Hemostatic Management: Surgical

Summary An increased bleeding risk has been observed in patients on potent antithrombotic/platelet therapy undergoing early invasive management for non-ST-segment elevation (NSTE) acute coronary syndromes (ACS).

Summary Recombinant factor VIIa (rFVIIa) is used for refractory bleeding following cardiopulmonary bypass (CPB) procedures. Tanaka et al investigated whether rFVIIa combined with fibrinogen would improve thrombus formation compared with with either agent alone in 12 volunteers and 7 patients undergoing cardiac surgery requiring at least 2 h of CPB. Using platelet-poor plasma from volunteers, coagulopathy was simulated using 0.1 U/mL heparin and 0.1 µg/mL tissue plasminogen activator (tPA).

Summary The surgical toolbox is expanding, and newer products are being developed to improve results. Reducing blood loss so that bloodless surgery can be performed may help minimize morbidity and length of stay. As patients, hospital administrators, and government regulators desire less invasive procedures, the surgical technical challenge is increasing. More operations are being performed through minimally invasive incisions with laparoscopic, endoscopic, and robotic approaches.

Summary Intracerebral haemorrhage accounts for 10-15% of strokes and is associated with high mortality and severe disability in survivors. Despite its seriousness, the treatment options for intracerebral haemorrhage are limited. Measures aimed at decreasing elevated intracranial pressure are of limited effectiveness. This has stimulated an interest in attempting to improve the prognosis of intracerebral haemorrhage by addressing the haematoma directly, either removing it by surgical means or limiting its early spontaneous growth.

Summary Hemorrhage is the second most common cause of direct maternal death. Conserving and using autologous blood is an option to avoid the risks associated with allogeneic blood transfusions. Because preoperative autologous donation does not provide enough blood for obstetric hemorrhages and because the need is rarely known before delivery, this procedure is currently not recommended in obstetric patients. Intraoperative cell salvage (IOCS) may be more effective in this patient population.

Summary Bleeding from the lower gastrointestinal tract (BLGIT) is common, with various degrees of severity that require intervention to halt bleeding in 10-15% of patients. Transarterial embolization (TAE) is an effective treatment, but data on its use as a definitive treatment without the need for subsequent surgery are limited. Koh and colleagues report the effectiveness of selective and superselective angiographic TAE in reducing the need for later surgery. The cohort included 36 men and 32 women, aged 26-95 y undergoing TAE for BLGIT.

Summary Microglial cells in the brain are activated in response to injury with either neurotrophic or neurotoxic action. Evidence suggests that these phagocytic cells, along with thrombin, contribute to brain damage induced by intracerebral hemorrhage. Thrombin activates the microglia, which then release proinflammatory cytokines, such as tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β), known to be harmful to the brain. Minocycline inhibits microglia activation and easily crosses the blood–brain barrier.

Summary Pancreaticoduodenectomy is standard procedure for benign or malignant

Summary Evidence indicates that more restrictive blood transfusion practices in patients undergoing cardiac surgery improves outcomes and several programs for blood conservation and management during cardiac surgery are being used throughout the United States. Brevig and colleagues have used a multidisciplinary approach to minimize transfusion safely and with good patient outcomes. This retrospective study was part of a quality improvement program to which clinical data from all cardiac surgeries were submitted.

Summary Among surgical patients receiving transfusions of packed RBCs (PRBCs), the incidence and degree of transfusion-related immunomodulation are related to, among other factors, the type of product transfused and patient parameters. Autologous donation and routine leukocyte filtration have reduced some of the adverse effects, and today most RBC transfusions in the United States are leukoreduced. The amount of transfused RBCs has a direct impact on negative clinical effects, with PRBCs known to increase morbidity and mortality in select patients.