Management of severe perioperative bleeding: ESA Guidelines
European Society of Anaesthesiology [ESA] in collaboration with representatives from the European Board of Anaesthesiology [EBA] (EDR), the European Association of Cardiothoracic Anaesthesiology [EACTA] (DFa) have updated Management of severe perioperative bleeding. The first update to 2016 guidelines has appeared in the European Journal of Anaesthesiology.
Following are the major recommendations:
1. Evaluation of coagulation status
- Before surgery or invasive procedures, we recommend the use of a structured patient interview or standardised questionnaire which considers clinical and family bleeding history and detailed information on the patient's medication.
- We recommend the use of standardised questionnaires on bleeding and drug history as preferable to the routine use of conventional coagulation screening tests such as activated partial thromboplastin time (aPTT), international normalised ratio (INR) and platelet count in elective surgery.
- Evaluation of platelet function
- We suggest preoperative platelet function testing only in association with a positive bleeding history.
- We suggest that preoperative platelet function testing be used to identify decreased platelet function caused by medical conditions or antiplatelet medication.
2. Preoperative and postoperative correction of anaemia
- Preoperative anaemia in adults and children appears to be a strong predictor for perioperative blood transfusion across various types of conditions and surgeries and may be associated with adverse events.
- We recommend that patients at risk of bleeding are assessed for anaemia 3 to 8 weeks before surgery.
- If anaemia is present, we recommend identifying the cause (iron deficiency, renal insufficiency or inflammation).
- We recommend treating iron deficiency with iron supplementation.
- We recommend the use of intravenous iron in preference to oral iron.
- If other causes of anaemia have been excluded or treated, we suggest erythropoietin-stimulating agents.
- If autologous blood donation is performed, we suggest treatment with iron and/or erythropoietin-stimulating agents to avoid preoperative anaemia and increased overall transfusion rates.
- In patients with preoperative anaemia, we recommend the use of combined therapy with intravenous iron and erythropoietin along with a restrictive transfusion policy.
- In non-cancer patients with preoperative anaemia scheduled for elective major surgery, we recommend postponing surgery until anaemia has been corrected.
- In patients who are anaemic following surgery, we suggest the use of intravenous iron.
3. Optimising circulation
- We recommend aggressive and timely stabilisation of cardiac pre-load throughout the surgical procedure, as this appears beneficial to the patient.
- In cases of uncontrolled bleeding, we suggest lower thresholds for cardiac pre-load and/or permissive hypotension may be considered.
- We recommend the avoidance of hypervolaemia secondary to crystalloids or colloids to a level exceeding the interstitial space in steady state, and beyond an optimal cardiac pre-load.
- We recommend against the use of central venous pressure (CVP) and pulmonary artery occlusion pressure as the only variables to guide fluid therapy and optimisation of pre-load during severe bleeding. Dynamic assessment of fluid responsiveness and non-invasive measurement of cardiac output should be considered instead.
- We suggest the replacement of extracellular fluid losses with isotonic crystalloids in a timely and protocol-based manner.
- Compared with crystalloids, haemodynamic stabilisation with iso-oncotic colloids, such as human albumin and hydroxyethyl starch, causes less tissue oedema.
- Infusion of colloids in patients with severe bleeding can aggravate dilutional coagulopathy by additional effects on fibrin polymerisation and platelet aggregation.
- We suggest the use of balanced solutions for crystalloids and as a basic solute for iso-oncotic preparations.
- Transfusion triggers
- We recommend a target haemoglobin concentration of 7 to 9 g dl during active bleeding.
- Continuous haemoglobin monitoring can be used as a trend monitor.
4. Oxygen fraction
- We recommend that the inspiratory oxygen fraction should be high enough to prevent arterial hypoxaemia in bleeding patients, while avoiding excessive hyperoxia [PaO2 >26.7 kPa (200 mmHg)].
5. Monitoring tissue perfusion
- We recommend repeated measurements of a combination of haematocrit (Hct)/haemoglobin, serum lactate, and base deficit to monitor tissue perfusion, tissue oxygenation and the dynamics of blood loss during acute bleeding. These parameters can be extended by measurement of cardiac output, dynamic parameters of volume status [e.g. stroke volume variation (SVV), pulse pressure variation (PPV)], CO2 gap and central venous oxygen saturation.
- Normovolaemic haemodilution
- We suggest the use of acute normovolaemic haemodilution (ANH) in selected settings.
- We recommend against ANH in combination with controlled hypotension.
- In patients with pre-existing or acquired coagulopathy we suggest that the use of ANH is considered carefully.
6. Transfusion of labile blood products
- We recommend that all countries implement national haemovigilance quality systems.
- We recommend a restrictive transfusion strategy which is beneficial in reducing exposure to allogeneic blood products.
- We recommend pathogen inactivation for fresh frozen plasma (FFP) and platelets.
- We recommend that labile blood components used for transfusion are leukodepleted.
