A landmark expert consensus on perioperative bleeding and coagulation management has been released, offering clinicians a comprehensive, evidence‑based framework that spans the entire surgical journey—from the preoperative clinic to the operating room and beyond. The Anesthesiology Expert Opinion on Perioperative Bleeding and Coagulation Management (2026 Edition) aims to resolve one of the most persistent challenges in modern surgery: how to balance effective hemostasis with the ever‑present risk of thrombosis.
Developed by a panel of leading anesthesiologists and transfusion specialists, the document integrates the latest available evidence and provides standardized yet individualized strategies for patients of all ages across multiple surgical specialties. Its release comes at a time when surgical procedures are becoming increasingly complex and patient populations are older and sicker, making precise blood management more critical than ever.
A Closed‑Loop, Whole‑Cycle Philosophy
At the heart of the new guidance is a philosophy of closed‑loop, whole‑cycle management that emphasizes risk prediction, dynamic monitoring, precision intervention, and balanced protection. Rather than treating bleeding and clotting as separate issues, the consensus views them as two sides of the same coin—and argues that both must be addressed simultaneously.
The document sets out three primary clinical goals: standardizing perioperative coagulation monitoring workflows; establishing clear thresholds for blood product transfusion and hemostatic drug use to promote rational, evidence‑based practice; and crafting tailored strategies for special populations that optimize both hemostatic efficacy and thromboprophylaxis. Ultimately, the aim is to maximize perioperative safety and improve long‑term patient outcomes.
Moving Beyond Traditional Lab Tests
One of the most significant shifts in the consensus is its strong endorsement of a multidimensional, dynamic approach to coagulation assessment. The days of relying on a single laboratory test are over.
Preoperatively, the expert group recommends screening for bleeding risk using seven key clinical indicators—including history of hematoma, previous bleeding episodes, menorrhagia, surgical bleeding, post‑extraction hemorrhage, postpartum hemorrhage, and family history of coagulation disorders—alongside baseline tests such as prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), and fibrinogen levels.
Intraoperatively, the guidance prioritizes point‑of‑care testing (POCT) technologies, particularly thromboelastography (TEG) and rotational thromboelastometry (ROTEM), as well as activated clotting time (ACT). These tools provide real‑time, visual assessments of the entire coagulation process, replacing older, less reliable bleeding‑time tests.
Throughout the perioperative period, clinicians are urged to simultaneously evaluate blood loss, organ perfusion, and oxygen delivery—enabling early warning and early intervention when coagulation abnormalities are detected.
Restrictive Transfusion with Precise Triggers
The consensus firmly endorses a restrictive transfusion strategy, backed by clear numerical thresholds that guide clinical decision‑making.
Red blood cells: transfusion is indicated when hemoglobin falls below 7 g/dL for general patients, with higher triggers for cardiac surgery (7.5 g/dL) and orthopedic procedures (8 g/dL). The Huaxi score is recommended to support individualized decisions.
Platelets: platelet transfusion is recommended when the count falls below 50 × 10⁹/L; in the event of uncontrolled intraoperative bleeding, platelets should be given immediately regardless of the count.
Plasma: transfusion is indicated when PT or APTT exceeds 1.5 times the normal value or when INR > 2.0 in the presence of diffuse bleeding.
Cryoprecipitate: administration is prioritized when fibrinogen is below 1.5 g/L to replenish clotting factors.
By setting these explicit thresholds, the consensus aims to reduce unnecessary transfusions, minimize associated risks, and ensure that blood products are used only when truly needed.
Targeted Hemostatic Drugs and Standardized Dosing
The guidance also provides detailed recommendations on the use of hemostatic medications, specifying indications, initiation criteria, and safe dosage ranges.
Fibrinogen concentrate is recommended when levels are between 1.5 and 2.0 g/L with functional impairment, at an initial dose of 25–50 mg/kg.
Tranexamic acid is advised for major surgery to prevent or treat bleeding, at a dose of 20–25 mg/kg, but clinicians are cautioned about the increased risk of seizures associated with high doses.
Recombinant activated factor VII (rFVIIa) is not recommended for prophylaxis and should be reserved exclusively for refractory bleeding that does not respond to conventional measures.
These targeted recommendations reflect a shift toward more rational, evidence‑based pharmacotherapy, avoiding both under‑treatment and over‑treatment.
A Roadmap for the Future
The authors of the consensus emphasize that perioperative bleeding and coagulation management is rapidly evolving toward greater precision, individualization, and intelligent decision support. This 2026 edition is intended to provide a standardized, multidisciplinary framework that can be adapted across institutions and clinical settings.
However, the document also acknowledges that implementation will require ongoing education, institutional commitment, and further research to refine thresholds and validate new technologies. As surgical care continues to advance, the integration of real‑time monitoring, decision‑support tools, and personalized protocols will likely become the norm.
For now, the new expert opinion offers a clear and actionable blueprint—one that promises to improve patient safety, reduce complications, and ultimately transform the way clinicians approach the delicate balance between bleeding and clotting in the perioperative period.
Publication Details
Journal: Perioperative Precision Medicine
Article Title: Expert Opinion on Perioperative Management of Bleeding and Coagulation in Anesthesiology (2026 Edition)
Article Type: Expert Consensus
Website Link: View Article
DOI: 10.61189/909222ormctb
Publication Date: March 2026
Author: Task Force on “Expert Opinion on Perioperative Management of Bleeding and Coagulation in Anesthesiology (2026 Edition)”
Statement: The Chinese version of Expert Opinion on Perioperative Management of Bleeding and Coagulation in Anesthesiology (2026 Edition) was officially published in the Chinese Journal of Anesthesiology, Volume 46, Issue 1, in January 2026
