Transcript - Blood CME Center

Strategies for Preventing
and Treating Uncontrolled
Perioperative Bleeding
Richard P. Dutton, MD, MBA
Associate Professor of Anesthesiology
R Adams Cowley Shock Trauma Center
University of Maryland School of Medicine
Baltimore, Maryland
Disclosure Information
Presenting Faculty
• Richard P. Dutton, MD, MBA

Consultancy fees for Novo Nordisk Pharmaceuticals
Sponsorship
• Jointly sponsored by Postgraduate Institute for Medicine, Cardiovascular
& Metabolic Health Foundation, and Educational Concepts in Medicine
Support
• Supported by an educational grant from Novo Nordisk Pharmaceuticals
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Strategies for Preventing and Treating
Uncontrolled Perioperative Bleeding
About This Initiative
• Part of a special project from the
Cardiovascular & Metabolic Health Foundation
• Led by renowned surgeons, anesthesiologists,
blood banking specialists, and other experts in
operative hemostasis and transfusion management
• Offers peer-driven programs and activities,
including live, online teleconferences and
other education
Find out more at:
www.bloodcmecenter.org
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Learning Objectives
Upon completion of this activity, participants should be better able
to:
1. Identify specific patient types who may be at increased risk for
perioperative bleeding and complications from acquired
coagulopathy
2. Specify the importance of the preoperative patient evaluation as
a tool in determining risk for perioperative bleeding
3. Explain the essentials of surgical hemostasis and current
guidelines for achieving balance between bleeding and clotting
4. Explain the benefits and risks of blood products as a therapeutic
modality
5. Describe the role of available nontransfusional treatment
modalities for achieving operative hemostasis
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Polling Question 1
Generally, what percentage of surgical complications that
you encounter relate to bleeding or clotting?
1. Only a small percentage
2. No more than other complications
3. More than many other complications
4. Most complications relate to bleeding or clotting
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Prevalence of Uncontrolled Bleeding
Surgical Discipline
Uncontrolled Bleeding Rate
Cardiovascular
5%-7% Post-op1
General
1.9% Laparoscopic cholecystectomy2
Obstetric
3.9% (vaginal); 6.4% (cesarean)3,4
Orthopedic
2%-6.3% Hip/knee arthroplasty5-7
Urologic
4%-8% TURP8; 3.3%-9.9% URL9
Trauma
30%-40%10,11
TURP=transurethral resection of prostate; URL=upper retroperitoneal laparoscopy.
1. Despotis GJ, et al. Anesth Analg. 1996;82:13-21; 2. Erol DD, et al. The Internet Journal of Anesthesiology. 2005;9:2;
3. Combs CA, et al. Obstet Gynecol. 1991;77:69-76; 4.Combs CA, et al. Obstet Gynecol. 1991;77:77-82; 5. Hull R, et al.
N Engl J Med. 1993;329:1370-1376; 6. Leclerc JR, et al. Ann Intern Med. 1996;124:619-626; 7. Strebel N, et al. Arch
Intern Med. 2002;162:1451-1455; 8. Daniels PR. Nat Clin Pract Urol. 2005;2:343-350; 9.Rosevear HM, et al. J Urol.
2006;176:1458-1462; 10. Holcomb JB. Crit Care. 2004;8(suppl 2):S57-S60; 11. Sauaia A, et al. J Trauma. 1995;38:
185-193.
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Practical Applications
After this presentation, we urge participants to:
•
Assess and review recent patient cases where surgical
complications were attributed to bleeding or clotting
•
Evaluate how real-world scenarios have fit with practice
guidelines and evidence on bleeding and clotting
•
Assess recent cases when transfusions may have been avoided
with alternate approaches
•
Determine how best to conduct thorough patient histories to
gauge perioperative risk for bleeding or clotting
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Definition of Hemostasis
Hemostasis: “The Arrest of Bleeding”
