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Perioperative bleeding

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Updated 2025 AoA guidelines for the management of perioperative bleeding .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of perioperative bleeding are prepared by our editorial team based on guidelines from the Association of Anaesthetists (AoA 2025), the American Academy of Orthopaedic Surgeons (AAOS 2024,2023,2022,2020), the American Society of Interventional Pain Physicians (ASIPP 2024), the British Society for Haematology (BSH 2024,2022), the European Society of Intensive Care Medicine (ESICM ...
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Diagnostic investigations

Initial assessment
As per BSH 2024 guidelines:
Elicit a structured bleeding history, including personal and family history of spontaneous or procedure-related bleeding (such as using the HEMSTOP questionnaire), before elective procedures associated with a risk of bleeding.
B
Consider referring patients with a history of bleeding to a hematologist for further advice.
C
HEMSTOP preoperative hemostatic assessment questionnaire
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When to use
Hematoma. Have you ever experienced bruises or hematomas > 2 cm without trauma or severe bruising after minor trauma?
Yes
No
Hemorrhage. Have you ever consulted a doctor or received treatment for prolonged or unusual bleeding, such as nosebleeds or minor wounds?
Yes
No
Menorrhagia. Have you ever consulted a doctor or received a treatment for heavy or prolonged menstrual periods (such as contraceptive pill, iron, or other)?
Yes
No
Surgery. Have you ever experienced excessive bleeding during or after surgery?
Yes
No
Tooth extraction. Have you ever experienced prolonged bleeding requiring medical/dental consultation after a tooth extraction?
Yes
No
Obstetrics. Have you ever experienced prolonged or excessive bleeding after delivery?
Yes
No
Parents. Is there anyone in your family who has a coagulation disease (such as hemophilia, von Willebrand disease, or other)?
Yes
No
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  • Preoperative coagulation testing

Perioperative care

General principles: as per ESAIC 2023 guidelines, maintain perioperative normothermia to reduce blood loss and transfusion requirements.
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  • Management of preoperative anemia (assessment and timing of surgery)

  • Management of preoperative anemia (thresholds)

  • Management of preoperative anemia (iron supplements and EPO-stimulating agents)

  • Management of preoperative anemia (RBC transfusion)

  • Management of antithrombotic therapy (aspirin)

  • Management of antithrombotic therapy (P2Y12 inhibitors)

  • Management of antithrombotic therapy (VKAs)

  • Management of antithrombotic therapy (DOACs)

  • Management of antithrombotic therapy (heparins)

  • Management of other therapies

  • Preoperative prophylactic platelet transfusion

  • Preoperative prophylactic plasma transfusion

  • Preoperative prophylactic vitamin K replacement

  • Intraoperative antifibrinolytics and cell salvage

  • Preoperative prophylactic tranexamic acid

  • Predeposit autologous donation

  • Perioperative fluid management

  • Intraoperative fluid management

  • Intraoperative transfusion

  • Management of bleeding related to antiplatelets

  • Management of bleeding related to heparins

  • Management of bleeding related to VKAs

  • Management of bleeding related to DOACs

  • Management of postoperative anemia (monitoring)

  • Management of postoperative anemia (iron supplements and EPO-stimulating agents)

  • Management of postoperative anemia (RBC transfusion)

Surgical interventions

Damage control surgery: as per AoA 2025 guidelines, consider performing surgical implementation of damage or proximal control strategies in an emergency until hemorrhage control is achieved.
E

Specific circumstances

Pediatric patients
As per AoA 2025 guidelines:
Prescribe blood components in pediatric patients as a volume (mL/kg) rather than in units.
E
Perform cell salvage and administer antifibrinolytics, such as tranexamic acid, in pediatric patients (weighing > 10 kg) with blood loss ≥ 8 mL/kg and/or unable to receive donor blood.
E

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  • Critically ill patients

  • Patients with kidney disease

  • Patients with liver disease

  • Patients with COVID-19 infection

  • Patients with hereditary bleeding disorders (general principles)

  • Patients with hereditary bleeding disorders (hemophilia and vWD)

  • Patients with hereditary bleeding disorders (factor VII deficiency)

  • Patients with hereditary bleeding disorders (congenital dysfibrinogenemia)

  • Patients with hereditary bleeding disorders (platelet disorders)

  • Patients undergoing cardiac surgery (management of antiplatelets)

  • Patients undergoing cardiac surgery (monitoring)

  • Patients undergoing cardiac surgery (antifibrinolytics)

  • Patients undergoing cardiac surgery (transfusion)

  • Patients undergoing cardiac surgery (hemoadsorption and hemodilution)

  • Patients undergoing cardiac surgery (plasmapheresis)

  • Patients undergoing orthopedic surgery (surgical techniques)

  • Patients undergoing orthopedic surgery (antifibrinolytics)

  • Patients undergoing orthopedic surgery (blood transfusion)

  • Patients undergoing liver surgery (resection)

  • Patients undergoing liver surgery (transplantation)

  • Patients undergoing other visceral surgery

  • Patients undergoing gynecological surgery (management of preoperative anemia)

  • Patients undergoing gynecological surgery (tranexamic acid)

  • Patients undergoing gynecological surgery (misoprostol)

  • Patients undergoing gynecological surgery (blood transfusion)

  • Patients undergoing gynecological surgery (management of postoperative bleeding)

  • Patients undergoing neurosurgery

  • Patients undergoing interventional procedures (risk stratification)

  • Patients undergoing interventional procedures (preprocedural discontinuation of antiplatelet agents)

  • Patients undergoing interventional procedures (preprocedural discontinuation of anticoagulant agents)

  • Patients undergoing interventional procedures (resumption of antithrombotic therapy)

  • Patients undergoing interventional procedures (diagnosis of epidural hematoma)

Patient education

Preoperative counseling: as per AoA 2025 guidelines, consider discussing anticipated blood transfusion and alternatives with patients before surgery, and document their consent according to local protocols.
E

Quality improvement

Institutional protocols
As per AoA 2025 guidelines:
Ensure every institution has a major hemorrhage protocol that is regularly audited and reviewed. Protocols should be concise, targeted, and allow for immediate release and protocolized administration of blood components.
E
Recognize obstetric bleeding early and measure it accumulatively to facilitate a clear escalation plan for intervention and involve the multidisciplinary team.
E