Perioperative use of factor concentrates and blood products—a survey of clinical practices in the United States: communication from the ISTH Subcommittee on Perioperative and Critical Care

BACKGROUND: Educational efforts to improve perioperative physician knowledge on managing bleeding and oral anticoagulants may have influenced clinical practice. This study evaluated management strategies for major bleeding and use of fibrinogen and prothrombin complex concentrates (PCCs) across different clinical scenarios. OBJECTIVES: To assess contemporary perioperative practices in bleeding management and anticoagulant reversal among anesthesiologists in the United States. METHODS: A 20-question electronic survey addressing perioperative bleeding and anticoagulant reversal management was distributed to American Society of Anesthesiologists members between June and August 2023. Responses were analyzed descriptively. RESULTS: Among 1030 respondents (98.5% in the United States), PCCs were most frequently selected for warfarin reversal before emergency surgery (62.5%) and for perioperative major bleeding (71.5%), with 4-factor PCCs being predominant. For direct oral anticoagulant reversal, PCCs were preferred for emergency surgery (76.9%) and major bleeding (81.7%). Over half (53.1%) reported discretionary access to PCCs. Fresh frozen plasma was less commonly chosen for warfarin reversal (38.3%) and major bleeding (45.9%). Cryoprecipitate was the leading treatment for fibrinogen replacement in bleeding patients (65.9%). Most respondents (92.9%) reported a massive transfusion protocol, with 44.3% indicating inclusion of cryoprecipitate rather than fibrinogen concentrate. For severe factor deficiencies, fresh frozen plasma remained the first-line choice in cardiac surgery (60.0%), liver surgery (66.9%), and postpartum hemorrhage (71.3%). CONCLUSION: These findings provide an updated overview of perioperative anticoagulant reversal and bleeding management practices. The results highlight increasing reliance on PCCs and cryoprecipitate in emergency and perioperative settings, underscoring evolving trends in therapeutic decision making among anesthesiologists in the United States.