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“Hemorrhage and thrombosis . . . they’re probably both ends of the same biologic process. . .” Jeffrey H. Lawson, MD, PhD

According to various practice guidelines, including those of the Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists, determination of patient risk for surgical bleeding and subsequent treatment are based on a finely delineated classification system, whereby Class I recommendations may apply to low-risk patients and Class III, to high-risk patients. In this schematic, patients are compartmentalized by risk and treated accordingly.

Vascular surgeon Jeffrey H. Lawson, director of the Vascular Surgery Research Lab at Duke University, sees it differently. Taking a more philosophical view, Dr. Lawson believes that a formal risk stratification system to achieve hemostatic stability in surgical patients works best in theory; in practice, a continuum model is best employed by the surgeon and the OR team.

The spectrum of patients is broad: some patients represent the extremes of hemorrhage, such as those with hemophilia; others represent the extremes of thrombosis, such as those with protein C deficiencies. Although a high-risk patient may have different treatment needs than a low-risk patient regarding anesthesiology and cardiology clearance, for example, both patient types are two extremes of the same continuum, and in the course of a surgical procedure, one patient may occupy both extremes. The goal is to determine, through clinical observation, medical history, and biochemical testing, where the patient is on the continuum preoperatively and then try to understand where he or she needs to be perioperatively, so that the patient may be kept balanced on the continuum. For instance, in the case of someone who has undergone a precarious vascular procedure and who poses a risk for clotting, anticoagulation—maintenance just short of bleeding—may be in order.

The keystone that supports this “seesaw” of bleeding and clotting is the knowledge that more than one hemostatic phenotype exists. Patients can have a phenotype for hemorrhage or thrombosis, and they can swing from one phenotype to the other at any given point in time. Armed with the knowledge that hemorrhage and thrombosis are two extremes of the same continuum, surgeons and the OR team can support patients through a critical period, doing whatever is clinically necessary to keep patients “centered” on the continuum so that, ultimately, they may use their own biology as a healing force.


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