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Hypercoagulability Is Part of the Yin/Yang of Hemostasis Management

Surgeons, particularly those who perform cardiac and vascular procedures, often must perform a balancing act as they manage both the perioperative and postoperative aspects of the hemostatic spectrum.

Surgical patients who have preexisting conditions, such as cardiovascular disease, or inherited disorders leading to hypercoagulability, frequently require preoperative antiplatelet and antithrombotic therapy, placing them at risk for coagulopathy.

Other patients may have hemophilia or inherited platelet disorders for which coagulopathy can prevent normal hemostatic mechanisms from functioning. Although patients may represent the hemostatic Yin and Yang of diversity, there are predictors of excessive surgical bleeding that can guide clinicians in their choice of available treatments, comprising transfusional and nontransfusional prohemostatic pharmacologic agents.

Despite available treatments, however, bleeding remains a problem, and data to support clinicians’ understanding of optimal therapy for coagulopathy are limited or conflicting. Transfusions, for instance, are routinely administered to surgical patients; yet while a paucity of data demonstrate their efficacy, especially regarding fresh frozen plasma and red cells, the data clearly show an association between transfusions and adverse outcomes, including TRALI and other hypersensitivity reactions. With the FDA suspension of aprotinin, the armamentarium of nontransfusional agents used to treat surgical bleeding includes the lysine analogs, protamine, desmopressin, and recombinant factor VIIa (rVIIa). Much of the available data demonstrating the efficacy and safety of these agents as optimal treatment for surgical coagulopathy are inconclusive. Lysine analogs have been shown to have variable effects on bleeding reduction; protamine only reverses unfractionated heparin, not low-molecular-weight heparin; a meta-analysis of desmopressin trials revealed a 2.4-fold increase in the risk of myocardial infarction, a small decrease in perioperative blood loss, but no beneficial effects on other clinical outcomes; off-label studies of rVIIa have revealed its efficacy in refractory bleeding, but more studies are ongoing to establish its beneficial effect.

Given the diverse nature of disorders that can place patients at risk for surgical bleeding and the hemostatic treatment options available to clinicians, a multimodal approach rather than reliance on a single treatment method is an effective strategy for managing acquired coagulopathy in the surgical setting.


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