Surgery
Pioneering approaches to managing bleeding
Walter Danker & Gerard Llanos discuss the burden of surgical bleeding, the importance of haemostatic agents and how management of surgical bleeding can be improved.
Millions of surgeries are conducted worldwide every year,1
and controlling a patient’s bleeding
during and after a procedure is a major focus for the care team. Excessive bleeding is common in adult in-patients, and various factors, including the general risk of surgery, can complicate these attempts. Structural issues, the effects of medication, disease or unexpected bleeding from an undiagnosed or newly acquired bleeding disorder, can all result in unplanned or excessive bleeding.2 Outside of surgery, haemorrhages are globally responsible for the majority of deaths of trauma patients who did not reach the hospital, and up to 40% of deaths for those who did.3 Other types of non-trauma haemorrhage – for example postpartum haemorrhage – are still a concern within the hospital setting.3 When encountering bleeding in patients,
clinicians usually check whether the patient has a history of abnormal bleeding. Those with abnormal bleeding may have inherited bleeding disorders, such as platelet function disorders, von Willebrand disease, haemophilia, or rare factor deficiencies. Even patients with no history of excessive bleeding and no acquired blood clotting disorders may need to be checked for
liver dysfunction, disseminated intravascular coagulation, or certain vitamin deficiencies. Unexpected and excessive bleeding in adults
who are hospitalised is common but may be due to both common (structural issues, medication effects, and systemic illnesses) and uncommon factors (congenital or acquired bleeding disorders).2
Bleeding can be unpredictable,
especially around surgery. Therefore, it is critical to evaluate both novel haemostatic agents and the systematic approaches available to manage their use in a bid to help combat the burden of surgical bleeding.
The burden of surgical bleeding Surgery-related disruptive bleeding can lead to an increased likelihood of morbidity and mortality and imposes a substantial economic burden through the use of expensive healthcare services like critical and intensive care units, extended operating room times, longer hospital stays, and a need for repeat procedures, which equate to significantly higher total hospital costs compared to bleeding controlled with adjunctive haemostats.4-6 Effective haemostasis is a critical
requirement for patients undergoing surgery
and can reduce or avoid the need for blood transfusions.7
Haemostatic agents are essential
and those choosing the optimal haemostatic product for their surgery should consider bleeding-related factors including severity, risk and variability based on the type of surgery to improve outcomes.7 However, while haemostatic agents are
used to control surgical bleeding, patients can still experience disruptive bleeding – a common surgical complication that can occur during/after invasive or minimally invasive surgery (MIS) procedures.8
Up to 44% of open
and MIS procedures experienced disruptive bleeding events.8
Up to 68% of cases of
surgical procedures across several specialties experience disruptive bleeding events despite treatment with haemostats.9 According to a retrospective study of
51,448 patients, across nine procedure types, including open and MIS approaches, 16% of procedures experienced a disruptive bleeding event.8
Disruptive bleeding was associated with additional hospital costs ranging from $3,329 to $14,762 depending on procedure type.8
An additional study showed incremental
costs were up to 1.5x higher for patients with disruptive bleeding events vs those without ($28,952 vs $19,623).6
This highlights the need
for innovative and more optimal haemostatic agents, especially when considering the recent expansion of MIS.
Rise of minimally invasive surgery and the need for novel haemostatic agents MIS was pioneered in the 1980s and came to prominence in the 1990s due to its potential to improve patient outcomes. It has become the standard of care for many procedures today; however, an estimated 5% of MIS convert to open surgeries – posing serious challenges for bleeding control.10
Haemostatic agents can be
used in MIS to help prevent conversions which, given the risks, are detrimental to both patients and surgeons alike, all the while significantly straining hospital resources.10
Adjunctive haemostats help manage bleeding 68
www.clinicalservicesjournal.com I November 2024
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