How to manage bleeding disorders in aging patients needing surgery

Abstract

With improvements in medical care, the life expectancy of patients with bleeding disorders is approaching that of the general population. A growing population of older adult patients with bleeding disorders is at risk of age-related comorbidities and in need of various elective and emergent age-related procedures. The increased risk of thrombosis and volume overload in older adults complicates perioperative hemostatic management. Furthermore, antithrombotic treatment such as antiplatelet or anticoagulant therapy, which is frequently required for various cardiovascular interventions, requires a meticulous individualized approach. Evidence-based guidelines for the management of aging patients with bleeding disorders are lacking, largely due to the underrepresentation of older adult patients in clinical trials as well as the rarity of many such bleeding disorders. We discuss the current guidelines and recommendations in the perioperative hemostatic management of older adult patients with hemophilia and von Willebrand disease as well as other rare bleeding disorders. The optimal management of these patients is often complex and requires a thorough multidisciplinary and individualized approach involving hematologists, surgeons, anesthesiologists, and the specialists treating the underlying disorder.

A Unique Case of Post-Biopsy Bleeding in a Jehovah’s Witness with a Rare Inherited Undetermined Coagulopathy

“…Bleeding is a common complication of these rare bleeding disorders and is of special concern in patients undergoing procedures. 3 These patients require perioperative management to prevent complications and should have a plan in place to manage bleeding even in undefined disorders.…”

“…Although rare bleeding disorders are not common, hemophilia treatment centers have registries, and the treatments patients typically respond to have been studied. 3 , 5 In rare disorders, such as factor II, V, VII, dysfibrinogenemia, and afibrinogenemia, patients have seen hemostatic response to fresh frozen plasma, activated prothrombin complex concentrate/prothrombin complex concentrate, epsilon-aminocaproic acid, and recombinant factor VII. 3 , 5 , 6 However, patients who identify as Jehovah’s Witnesses tend to deny blood products including packed red blood cells, plasma, fresh frozen plasma, and cryoprecipitate.…”

“… 3 , 5 In rare disorders, such as factor II, V, VII, dysfibrinogenemia, and afibrinogenemia, patients have seen hemostatic response to fresh frozen plasma, activated prothrombin complex concentrate/prothrombin complex concentrate, epsilon-aminocaproic acid, and recombinant factor VII. 3 , 5 , 6 However, patients who identify as Jehovah’s Witnesses tend to deny blood products including packed red blood cells, plasma, fresh frozen plasma, and cryoprecipitate. The use of recombinant factors is typically acceptable in Jehovah’s Witness patients; however, the use of activated prothrombin complex concentrate/prothrombin complex concentrate is accepted variably.…”

“… 1 , 3 , 4 However, in patients with rare bleeding disorders where incidence is as low as 1–2 per million, there is not a clear consensus on management of bleeding and especially in those patients who decline blood products for religious reasons. 3 – 10 Management of GI bleeding is important for these patients as untreated bleeding can result in hemodynamic instability, and treatment with replacement blood and hemostatic agents can cause volume overload and the associated cardiac and renal sequelae. 3 – 4 …”

“… 3 – 10 Management of GI bleeding is important for these patients as untreated bleeding can result in hemodynamic instability, and treatment with replacement blood and hemostatic agents can cause volume overload and the associated cardiac and renal sequelae. 3 – 4 …”