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Perioperative bleeding

What's new

Updated 2024 BSH guidelines for the evaluation and management of preoperative anemia.

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 American Academy of Orthopaedic Surgeons (AAOS 2024,2023,2022,2020), the British Society for Haematology (BSH 2024,2022), the European Society of Intensive Care Medicine (ESICM 2024), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the American College of...
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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
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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

  • Preoperative prophylactic tranexamic acid

  • 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)

Specific circumstances

Pediatric patients: as per ESAIC 2023 guidelines, Consider using viscoelastic hemostatic assay-guided interventions to help guide transfusion in neonates and pediatric patients undergoing cardiac and non-cardiac surgery.
C
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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