Hemostasis: a practical review of conservative and operative care

Progress in the treatment of persons with hemophilia has improved quality of life and made surgical intervention in these patients possible. Optimum management should include a facility equipped with a special coagulation laboratory, a hematologist proficient in the management of coagulation disorders, a surgeon with experience operating on persons with a clotting disorder, and a blood bank with experienced personnel. Persons with inhibitors should undergo elective procedures only after consultation between surgeon and hematologist. Replacement of deficient factor protein by the intravenous infusion of factor concentrates allows normal hemostasis. The manufacture of factor concentrates includes purification and viral attenuation procedures to limit exposure to other proteins and decrease the risk of transmission of viral infection. These concentrates may be delivered by bolus intravenous infusion or as a continuous intravenous infusion which allows for less total units of factor to be administered. In patients with mild hemophilia A, intravenous or intranasal desmopressin acetate may be used to increase the Factor VIII: coagulant level and eliminate exposure to blood products. With careful perioperative management, patients with hemophilia may undergo surgery safely without excessive bleeding. In the future because of prophylactic therapy, the need for orthopaedic procedures may be decreased substantially.