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Dorgalaleh A. Novel Insights into Heterozygous Factor XIII Deficiency. Semin Thromb Hemost 2024; 50:200-212. [PMID: 36940714 DOI: 10.1055/s-0043-1764471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023]
Abstract
The prevalence and clinical significance of heterozygous factor XIII (FXIII) deficiency has long been debated, with controversial reports emerging since 1988. In the absence of large epidemiologic studies, but based on a few studies, a prevalence of 1 per 1,000 to 5,000 is estimated. In southeastern Iran, a hotspot area for the disorder, a study of more than 3,500 individuals found an incidence of 3.5%. Between 1988 and 2023, a total of 308 individuals were found with heterozygous FXIII deficiency, of which molecular, laboratory, and clinical presentations were available for 207 individuals. A total of 49 variants were found in the F13A gene, most of which were missense (61.2%), followed by nonsense (12.2%) and small deletions (12.2%), most occurring in the catalytic domain (52.1%) of the FXIII-A protein and most frequently in exon 4 (17%) of the F13A gene. This pattern is relatively similar to homozygous (severe) FXIII deficiency. In general, heterozygous FXIII deficiency is an asymptomatic condition without spontaneous bleeding tendency, but it can lead to hemorrhagic complications in hemostatic challenges such as trauma, surgery, childbirth, and pregnancy. Postoperative bleeding, postpartum hemorrhage, and miscarriage are the most common clinical manifestations, while impaired wound healing has been rarely reported. Although some of these clinical manifestations can also be observed in the general population, they are more common in heterozygous FXIII deficiency. While studies of heterozygous FXIII deficiency conducted over the past 35 years have shed light on some of the ambiguities of this condition, further studies on a large number of heterozygotes are needed to answer the major questions related to heterozygous FXIII deficiency.
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Gomez Builes JC, Baker AJ, Callum J, Barahi S, Bai J, Karkouti K, Nisenbaum R, Sholzberg M. Evaluation of the association of factor XIII at hospital arrival and outcomes in a cohort of severely injured patients. J Thromb Haemost 2023; 21:3085-3098. [PMID: 37453456 DOI: 10.1016/j.jtha.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Severe traumatic bleeding depletes coagulation factor XIII (FXIII) and fibrinogen. However, the role of FXIII level in bleeding-related outcomes is unknown. OBJECTIVES To evaluate the association between FXIII levels at hospital arrival and critical administration threshold (≥3 red blood cell units in 1 hour within the first 24 hours), bleeding-related outcomes, death, and baseline characteristics. METHODS A retrospective cohort study was conducted in severely injured adult patients (Injury Severity Score of ≥22 or ≥2 red blood cell units transfused in 24 hours) admitted to a level 1 trauma center. Clinical and laboratory data were collected. Baseline FXIII antigen levels were measured in banked patient plasma. Multivariable logistic and linear regression models were used to estimate the association between FXIII levels, outcomes, and baseline characteristics. RESULTS Three hundred sixty-four of 1730 subjects admitted during a 2-year period were analyzed. Median age was 44 years (IQR, 27-62 years), and median Injury Severity Score was 29 (IQR, 22-34). FXIII levels were not associated with critical administration threshold (odds ratio [OR], 1.06; 95% CI, 0.97-1.17) or death (OR, 0.98; 95% CI, 0.90-1.07). FXIII was associated with major bleeding (OR, 1.10; 95% CI, 1.02-1.2) and massive transfusion (OR, 1.25; 95% CI, 1.08-1.44). Lower baseline FXIII levels were associated with arrival from a referring hospital (FXIII level, -0.07 U/mL; 95% CI, -0.11 to -0.03), hemoglobin (FXIII level, -0.05 U/mL; 95% CI, -0.07 to -0.03), fibrinogen level (FXIII level, -0.05 U/mL; 95% CI, -0.08 to -0.02), and platelet count (FXIII level, -0.02 U/mL; 95% CI, -0.04 to -0.008). CONCLUSIONS Baseline FXIII levels in severely injured patients were inconsistently associated with bleeding-related outcomes and mortality. However, their association with major bleeding warrants further investigation of the role of FXIII in massively transfused patients with trauma.
