Anesthesiologists’ Approach to Perioperative Bleeding Management

ASH ’25 Report from Dr. Wolfgang Miesbach: Perioperative Bleeding Management: What 1,030+ U.S. Anesthesiologists Think About Current Challenges
50.6% practiced primarily at academic medical centers, while 42.3% worked in community hospitals, with additional representation from military/VA hospitals (3.7%). Nearly half (48.4%) worked at Level I trauma centers.
The Progress…

• Prothrombin complex concentrates (PCCs) have become the dominant choice for managing anticoagulated patients in emergency settings. For warfarin reversal, 4-factor PCCs jumped from 30% adoption in 2019 to 55.4% in 2023. Similarly, PCCs are now chosen by 76.9% of clinicians for DOAC reversal before emergency surgery, up from 44% just four years earlier.
• Fresh frozen plasma (FFP)—once the default choice—has dramatically declined in use from 75% to just 38.3% for warfarin reversal, replaced by more targeted, efficient interventions.

The Challenges That Remain…

• Access & Approval Remain Fragmented: Despite clear guidelines, 19.3% of respondents lack access to PCCs entirely, while 18.9% face approval requirements that could delay life-saving interventions. ​
  Inconsistent Institutional Protocols: For DOAC management, only 33.8% of clinicians have formal institutional protocols in place, while 44% didn’t even know if their hospital had one.
• Resource Limitations for Advanced Testing: Just 36.2% of hospitals can access drug-specific anti-FXa level testing for apixaban or rivaroxaban—essential data for informed decision-making in urgent scenarios.
• The DOAC Reversal Agent Gap: While specific DOAC reversal agents exist—idarucizumab for dabigatran and andexanet alfa for apixaban/rivaroxaban—the survey revealed a notable limitation: their usage patterns weren’t assessed. However, the recent ANNEXA-I trial showed that 85.5% of patients in the standard care group received PCCs, highlighting their continued prominence despite available specific antidotes.
• Fibrinogen Concentrate: While fibrinogen concentrate (FIBRYGA®) recently received FDA approval for acquired fibrinogen deficiency based on the FIBRES trial demonstrating non-inferiority to cryoprecipitate, uptake remains remarkably low at just 5.5%, with cryoprecipitate dominating at 65.9%.
• Massive Transfusion Protocols (MTPs): While 92.9% of respondents reported having an MTP at their hospital, there’s striking heterogeneity in fibrinogen replacement strategies: 44.3% use cryoprecipitate exclusively, 24.5% use either product based on availability, but 26.3% don’t include fibrinogen replacement at all in their protocols.
• For severe acquired factor deficiencies during cardiac surgery (60.0%), liver surgery (66.9%), and postpartum hemorrhage (71.3%), FFP remains the first-line choice—despite its limitations, including volume overload and delayed onset.