Recommendations on multidisciplinary management of elective surgery in people with haemophilia

Abstract

Planning and undertaking elective surgery in people with haemophilia (PWH) is most effective with the involvement of a specialist and experienced multidisciplinary team (MDT) at a haemophilia treatment centre. However, despite extensive best practice guidelines for surgery in PWH, there may exist a gap between guidelines and practical application. For this consensus review, an expert multidisciplinary panel comprising surgeons, haematologists, nurses, physiotherapists and a dental expert was assembled to develop practical approaches to implement the principles of multidisciplinary management of elective surgery for PWH. Careful preoperative planning is paramount for successful elective surgery, including dental examinations, physical assessment and prehabilitation, laboratory testing and the development of haemostasis and pain management plans. A coordinator may be appointed from the MDT to ensure that critical tasks are performed and milestones met to enable surgery to proceed. At all stages, the patient and their parent/caregiver, where appropriate, should be consulted to ensure that their expectations and functional goals are realistic and can be achieved. The planning phase should ensure that surgery proceeds without incident, but the surgical team should be ready to handle unanticipated events. Similarly, the broader MDT must be made aware of events in surgery that may require postoperative plans to be changed. Postoperative rehabilitation should begin soon after surgery, with attention paid to management of haemostasis and pain. Surgery in patients with inhibitors requires even more careful preparation and should only be undertaken by an MDT experienced in this area, at a specialized haemophilia treatment centre with a comprehensive care model.

Neuromuscular control during gait in people with haemophilic arthropathy

“…The selection of the best exercise protocol to reduce the extent of co‐activation between joint flexor and extensor muscles could be relevant to prevent joint deterioration . This may help to improve solutions for rehabilitation after conservative treatment and orthopaedic surgery …”

“…31 TA B L E 3 Clinical characteristic between clusters in PWHA may help to improve solutions for rehabilitation after conservative treatment and orthopaedic surgery. 39,40 A limitation of this study is that joint kinematics and kinetics were not assessed. Therefore, it is unclear if the gait movement pattern and mechanics were different in PWHA, and if this was related to the changes in neuromuscular control.…”

U.K. hemophilia treaters’ knowledge of risk assessment for prolonged bleeding associated with dental procedures

“…The overprescription of hemostatic coverage by hemophilia teams and the low adherence to guidelines has been reported previously, including those associated with dental procedures . To our knowledge, this is the first study to specifically evaluate the dental knowledge of hemophilia teams.…”

“…Aiming to confine the use of factor replacements to those high risk patients undergoing high risk procedures is likely to be more beneficial for patients in general as it should decrease the possibility of developing inhibitors throughout the life course, eliminate the potential transmission of infectious agents, and minimize overtreatment. However, adherence with published guidelines seems variable between different hemophilia centres …”

“…Of equal importance, is that the treating hemophilia Multidisciplinary team (MDT) should understand the prolonged bleeding risk associated with certain dental procedures to ensure hemostatic management is planned accordingly. Close cooperation between the dentist and the patient's MDT is crucial for risk assessment and identification of the appropriate management plan and the WHF suggests that a dentist should be part of the MDT. There is some evidence that factor replacement may be overprescribed for certain dental procedures .…”