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Affiliation(s)
- Johana Carolina Gomez Builes
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada. https://twitter.com/cgomezbuiles
| | - Andrew J Baker
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada; Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario, Canada
| | - Sunti Barahi
- Department of Anesthesia and Pain Medicine, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Johnny Bai
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, University Health Network, Sinai Health System, and Women's College Hospital, Toronto, Ontario, Canada
| | - Rosane Nisenbaum
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; MAP Centre for Urban Health Solutions, Toronto, Ontario, Canada; Applied Health Research Centre, Toronto, Ontario, Canada; Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Sholzberg
- Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; Department of Hematology, St. Michael's Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Sakane K, Hasegawa S, Nakao H, Sasaki J, Miyachi H, Nagao T. Factors affecting progressive facial swelling immediately after orthognathic surgery: A retrospective cohort study. J Craniomaxillofac Surg 2023; 51:692-695. [PMID: 37816659 DOI: 10.1016/j.jcms.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 08/27/2023] [Accepted: 09/30/2023] [Indexed: 10/12/2023] Open
Abstract
The aim of this study was to identify clinical factors associated with progressive facial swelling after orthognathic surgery. Patients diagnosed with jaw deformities and undergoing orthognathic surgery were retrospectively evaluated, and those with surgical site infection, Le Fort I osteotomy, or genioplasty only were excluded. Facial swelling volume was calculated by comparing facial volume preoperatively and three days postoperatively using 3D images and image analysis software (VECTRA H2). FXIII was measured within three days after surgery in only patients with unexplained postoperative bleeding or hematoma. The correlation between facial swelling volume and clinical factors was statistically analyzed. Facial swelling volume was examined in 78 patients. Univariate analysis showed a significant difference between facial swelling volume (mean = 41.6 cm3) and operation time (mean = 209.3 min, r = 0.283, p = 0.012), ΔHb level (mean = 1.18 g/dL, r = 0.235, p = 0.039), as well as decreased factor XIII activity (mean = 75.3%, p = 0.012). Multivariate analysis showed a significant difference between facial swelling volume and FXIII deficiency (standard error = 6.44, p = 0.031).Progressive facial swelling immediately after orthognathic surgery may be due to factor XIII deficiency.
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Affiliation(s)
- Kaori Sakane
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Shogo Hasegawa
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan.
| | - Hiroaki Nakao
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Jun Sasaki
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Hitoshi Miyachi
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
| | - Toru Nagao
- Department of Maxillofacial Surgery, School of Dentistry, Aichi-Gakuin University, 2-11 Suemori-Dori, Chikusa, Nagoya, Aichi, 464-8651, Japan
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Bucher F, Dastagir N, Obed D, Enechukwu A, Dieck T, Vogt PM, Dastagir K. Factor XIII: More than just a fibrin stabilizer for the burn patient? A matched-pair analysis. JPRAS Open 2023; 37:1-8. [PMID: 37288428 PMCID: PMC10242619 DOI: 10.1016/j.jpra.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/15/2023] [Indexed: 06/09/2023] Open
Abstract
Background Acquired factor XIII deficiency is an underestimated risk in patients with large surface burns, which potentially exposes these patients to prolonged bleeding and delayed wound healing if undetected. Methods A retrospective matched-pair analysis of the burn registry of the Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery of Hannover Medical School was performed from 2018 to 2023. Results A total of 18 patients were included. Acquired factor XIII deficiency was not statistically significant correlated with age, sex, or body mass index. Patients who developed acquired factor XIII deficiency had a significantly longer hospital stay (72.8 days) compared with those in the matched group (46.4 days), although burn depths, total body surface area, and Abbreviated Burn Severity Index were not statistically correlated with factor XIII deficiency. Conclusions Little is known about acquired factor XIII deficiency in patients with burns. Factor XIII supplementation may improve hemostasis, wound healing, and general outcome while reducing the patient's exposure to blood products.
