title: Pharmacologic tools to reduce bleeding in surgery.
abstract: Strategies to reduce blood loss and the need for transfusions in surgery include enhancement of coagulation, inhibition of fibrinolysis, and an improved decision algorithm for transfusion based on bedside monitoring of global hemostasis. The synthetic antifibrinolytic drug tranexamic acid has emerged as an effective alternative in this respect for orthopedic and cardiac surgery. Although it seems less effective than aprotinin, it has not been associated with the increased risk of mortality of the latter. Thromboelastography to monitor the global hemostatic capacity and to guide the appropriate use of blood components in cardiac surgery is also effective in reducing the need for transfusion. Patients on antithrombotic drug therapy may need reversal before surgery to avoid excessive blood loss, or intraoperatively in cases of unexpected bleeding. Available options are protamine for unfractionated or low-molecular-weight heparin, recombinant activated factor VII for fondaparinux, prothrombin complex concentrate for vitamin K antagonists and possibly for oral factor Xa inhibitors, dialysis and possibly activated prothrombin complex concentrate for oral thrombin inhibitors, desmopressin for aspirin and possibly for thienopyridines, and platelet transfusions for the latter.
authors.affiliation: Department of Medicine, McMaster University, Hamilton, ON, Canada. schulms@mcmaster.ca
authors.forename: Sam
authors.initials: S
authors.lastname: Schulman
mesh_terms: D000284:Administration, Oral; D000933:Antifibrinolytic Agents / Q000494:pharmacology* / Q000627:therapeutic use; D003894:Deamino Arginine Vasopressin / Q000494:pharmacology / Q000627:therapeutic use; D065427:Factor Xa Inhibitors; D005340:Fibrinogen / Q000737:chemistry; D005342:Fibrinolysis; D005343:Fibrinolytic Agents / Q000494:pharmacology; D006405:Hematology / Q000379:methods*; D006470:Hemorrhage / Q000188:drug therapy* / Q000517:prevention & control*; D006487:Hemostasis; D006493:Heparin / Q000627:therapeutic use; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D008954:Models, Biological; D009985:Orthopedics; D011479:Protamines / Q000378:metabolism; D011994:Recombinant Proteins / Q000627:therapeutic use; D013916:Thrombelastography / Q000379:methods; D014148:Tranexamic Acid / Q000494:pharmacology*; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D000933:Antifibrinolytic Agents; D065427:Factor Xa Inhibitors; D005343:Fibrinolytic Agents; D006495:Heparin, Low-Molecular-Weight; D011479:Protamines; D011994:Recombinant Proteins; D014812:Vitamin K; D014148:Tranexamic Acid; D005340:Fibrinogen; D006493:Heparin; D003894:Deamino Arginine Vasopressin