4

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 goaldirected 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 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 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

“ We need to implement the coagulation algorithm with educational activities and monitor algorithm adherence to make patients benefit”

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 that point-of-care and factor concentrate-based coagulation algorithms result in reduced:

• need for allogeneic blood products 10-16

10, 12

• mortality

13, 14

• incidence of acute kidney injury

• costs

10, 11, 17

• re-exploration rate 13 and

• length of stay. 11 These benefits have been

demonstrated in major trauma, 12, 17 cardiac surgery, 10, 11, 13, 14, 17 paediatric surgery, 16 and post-partum haemorrhage. 15

The case therefore is clear. We are to introduce point-of-care and factor concentrate-based coagulation algorithms in the management of bleeding and haemostasis. However, creating such algorithms is not sufficient. We need to implement them and provide training in interdisciplinary situations, and monitor algorithm compliance to ensure that the patients benefit from the most advanced bleeding treatment concepts.

References 1 Ranucci M et al. Major bleeding, transfusions, and anemia: the deadly triad of cardiac surgery. Ann Thoracic Surg 2013; 96( 2): 478 – 85. 2 Frith D et al. Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations. J Thromb Haemost 2010; 8( 9): 1919 – 25. 3 Rossaint R et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016, 20( 1): 100. 4 Shapiro MB et al. Damage control: collective review. J Trauma 2000; 49( 5): 969 – 78. 5 Mannucci PM. Treatment of von Willebrand’ s Disease. N Engl J Med 2004; 351( 7): 683 – 94. 6 Collins PW et al. Fibrin-based clot formation as an early and rapid biomarker for progression of

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