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Affiliation(s)
- Florian Bucher
- Corresponding author: Florian Bucher MD, Department of Plastic, Aesthetic, Hand, and Reconstructive Surgery, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany, Fax: +49 511 532-8864 Tel.: +49 176 15323754
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Noitz M, Brooks R, Szasz J, Jenner D, Böck C, Krenner N, Dünser MW, Meier J. Acquired Factor XIII Deficiency Is Common during ECMO Therapy and Associated with Major Bleeding Events and Transfusion Requirements. J Clin Med 2023; 12:4115. [PMID: 37373805 DOI: 10.3390/jcm12124115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Bleeding events are frequent complications during extracorporeal membrane oxygenation therapy (ECMO). OBJECTIVE To determine the rate of acquired factor XIII deficiency and its association with major bleeding events and transfusion requirements in adults undergoing ECMO therapy. MATERIALS AND METHODS A retrospective single centre cohort study. Adult patients receiving veno-venous or veno-arterial ECMO therapy during a 2-year period were analysed and screened for factor XIII activity measurements. Factor XIII deficiency was defined based on the lowest factor XIII activity measured during ECMO therapy. RESULTS Among 84 subjects included into the analysis, factor XIII deficiency occurred in 69% during ECMO therapy. There were more major bleeding events (OR, 3.37; 95% CI, 1.16-10.56; p = 0.02) and higher transfusion requirements (red blood cells, 20 vs. 12, p < 0.001; platelets, 4 vs. 2, p = 0.006) in patients with factor XIII deficiency compared to patients with normal factor XIII activity. In a multivariate regression model, factor XIII deficiency was independently associated with bleeding severity (p = 0.03). CONCLUSIONS In this retrospective single centre study, acquired factor XIII deficiency was observed in 69% of adult ECMO patients with a high bleeding risk. Factor XIII deficiency was associated with higher rates of major bleeding events and transfusion requirements.
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Affiliation(s)
- Matthias Noitz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Roxane Brooks
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Johannes Szasz
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Dennis Jenner
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Carl Böck
- Institute of Signal Processing, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Niklas Krenner
- Department of Cardiac, Vascular and Thoracic Surgery, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4020 Linz, Austria
| | - Martin W Dünser
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
| | - Jens Meier
- Department of Anesthesiology and Intensive Care Medicine, Kepler University Hospital GmbH, Johannes Kepler University Linz, Krankenhausstraße 9, 4020 Linz and Altenberger Strasse 69, 4040 Linz, Austria
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Okumura E, Onuki H, Otsuka K, Sunaga S, Tanaka A, Jimbo H. A Case of Acquired Factor XIII Deficiency with Systemic Lupus Erythematosus Diagnosed after Repeated Intracerebral Hemorrhages. NMC Case Rep J 2023; 10:121-124. [PMID: 37293197 PMCID: PMC10247216 DOI: 10.2176/jns-nmc.2022-0373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 02/09/2023] [Indexed: 06/10/2023] Open
Abstract
We present a case of autoimmune-acquired factor XIII deficiency associated with systemic lupus erythematosus, which was diagnosed as a cause of repeated intracerebral hemorrhage. An intracerebral hemorrhage occurred in a 24-year-old female patient. Craniotomy was performed to remove the hematoma, but rebleeding occurred at the same site on days 2 and 11, respectively. Detailed blood tests revealed that factor XIII activity decreased. Although autoimmune-acquired factor XIII deficiency is a very rare disease, it can sometimes be fatal when intracerebral hemorrhage occurs. If there is repeated intracerebral hemorrhage, factor XIII activity should be confirmed.
