Intermediate and Major Procedures Plan of management

Should include:

Type of concentrate to be used (or DDAVP). The initial level required to cover surgery.

The duration of treatment required (the exact frequency of treatment will have to be managed on an ad hoc basis). Need for tranexamic acid.

Frequency of monitoring and exact timing in relation to surgery.

Perioperative management

Give the FVIII approximately 90 minutes before the planned operation time.

Take pre- and post-infusion levels.

Except for minor procedures, take a "fall off'' level 4 hours postoperatively to plan further replacement therapy.

Postoperative management

After major procedures the FVIII level should not be allowed to fall below 50% for at least 10 days.

Beyond the immediate postoperative period treatment is determined by FVIII half-life (12 hours), therefore, 12-hourly infusions to 100% levels is satisfactory.

Frequent measurement of levels is very helpful as there is a tendency for them to drift either up or down.

Any postoperative procedures, such as, removal of drains or physiotherapy should be timed to follow shortly after FVIII administration.

A period of once daily treatment, which may be given at home may be necessary in some patients. Its duration should be judged from the nature of the procedure and the need for any further treatment, such as, physiotherapy.

Minor procedures

Some minor procedures require only a single dose of FVIII to approximately 60%, unless problems arise. This can be used in the following procedures:

Skin biopsy and minor skin surgery Endoscopy

Straightforward dental extraction Liver biopsy:

The transjugular approach is the preferred method in patients with bleeding disorders in general.

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