What are the principles of hemostasis (control of bleeding) in surgery, including pre-operative (pre-op), intra-operative (intra-op), and post-operative (post-op) periods?

From the Guidelines

Effective hemostasis management throughout the surgical process is crucial for minimizing morbidity, mortality, and optimizing patient outcomes, and should be guided by the most recent and highest quality evidence, such as the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1. Preoperatively, a thorough patient assessment is essential, including bleeding history, medication review, and laboratory testing, to identify patients at high risk of bleeding or thrombosis.

• Patients on anticoagulants like warfarin should discontinue 5 days before surgery and bridge with low molecular weight heparin if necessary, while direct oral anticoagulants should be stopped 24-48 hours before surgery depending on renal function, as recommended by the French working group on perioperative haemostasis (GIHP) 1.
• Antiplatelet agents like aspirin and clopidogrel typically require 5-7 days cessation, though aspirin may continue for cardiac patients. Intraoperatively, meticulous surgical technique forms the foundation of hemostasis, supplemented by:
• Electrocautery
• Hemostatic agents (like Surgicel, Gelfoam, or fibrin sealants)
• Topical hemostatics, such as collagen-based agents, gelatine-based products, or fibrin and synthetic glues or adhesives, which have been shown to be effective in controlling bleeding in various surgical procedures 1
• Hypotensive anesthesia may reduce bleeding in specific cases
• Cell salvage can recover and reinfuse the patient's blood Temperature, pH, and calcium levels should be maintained within normal ranges to support coagulation. Postoperatively, close monitoring for bleeding is crucial, with interventions including:
• Compression
• Topical hemostatics
• Surgical re-exploration if necessary Anticoagulation should be restarted according to bleeding risk, typically 24 hours after surgery for prophylactic doses and 48-72 hours for therapeutic doses, as recommended by the American Society of Clinical Oncology guideline for venous thromboembolism prophylaxis and treatment in patients with cancer 1. Throughout all phases, maintaining normothermia, normal pH, and adequate blood volume supports the body's natural coagulation mechanisms, while transfusion of blood products should follow a targeted approach based on laboratory values and clinical assessment, with a restrictive transfusion threshold of 8 g/dL for orthopedic surgery patients and those with cardiovascular disease, as recommended by the Association for the Advancement of Blood & Biotherapies 1. The use of tranexamic acid is reasonable to reduce intraoperative blood loss, reduce transfusions, and avoid anemia, especially in patients with expected blood loss, as recommended by the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1.

From the FDA Drug Label

WARNING: THROMBOSIS ●Serious arterial and venous thrombotic events may occur following administration of SEVENFACT®.[See Warnings and Precautions (5.1)] Monitor patients for signs or symptoms of activation of the coagulation system and for thrombosis. The dose, frequency, and duration of SEVENFACT therapy should be based on the patient’s clinical response and hemostasis evaluation.

The principles of hemostasis in surgery using recombinant factor VIIa (SEVENFACT) involve:

• Pre-op: No specific information is provided in the label.
• Intra-op:
  • Administer SEVENFACT as soon as a bleeding event occurs.
  • The dose and duration of treatment depend on the location and severity of the bleeding.
  • Monitor patients for signs or symptoms of activation of the coagulation system and for thrombosis.
• Post-op:
  • Continue therapy to support healing and prevent recurrent hemorrhage after hemostasis.
  • The site and severity of bleeding should determine therapy duration.
  • Consider the risk of thrombosis with subsequent dosing after achieving hemostatic efficacy 2

From the Research

Pre-Operative Hemostasis

• Pre-operative preparation is crucial for minimizing the risk of bleeding during surgery 3
• Patients with coagulation disorders or those taking anticoagulant medications require special attention to ensure optimal hemostasis 3
• Tranexamic acid (TXA) can be used for prophylaxis and treatment of bleeding caused by hyperfibrinolysis, especially in patients undergoing surgical procedures involving organs rich in plasminogen proactivators 4

Intra-Operative Hemostasis

• Intraoperative control of bleeding is vital for achieving a positive patient outcome 5, 6
• Various hemostatic methods can be employed, including manual pressure application, electrical tissue cauterization, and systemic or topical administration of procoagulation agents 5
• Topical agents, such as gelatins, collagens, and fibrin sealants, can be effective adjuncts to aid in hemostasis when bleeding is not controllable with pressure application or electrocautery 5
• The choice of hemostatic technique depends on patient and procedural factors, as well as the surgeon's preference 6

Post-Operative Hemostasis

• Post-operative bleeding complications can occur when surgical hemostasis is inadequate or when there is insufficient activity of the hemostatic system 3
• Optimal surgical hemostasis and a satisfactory function of the coagulation system are complementary 3
• TXA can be used to reduce perioperative blood loss and blood transfusion requirements in patients at high risk of bleeding 4
• Monitoring of the patient's coagulopathic status and timely intervention with hemostatic agents can help prevent post-operative bleeding complications 7