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larger volumes of transfused plasma. 14 FPP was
also associated with an increased risk of acute
lung injury in patients in the intensive care unit 15
and of multiple organ failure in patients with
critical injuries. 16 In a study of patients
undergoing coronary artery bypass, transfusion
of FPP correlated with a higher long-term
mortality. 17 Finally, FPP showed to be ineffective
to correct mildly prolonged coagulation values in
non-bleeding patients; 18,19 however, another study
showed that plasma therapy reduced mortality
rates in cases of massive transfusions when it was
implemented at an early stage. 20 These results
were not verified by a meta-analysis of
randomised controlled trials evaluating FPP for
anticoagulation reversal or for the prevention and
treatment of bleeding associated with invasive
interventions or specific pathologies. 21
Whereas the transfusion of FPP is associated
with increased incidence of nosocomial infections
in patients undergoing surgery for conditions
other than traumatic injuries, 22 goal-directed
therapy with coagulation factor concentrates has
a lower potential for infectiousness and incidence
of multiple organ failure compared with FFP,
although no significant differences in mortality
rates have been observed with the two
approaches. 23 Prothrombin complex concentrates
(PCCs), traditionally used in the treatment of
haemophilia and other congenital bleeding
disorders, are recommended in the emergency
reversal of vitamin K-dependent oral
anticoagulants. 2 A recent systematic review and
meta-analysis of randomised and observational
studies demonstrated a lower rate of all-cause
mortality and risk of post-transfusion volume
overload, accompanied by rapid INR reduction,
compared with FFP in patients receiving
treatment with warfarin who experienced a
major bleeding event or who needed urgent
surgery. 24 Unlike FPP, PCCs require small infusion
volumes and can be promptly administered to
patients without the need for blood group
matching or thawing, which can be particularly
relevant is urgent cases of patients with intracranial haemorrhage who receive oral
anticoagulants, 25 but their use is associated
with an increased risk of thrombosis and should
therefore be carefully analysed for trauma
patients.
Fibrinogen supplementation, by contrast, is
superior to FPP in the reversal of severe trauma-
induced coagulopathy, but because fibrinogen is
a critical haemostatic factor for efficient local clot
formation it reaches its critical lower reference
values before all the other factors. 26,27 Rescue
therapy with recombinant activated FVIIa,
commonly used in the treatment of haemophilia,
may be considered for life-threatening bleeding
events that cannot be controlled with standard
surgical interventions or coagulation therapy,
although its cost and risk of arterial
thromboembolic events associated with higher
doses, especially among the elderly, should be
taken into consideration in treatment decision
making. Finally, replacement therapy with FXIII
concentrate does not seem to have an effect in
reducing transfusion needs. 2,4
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effectiveness and safety of
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11 WOMAN trial collaborators.
Effect of early tranexamic acid
administration on mortality,
hysterectomy, and other
morbidities in women with
post-partum haemorrhage
(WOMAN): an international, long-term mortality with plasma
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14
HHE 2018 | hospitalhealthcare.com
Conclusions
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. This involves a rapid and
comprehensive diagnosis of the existing
coagulation deficits and the use of coagulation
factor concentrates to restore function.
Nevertheless, the question of superiority of factor
concentrates versus. allogenic blood products
cannot be definitely answered at this time
because allogenic blood products are still
indicated for particular conditions, mainly for the
management of extensive blood loss with massive
transfusions, and in situations where the use of
factor concentrates cannot correct the underlying
pathology. In conclusion, goal-directed therapy
with coagulation factor concentrates is preferred,
but in some rare cases clinicians may have to
resort to allogenic blood products.
of fresh frozen plasma vs
coagulation factor concentrates
on morbidity and mortality in
trauma-associated haemorrhage
and massive transfusion. Injury
2011;42(7):697–701.
24 Chai-Adisaksopha C et
al. Prothrombin complex
concentrates versus fresh frozen
plasma for warfarin reversal.
A systematic review and
meta-analysis. Thromb Haemost
2016;116(5):879–90.
25 Imberti D et al. Emergency
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a three-factor prothrombin
complex concentrate in patients
with intracranial haemorrhage.
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26 Innerhofer P et al. Reversal of
trauma-induced coagulopathy
using first-line coagulation factor
concentrates or fresh frozen
plasma (RETIC): a single-centre,
parallel-group, open-label,
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27 Hiippala ST et al. Hemostatic
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