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“We accept bleeding and clotting as part of our everyday business, and I’m not sure we have to live with that as a standard.”—Jeffrey H. Lawson, MD, PhD

For cardiothoracic anesthesiologist Jerrold H. Levy and vascular surgeon Jeffrey H. Lawson, bleeding and clotting are more than simply surgical complications to be accepted—they are challenges to be overcome in the OR and throughout the patient recovery period. As part of its multimedia educational initiative on blood management, the Cardiovascular & Metabolic Health (CMH) Foundation recently brought together these two experts to discuss issues of hemostasis that are of concern to them. The result is The Road to Optimal Hemostasis: Avoiding Misadventures in Bleeding and Thrombosis, a roundtable forum and the latest enduring activity to be posted on the Blood CME Center Web site.

It is generally acknowledged among the OR team that preoperative planning, intraoperative recognition of bleeding and clotting, and postoperative evaluation are critical factors in achieving optimal hemostasis. For Dr. Levy, minimizing risk for bleeding and clotting is taken one step further: preparation is everything—and therein lies the challenge of managing multiple factors that affect the coagulation cascade, including preoperative drug therapies and extrinsic pathway activation. Other factors, such as patient age and body type, are considered predictors of postoperative bleeding as well. Understanding these risk factors, as well as therapeutic protocols and the armamentarium of pharmacologic and nonpharmacologic treatments, makes the OR team better prepared to manage bleeding in complex, critically ill patient populations.

Whereas preoperative preparation is a key tool for anesthesiologists such as Dr. Levy in achieving hemostatic stability in patients, for surgeons, the intraoperative management of patients’ hemodynamic changes in physiology is key. Within any surgical procedure, patients can swing from a hemorrhagic physiologic state to a thrombotic one. The challenge for surgeons, who must react to these changes, is to determine what is “normal” hemostasis for any given patient and then maintain the patient intraoperatively somewhere between bleeding and clotting to death. Using whatever transfusional or nontransfusional means are available, the surgeon must control bleeding and restore hemostasis. “Tools” for doing so include topical and systemic therapies: oxidized regenerated cellulose, and collagen and gelatin sponges; blood products and purified factors; and antifibrinolytics.

Armed with the foreknowledge of risk factors for perioperative bleeding and strategies for achieving optimal hemostasis, the anesthesiologist, surgeon, and the OR team can potentially avoid misadventures in bleeding and thrombosis.


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