HHE Sponsored supplement: Managing perioperative bleed - Page 26

Currently, there are no studies published on the effectiveness of PCC in trauma patients on direct oral anticoagulants (DOACs). 46 However, our experiences with major trauma patients on DOACs revealed that high doses of PCC (50U/kg body weight) are necessary to control bleeding. Risk of thromboembolic events Joseph et al reported an incidence of thromboembolic events in the range of 6% after PCC administration in a heterogeneous group of trauma patients. 47 Our group has shown that PCC administration resulted in a substantial and prolonged increase in endogenous thrombin generation compared with patients who received no coagulation therapy or fibrinogen concentrate only. 48 PCCs are potent pro-coagulants and, as such, the possibility of associated thromboembolic complications should be considered carefully. 49 Robust safety data related to PCC use in TIC are still lacking. Studies on the use of coagulation factor concentrates in trauma Data showing that fibrinogen supplementation improves survival in trauma patients are still limited. In a retrospective study the administration of fibrinogen concentrate along with PCC (4 factor concentrate) resulted in favourable survival rates compared with those predicted by both the trauma injury severity score and the revised injury severity classification score.6 Innerhofer et al compared FFP transfusion versus coagulation factor concentrate (fibrinogen concentrate first line, PCC and FXIII) replacement in a cohort of major trauma patients. Significantly fewer patients in the coagulation factor concentrate group received massive transfusion and fewer patients received ‘rescue’ therapy by changing the treatment groups. However, the primary outcome, which was multi-organ failure, was not different between groups (the study was stopped at 50% recruitment). 8 One study compared a ROTEM-guided coagulation therapy based on coagulation factor concentrates (fibrinogen concentrate and PCC) with controls from the German Trauma Registry, treated with FFP. RBC and PC transfusions were avoided in significantly higher proportions of patients in the coagulation factor concentrate group. However, no difference in mortality was observed. 50 Conclusions It remains unclear whether early substitution of coagulation factor concentrate can improve outcome in major trauma-related bleeding. However, it has been clearly established that coagulation factor concentrates allow rapid and targeted supplementation of pro-coagulants, and that the administration of fibrinogen concentrate in cases of TIC effectively treats early and critical fibrinogen depletion. 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