Stedman’s Medical Dictionary
Bleeding
to Death
Clotting
to Death
• Trauma
• Major Surgery
• Hemophilia
• Stroke
• MI
• Thrombosis
Hemostasis: “Life in the Balance”
Lawson JH, et al. Semin Hematol. 2004;41(suppl 1):55-64.
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Significant Bleeding
• >2 L within the first 24 post-op hours1
• Surgical or vascular component: corrected by
surgical intervention or embolization2
• Coagulopathic component: more difficult to control
due to several interrelated mechanisms2,3
 Consumption of coagulation factors and platelets
 Dilution of coagulation factors
 Metabolic disorders (eg, hypothermia, acidosis)
 Inflammation due to tissue injury
1. Despotis GJ, et al. Ann Thorac Surg. 2000;70(2 suppl):S20-S32;
2. Vincent J-L, et al. Crit Care. 2006;10:1-12; 3. Brohi K, et al. Ann Surg.
2007;245:812-818.
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Reasons for Uncontrolled Bleeding
Patient-related
Procedure-related
•
•
•
•
•
•
•
•
•
•
•
Advanced age
Small body size
Gender
Pre-op anemia
(low red blood cell volume)
Antiplatelet or
antithrombotic drugs
Prolonged operation
Coronary artery bypass graft
Emergency/trauma
Surgical-site bleeding
Surgical skill
Comorbidities:
 Congestive heart failure
 Hypertension
 Chronic obstructive
pulmonary disease
 Peripheral vascular
disease
 Diabetes mellitus
 Renal insufficiency
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Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27-S86.
Can We Predict Who Will Bleed?
There Is a Difference Between Who Is At Risk and Who Will Bleed
Thrombosis
Clotting
Surgery
Post-op
Recovery
Bleeding
Hemorrhage
•
•
•
•
Who is likely to bleed or clot too much?
How do we optimize the patient’s physiology?
Which topical agents are effective?
Which biologic/pharmacologic agents are effective?
Adapted from Lawson JH, et al. Semin Hematol. 2004;41(suppl 1):55-64.
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Patients at Risk for Surgical Bleeding
Certain patients are at higher risk for surgical bleeding,
including:
•
Patients taking the following1:
 Long-acting anticoagulant therapy
 Clopidogrel
•
Patients undergoing the following1:
 Repeat surgical procedures
 Oncologic surgery
 Aortic surgery
 Cardiac surgery
 Neurologic procedures or neurosurgery
•
Dialysis patients2
•
Trauma patients2
1. Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27–S86; 2. Disorders of hemostasis. In: Fauci AS, et al, eds. Harrison’s Internal Medicine.
New York, NY: McGraw-Hill; 2007. Available at: http://www.accessmedicine.com/resourceToc.aspx?resourceID=4.
Accessed January 28, 2008.
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Conditions Associated With Coagulopathy
• Hemophilia
• Platelet disorders
• Liver disease
• Uremia
• Disseminated intravascular coagulation
(DIC)
• Dilutional coagulopathy
• Anticoagulant treatment
• Tissue injury
Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27–S86; Disorders of hemostasis. In: Fauci AS, et al, eds. Harrison’s Internal
Medicine. New York, NY: McGraw-Hill; 2007. Available at: http://www. accessmedicine.com/resourceToc.aspx?resourceID=4.
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Accessed January 28, 2008.
Thienopyridines (eg, clopidogrel) and
Postoperative Bleeding
• Evidence is more compelling than for aspirin1
 11 studies of clopidogrel and CABG
 All studies show increased bleeding when
clopidogrel given within 5 days of CABG —
some with increased mortality
• ACC/AHA and STS/SCA guidelines recommend
stopping clopidogrel for 5 days before surgery
(if possible)1,2
CABG=coronary artery bypass graft.
1. Ferraris VA, et al. Ann Thorac Surg. 2005;79:1454-1461;
2. Braunwald E, et al. J Am Coll Cardiol. 2002;40:1366-1374.
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The Preoperative Patient Evaluation
•
Labs for hemostatic abnormalities1

