Editorial

Bleeding is to an extent inevitable in most forms of surgery, and it is often multifactorial in origin. Of course it has been recognized for centuries that bleeding during or after surgery can cause hypovolaemia and shock often resulting in major complications or death. However, an additional factor in the modern era is that many patients are now on powerful drug treatments which ‘thin the blood’ such as anticoagulants or antiplatelet agents. This creates a dilemma for the surgeon – continue these agents and increase the risk of significant bleeding, or stop them and risk adverse events such as a coronary thrombosis?

This problem formed the basis for a symposium held at the Royal Society of Medicine in September 2008 at which a series of experts from various fields presented the available evidence, described modern best practice and debated controversial areas. Several important themes emerged. Many speakers stressed the need to recognize that there was a balance to be struck between risk and benefit and that many patients would require a multidisciplinary assessment to optimize management. Such an approach would involve haematology departments and other professionals such as cardiologists. Additionally it was agreed that difficult cases required an experienced surgical and anaesthetic team with access to modern techniques and equipment in theatre. Unfortunately currently available haematology laboratory tests are not capable of accurately predicting which patients are likely to run into bleeding problems and cannot assess platelet function in a routine clinical setting. All patients should therefore have a careful history taken about drug treatments, a family history and any personal history of problems with bleeding or bruising.

Some of the presenters described exciting new technical advances such as glues or sealants or mechanical devices to control bleeding, others stated that closer consultation with anaesthetic or haematology colleagues was the key. There was also much mention of the antiplatelet agent clopidogrel. Many patients are now on clopidogrel, either alone or in combination with aspirin. Such patients are very much more likely to bleed during surgery but there are also considerable potential hazards in stopping the drug in certain patients, such as those with drug eluting coronary stents. Ideally it should be stopped 5–7 days before surgery, in line with the manufacturer's recommendations. A surgeon who fails to recognize that a patient is on clopidogrel and operates without due consideration and discussion of the risk is probably as guilty of a breach of care as one who stops the clopidogrel without careful discussion with the patient's cardiologist. With the emergence of newer and more powerful agents such dilemmas are likely to increase.

It was also recognized that emergency patients presented an especial problem since there might not be time for extended discussions or the stopping of anticoagulants or antiplatelet agents. In that situation, minimally invasive techniques might be more appropriate than open surgery and again an experienced team with full access to modern equipment and technologies would be needed. The worst situation of all would be for the risk not to have been identified at an early stage such that major problems with bleeding were experienced by an inadequately prepared team. Attention to ‘process issues’ such as careful preoperative assessment and documentation is the best way to avoid this potentially disastrous scenario arising.

The main message from the symposium was simple. These patients should be identified in advance of the day of surgery whenever possible, a surgeon should involve colleagues in discussions about how bleeding risk can be reduced and in some cases routine surgery may need to be cancelled or re-scheduled if the risks of going ahead are too high.