1. The management of severe perioperative bleeding involves identifying patients at high risk of bleeding preoperatively, correcting any preexisting anemia or circulatory issues, and using strategies to minimize blood loss during and after surgery. 2. Key strategies include optimizing the patient's macrocirculation and microcirculation prior to surgery to improve their tolerance to bleeding, as well as applying techniques to reduce intraoperative and postoperative bleeding. 3. Guidelines for perioperative bleeding management emphasize the need to prepare for potential bleeding issues ahead of time, think holistically about the patient's care, and use algorithm-based approaches and transfusion triggers to guide therapy.

1. Management of severe perioperative
bleeding
Prof. Višnja Nesek Adam, MD, PhD
University Department for Anesthesiology, Resuscitation and Intensive Care
Emergency department
Clinical hospital Sveti Duh, Zagreb, Croatia

2. Prevalence of uncontrolled bleeding
Surgical discipline Uncontrolled bleeding rate
Cardiovascular 5%-7%
General 1.9%
Obstetric 3.9% (vaginal), 6.4% (cesarean)
Orthopedic 2% - 9% (THA and TKA)
Urologic 4% - 8% TURP; 3.3% - 9.9% URL
Trauma 30%-40 %
Lopes CT, Dos Santos TR, Brunori EH, et al. Excessive bleeding predictors after cardiac surgery in adults: integrative review. J Clin
Nurs 2015; 24:3046–3062; Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate
(TURP)--incidence, management, and prevention. Eur Urol. 2006 Nov; 50(5):969-79; Brennan R, Read RA, Pons PTEpidemiology of
trauma deaths: a reassessment.Sauaia A, Moore FA, Moore EE, Moser KS, J Trauma. 1995 Feb; 38(2):185-93.

3. Severe PostOperative Bleeding - POB
Significant blood loss and transfusion are clinically
relevant and prognostically important events in
perioperative care

4. The relationship between postoperative bleeding and adverse outcomes is
non-linear, with an increase in the risk of mortality only in cases of
severe perioperative bleeding

5. The management of severe perioperative bleeding
involves multiple assessments and strategies to
reduce of POB and ensure appropriate patient care.

6. Strategies...
1. important to identify patients with an increased risk of perioperative
bleeding.
2. should be apply to correct preoperative anemia and stabilization of
macrocirculation and microcirculation to optimize the patient's
tolerance to bleeding.
3. same intervention should be used to reduce intraoperative and
postoperative bleeding,
prevent subsequent morbidity and
mortality

7. Definition ...
is variable and lacks standardization
.
Minimal
Severe
>20 % blood volume loss
Life-organ threatening
Massive
>100% blood loos in 24 h
>50 % blood loos in 3 h
>1.5 ml/kg/min in20 min
>6 UPRBC in 24 h

8. Bleeding in different situation

9. Definition ...
is variable and lacks standardization
….if bleeding is more than expected for a given procedures

10. Severe PostOperative Bleeding - POB
• Emergency
• Risk factor of anemia
• Risk factor for transfusion
• Risk factor for morbidity and mortality
• Increase resource use & cost

11. Reduction in POB
• Reduced incidence of
– Anaemia
– Allogenic blood transfusion
– Coagulopathy
– Tissue hypoperfusion
• Increase patient safety
Predictor of survival

12. Current bleeding guidelines
•

15. ESA guidelines
• provide support in decision-making in different clinical settings,
• in bleeding patients with preexisting bleeding disorders
• comorbidities associated with bleeding risks.

16. ESA guidelines
• POB management is not restricted to procoagulant strategies but also
includes patients optimization before, during and after bleeding
• Another difference with previous guidelines is emphasis on personalized
medicine.
• Recommendation and suggestion can be summarized in simple
motto

17. Be prepared and think ahead

18. Guidelines make things easier
• improve quality of care ,
• increase patients safety
and make our life easier, especially in
complex and critical situation which are
difficult to treat

20. 1. …
to identify patients with an
increased risk

23. Questions with the four “W's”, who, when, where
and what are crucial

25. Limitations of routine test
• aPTT, PT, platelet count
• No informative test aPTT ↑
• Delayed availability of test results >30 min
• No assessment of fibrinolysis, hypercoagulability

26. Despite numerous guidelines suggesting against use
coagulation tests, these tests continue to be ordered routinely in
many pre-operative or pre-interventional setting

29. The primary outcome was to examine the relationship between pre-operative
coagulation results and peri-operative bleeding
54 articles we included

31. 2 ..
correct preoperative anemia and
stabilization of macrocirculation and
microcirculation to optimize the patient's
tolerance to bleeding.

32. Preoperative assessment of anemia

35. Optimizing circulation
Decrease CO and tissue oxygenation
Flow based hemodynamic monitoring and goal directed approach

37. Optimizing circulation
Hypervolemia predisposes patients to interstitial oedema,
Increase perioperative mortality

38. • Model "just right“
• The relationship between risk and
total volume transfused follow U
shape curved
• Infusing too much can be adverse
as infusing to little
• the exact volumes of fluid and
the timings of transitions would
need titrated for individual
patients and types of surgery

39. Neither wet nor dry

40. 3.
reduce intraoperative and
postoperative bleeding –
optimize hemostasis

43. Fibrinogen is a central position of the coagulation system
Fibrinogen is the coagulation element that become reduced first
No fibrinigen stores in body that can be mobilized

46. Conclusion
• Severe POB > 20% loss in blood volume
• Therapy is more than reflex FFP:RBC = 1:1
• Therapy is target action –
– From preOP to postOP
– Be prepared – think ahaed
– Use algorithm/triggers
• Be prepped
• ESA guidelines EXIST

47. Take home massages
• Indentify bleeding risk patients
• Preoperative anemia screening and treating
• Minimization of perioperative blood loose
• Optimize circulation and utilization of appropriate transfusion triggers