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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Papageorgiou C, Jourdi G, Adjambri E, Walborn A, Patel P, Fareed J, Elalamy I, Hoppensteadt D, Gerotziafas GT. Disseminated Intravascular Coagulation: An Update on Pathogenesis, Diagnosis, and Therapeutic Strategies. Clin Appl Thromb Hemost 2018; 24:8S-28S. [PMID: 30296833 PMCID: PMC6710154 DOI: 10.1177/1076029618806424] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Disseminated intravascular coagulation (DIC) is an acquired clinicobiological
syndrome characterized by widespread activation of coagulation leading to fibrin
deposition in the vasculature, organ dysfunction, consumption of clotting
factors and platelets, and life-threatening hemorrhage. Disseminated
intravascular coagulation is provoked by several underlying disorders (sepsis,
cancer, trauma, and pregnancy complicated with eclampsia or other calamities).
Treatment of the underlying disease and elimination of the trigger mechanism are
the cornerstone therapeutic approaches. Therapeutic strategies specific for DIC
aim to control activation of blood coagulation and bleeding risk. The clinical
trials using DIC as entry criterion are limited. Large randomized, phase III
clinical trials have investigated the efficacy of antithrombin (AT), activated
protein C (APC), tissue factor pathway inhibitor (TFPI), and thrombomodulin (TM)
in patients with sepsis, but the diagnosis of DIC was not part of the inclusion
criteria. Treatment with APC reduced 28-day mortality of patients with severe
sepsis, including patients retrospectively assigned to a subgroup with
sepsis-associated DIC. Treatment with APC did not have any positive effects in
other patient groups. The APC treatment increased the bleeding risk in patients
with sepsis, which led to the withdrawal of this drug from the market. Treatment
with AT failed to reduce 28-day mortality in patients with severe sepsis, but a
retrospective subgroup analysis suggested possible efficacy in patients with
DIC. Clinical studies with recombinant TFPI or TM have been carried out showing
promising results. The efficacy and safety of other anticoagulants (ie,
unfractionated heparin, low-molecular-weight heparin) or transfusion of platelet
concentrates or clotting factor concentrates have not been objectively
assessed.
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Affiliation(s)
- Chrysoula Papageorgiou
- Service Anesthésie, Réanimation Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Georges Jourdi
- INSERM UMRS1140, Université Paris Descartes, Paris, France.,Service d'Hématologie Biologique, Hôpital Cochin, Assistance Publique des Hôpitaux de Paris, France
| | - Eusebe Adjambri
- Département d'Hématologie, Faculté de Pharmacie, Université Félix Houphouët Boigny, Abidjan, Côte d'Ivoire
| | - Amanda Walborn
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Priya Patel
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Jawed Fareed
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Ismail Elalamy
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hoôpitaux de Paris, Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale, INSERM U938 and Faculté de Médecine Pierre et Marie Curie (UPMC), Sorbonne Universities, Paris, France
| | - Debra Hoppensteadt
- Department of Pathology, Cardiovascular Institute Loyola University Chicago, Maywood, IL, USA
| | - Grigoris T Gerotziafas
- Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique Hoôpitaux de Paris, Paris, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale, INSERM U938 and Faculté de Médecine Pierre et Marie Curie (UPMC), Sorbonne Universities, Paris, France
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