Perioperative bleeding is the main risk factor during and after surgery, and associated with a high rate of death and complications.

A multimodal approach should be executed to reduce intraoperative bleeding in surgical patients. Declining operative blood loss repairs patient outcomes and decreases healthcare costs.

The potential for major intraoperative blood loss remnants animportant concern for surgeons and anaesthetists. Policies to alleviate this, like identifying and management of high‐risk patients, can be executedfirst in the preoperative phase. During surgery, scrupuloussurgical techniques and local hemostasis are essential measures in the control of bleeding.

In case of normal renal function, directly acting anticoagulants can be stopped 48 hours prior to most of the surgery. Aspirin can be continued. Intraoperative cell salvage is suggested when anticipated blood loss is > 500 ml and can be continued afterward surgery in firm situations. Though, the ideal dose, timing and route of administration remain unclear, tranexamic acid can be considered as a safe, economical and effective, routine administration when anticipated blood loss is high. The use of topical agents, tourniquet and drains remains at the preference of the surgeon. Additional key considerations include avoidance of hypothermia, acidosis and excessive hemodilution along with early identification of coagulopathy using viscoelastic hemostatic assays.

Preoperative valuation with assessment and management of preoperative anemia, and antiplatelet and anticoagulant therapyProphylactic tranexamic administration should be considered for all patients undergoing major cardiac and orthopaedic surgery. Close association between anesthetists, surgeons and hematologist is a must.

Source: Br J Surg . 2020 Jan;107(2):e26-e38.