Bleeding during surgery is a potentially serious complication that can lead to increased morbidity, longer operative times, and prolonged hospital stays. While surgical technique and procedure type are important contributors, individual patient factors play a pivotal role in determining the risk and severity of bleeding during surgery. A thorough preoperative assessment of these factors is essential for anticipating complications, guiding perioperative management, and ensuring optimal outcomes.
Inherited or acquired coagulation abnormalities are among the most significant patient-related factors that contribute to the risk of bleeding during surgery. Patients with conditions such as hemophilia A or B, von Willebrand disease, or platelet function disorders are at particularly high risk. Preoperative coagulation profiles, including prothrombin time, activated partial thromboplastin time, and platelet count, are essential for identifying these risks early 1,2.
Many patients take anticoagulants or antiplatelet agents for cardiovascular or thromboembolic conditions—medications including but not limited to warfarin, direct oral anticoagulants, aspirin, and clopidogrel inhibit various components of the coagulation cascade or platelet function, significantly raising the risk of bleeding during and after surgery. Proper management, including temporary discontinuation, bridging therapy, or reversal agents, depends on the medication type, surgical bleeding risk, and underlying thrombotic risk 3–5.
Chronic kidney disease and hepatic insufficiency can both impair hemostasis. In kidney disease, uremia can lead to platelet dysfunction, while liver disease affects the production of clotting factors and the clearance of fibrinolytic proteins. These changes end up resulting in a complex hemostatic imbalance that can be difficult to predict or correct during surgery. Careful laboratory monitoring and preoperative optimization are critical for these patient populations 6–9.
Pre-existing anemia reduces the body’s reserve to tolerate blood loss and may mask the severity of intraoperative hemorrhage. In addition, patients with hematologic malignancies or bone marrow disorders may have thrombocytopenia or other abnormalities that impair coagulation. Transfusion planning and hematology consultation may be necessary in such cases in order to minimize any perioperative risks 10–12.
Deficiencies in certain vitamins, like vitamin C or vitamin K, can result in reduced synthesis of clotting factors. Chronic illnesses such as cancer or autoimmune diseases also influence the balance between coagulation and bleeding through inflammation-mediated changes in platelet function and clotting pathways and are important to evaluate in the perioperative patient 13–16.
Patient-specific factors significantly influence bleeding risk during surgery and must be carefully evaluated in the preoperative setting. Coagulation disorders, medication use, organ dysfunction, and chronic disease states all contribute to the complexity of bleeding management. A multidisciplinary approach involving surgical, anesthetic, and hematologic expertise is often required to mitigate these risks and ensure patient safety throughout the perioperative period.
References
1. Erdoes, G. et al. Perioperative Considerations in Management of the Severely Bleeding Coagulopathic Patient. Anesthesiology 138, 535–560 (2023). DOI: 10.1097/ALN.0000000000004520
2. Martlew, V. J. Peri‐operative management of patients with coagulation disorders. BJA: British Journal of Anaesthesia 85, 446–455 (2000). DOI: 10.1093/bja/85.3.446
3. Moster, M. & Bolliger, D. Perioperative Guidelines on Antiplatelet and Anticoagulant Agents: 2022 Update. Curr Anesthesiol Rep 12, 286–296 (2022). DOI: 10.1007/s40140-021-00511-z
4. Reed, B. L. et al. Effect of antiplatelet and anticoagulant therapy on bleeding complications following ventral hernia repair: An ACHQC analysis. The American Journal of Surgery 236, 115856 (2024). DOI: 10.1016/j.amjsurg.2024.115856
5. Tschan, S. L. & Bolliger, D. Coagulation and Aging: Implications for the Anesthesiologist. Curr Anesthesiol Rep 11, 387–395 (2021). DOI: 10.1007/s40140-021-00498-7
6. Acedillo, R. R. et al. The risk of perioperative bleeding in patients with chronic kidney disease: a systematic review and meta-analysis. Ann Surg 258, 901–913 (2013). DOI: 10.1097/SLA.0000000000000244
7. Northup, P. G., Lisman, T. & Roberts, L. N. Treatment of bleeding in patients with liver disease. J Thromb Haemost 19, 1644–1652 (2021). DOI: 10.1111/jth.15364
8. Westerkamp, A. C., Lisman, T. & Porte, R. J. How to minimize blood loss during liver surgery in patients with cirrhosis. HPB 11, 453–458 (2009). DOI: 10.1111/j.1477-2574.2009.00078.x
9. Gilbert-Kawai, N., Hogan, B. & Milan, Z. Perioperative management of patients with liver disease. BJA Education 22, 111–117 (2022). DOI: 10.1016/j.bjae.2021.11.006 External Link
10. Chacon, G. E. & Ugalde, C. M. Perioperative management of the patient with hematologic disorders. Oral Maxillofac Surg Clin North Am 18, 161–171, v (2006). DOI: 10.1016/j.coms.2005.12.010
11. Armas-Loughran, B., Kalra, R. & Carson, J. L. Evaluation and management of anemia and bleeding disorders in surgical patients. Med Clin North Am 87, 229–242 (2003). DOI: 10.1016/s0025-7125(02)00154-2
12. Patel, M. S. & Carson, J. L. Anemia in the Preoperative Patient. Med Clin North Am 93, 1095–1104 (2009). DOI: 10.1016/j.mcna.2009.05.007
13. Vitamin K Deficiency – Nutritional Disorders – MSD Manual Professional Edition. https://www.msdmanuals.com/professional/nutritional-disorders/vitamin-deficiency-dependency-and-toxicity/vitamin-k-deficiency.
14. Blee, T. H., Cogbill, T. H. & Lambert, P. J. Hemorrhage associated with vitamin C deficiency in surgical patients. Surgery 131, 408–412 (2002). DOI: 10.1067/msy.2002.122373
15. Pandya, A., Jackson, G., Wigmore, T. & Baikady, R. R. Management of surgery-associated bleeding in cancer patients. Current Anaesthesia & Critical Care 19, 59–69 (2008). DOI: 10.1016/j.cacc.2008.01.006
16. Favaloro, E. J., Pasalic, L. & Lippi, G. Autoimmune Diseases Affecting Hemostasis: A Narrative Review. Int J Mol Sci 23, 14715 (2022). DOI: 10.3390/ijms232314715