benefit

• Requires a highly committed surgical team Anesthesia support OR staff Nursing staff

• Intellectual shift required in postoperative management of patients

Newer Strategies for Achieving Optimal Hemostasis

You had mentioned some “newer strategies” for achieving optimal hemostasis. Can you describe some of these and how you’re implementing them now?

Newer Strategies for Achieving Optimal Hemostasis

• rVIIa Off-label use has gained wide acceptance in surgical community Trauma Intracranial bleeding General surgery

Novel, effective therapy

• Antifibrinolytics Despite FDA concerns regarding aprotinin*, role for halting fibrinolysis

is an exciting one Area of unique biologic therapy

• Protamine Useful in stopping systemic heparinization

• Future strategies in hemostasis Molecules with shorter half-lives Novel antidote therapies to reverse anticoagulation

*Currently suspended for use in the United States.

Clopidogrel: Hemostatic Considerations

What are some of the special considerations for patients taking clopidogrel (PLAVIX)?

Clopidogrel: Hemostatic Considerations

• Standard of care for patients with drug-eluting coronary stents

• Options for perioperative management of clopidogrel-treated patients:

Operate through the clopidogrel Treat patient with systemic anticoagulation prior to surgery while clopidogrel wears off No randomized trials demonstrating efficacy

• In many cases, accept clopidogrel as a surgical reality and manage hemorrhagic complications that may result

The Hemorrhage and Thrombosis Continuum

Let’s discuss the general balance between hemorrhage and thrombosis. How do they relate?

The Hemorrhage and Thrombosis Continuum

• Hemorrhage and thrombosis are both extreme ends of the same biologic process

• Lethal in their own right

• Determine patient’s position on the continuum

Hemorrhagic phenotype?

Thrombotic phenotype?

• Goal is to manage patients through a critical period—clinically, maintaining them in the center of both extremes

Healthcare Provider Call to Action

Based on our conversation today, what would be your call to action to the audience?

Healthcare Provider Call to Action

• Consider the way bleeding is approached clinically

• Recognize that patients comprise a broad spectrum

• No one type of normal phenotype in hemostasis

• Each patient has different hemostatic needs

Perioperative use of blood thinners

Perioperative use of hemostatic tools

Identifying postoperative risk for thrombosis

• Despite lack of good biomarkers, use clinical intuition to identify who may be at risk for bleeding or thrombosis

Thank you for participating in today’s program

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