Concentrates/blood products
Coagulation factor concentrates
vs allogeneic blood products
In light of the current evidence in the management of perioperative bleeding, prompt and goal-directed
therapy is the key element in the implementation of haemotherapy for patients with coagulopathies
Christian Weber MD
Clinic of Anesthesiology,
Intensive Care Medicine
and Pain Therapy,
Goethe-University
Hospital Frankfurt,
Germany
Bleeding events have a substantial impact on the
supply of blood to the organs and tissues and
increase morbidity and mortality as well as the
length and cost of hospital stay. Its major
contributors are haemorrhage resulting from
trauma, surgery, anticoagulatory therapy and
acquired coagulopathies such as coagulation
factor deficiencies or bleeding caused by
hypothermia or acidosis. Surgical bleeding must
be corrected as soon as possible through damage
control measures or interventional therapy in
order to prevent catastrophic outcomes for the
patients. An adequate assessment and
management of perioperative bleeding can be
challenging and involves both the identification
of patients at increased risk of bleeding and
goal-directed haemotherapy to control
coagulation function, restore blood circulation,
and attain haemodynamic stability.
Clinical importance of perioperative
bleeding
Significant blood loss results in the dilution of
coagulation factors and platelets, accompanied
by delayed thrombin formation and propagation
and low fibrinogen levels. Despite the availability
of different strategies to contain blood loss,
the management of perioperative bleeding can
be complex and is defined by a fine balance
between reducing haemorrhage and preventing
thromboembolic events at the same time.
Disturbances in the coagulation process
(coagulopathies) can have a multitude of causes
and may result in spontaneous bleeding or
bleeding following an injury or medical
procedure. 1 Conversely, in the event of major
trauma, bleeding can induce an acute
coagulopathic state, which comprises several
pathological components and can be modified by
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HHE 2018 | hospitalhealthcare.com
individual characteristics, including age,
ethnicity, presence of comorbidities, use of oral
anticoagulants, and fluid intake before
hospitalisation. 2
In the specific perioperative context, acquired
coagulopathy can develop as a consequence of
loss of coagulation factors (for example, caused
by a traumatic event) or haemodilution due to
excessive fluid replacement, and constitutes
a risk factor for progression to severe bleeding.
Although fluid restriction during resuscitation
efforts following a major trauma or major
bleeding event during surgery results in shorter
stays in the intensive care unit, reduced blood
volumes can lead to acidosis, which in turn
worsens the coagulopathy. Alternatively,
coagulopathy can be induced by antithrombotic
agents. 3 Keeping in mind these distinct scenarios,
patients receiving anticoagulation therapy, or
those with congenital bleeding disorders, should
be evaluated preoperatively by a multidisciplinary
team, which will determine their risk of bleeding
through a detailed medical history and
coagulation tests. 4
Preoperative anaemia, which is common in
patients undergoing elective surgery, is known
to contribute significantly to increased morbidity
and mortality and is a strong predictor of the
need for perioperative transfusion of allogeneic
blood products. 4 However, a large retrospective
study showed that red blood cell transfusion
during surgery actually increased morbidity and
mortality outcomes for patients presenting with
severe anaemia before a general, non-emergent,
non-cardiac surgical procedure. Although surgical
bleeding could not be ruled out as a culprit for
the worse outcomes observed with blood
transfusion in this study, the results pointed
to the importance of promptly managing