Complete blood count (CBC)

Platelet count

Clot-based assays
 Activated clotting time (ACT)
 Activated partial thromboplastin time (aPTT)
 Fibrinogen
 Prothrombin time (PT)
 Thrombin time (TT)
•
Clinical patient history2

Multiple miscarriages?

Bleeding from minor procedures?

Easy bruising?

Complications with previous surgeries?

Family members had difficult surgeries?
1. Riley RS, et al. Laboratory Evaluation of Hemostasis. Richmond, VA: Virginia Commonwealth University.
Available at: www.pathology.vcu.edu/clinical/coag/Lab%20Hemostasis.pdf. Accessed March 4, 2008;
2. Lawson JH. PPT presentation available at: www.bloodcmecenter.org. Accessed March 4, 2008.
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Preparatory Measures for the Management
of Perioperative Bleeding
• Availability of anesthesia/support
• Topical hemostatic agents
• Systemic therapies

Antifibrinolytic agents

Cryoprecipitate

Fresh frozen plasma (FFP)

Platelets

Recombinant factor VIIa (rVIIa)
Lawson JH. PPT presentation available at: www.bloodcmecenter.org. Accessed March 4, 2008.
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Question and Answer Session
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Patient Profile: Claire W.
Dx: Hepatocellular adenoma
Hx: 34-year-old Caucasian female; nulliparous;
5’4,” 110 lb; pain in right upper quadrant
•
Physical exam findings:

Palpable tender mass in
right hypochondrium

Jaundice
•
Labs:

AST/ALT (mildly elevated)

AFP (within reference range)

Normal HbA1c (5%)

Normal fasting blood glucose level
(100 mg/dL)

Prolonged aPTT and PT
Imaging studies:

Ultrasonography reveals hypoechoic lesion, well circumscribed,
15 cm, located predominantly in right lobe of liver
•
•
Liver resection surgery scheduled in 2 days
AST=aspartate aminotransferase; ALT=alanine aminotransferase;
AFP=serum alpha-fetoprotein; HbA1c=glycosylated hemoglobin.
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Patient Profile: Claire W. (cont)
•
Surgical history:
 Flexor tendon repair (uneventful surgery)
 Laparoscopic appendectomy (intraoperative bleeding
complications encountered; cautery used to resolve)
•
Patient concerned about family history of surgical complications;
no further details available
•
Medications:
 Ethinyl estradiol and norethindrone combination oral
contraceptive pill; discontinued 3 months ago after 7 years
of use; wants to become pregnant
•
Comorbidities:
 None
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Polling Question 2
Given this patient’s medical history and lab results, how
concerned are you regarding her risk of bleeding?
1. I am not concerned; she is less likely to bleed than most
patients
2. I am not unduly concerned; she runs the normal risk of bleeding
3. I am somewhat concerned and would prepare for potential
bleeding complications
4. I am gravely concerned; she runs a great risk of bleeding
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The Model of Hemostasis Is Evolving
II
X
TF
VIIa
VIII/vWF
Xa
IIa
Va
VIIIa
TF-Bearing Cell
TF
VIIa
IXa
IX
Va
Platelet
II
X
Xa
IXa VIIIa
VIIa
V
IX
IIa
Va
Activated Platelet
IXa
VIIIa
Xa
X
Va
II
TF=tissue factor; vWF=von Willebrand factor.
Hoffman M, et al. Blood Coag Fibrinol. 1998;9(suppl 1):S61-S65.
IIa
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Normal Hemostasis Is a Balance
Bleeding
to Death
Clotting
to Death
• Trauma
• Major Surgery
• Hemophilia
