Concentrates/blood products
Coagulation factor
concentrates vs allogeneic
blood products
In light of the current evidence in the management of perioperative bleeding,
prompt and goal-directed therapy is the key element in the implementation of
haemotherapy for patients with coagulopathies
Christian Weber MD
Clinic of Anesthesiology, Intensive Care
Medicine and Pain Therapy, Goethe-University
Hospital Frankfurt, Germany
Bleeding events have a substantial impact
on the supply of blood to the organs and
tissues and increase morbidity and
mortality as well as the length and cost of
hospital stay. Its major contributors are
haemorrhage resulting from trauma,
surgery, anticoagulatory therapy and
acquired coagulopathies such as
coagulation factor deficiencies or bleeding
caused by hypothermia or acidosis.
Surgical bleeding must be corrected as
soon as possible through damage control
measures or interventional therapy in
order to prevent catastrophic outcomes
for the patients. An adequate assessment
and management of perioperative
bleeding can be challenging and involves
both the identification of patients at
increased risk of bleeding and goal-
directed haemotherapy to control
coagulation function, restore blood
circulation, and attain haemodynamic
stability.
Clinical importance of
perioperative bleeding
Significant blood loss results in the
dilution of coagulation factors and
platelets, accompanied by delayed
thrombin formation and propagation and
low fibrinogen levels. Despite the
availability of different strategies to
contain blood loss, the management of
perioperative bleeding can be complex
and is defined by a fine balance between
reducing haemorrhage and preventing
thromboembolic events at the same time.
Disturbances in the coagulation process
(coagulopathies) can have a multitude of
causes and may result in spontaneous
bleeding or bleeding following an injury
or medical procedure. 1 Conversely, in the
event of major trauma, bleeding can
induce an acute coagulopathic state,
which comprises several pathological
components and can be modified by
individual characteristics, including age,
ethnicity, presence of comorbidities, use
of oral anticoagulants, and fluid intake
before hospitalisation. 2
In the specific perioperative context,
acquired coagulopathy can develop as
a consequence of loss of coagulation
factors (for example, caused by
a traumatic event) or haemodilution
due to excessive fluid replacement, and
constitutes a risk factor for progression to
severe bleeding. Although fluid restriction
during resuscitation efforts following
a major trauma or major bleeding event
during surgery results in shorter stays
in the intensive care unit, reduced blood
volumes can lead to acidosis, which
in turn worsens the coagulopathy.
Alternatively, coagulopathy can be
induced by antithrombotic agents. 3
Keeping in mind these distinct scenarios,
patients receiving anticoagulation
therapy, or those with congenital bleeding
disorders, should be evaluated
preoperatively by a multidisciplinary
team, which will determine their risk
of bleeding through a detailed medical
history and coagulation tests. 4
Preoperative anaemia, which is
common in patients undergoing elective
surgery, is known to contribute
significantly to increased morbidity and
mortality and is a strong predictor of the
need for perioperative transfusion of
allogeneic blood products. 4 However,
a large retrospective study showed that red
blood cell transfusion during surgery
actually increased morbidity and mortality
outcomes for patients presenting with
severe anaemia before a general, non-
emergent, non-cardiac surgical procedure.
Although surgical bleeding could not be
ruled out as a culprit for the worse
outcomes observed with blood transfusion
in this study, the results pointed to the
importance of promptly managing
perioperative bleeding. 5 Other studies have
yielded similar findings for patients
undergoing cardiac surgery. 6
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