The role of the anesthesiologist in the modulation of the coagulation cascade has grown greatly in the past few years. We no longer only give blood products and fluids during periods of massive blood loss. We have gained a leadership role at the forefront of basic science research into the intricate nature of coagulation. It is paramount that we give our residents and fellows a complete understanding of the physiology and pathology of bleeding. We must become experts on the pharmacodynamics of the many new agents that modulate coagulation. Who better to manage perioperative bleeding than the anesthesiologist?

In this article, we discuss the action of several of the drugs in the forefront of hemostasis, starting with desmopressin, which has the longest track record, to the newer agents, aprotinin, tranexamic acid, and epsilon-aminocaproic acid (EACA). We also discuss the use of the technique of deliberate hypotension to decrease blood loss. We must work hand-in-hand with our surgical colleagues to decrease blood loss, and, if we have cases with marked blood loss, use agents that are appropriate to modulate the coagulation cascade.