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Affiliation(s)
- Eitaro Okumura
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hiroyuki Onuki
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Kunitoshi Otsuka
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Shigeki Sunaga
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Asashi Tanaka
- Department of Clinical Laboratory Medicine, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hiroyuki Jimbo
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
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Wagner A, Wostrack M, Hartz F, Heim J, Hameister E, Hildebrandt M, Meyer B, Winter C. The role of extended coagulation screening in adult cranial neurosurgery. BRAIN & SPINE 2023; 3:101756. [PMID: 37383462 PMCID: PMC10293229 DOI: 10.1016/j.bas.2023.101756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Postoperative hemorrhage after adult cranial neurosurgery is a serious complication with substantial morbidity and mortality. Research question We investigated if an extended preoperative screening and an early treatment of previously undetected coagulopathies may decrease the risk of postoperative hemorrhage. Methods A prospective study cohort of patients undergoing elective cranial surgery and receiving the extended coagulatory work-up were compared to a propensity matched historical control cohort. The extended work-up included a standardized questionnaire on the patient's bleeding history as well as coagulatory tests of Factor XIII, von-Willebrand-Factor and PFA-100®. Deficiencies were substituted perioperatively. The primary outcome was determined as the surgical revision rate due to postoperative hemorrhage. Results The study cohort and the control cohort included 197 cases each, without any significant difference in the preoperative intake of anticoagulant medication (p = .546). Most common interventions were resections of malignant tumors (41%), benign tumors (27%) and neurovascular surgeries (9%) in both cohorts. Imaging revealed postoperative hemorrhage in 7 cases (3.6%) in the study cohort and 18 cases (9.1%) in the control cohort (p = .023). Of these, revision surgeries were significantly more common in the control cohort with 14 cases (9.1%) compared to 5 cases (2.5%) in the study cohort (p = .034). Differences in mean intraoperative blood loss were not significant with 528 ml in the study cohort and 486 ml in the control cohort (p = .376). Conclusion Preoperative extended coagulatory screening may allow for revealing previously undiagnosed coagulopathies with subsequent preoperative substitution and thereby reduction of risk for postoperative hemorrhage in adult cranial neurosurgery.
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Affiliation(s)
- Arthur Wagner
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Frederik Hartz
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Johannes Heim
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Erik Hameister
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Martin Hildebrandt
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Technical University Munich School of Medicine, Munich, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Technical University Munich School of Medicine, Munich, Germany
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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Wilhelmi M, Albrecht A, Macke C, Wilhelmi M, Omar M, Winkelmann M, Clausen JD. The potential impact of coagulation factor XIII in trauma-induced coagulopathy - a retrospective case series analysis. Eur J Trauma Emerg Surg 2023; 49:1517-1523. [PMID: 36670303 DOI: 10.1007/s00068-023-02221-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 01/07/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND The role of factor XIII (FXIII) in trauma-induced coagulopathy (TIC) is not fully understood. METHODS We evaluated FXIII supplementation in severely injured patients with persistent bleeding. This was a retrospective case series analysis. RESULTS Twenty-four patients received FXIII concentrate within 24 h of admission for bleeding that continued after transfusion of > 6 U red blood cells (RBCs); control patients (n = 27) did not receive FXIII concentrate. Both study groups were similar regarding injury severity score and global coagulation tests, but FXIII activity levels were significantly higher and lactate levels significantly lower in the control group, respectively. The differences in FXIII activity between the groups could be attributed to a more severe trauma-induced coagulopathy in FXIII-deficient patients, as demonstrated by lower fibrinogen and higher lactate levels. The median dose of FXIII concentrate within 24 h of admission was 2500 IU (IQR: 1250-4375). Median 24-h transfusion of RBCs (primary study endpoint) was significantly higher in the FXIII group versus controls (10.0 U, IQR 5-14 U vs. 2, IQR 0-6 U; p < 0.01). Subsequently, while patients were in the intensive care unit, there was no statistically significant difference regarding RBC transfusion anymore and the overall clinical outcomes were similar in both patient groups. CONCLUSIONS The substitution of FXIII in patients who were more seriously compromised due to higher lactate levels and who presented with initially more severe bleedings than patients in the control group, resulted in a comparable transfusion necessity after 24 h. Thus, we guess that the substitution of FXIII in severely injured patients with ongoing bleeding might have an impact on their clinical outcome.
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Affiliation(s)
| | | | - Christian Macke
- Trauma Department, Hannover Medical School, Hannover, Germany
| | - Mathias Wilhelmi
- Department for Vascular and Endovascular Surgery, St. Bernward Hospital, Hildesheim, Germany
| | - Mohammed Omar
- Trauma Department, Hannover Medical School, Hannover, Germany
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Kalbhenn J, Zieger B. Bleeding During Veno-Venous ECMO: Prevention and Treatment. Front Med (Lausanne) 2022; 9:879579. [PMID: 35677828 PMCID: PMC9168900 DOI: 10.3389/fmed.2022.879579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022] Open
Abstract
Veno-venous extracorporeal membrane oxygenation (vvECMO) has become a routine treatment for severe lung failure in specialized centers. Spontaneous bleeding complications, however, are observed in 30–60% of patients during vvECMO treatment. Bleeding increases mortality by factors 2–3. Anticoagulation in combination with several acquired bleeding disorders caused by the mechanical pump and the foreign layer of the extracorporeal system contribute to the risk of bleeding. In this review, the mechanisms of the underlying pathologies and the route from diagnosis to treatment are described.
