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“The future of this business is going to be figuring out how to use alternative hemostatic agents.”—Richard P. Dutton, MD, MBA

In a recently recorded live CME Webinar addressed to an audience of anesthesiologists and surgeons, trauma anesthesiologist Richard P. Dutton spoke on “Strategies for Preventing Uncontrolled Perioperative Bleeding.” An archived version of this talk is now available to registered members of the Blood CME Center.

Drawing on his experience as Chief of Trauma Anesthesiology at the R Adams Cowley Shock Trauma Center, the nation’s premier Level 1 trauma center, Dr. Dutton presented on the means by which hemostasis in surgical patients is achieved perioperatively. Surgery is not a static situation, as patients typically vacillate between thrombosis and hemorrhage. The challenge for the surgical team lies in keeping the patient poised between bleeding and clotting to death, balanced between the effects of different drugs and blood products, which sometimes may push patients out of balance. By making adjustments from early in the perioperative period, when patients may be inappropriately coagulopathic and hemorrhaging, to the postoperative period, when patients may be inappropriately clotting and thrombosis becomes a concern, the surgical team strives for hemostatic balance.

The surgical “toolbox” for managing perioperative bleeding comprises transfusional and nontransfusional treatment modalities, all of which have risks and benefits. Transfusion is a widely utilized treatment option, with approximately 14 million units of blood products transfused annually. Despite short-term safety benefits, however, no one who does not need one should have a transfusion, given the long-term consequences that are only beginning to be understood and quantified.

Although clinicians should use whatever means possible to manage perioperative bleeding, for achieving optimal hemostasis, the future lies in the use of alternatives to transfusion, such as topical hemostatic agents and biologic prohemostatic agents, such as recombinant factor VIIa (rVIIa). A number of ongoing studies are examining use of topical hemostatic agents in the OR, particularly human-derived products. Other studies are examining the prophylactic use of rVIIa in trauma- and non–trauma-related surgeries.

Given the armamentarium of hemostatic agents presently available and prohemostatic drugs on the horizon, there will come a day, according to Dr. Dutton, “when the surgeon will be able to look over the drapes and say, ‘Can you make this patient stop bleeding?’ and we will be able to have the same kind of control over the coagulation system that we now have over the neuromuscular system.”


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