Perioperative Considerations in Management of the Severely Bleeding Coagulopathic Patient

Abstract

Inherited and acquired coagulopathy are frequently associated with major bleeding in severe trauma, cardiac surgery with cardiopulmonary bypass, and postpartum hemorrhage. Perioperative management is multifactorial and includes preoperative optimization and discontinuation of anticoagulants and antiplatelet therapy in elective procedures. Prophylactic or therapeutic use of antifibrinolytic agents is strongly recommended in guidelines and has been shown to reduce bleeding and need for allogeneic blood administration. In the context of bleeding induced by anticoagulants and/or antiplatelet therapy, reversal strategies should be considered when available. Targeted goal-directed therapy using viscoelastic point-of-care monitoring is increasingly used to guide the administration of coagulation factors and allogenic blood products. In addition, damage control surgery, which includes tamponade of large wound areas, leaving surgical fields open, and other temporary maneuvers, should be considered when bleeding is refractory to hemostatic measures.

Fig. 1.

Common pathophysiology pathways of postpartum hemorrhage, trauma, and cardiac surgery and related therapy strategies. vWF, von Willebrand factor.

Fig. 2.

Schematic model of normal hemostasis. CPB, cardiopulmonary bypass; vWF, von Willebrand factor. From Hofmann M et al., Blood Coag Fibrinolysis 1998; 9(suppl 1), modified by the University of Minnesota.