Coagulopathy and hemorrhage management in major abdominal surgery

Abstract

Whilst some guidelines for hemorrhage management during major abdominal surgery have been written, evaluation of the patient’s basal condition remains the headmost factor. Firstly, an assessment to predict perioperative bleeding should be performed, although its prognostic ability is limited as it relies on the patient’s anamnesis and on standardized tests that can have a low predictive accuracy. Upon hemorrhage, monitoring the therapeutic window between hypovolemia and hypervolemia is of crucial importance. According to the guidelines, both a prompt stabilization of cardiac preload and goal-directed fluid therapy (with either colloids or crystalloids) are advised in case of both hypovolemia and hypervolemia. Plasma transfusion, instead, is discouraged for treatment of elevated (mild to moderate) International normalized ratio (INR), as it was shown to have minimal effects and increase the risk of infection. In summary, to define the weak link in the coagulation cascade and the etiopathogenesis of postoperative bleeding is necessary to rely on all available methodologies, such as standardized tests, Point-of-care tests and goal-directed therapies. This review gives an overview of the many factors that are to be monitored during surgical hemorrhage and a summary of the approaches to manage coagulopathy.