HHE Sponsored supplement: Managing perioperative bleed - Page 4

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