• Stroke
• MI
• Thrombosis
•
Blood coagulation
•
Anticoagulation
•
Fibrinolysis
•
Antifibrinolysis
•
Vascular tone and blood flow
•
Endothelial cells and platelets
Adapted from Lawson JH, et al. Semin Hematol. 2004;41(suppl 1):55-64.
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“Keeping On Center”: Moving Toward
Normal Hemostasis
Topical Hemostatics
Purified Factors, FFP, Cryo, PLTs
Procoagulant
Activity
Bleeding
Clotting
Aminocaproic acid,
Tranexamic acid, Aprotinin
Antifibrinolytic
Activity
Normal
Hemostasis
Fibrinolytic
Activity
t-PA, SK, UPA
FFP=fresh frozen plasma; Cryo=cryoprecipitate; PLTs=platelets; SK=streptokinase;
UPA=urinary-type plasminogen activator; LMWH=low-molecular-weight heparin.
Anticoagulant
Activity
Heparin, Warfarin
LMWH, Argatroban
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Adapted from Lawson JH, et al. Semin Hematol.
2004;41(suppl):55-64.
Achieving Optimal Operative Hemostasis
Thrombosis
Clotting
Physiology and Good Surgery
Bleeding
Topical Hemostatic Agents
Hemorrhage
Systemic Biologic Therapies
Adapted from Lawson JH, et al. Semin Hematol.
2004;41(suppl):55-64.
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Hemostasis: Practical Application Points
• Many surgical complications, regardless of
surgery type, can be attributed to issues of
bleeding or clotting
• It is important to determine which patients are at
greatest risk for acquired coagulopathy as a result
of uncontrolled bleeding
• Achieving optimal hemostasis involves a balancing
act, whereby patients must be kept from bleeding
or clotting to death through transfusional and
nontransfusional therapies
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Patient Case: Claire W.
• Liver resection surgery commences as planned
• 2 hours into procedure, surgeon notices that
sponges are not clotting
• Excessive bleeding visible in surgical field
• Cauterization attempts fail
• Indeterminate origin of bleeding
• Hematocrit (HCT) 15%, hemoglobin (Hb) 5 g/dL,
platelets 120,000, fibrinogen <100 mg/dL
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Question and Answer Session
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Polling Question 3
At this juncture in the procedure, what would your
recommendation be, given that the source of this
patient’s bleeding is unclear?
1. I would attempt to stop the bleeding using mechanical means
2. I would transfuse using blood products
3. I would utilize a nontransfusional method
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Blood Products in the Treatment of Hemorrhage
Decision Made to Transfuse in This Case
• 80 million units donated worldwide on an
annual basis1
• According to recent estimates, 14.2 million units
transfused annually in the United States2
• A blood transfusion is the most intimate possible
contact with a stranger
1. World Health Organization. Available at:
www.who.int/bloodsafety/en/Blood_Transfusion_Safety/pdf;
2. Whitaker BI, et al. 2005 Nationwide Blood Collection and Utilization Survey.
Bethesda, MD: US Department of Health and Human Services; 2005.
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Blood Transfusion: An Overview
Benefits:
Potential Risks:
•
Blood volume replacement
•
•
Transport of O2 and CO2
Transfusion-associated
circulatory overload (TACO)
•
Coagulation
•
Transfusion-related acute lung
injury (TRALI)
•
Disease transmission (especially
platelets)

