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Bleeding Risk/Bleeding Disorders

ASSESSMENT

Data Gathering

History

Symptoms

  • Previous evaluation for bleeding disorder

  • Bleeding with invasive procedures

  • Family history of easy bruising, bleeding, anemia, or thromboembolism

  • Spontaneous bleeding (epistaxis, hematochezia, hematuria, hematemesis, melena)

  • Heavy menses

  • Fatigue

  • Easy bruising

  • Peripheral edema

Exam

  • Ecchymoses/petechiae on skin or mucosa

  • Pallor

Risk Stratification

Diagnostic Studies

Bleeding Risk

  • SCREENING: if craniotomy or history/exam suggestive of bleeding disorder, obtain platelet count, INR, PTT, and platelet aggregation testing (e.g., PFA-100)​. 

  • KNOWN BLEEDING DISORDERS: see Management section

  • ABNORMAL SCREENING STUDIES: follow figures below

Isolated PTT Elevation

MANAGEMENT

Indications for Surgical Delay

  • Uncharacterized bleeding disorder & surgery with less-than-minimal bleeding risk

  • Thrombocytopenia that is new/significant (<50k or decrease by 50% with platelet count <150k or related to microangiopathic hemolytic anemia (DIC, TTP, HUS)

Thrombocytopenia Management

Platelet Transfusion Indications (AABB guideline)

  • Platelet count <10,000/mm3

  • Platelet count <20,000/mm3 and undergoing central venous access device placement

  • Platelet count <50,000/mm3 and undergoing non-neuraxial surgery or lumbar puncture

  • Platelet count <100,000/mm3 and undergoing intracranial or cardiac surgery

Von Willebrand Disease (vWD) (ASH vWD pocket guide)

  • Obtain specific perioperative management plan from hematology

  • DDAVP may only be used for minor procedures in type 1 vWD

    • Based on prior response to test dose

    • 0.3 mcg/kg IV or 300 mcg intranasally 30 min before procedure

    • May redose q12-24 hrs depending on bleeding risk

    • Tachyphylaxis occurs after >3 doses

    • Decrease water intake and monitor for hyponatremia and volume overload

  • Provide von Willebrand factor (vWF) concentrates for all other situations and types of vWD

    • Most products are “impure” factor VIII concentrates that contain vWF in all multimers (e.g., Humate-P ©)

    • Dose: 30-60 units/kg IV 1 hr prior to surgery and repeated q12-24 hrs to maintain target vWF level

    • Minor surgery: vWF level >30 units/dl for 3-5 days postop

    • Major surgery: vWF level >50 units/dl for 7-14 days postop

Hemophilia

  • Obtain specific perioperative management plan from hematology

  • Provide factor VIII or IX as needed to maintain factor activity level 75-100% for 3 days after surgery and then 50% until healing complete

    • Need info on patient’s factor VIII/IX response (what dose achieved 75-100% level) & if they have known factor inhibitors

    • Requires dosing/factor level measurement 1 hour prior to surgery and q8-12 hours initially

    • Since therapy needed for prolonged period of time, consider placement of PICC​

  • Usually require postop admission, even for minor surgeries

Other Bleeding Disorders

  • Obtain specific perioperative management plan from hematology

  • Often require postop admission, even for minor surgeries

COMMUNICATION/COUNSELING

  • Collaborate with patient's hematologists

  • For patients with bleeding disorders requiring blood products (vWD, hemophilia, and others) provide advance notice to blood bank of pending surgery and likely product needs since these may not be kept in stock in the amounts required

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