Hostname: page-component-586b7cd67f-g8jcs Total loading time: 0 Render date: 2024-11-23T08:35:53.508Z Has data issue: false hasContentIssue false
  • English
  • Français

Strategies to reduce perioperative blood loss related to non-surgical bleeding

Published online by Cambridge University Press:  11 July 2005

A. Menzebach ,
U. Cassens ,
H. Van Aken  and
M. Booke
A. Menzebach
Affiliation:
University Hospital Muenster, Department of Anaesthesiology and Intensive Care, Muenster, Germany
U. Cassens
Affiliation:
University Hospital Muenster, Department of Transfusion Medicine, Muenster, Germany
H. Van Aken
Affiliation:
University Hospital Muenster, Department of Anaesthesiology and Intensive Care, Muenster, Germany
M. Booke
Affiliation:
MTK-Kliniken, Department of Anaesthesiology, Bad Soden, Germany
Get access

Extract

Summary

The treatment of critically ill patients has advanced markedly over the last decade. However, non-surgical bleeding of a diffuse nature from numerous tiny capillaries still remains a challenge. Once initiated, this type of bleeding may be troublesome and a vicious circle develops since it is not a single vessel contributing to this blood loss. The description ‘non-surgical blood loss’ is often given to this. This review describes a step-by-step approach for the treatment of non-surgical bleeding and includes various measures, such as desmopressin, blood components, antifibrinolytics, antithrombin III, prothrombin complex concentrates and factor XIII. While most non-surgical bleedings can be managed using the approach described here, a number of patients still continue to bleed. In these cases, the surgeon should re-evaluate the bleeding in terms of its surgical origin. If this can positively be excluded and if all of measures described fail to reduce or stop the bleeding, further treatment of such uncontrolled bleeding remains symptomatic.

Keywords

BLOOD COAGULATION FACTORS, factor XIIIBLOOD TRANSFUSION, blood component transfusionCRITICAL CARE, intensive careENZYME INHIBITORS, protease inhibitors, serine proteinase inhibitors, antithrombin IIIHAEMORRHAGE, blood loss, surgicalHAEMOSTASIS, blood coagulationHAEMOSTATICS, antifibrinolytic agentsPITUITARY HORMONES, POSTERIOR, vasopressins, desmopressin
Type
Review
Information
European Journal of Anaesthesiology , Volume 20 , Issue 10 , November 2003 , pp. 764 - 770
Copyright
© 2003 European Society of Anaesthesiology

