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Pharmacologic tools to reduce bleeding in surgery.
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.
Hematology Am Soc Hematol Educ Program. 2012;2012:517-21. doi: 10.1182/asheducation-2012.1.517.