HPE CSL Managing Perioperative Bleeding handbook - Page 19

Paediatrics Fibrinogen and other concentrates in paediatrics Options for using coagulation factors in children are discussed and a brief overview of current literature is given Thorsten Haas MD Professor of Anaesthesiology Department of Paediatric Anaesthesia University Children’s Hospital Zurich Switzerland Management of perioperative bleeding in children is a major challenge for paediatric anaesthetists. The reasons for haemostatic changes during major paediatric surgery is multifactorial and may be related to dilutional coagulopathy, loss and consumption of coagulation factors, hyperfibrinolysis, or surgical bleeding. 1 Therefore, timely laboratory testing is crucial in detecting and guiding adequate management. The most recently published guidelines recommend performance of viscoelastic coagulation testing (for example, ROTEM ® or TEG ® ), 2,3 which have been shown to be effective in guiding perioperative bleeding management. 2,4-8 In addition, such tests are effective at reducing transfusion requirements and related costs. 9,10 However, the implementation of fast and “However, the implementation of fast and reliable haemostatic testing is just half of the equation; a tailored and individualised administration of blood products and factors concentrates to further improve effectiveness of adequate bleeding management is also required” reliable haemostatic testing is just half of the equation; a tailored and individualised administration of blood products and factors concentrates to further improve effectiveness of adequate bleeding management is also required. The targeted usage of purified coagulation factor concentrates offers a great alternative to transfusion of allogeneic blood products, as they are easy to reconstitute, available in a short period of time, have no requirement for blood group-compatible administration, and are not linked to transfusion- associated side effects, such as transfusion-related immunomodulation (TRIM) or transfusion-related acute lung injury (TRALI). In addition, the total volume of reconstituted purified coagulation factors is markedly less and, therefore, transfusion-related cardiac overload (TACO) is less likely. Fibrinogen concentrate Fibrinogen is the first coagulation factor that achieves critically low levels during massive blood loss, whereas all other factors seem to be less affected by haemodilution and blood loss; 11 this has been observed in both adult and paediatric perioperative settings. 1 Fibrinogen plays several key roles in the maintenance of haemostasis. 12,13 Fibrinogen acts by crosslinking platelets via glycoprotein IIb–IIIa receptors, which builds the surface for the following haemostatic process, and is the key substrate for activated thrombin, which converts it to fibrin, the key component of the mechanically stable clot. It is well known that acquired hypofibrinogenaemia seems to be the leading determinant in dilutional hospitalpharmacyeurope.com 19