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Kuehnert MJ, Roth VR, Haley NR, et al. Transfusion-transmitted bacterial infection in the United States, 1998 through 2000. Transfusion 2001; 41: 1493–1499.Google Scholar
Popovsky MA. Transfusion and lung injury. Transfus Clin Biol 2001; 8: 272–277.Google Scholar
Titlestad IL, Ebbesen LS, Ainsworth AP, Lillevang ST, Qvist N, Georgsen J. Leukocyte-depletion of blood components does not significantly reduce the risk of infectious complications. Results of a double-blinded, randomized study. Int J Colorectal Dis 2001; 16: 147–153.Google Scholar
Klowden AJ, Salem MR, Crystal GJ. Eliminating blood transfusions: what about hypotensive anesthesia? Anesthesiology 2001; 94: 542; author reply 543.Google Scholar
Praveen K, Narayanan V, Muthusekhar MR, Baig MF. Hypotensive anaesthesia and blood loss in orthognathic surgery: a clinical study. Br J Oral Maxillofac Surg 2001; 39: 138–140.Google Scholar
Ng KF, Lam CC, Chan LC. In vivo effect of haemodilution with saline on coagulation: a randomized controlled trial. Br J Anaesth 2002; 88: 475–480.Google Scholar
Wong JC, Torella F, Haynes SL, Dalrymple K, Mortimer AJ, McCollum CN. Autologous versus allogeneic transfusion in aortic surgery: a multicenter randomized clinical trial. Ann Surg 2002; 235: 145–151.Google Scholar
Kanwar S, Woodman RC, Poon MC, et al. Desmopressin induces endothelial P-selectin expression and leukocyte rolling in postcapillary venules. Blood 1995; 86: 2760–2766.Google Scholar
Wun T, Paglieroni TG, Lachant NA. Desmopressin stimulates the expression of P-selectin on human platelets in vitro. J Lab Clin Med 1995; 126: 401–409.Google Scholar
Lethagen S, Olofsson L, Frick K, Berntorp E, Bjorkman S. Effect kinetics of desmopressin-induced platelet retention in healthy volunteers treated with aspirin or placebo. Haemophilia 2000; 6: 15–20.Google Scholar
Lethagen S, Rugarn P, Aberg M, Nilsson IM. Effects of desmopressin acetate (DDAVP) and dextran on hemostatic and thromboprophylactic mechanisms. Acta Chir Scand 1990; 156: 597–602.Google Scholar
Sakariassen KS, Cattaneo M, vd Berg A, Ruggeri ZM, Mannucci PM, Sixma JJ. DDAVP enhances platelet adherence and platelet aggregate growth on human artery subendothelium. Blood 1984; 64: 229–236.Google Scholar
Agnelli G, Parise P, Levi M, Cosmi B, Nenci GG. Effects of desmopressin on hemostasis in patients with liver cirrhosis. Haemostasis 1995; 25: 241–247.Google Scholar
Peter FW, Benkovic C, Muehlberger T, et al. Effects of desmopressin on thrombogenesis in aspirin-induced platelet dysfunction. Br J Haematol 2002; 117: 658–663.Google Scholar
Lethagen S. Desmopressin – a haemostatic drug: state-of-the-art review. Eur J Anaesthesiol 1997; 14 (Suppl): 1–9.Google Scholar
Henry DA, Moxey AJ, Carless PA, et al. Desmopressin for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2001; 2: CD001884.Google Scholar
Ozkisacik E, Islamoglu F, Posacioglu H, et al. Desmopressin usage in elective cardiac surgery. J Cardiovasc Surg (Torino) 2001; 42: 741–747.Google Scholar
Gratz I, Koehler J, Olsen D, et al. The effect of desmopressin acetate on postoperative hemorrhage in patients receiving aspirin therapy before coronary artery bypass operations. J Thorac Cardiovasc Surg 1992; 104: 1417–1422.Google Scholar
Kam PC. Use of desmopressin (DDAVP) in controlling aspirin-induced coagulopathy after cardiac surgery. Heart Lung 1994; 23: 333–336.Google Scholar
Heim MU, Lutze G, Aumann V, Schumacher J, Freigang B. Postoperative haemorrhagia in a girl with congenital factor XI deficiency – successful treatment with desmopressin (DDAVP, Minirin(R)). Klin Padiatr 2002; 214; 128–131.Google Scholar
Meijer K, Peters FT, van der Meer J. Recurrent severe bleeding from gastrointestinal angiodysplasia in a patient with von Willebrand's disease, controlled with recombinant factor VIIa. Blood Coagul Fibrinoly 2001; 12: 211–213.Google Scholar
Practice Guidelines for blood component therapy. A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996; 84: 732–747.
Ness PM, Campbell-Lee SA. Single donor versus pooled random donor platelet concentrates. Curr Opin Hematol 2001; 8: 392–396.Google Scholar
Stephan F, Hollande J, Richard O, Cheffi A, Maier-Redelsperger M, Flahault A. Thrombocytopenia in a surgical ICU. Chest 1999; 115: 1363–1370.Google Scholar
Murray DJ, Olson J, Strauss R, Tinker JH. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology 1988; 69: 839–845.Google Scholar
Reed RL II, Ciavarella D, Heimbach DM, et al. Prophylactic platelet administration during massive transfusion. A prospective, randomized, double-blind clinical study. Ann Surg 1986; 203: 40–48.Google Scholar
Rosen NR, Bates LH, Herod G. Transfusion therapy: improved patient care and resource utilization. Transfusion 1993; 33: 341–347.Google Scholar
Furie B, Furie BC. Molecular and cellular biology of blood coagulation. N Engl J Med 1992; 326: 800–806.Google Scholar
