title: Management of bleeding in vascular surgery.
abstract: Management of acute coagulopathy and blood loss during major vascular procedures poses a significant haemostatic challenge to anaesthetists. The acute coagulopathy is multifactorial in origin with tissue injury and hypotension as the precipitating factors, followed by dilution, hypothermia, acidemia, hyperfibrinolysis and systemic inflammatory response, all acting as a self-perpetuating spiral of events. The problem is confounded by the high prevalence of antithrombotic agent use in these patients and intraoperative heparin administration. Trials specifically examining bleeding management in vascular surgery are lacking, and much of the literature and guidelines are derived from studies on patients with trauma. In general, it is recommended to adopt permissive hypotension with a restrictive fluid strategy, using a combination of crystalloid and colloid solutions up to one litre during the initial resuscitation, after which blood products should be administered. A restrictive transfusion trigger for red cells remains the mainstay of treatment except for the high-risk patients, where the trigger should be individualized. Transfusion of blood components should be initiated by clinical evidence of coagulopathy such as diffuse microvascular bleeding, and then guided by either laboratory or point-of-care coagulation testing. Prophylactic antifibrinolytic use is recommended for all surgery where excessive bleeding is anticipated. Fibrinogen and prothrombin complex concentrates administration are recommended during massive transfusion, whereas rFVIIa should be reserved until all means have failed. While debates over the ideal resuscitative strategy continue, the approach to vascular haemostasis should be scientific, rational, and structured. As far as possible, therapy should be monitored and goal directed.
authors: Department of Anesthesia, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong yeeeot@gmail.com.
authors: Y E
authors: YE
authors: Chee
authors: Department of Anesthesia, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong.
authors: S E
authors: SE
authors: Liu
authors: Department of Anesthesia, Queen Mary Hospital, The University of Hong Kong, 102 Pokfulam Road, Hong Kong.
authors: M G
authors: MG
authors: Irwin
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D001779:Blood Coagulation Factors / Q000627:therapeutic use; D001803:Blood Transfusion; D015942:Factor VIIa / Q000627:therapeutic use; D005340:Fibrinogen / Q000627:therapeutic use; D005440:Fluid Therapy; D006470:Hemorrhage / Q000188:drug therapy*; D006801:Humans; D010949:Plasma; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019095:Point-of-Care Systems; D011994:Recombinant Proteins / Q000627:therapeutic use; D014656:Vascular Surgical Procedures / Q000009:adverse effects*; D014812:Vitamin K / Q000037:antagonists & inhibitors
chemical_list: D000925:Anticoagulants; D001779:Blood Coagulation Factors; D010975:Platelet Aggregation Inhibitors; D011994:Recombinant Proteins; D014812:Vitamin K; C025667:prothrombin complex concentrates; D005340:Fibrinogen; C103587:recombinant FVIIa; D015942:Factor VIIa
keywords: acute coagulopathy; bleeding management; vascular surgery