- We recommend that blood services implement standard operating procedures for patient identification and that staff be trained in early recognition of, and prompt response to, transfusion reactions.
- We recommend a male-only donor policy for plasma-containing blood products to prevent the onset of transfusion-related acute lung injury (TRALI).
- We recommend that all red blood cell (RBC), platelet and leukocyte donations from first-degree or second-degree relatives be irradiated even if the recipient is immunocompetent, and all RBC, platelet and leukocyte products be irradiated before transfusing to at-risk patients.
- Allogeneic blood transfusion is associated with an increased incidence of nosocomial infections.
- Storage lesions
- We recommend that RBCs should be transfused according to the first-in, first-out method in the blood services to minimise wastage of erythrocytes.
- Cell salvage
- We recommend the use of red cell salvage which is helpful for blood conservation in major cardiac and orthopaedic surgery.
- We recommend against the routine use of intraoperative platelet-rich plasmapheresis for blood conservation during cardiac operations using cardiopulmonary bypass (CPB).
- We recommend that cell salvage is not contraindicated in bowel surgery, provided that the initial evacuation of soiled abdominal contents is undertaken, additional cell washing is performed and broad-spectrum antibiotics are used.
- We suggest that cell salvage is not contraindicated in cancer surgery, provided that blood aspiration close to the tumour site is avoided and leukodepletion filters are used.
- Plasma and platelet transfusion
- We recommend against the use of plasma transfusion for pre-procedural correction of mild-to-moderately elevated INR.
- We recommend early and targeted treatment of coagulation factor deficiencies in the plasma. Sources of coagulation factors are coagulation factor concentrates, cryoprecipitate or high volumes of plasma, depending on the clinical situation, type of bleeding, type of deficiency and resources provided.
- In the treatment of acquired coagulation factor deficiency, we suggest the consideration of a ratio-driven protocol (RBC: plasma: platelet concentrates) early in uncontrolled massive bleeding outside the trauma setting followed by a goal-directed approach as soon as possible.
- We suggest coagulation factor concentrates for the primary treatment of acquired coagulation factor deficiency due to their high efficacy and their minimal infectiousness.
- We recommend against indiscriminate use of plasma transfusion in perioperative bleeding management.
- We suggest platelet concentrate transfusion in bleeding situations clearly related to antiplatelet drugs or thrombocytopaenia less than 50 × 109 l−1.
7. General coagulation management
- Fibrinogen concentration of less than 1.5 to 2 g l−1 is considered as hypofibrinogenaemia in acquired coagulopathy and is associated with increased bleeding risk.
- We recommend treatment of hypofibrinogenaemia in bleeding patients.
- We suggest an initial fibrinogen concentrate dose of 25 to 50 mg kg−1.
- In cases wherein fibrinogen concentrate is not available we suggest cryoprecipitate at an initial dose of 4 to 6 ml kg−1.
- Plasma transfusion alone is not sufficient to correct hypofibrinogenaemia.
- In cases of bleeding and low factor XIII activity (e.g. <30%) we suggest administration of factor XIII concentrate (30 IU kg−1).
- In severe perioperative bleeding, we recommend that patients on vitamin K antagonists (VKAs) should be given prothrombin complex concentrate (PCC) and intravenous vitamin K before any other coagulation management steps.
- Prolonged INR/prothrombin time (PT) or VHA clotting times alone are not an indication for PCC in bleeding patients not on oral anticoagulant therapy.
- We recommend against the prophylactic use of recombinant activated factor VII (rFVIIa) due to increased risk of fatal thrombosis.
- We suggest that off-label administration of rFVIIa can be considered for life-threatening bleeding which cannot be stopped by conventional, surgical or interventional radiological means and/or when comprehensive coagulation therapy fails.
- We recommend tranexamic acid to prevent bleeding during major surgery and/or treat bleeding due to (or at least suspected) hyperfibrinolysis (e.g. a dose of 20 to 25 mg kg−1).
- We suggest the use of desmopressin (DDAVP) under specific conditions [acquired von Willebrand syndrome (VWS)].
- Based on the current literature there is no evidence to recommend antithrombin supplementation in elective surgical patients while they are bleeding.
- We recommend structured staff education and training.
- Correction of confounding factors
- We recommend maintaining perioperative normothermia because it reduces blood loss and transfusion requirements.
- We recommend that pH correction should be pursued during the treatment of acidotic coagulopathy, although pH correction alone cannot immediately correct acidosis-induced coagulopathy.
- We recommend that rFVIIa should only be considered alongside pH correction.
- We recommend that calcium should be administered during massive transfusion if calcium concentration is low, to preserve normocalcaemia (>0.9 mmol l−1).
- We suggest that endovascular embolisation is a well tolerated alternative to open surgical intervention after failed endoscopic treatment for non-variceal upper gastrointestinal bleeding (UGIB).
- We suggest super-selective embolisation as primary therapy for treatment of angiogram positive lower gastrointestinal tract bleeding.
- We suggest embolisation as first-line therapy for arterial complications in pancreatitis.
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