Managing clotting: a North American perspective

Bleeding in a perioperative setting occurs due to multiple causes, but newer anticoagulant and antiplatelet therapies are increasingly used preoperatively. As a result, patients often can present for surgery with underlying hemostatic disorders due to these acquired disorders or following major surgery or trauma. Because bleeding occurs due to multiple causes, the addition of pharmacologic agents creates an acquired defect that complicates the surgical injury and may result in increased blood loss. An understanding of hemostasis and therapeutic approaches, especially those in our current clinical settings, is crucial in managing these patients.

Pharmacologic agents including antifibrinolytics and prohemostatic proteins are commonly administered, but a multimodal approach to management is important. Of note is that aprotinin has been reintroduced into the Canadian market in September 2011. Recombinant and purified coagulation therapies are under investigation, and provide clinicians specific agents to treat targeted deficiencies.

Nonsurgical bleeding in the operating room is the result of a multitude of factors including preoperative anticoagulants, dilution, fibrinolysis, and factor consumption. Therapeutic prohemostatic pharmacologic approaches, in addition to standard transfusion therapy, need to be considered in the prevention and treatment of coagulopathy in surgical patients.