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Affiliation(s)
- Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany
- *Correspondence: Johannes Kalbhenn ; orcid.org/0000-0001-7551-5082
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, Medical Center—University of Freiburg, Freiburg im Breisgau, Germany
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The impact of acquired coagulation factor XIII deficiency in traumatic bleeding and wound healing. Crit Care 2022; 26:69. [PMID: 35331308 PMCID: PMC8943792 DOI: 10.1186/s13054-022-03940-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
Factor XIII (FXIII) is a protein involved in blood clot stabilisation which also plays an important role in processes including trauma, wound healing, tissue repair, pregnancy, and even bone metabolism. Following surgery, low FXIII levels have been observed in patients with peri-operative blood loss and FXIII administration in those patients was associated with reduced blood transfusions. Furthermore, in patients with low FXIII levels, FXIII supplementation reduced the incidence of post-operative complications including disturbed wound healing. Increasing awareness of potentially low FXIII levels in specific patient populations could help identify patients with acquired FXIII deficiency; although opinions and protocols vary, a cut-off for FXIII activity of ~ 60–70% may be appropriate to diagnose acquired FXIII deficiency and guide supplementation. This narrative review discusses altered FXIII levels in trauma, surgery and wound healing, diagnostic approaches to detect FXIII deficiency and clinical guidance for the treatment of acquired FXIII deficiency.
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Recurrent Bleeding after Head Trauma Caused by Acquired Factor XIII Deficiency. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4109. [PMID: 35186643 PMCID: PMC8846273 DOI: 10.1097/gox.0000000000004109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 12/14/2021] [Indexed: 11/26/2022]
Abstract
Factor XIII (FXIII) is the final factor in the coagulation cascade. FXIII plays a critical role in clot stabilization by cross-linking fibrin and making the clot denser and stiffer. FXIII plays crucial roles in platelet clot retraction, wound healing, and tissue repair. When FXIII is deficient, unusual bleeding that persists for several days, delayed healing, and morbid granulation may occur. We present a case of acquired FXIII deficiency presenting as recurrent bleeding after head trauma. A 66-year-old man fell from a ladder and sustained a head injury. The patient had a history of postremission acute myeloid leukemia and Stanford type B aortic dissection and was on three antihypertensives but no antiplatelets or anticoagulants. Approximately 1 month postinjury, the patient suddenly experienced repeated bleeding and hematoma. Routine coagulation tests were normal; therefore, we suspected another type of coagulation disorder. Low FXIII activity was identified 39 days postinjury. We immediately administered concentrated human coagulation FXIII (Fibrogammin P). The patient’s head contusion was completely healed by day 55 postinjury. Acquired FXIII deficiency should be considered when routine coagulation test results are normal. Plastic surgeons who treat injuries routinely must be cognizant of FXIII deficiency because the condition can be life-threatening and early detection is important. Whenever the process of wound healing is unusual or hematoma and bleeding recur unexpectedly with no clear explanation—despite suitable treatments—FXIII deficiency should be suspected and, if present, must be appropriately treated without delay.
