HHE Sponsored supplement: Managing perioperative bleed - Page 21

Factor FXIII concentrate Factor XIII represents another major contributor in achieving clot stability by cross-linking fibrin monomers, and preventing clot lysis by covalent binding of α2-plasmin inhibitor to fibrin molecules. Although congenital FXIII deficiency is a very rare bleeding disorder, there are clinical data proving that acquired FXIII deficiency can be observed frequently during major paediatric surgery. 37,38 In the latter study, FXIII levels decreased to minimal levels of activity of 33% (15–61%), which has been determined to be the lower threshold in adults to initiate FXIII supplementation. 3 However, clinical efficacy of FXIII administration to treat acquired FXIII deficiency in paediatric surgery is currently based on clinical observation rather than on evidence- based data. Recombinant activated FVII Management of intractable bleeding has led to a call for a defined rescue therapy. Although it is well known that some prerequisites including normothermia, undisturbed acid–base status, and normal calcium levels, as well as sufficient platelet count and plasma fibrinogen levels are the mainstay for adequate clot building, many authors have declared a special role in improving thrombin potential to enable cessation of bleeding. Therefore, administration of recombinant activated FVII (rFVIIa) has been advocated, whereby clinical evidence to support its use are lacking. Activated rFVII is licensed for the treatment of patients with haemophilia A or B with inhibitors, and patients with congenital FVII deficiency. In Europe, additional approval was granted for treatment of Glanzmann’s thrombasthenia. There are published data for the off-label treatment using rFVIIa to stop severe bleeding in children with bleeding during neurosurgical procedures 39,40 and cardiac surgery. 41 It has been hypothesised that administration of rFVIIa for treatment of severe bleeding in adults may only be efficacious if critical amounts of fibrinogen and platelets have been established. 3 As no clear dose has been established, sound evidence-based data are lacking, and the treatment using rFVIIa increases thromboembolic risk considerably, a recent Cochrane analysis has advocated against the use of rFVIIa outside its licensed indications. 42 Conclusions Prompt and timely identification of the underlying coagulopathy and, consequently, individualised treatment of depleted factors are the mainstay of a modern and advanced coagulation management. The use of coagulation factors as part of an algorithm offers great advantages for effective bleeding management, as it does not require cross-matching or thawing, is almost immediately available, it does not alter serum ionised calcium level, it is less immunogeneic, the increase in desired coagulation factor levels can be reliably calculated, and it can be administered in a significantly less volume than plasma transfusion. Although more clinical data in children are needed, this approach seems very likely to permit rapid and effective targeted management. References 1 Haas T et al. Management of dilutional coagulopathy during pediatric major surgery. Transfus Med Hemother 2012;39:114–19. 2 American Society of Anesthesiologists Task Force on Perioperative Blood M. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. 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