HIV

Hepatitis B

Hepatitis C
•
Transfusion-related
immunomodulation (TRIM)
•
Transfusion errors
Evidence: Not enough data about benefits
Adapted from Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27-S86.
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Blood Transfusion: ASA Guidelines
Red blood cell transfusion
• Rarely indicated with Hb >10 g/dL
• Almost always indicated with Hb <6 g/dL
• With intermediate Hb concentrations (6-10 g/dL),
base decision on patient’s risk for complications of
inadequate oxygenation
ASA=American Society of Anesthesiologists.
Stehling LC, et al. Anesthesiology. 1996;84:732-747.
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Blood Transfusion: STS/SCA Guidelines
•
Transfuse patients on CPB with Hb ≤6 g/dL
•
Transfusion justified when Hb ≤7 g/dL in patients older than
65 years and patients with chronic CVD or respiratory disease
•
Benefit unclear for stable patients with Hb between 7 and
10 g/dL
•
Transfusion recommended for patients with acute blood loss
>1500 mL or >30% of blood volume
•
Evidence of rapid blood loss without immediate control warrants
transfusion
•
Issue of “triggers”—have come a long way since “10/30” rule,
but still a long way to go
CPB=cardiopulmonary bypass; CVD=cardiovascular disease.
Adapted from Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27-S86.
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Risks of Blood Transfusion
TACO
• Common reaction from rapid or massive transfusion
of blood1
• Usually occurs within several hours after start
of transfusion
• Manifested in signs and symptoms that include:
 Dyspnea
 Orthopnea
 Peripheral edema
 Rapid increase in BP
• Incidence difficult to determine due to underreporting2
• Patients at risk include3,4:
 Infants and elderly >60/years
 Those with chronic anemia
 Those with cardiac/pulmonary/renal failure
1.
2.
3.
4.
Popovsky MA. Transfusion Clin Biol. 2001; 8:272-277;
American Association of Blood Banks. Technical Manual. 1999:577-600;
Gresens CJ, et al. New York, NY: Marcel Dekker, Inc; 2001:71-86;
Popovsky MA. Transfus Clin Biol. 2001;8:272-277.
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Risks of Blood Transfusion (cont)
TRALI
•
Rare and life-threatening complication
•
Associated with transfusion of blood components containing
RBCs, platelets, granulocytes, and cryoprecipitates1
•
Usually occurs within 1-2 hours after start of transfusion2
•
Characterized by acute respiratory distress2
•
Symptoms include2:
 Severe bilateral pulmonary edema
 Cyanosis
 Severe hypoxemia
 Tachycardia
 Hypotension
 Fever
•
Incidence varies considerably from 1/5000 to 16/10,0001
•
Fatality rate ranges from 5% to 14%2
1. Kopko PM, et al. Transfusion. 2001;41:1244-1248;
2. Popovsky MA. Transfus Clin Biol. 2001;8:272-277.
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Risks of Blood Transfusion (cont)
• Infectious diseases
 HIV
 Hepatitis B
 Hepatitis C
 Bacterial infection
• Immunologic reactions
 Febrile nonhemolytic transfusion reactions
 Anaphylactic transfusion reactions
• Complications resulting from misidentification or
clerical error
Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27-S86.
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How to Reduce Transfusions
• Immediate measures
 Employ multidisciplinary, multimodal
treatment approach
 The lead clinician should provide proactive
management
 Minimize iatrogenic blood loss, including phlebotomies
• Additional measures
 Modify routine practices if necessary
 Employ a restrictive transfusion strategy
 Reassess preoperative/postoperative use of
anticoagulant and antiplatelet agents
 Establish in advance a management plan for rapid
control of hemorrhage and transfusion
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Shander A, et al. Curr Opin Hematol. 2006;13:462-470.
Transfusion: Practical Application Points
• Although transfusion is an important treatment
modality for achieving operative hemostasis, data
demonstrate that it also carries risks
• The threshold for initiating transfusions may be
too low
 Are we transfusing more than we need to
because triggers are not high enough?
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Considering Alternatives to Blood Transfusion
• Is transfusion always appropriate?
• What are the other treatment options?
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Prohemostatic Agents
Antifibrinolytics
 Lysine analogs
 Aprotinin
• Topical hemostatics
• Protamine
• Desmopressin (DDAVP)
• Recombinant factor VIIa (rVIIa)
• Factor VIII inhibitor bypassing activity (FEIBA)/
prothrombin complex concentrate (PCC)
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Antifibrinolytics
• As implied by the name, these agents enhance
hemostasis when fibrinolysis contributes
to bleeding
• Lysine analogs
 ε-Aminocaproic acid (EACA)
 Tranexamic acid (TXA)
• Aprotinin: Approved by FDA to reduce blood loss
and transfusion in CABG but marketing suspended
11/5/07
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Lysine Analogs: EACA and TA
•
Trial data have limitations

