Perioperative bleeding. General coagulation management.

Guidelines from the European Society of Anaesthesiology:

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. C

We recommend treatment of hypofibrinogenaemia in bleeding patients. 1C

We suggest an initial fibrinogen concentrate dose of 25 to 50 mg kg−1. 2C

In cases wherein fibrinogen concentrate is not available we suggest cryoprecipitate at an initial dose of 4 to 6 ml kg−1. 2C

Plasma transfusion alone is not sufficient to correct hypofibrinogenaemia. C

In cases of bleeding and low factor XIII activity (e.g. < 30%) we suggest administration of factor XIII concentrate (30 IU kg−1). 2C

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. 1B

Prolonged INR/prothrombin time (PT) or VHA clotting times alone are not an indication for PCC in bleeding patients not on oral anticoagulant therapy. C

We recommend against the prophylactic use of recombinant activated factor VII (rFVIIa) due to increased risk of fatal thrombosis. 1B

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. 2C

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). 1B

We suggest the use of desmopressin (DDAVP) under specific conditions [acquired von Willebrand syndrome (VWS)]. 2C

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. 1C