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Yamanishi S, Kimura H, Hayashi H, Yamaguchi Y, Fujita Y, Nakai T, Uozumi Y, Katayama Y, Taniguchi M, Sasayama T. Acute Occlusion of the Ventriculoperitoneal Shunt Due to Factor XIII Deficiency-related Postoperative Hemorrhage: A Case Report. NMC Case Rep J 2022; 8:573-577. [PMID: 35079519 PMCID: PMC8769428 DOI: 10.2176/nmccrj.cr.2020-0330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 04/01/2021] [Indexed: 12/02/2022] Open
Abstract
Coagulation factor XIII (F13) deficiency has been known to be a rare disease with estimated one per two million and one of the possible reasons of postoperative hemorrhage; however, it still remains unpenetrated to physicians. We report a case of acute ventriculoperitoneal (VP) shunt dysfunction due to delayed intraventricular hemorrhage, which could be because of F13 deficiency. The patient was a 48-year-old man with a history of post-meningitis hydrocephalus followed by VP shunt placement. He was found unconscious and transferred to our hospital. A brain CT scan demonstrated shunt malfunction, and he underwent emergency shunt revision. The postoperative course was uneventful except for unexpected neck bruises and continuous minor bleeding from the surgical wound. Three days after surgery, he suddenly became comatose and a CT scan revealed the recurrence of hydrocephalus with newly identified small volume of intraventricular hemorrhage. Emergency shunt revision was performed again. The shunt valve was filled with a hematoma and bloody cerebrospinal fluid was drained from the ventricle. Postoperative blood sample examination demonstrated no abnormal findings but a decreased level of F13 activity, which was thought to be a possible cause of postoperative hemorrhage and the shunt valve hematoma. F13 deficiency causes delayed intracranial hemorrhage 24–48 h after neurological surgery. It can only be diagnosed by checking F13 activity with suspicion. If diagnosed accurately beforehand, unexpected postoperative bleeding can be preventable with proper treatment, such as F13 concentrate and cryoprecipitate. The actual number of the patient with F13 deficiency may be more than estimated ever.
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Affiliation(s)
- Shunsuke Yamanishi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Hidehito Kimura
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Hideya Hayashi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Yoji Yamaguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Yuichi Fujita
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Tomoaki Nakai
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Yoichi Uozumi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Yoshio Katayama
- Department of Hematology, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Masaaki Taniguchi
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, Kobe University Graduate School of Medicine, School of Medicine, Kobe, Hyogo, Japan
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Schwaiger M, Edmondson SJ, Rabensteiner J, Prüller F, Gary T, Zemann W, Wallner J. Gender-specific differences in haemostatic parameters and their influence on blood loss in bimaxillary surgery. Clin Oral Investig 2022; 26:3765-3779. [PMID: 35013785 PMCID: PMC8979869 DOI: 10.1007/s00784-021-04347-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 12/14/2021] [Indexed: 11/28/2022]
Abstract
Objective The objectives of this prospective cohort study were to establish gender-related differences in blood loss and haemostatic profiles associated with bimaxillary surgery. In addition, we aimed to identify if any gender differences could be established which might help predict blood loss volume. Materials and methods Fifty-four patients (22 males; 32 females) undergoing bimaxillary surgery for skeletal dentofacial deformities were eligible for inclusion. Blood samples were taken 1 day preoperatively and 48 h postoperatively for detailed gender-specific coagulation analysis incorporating global coagulation assays (endogenous thrombin potential) and specific coagulation parameters. Blood loss was measured at two different time points: (1) the end of surgery, visible intraoperative blood loss (IOB) using ‘subtraction method’; and (2) 48 h postoperatively perioperative bleeding volume (CBL-48 h) using ‘haemoglobin-balance method’ and Nadler’s formula. Correlation and regression analyses were performed to identify relevant parameters affecting the amount of blood loss. Results Significant differences in IOB and CBL-48 h were observed (p < 0.001). Men had higher IOB versus women, lacking statistical significance (p = 0.056). In contrast, men had significantly higher CLB-48 h (p = 0.019). Reduced CBL-48 h was shown to be most closely associated with the level of Antithrombin-III being decreased in females. Conclusions Male gender is associated with higher IOB and CBL-48 compared with females. Gender does not affect IOB regarding haemostatic profile but does correlate strongly with procedure length. Conversely, CBL-48 is closely associated with gender-specific imbalances in the anticoagulant system. Clinical relevance Knowledge of gender-related differences will help clinicians establish predictive factors regarding excessive blood loss in orthognathic surgery and identify at-risk patients.
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Affiliation(s)
- Michael Schwaiger
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Sarah-Jayne Edmondson
- Department of Plastic and Reconstructive Surgery, Guy's and St. Thomas' Hospital, London, UK
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Florian Prüller
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Thomas Gary
- Division of Angiology, Medical University of Graz, Graz, Austria
| | - Wolfgang Zemann
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Jürgen Wallner
- Department of Oral and Maxillofacial Surgery, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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Yamada Y, