Excessive Bleeding in the Surgical Patient. Jeffrey H. Lawson, MD, PhD Director, Vascular Surgery Research Lab Director of Clinical Trials in Vascular Surgery Duke University Medical Center Durham, North Carolina. Learning Objectives.
Jeffrey H. Lawson, MD, PhD
Director, Vascular Surgery Research Lab
Director of Clinical Trials in Vascular Surgery
Duke University Medical Center
Durham, North Carolina
We’ve discussed previously in this initiative about certain risk factors to determine who might bleed perioperatively. Can you walk us through a proper “preoperative” patient evaluation?
Drawback: Not sophisticated enough to identify patients with subtle, undetectable polymorphisms
Question patient on:
PT = prothrombin time; PTT = partial thromboplastin time.
Would you suggest using a formal risk stratification system in real practice?
Patient placement on continuum based on medical history, family
medical history, surgery type
Availability of blood, other clotting factors
Although there may not be an awful lot of data to this end, is it rare to see patients on the more risky side of the continuum?
Primarily low-risk patient cohorts
High-risk patient cohorts
Outside of vascular surgery, for example in oncology, urology, orthopedic surgery … is this issue of hemostasis as critical as it is in vascular surgery?
As common as breathing air
Like gravity that existed before Newton described it
What are some of the things that can be done perioperatively to manage bleeding and clotting issues when they occur?
Good anesthesia support
Patients kept warm
Patients well resuscitated
Management of calcium and acidemia
“Don’t get caught . . . behind the 8-ball”
Ensure anesthesia is available
Role for topical hemostatic agents
Role for systemic therapies
It seems the threshold for initiating transfusion when bleeding occurs has been creeping lower. Can you discuss the use of blood and blood products?
Fresher blood has healthier red cells than older blood
Older, nearly expired red cells can be deleterious to patients
What is the concept of “bloodless medicine”?
Accept some risk
Derive some benefit
You had mentioned some “newer strategies” for achieving optimal hemostasis. Can you describe some of these and how you’re implementing them now?
Off-label use has gained wide acceptance in surgical community
Novel, effective therapy
Despite FDA concerns regarding aprotinin*, role for halting fibrinolysis
is an exciting one
Area of unique biologic therapy
Useful in stopping systemic heparinization
Molecules with shorter half-lives
Novel antidote therapies to reverse anticoagulation
*Currently suspended for use in the United States.
What are some of the special considerations for patients taking clopidogrel (PLAVIX)?
Operate through the clopidogrel
Treat patient with systemic anticoagulation prior to surgery while
clopidogrel wears off
Let’s discuss the general balance between hemorrhage and thrombosis. How do they relate?
Based on our conversation today, what would be your call to action to the audience?
Perioperative use of blood thinners
Perioperative use of hemostatic tools
Identifying postoperative risk for thrombosis
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