Levi M, Cromheecke ME, de Jonge E, et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a meta-analysis of clinically relevant endpoints. Lancet 1999; 354: 1940–1947.Google Scholar
Salooja N, Perry DJ. Thrombelastography. Blood Coagul Fibrinoly 2001; 12: 327–337.Google Scholar
Favaloro EJ. Clinical application of the PFA-100. Curr Opin Hematol 2002; 9: 407–415.Google Scholar
Buller HR, ten Cate JW. Acquired antithrombin III deficiency: laboratory diagnosis, incidence, clinical implications, and treatment with antithrombin III concentrate. Am J Med 1989; 87; 44S–48S.Google Scholar
Levi M, ten Cate H. Disseminated intravascular coagulation. N Engl J Med 1999; 341: 586–592.Google Scholar
Blauhut B, Kramar H, Vinazzer H, Bergmann H. Substitution of antithrombin III in shock and DIC: a randomized study. Thromb Res 1985; 39: 81–89.Google Scholar
Vinazzer H. Therapeutic use of antithrombin III in shock and disseminated intravascular coagulation. Semin Thromb Hemost 1989; 15: 347–352.Google Scholar
Fourrier F, Chopin C, Huart JJ, Runge I, Caron C, Goudemand J. Double-blind, placebo-controlled trial of antithrombin III concentrates in septic shock with disseminated intravascular coagulation. Chest 1993; 104: 882–888.Google Scholar
Lee WL, Downey GP. Coagulation inhibitors in sepsis and disseminated intravascular coagulation. Intens Care Med 2000; 26: 1701–1706.Google Scholar
Lusher JM. Thrombogenicity associated with factor IX complex concentrates. Semin Hematol 1991; 28 (Suppl 6): 3–5.Google Scholar
Staudinger T, Frass M, Rintelen C, et al. Influence of prothrombin complex concentrates on plasma coagulation in critically ill patients. Intens Care Med 1999; 25: 1105–1110.Google Scholar
Kohler M, Hellstern P, Lechler E, Uberfuhr P, Muller-Berghaus G. Thromboembolic complications associated with the use of prothrombin complex and factor IX concentrates. Thromb Haemost 1998; 80: 399–402.Google Scholar
Lechner K, Kyrle PA. Antithrombin III concentrates – are they clinically useful? Thromb Haemost 1995; 73: 340–348.Google Scholar
Aeschlimann D, Paulsson M. Transglutaminases: protein cross-linking enzymes in tissues and body fluids. Thromb Haemost 1994; 71: 402–415.Google Scholar
Shainoff JR, Estafanous FG, Yared JP, DiBello PM, Kottke-Marchant K, Loop FD. Low factor XIIIA levels are associated with increased blood loss after coronary artery bypass grafting. J Thorac Cardiovasc Surg 1994; 108: 437–445.Google Scholar
Chandler WL, Patel MA, Gravelle L, et al. Factor XIIIA and clot strength after cardiopulmonary bypass. Blood Coagul Fibrinoly 2001; 12: 101–108.Google Scholar
Gerlach R, Tolle F, Raabe A, Zimmermann M, Siegemund A, Seifert V. Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity: implications of a prospective study. Stroke 2002; 33: 1618–1623.Google Scholar
Godje O, Haushofer M, Lamm P, Reichart B. The effect of factor XIII on bleeding in coronary surgery. Thorac Cardiovasc Surg 1998; 46: 263–267.Google Scholar
Negrier C, Lienhart A. Overall experience with NovoSeven. Blood Coagul Fibrinoly 2000; 11 (Suppl 1): S19–S24.Google Scholar
Wildgoose P, Nemerson Y, Hansen LL, Nielsen FE, Glazer S, Hedner U. Measurement of basal levels of factor VIIa in hemophilia A and B patients. Blood 1992; 80: 25–28.Google Scholar
Shapiro AD, Gilchrist GS, Hoots WK, Cooper HA, Gastineau DA. Prospective, randomised trial of two doses of rFVIIa (NovoSeven) in haemophilia patients with inhibitors undergoing surgery. Thromb Haemost 1998; 80: 773–778.Google Scholar
Key NS, Aledort LM, Beardsley D, et al. Home treatment of mild to moderate bleeding episodes using recombinant factor VIIa (Novoseven) in haemophiliacs with inhibitors. Thromb Haemost 1998; 80: 912–918.Google Scholar
Diness V, Bregengaard C, Erhardtsen E, Hedner U. Recombinant human factor VIIa (rFVIIa) in a rabbit stasis model. Thromb Res 1992; 67: 233–241.Google Scholar
Kristensen J, Killander A, Hippe E, et al. Clinical experience with recombinant factor VIIa in patients with thrombocytopenia. Haemostasis 1996; 26 (Suppl 1): 159–164.Google Scholar
Vidarsson B, Onundarson PT. Recombinant factor VIIa for bleeding in refractory thrombocytopenia. Thromb Haemost 2000; 83: 634–635.Google Scholar
Erhardtsen E, Nilsson P, Johannessen M, Thomsen MS. Pharmacokinetics and safety of FFR-rFVIIa after single doses in healthy subjects. J Clin Pharmacol 2001; 41: 880–885.Google Scholar
Martinowitz U, Kenet G, Segal E, et al. Recombinant activated factor VII for adjunctive hemorrhage control in trauma. J Trauma 2001; 51: 431–438; discussion 438–439.Google Scholar
Vlot AJ, Ton E, Mackaay AJ, Kramer MH, Gaillard CA. Treatment of a severely bleeding patient without preexisting coagulopathy with activated recombinant factor VII. Am J Med 2000; 108: 421–423.Google Scholar
Hedner U. NovoSeven as a universal haemostatic agent. Blood Coagul Fibrinoly 2000; 11 (Suppl 1): S107–S111.Google Scholar