foreword
Point-of-care and
coagulation algorithms
improve patient outcomes
Donat R Spahn
MD FRCA
Institute of
Anesthesiology,
University and University
Hospital of Zurich,
Switzerland
Bleeding and coagulopathy both increase
mortality and morbidity of patients undergoing
surgery or after trauma. 1–3 Therefore, the
following aspects are key for the successful
management of a bleeding patient: Early surgical
or interventional source control within the
concept of damage control surgery, understanding
of the physiology and pathophysiology of
haemostasis, early and repeated monitoring of
coagulation and having an individualised
goal-directed coagulation algorithm. 3
“Severely injured patient presenting with deep
haemorrhagic shock, signs of ongoing bleeding
and coagulopathy to undergo damage control
surgery’’. 3 This situation is characterised by a core
We need to implement the
coagulation algorithm with
educational activities and monitor
algorithm adherence to make
patients benefit
temperature below 34 °C, a pH ≤ 7.2 and ongoing
coagulopathy. 3 In this situation, fractures are
stabilised with external fixators rather than
primary definitive osteosynthesis, the aim
being to arrive in the intensive care unit
within 60 min for rewarming and further
stabilisation. 3,4
Physiologically, the haemostasis
process starts when the endothelial
layer is disrupted and platelets
become in contact with the sub-
endothelial structures; 5 they then
become progressively linked to the
subendothelium via von Willebrand factor
and collagen and are activated. This activation
results in an inside-out activation of
glycoprotein 2b3a receptors that will serve as
anchor points for fibrinogen. This
fibrinogen platelet to platelet linking
results in an initial platelet plug. 5 The
activation of platelets at the same time
results in the secretion of thromboxane
A2, ADP and von Willebrand to recruit
and activate additional platelets. Last
but not least, the surface of these
4
HHE 2018 | hospitalhealthcare.com
activated platelets provide the ideal internal
milieu for the generation of a thrombin burst,
which results in the transformation of fibrinogen
into (soluble) fibrin and the activation of FXIII,
which stabilises the fibrin. Fibrinogen therefore
has a central role in coagulation because it is key
in the stabilisation of the platelet plug and it is
also the substrate of the plasmatic coagulation.
This is particularly important because fibrinogen
is the ‘coagulation element’ that is the first factor
to become critically low in many bleeding
situations, particularly in trauma and
post-partum haemorrhage. 3,6
Nevertheless, the individual
coagulation situations are
extremely variable and therefore
early and repeated monitoring of
coagulation and an
individualised goal-directed
coagulation algorithm is key for
a successful management of any
major bleeding following trauma,
in surgery and post-partum. 3,7 In
order to get coagulation results quickly,
point-of-care technologies are key. 8,9
In this educational handbook, world-
renowned experts review their field of
expertise in a variety of clinical
scenarios. It is extremely
interesting to note, that
today there is high-level
scientific
evidence