Often only small numbers of
patients studied
•

Variable design

?Treatment criteria

?Factor reduction

Most data are for TA, not EACA

TA doses range from 2 g to 25 g

Most EACA/TA studies in lower-risk patients
EACA removed from many European markets

?Safety data
Levy JH. Am J Health-Syst Pharm. 2005;62(suppl 4):S15-S19; Mangano DT, et al. N Engl J Med.
2006;354:353-365; Mannucci PM, et al. N Engl J Med. 2007;356:2301-2311.
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Aprotinin: Meta-analyses of Safety and Efficacy
in CABG
•
•
Quantitative overview of clinical outcomes of aprotinin in CABG
MEDLINE, EMBASE, PHARMLINE
(1988 to 2001), and reference lists
Mortality
of CABG studies
 Random allocation of treatment




MI
Placebo control
Enrollment of only CABG patients
Renal failure
Noncombined use with another
experimental medication or
Stroke
Atrial
fibrillation
device
Prophylactic and continuous
Blood
transfusion
intraoperative use
•
Data from 35 CABG trials (N=3879)
0.1
1
10
RR
MI=myocardial infarction; RR=relative risk.
Sedrakyan J, et al. J Thorac Cardiovasc Surg.
2004;128:442-448. With permission from Elsevier.
43
Topical Hemostatic Agents
•
Identified by FDA as “a device intended to produce hemostasis
by accelerating the clotting process of blood”1
•
Used to augment hemostasis in surgery/trauma
•
Available in a variety of forms (solutions, gels, granules,
sprays) and used in conjunction with collagen, gelatin,
cellulose matrices
•
Local thrombin and fibrinogen levels determine the rate of clot
formation at wound site
•
Classification:
 Tissue/fibrin sealants (contain thrombin, fibrin, etc)
 Absorbable hemostatic agents (contain matrices)
 Combination products (contain both groups above)
•
Efficacy: Few RCTs1
•
Safety: Associated with numerous adverse events2
1. Lawson JH, et al. Available at: www.
Fda.gov/ohrms/dockets/dockets/06n0362/06N-0362_ECI-Attach-1.pdf. Accessed
February 20, 2008; 2. Gabay M. Am J Health-Syst Pharm. 2006;63:1244-1253.
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Protamine
• Basic polypeptide isolated from salmon sperm
• 70% arginine
 Reverses unfractionated heparin, not LMWH
• Heparin rebound may occur
• Causes adverse drug reactions
• No alternatives available
LMWH=low-molecular-weight heparin.
Levy JH, et al. Anesth Analg. 1986;65:739-742; Levy JH, et al. J Thorac Cardiovasc Surg.
1989;98:200-204; Ferraris VA, et al. Ann Thorac Surg. 2007;83:S27–S86.
45
Desmopressin
• Originally developed and licensed for the treatment
of inherited defects of hemostasis1,2
• Several reviews suggest its effect is too small to
influence the need for transfusion and reoperation1,2
• Most evidence of efficacy is in mild hemophilia A and
von Willebrand’s disease1,2
• Not indicated for use in cardiac surgery patients1,2
 Meta-analysis in cardiac patients: 2-fold increase in
MI, a small decrease in perioperative blood loss, and
no added benefits on clinical outcomes
1. Mannucci PM, et al. N Engl J Med. 2007;356:2301-2311;
2. Levy JH. Am J Health-Syst Pharm. 2005; 62(suppl 4):S15-S19.
46
Recombinant Factor VIIa
• Potent biologic prohemostatic agent
• Promotes hemostasis by activating the
coagulation cascade
• Approved for use in complicated coagulation disorders

Hemophilia A or B

Patients with inhibitors to factors VIII or IX
• Generates prohemostatic response in patients treated
with new-generation anticoagulation agents
• Safety

Thromboembolic events

More randomized controlled trials needed
Kempton CL, et al. Cardiovasc Hematol Agents Med Chem. 2006;4:319-334; O’Connell KA, et al.
JAMA. 2006;295:293-298.
47
“Off-label” Uses of rVIIa
• Increasingly being considered for:
 Reversal of oral anticoagulation
 Reversal of heparin, lepirudin, and fondaparinux
 Thrombocytopenia and thrombocytopathy
 Bleeding with impaired liver function
 Gastrointestinal bleeding
 Trauma
 Surgery: Non-traumarelated (hepatic resection,
prostatectomy, cardiac, spinal)
• “Off-label” uses are primarily based on case reports
 Ongoing trials in cardiac surgery, trauma and
burns, postpartum hemorrhage, etc
Kempton CL, et al. Cardiovasc Hematol Agents Med Chem. 2006;4:319-334.
48
Prohemostatic Agents:
Practical Application Points
• Lysine analogs have variable effects on reducing
bleeding; no safety data exist
• Aprotinin reduces bleeding and transfusions;
November 2007: Marketing suspended
in United States*1
• Topical hemostatics are useful as adjunctive
therapy; numerous adverse events have occurred
with their use
• Protamine does not reverse low-molecularweight heparin
• DDAVP has minimal effects on bleeding
• rVIIa is increasingly used “off-label” to control
perioperative bleeding/achieve operative
hemostasis; global RCTs in progress
*According to a May 14, 2008, FDA news release, aprotinin stock is being removed from the US market, with
access limited to “on-label” investigational uses with IRB approval.
1. US Food and Drug Administration. Available at: http://www.fda.gov/bbs/topics/NEWS/2008/NEW01834.html.
Accessed June 6, 2008.
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Polling Question 4
If transfusion proved ineffective in Claire W.’s clinical
situation, how comfortable would you be using the
prohemostatic biologic/pharmacologic agents to achieve
optimal hemostasis?
1. I would feel very comfortable using any of the prohemostatic
agents
2. I would use the available prohemostatic agents as indicated
3. I would have reservations about using some of the available
prohemostatic agents
50
Final Thoughts
This presentation has demonstrated the following:
• The preoperative patient evaluation is an important
tool in determining risk for perioperative bleeding
• Transfusion is only one treatment option for
achieving operative hemostasis
• Alternative hemostatic agents are available to
balance bleeding and clotting
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Question and Answer Session
52
For more CE/CME educational programs on
the subject of operative hemostasis and
transfusion medicine, including uniquely
progressive learning designed for each
clinical discipline, log on to:
www.bloodcmecenter.org
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