Coagulation disorders are diseases marked by abnormal bleeding or blood clotting due to issues in the coagulation system, platelets or blood vessels.1 Coagulation disorders can be acquired (e.g. vitamin K deficiency or liver disease) or hereditary (e.g. hemophilia).1 Though these disorders are rare, they present major challenges during the perioperative period.2 Anesthesiology professionals are especially affected by patients’ coagulation disorders, given the common perioperative provision of anticoagulants and antiplatelet agents.3 In order to prevent potentially fatal complications in a patient with a coagulation disorder, the anesthesia provider must provide quality care before, during and after a procedure.3
Preoperative medical evaluation of a patient with a coagulation disorder is vital to the anesthesia provider’s practice.2 For one, the anesthesia provider should question all patients about surgical and medical history to determine if a coagulation disorder exists.4 A review by Shah et al. makes specific recommendations for the preoperative assessment for patients with hereditary clotting disorders, such as hemophilia and von Willebrand disease.2 The authors emphasize the importance of an interdisciplinary evaluation team, including a hematologist, surgeon and anesthesiologist.2 Preparation includes communication with the laboratory to screen the patient’s blood and ensure sufficient availability of clotting factors.2 According to the authors, surgery should be scheduled in the morning if possible, and careful temperature control should be maintained throughout the preoperative period.2 Meanwhile, Grottke et al.’s review found that acquired coagulation disorders can develop in the preoperative period, such as upon a trauma patient’s arrival to the emergency room.5 Levy and Azran state that preoperative medications can induce coagulation issues, stressing the importance of the anesthesiologist in preventing such coagulopathies from developing.3 The anesthesia provider is responsible for evaluating the patient for any coagulation disorder diagnoses, as well as any coagulation issues that may arise during the perioperative period.
During a procedure, the anesthesiologist must be careful to prevent any trauma to a patient with a coagulation disorder, as it may result in heavy bleeding.3 This includes taking extra precautions with invasive processes, such as vascular access or monitoring, and avoiding injections.2 Vital signs monitoring is crucial, as tachycardia (i.e., fast heart rate) and hypertension can be especially dangerous for a patient with a coagulation disorder.2 The anesthesia provider should be mobilized for any potential bleeding situation, and may consider mechanical deep vein thrombosis prevention.2 As Grottke et al. state, a coagulation disorder can also develop during a procedure such as cardiopulmonary bypass, so anesthesia providers may need to act quickly.5 To oppose any effects of anticoagulants or antiplatelet drugs used before surgery, the clinician will use prohemostatic pharmacological therapies to prevent bleeding or transfusions if bleeding occurs.3 Furthermore, it is important that the anesthesiologist use an appropriate anesthetic agent for a patient with disordered coagulation. For example, the use of neuraxial anesthesia in an obstetric patient with a coagulation disorder is complex and can involve consultation with clinicians overseeing prenatal care.6 Also, administration of local anesthesia with a vasoconstrictor can slow bleeding.4 Intraoperative care of a patient with coagulopathy includes trauma avoidance, vital signs monitoring, quick mobilization and proper use of anesthetics.
Postoperative management is a fundamental aspect of anesthesia provision, and it may be altered in patients with coagulation disorders. Clinicians should continue to avoid trauma or the potential for heavy bleeding after surgery.3 If bleeding occurs, the surgical and anesthetic teams should have transfusions and pharmacological agents available.3 Acquired coagulopathy can also arise in patients with ongoing bleeding after childbirth, which may require an anesthesiologist to administer medications postoperatively.5 Pain management in patients with clotting disorders should be multimodal and clinicians should avoid the use of non-steroidal anti-inflammatory drugs (NSAIDs).2
Coagulation disorders present anesthesia providers with various challenges, including anemia, which interferes with oxygen delivery, and the possibility of heavy bleeding.7 Anesthesiologists can prevent complications by performing a thorough preoperative assessment, taking extra precautions during a procedure and choosing appropriate agents for anesthesia and analgesia. Researchers should aim to remedy the lack of data on pharmacological agents that can combat anticoagulant medications or provide an alternative to blood transfusions.3
1. Moake JL. Overview of Coagulation Disorders. Merck Manual: Professional Version. Kenilworth, New Jersey: Merck & Co., Inc.; July 2018.
2. Shah UJ, Narayanan M, Graham Smith J. Anaesthetic considerations in patients with inherited disorders of coagulation. Continuing Education in Anaesthesia Critical Care & Pain. 2014;15(1):26–31.
3. Levy JH, Azran M. Anesthetic concerns for patients with coagulopathy. Current Opinion in Anaesthesiology. 2010;23(3):400–405.
4. Beirne OR. Anesthetic Considerations for Patients with Bleeding Disorders. In: Bosack RC, Lieblich S, eds. Anesthesia Complications in the Dental Office2015:103–112.
5. Grottke O, Fries D, Nascimento B. Perioperatively acquired disorders of coagulation. Current Opinion in Anesthesiology. 2015;28(2):113–122.
6. Karaman S, Cagiran Z. Anesthesia for Pregnant Patient with Coagulation Disorders. In: Gunaydin B, Ismail S, eds. Obstetric Anesthesia for Co-morbid Conditions. Cham: Springer International Publishing; 2018:155–168.
7. Philip MH, Herman GDH, Joost TMdW. Haematological and coagulation disorders and anaesthesia. Oxford Textbook of Anaesthesia. Oxford, UK: Oxford University Press; April 2017.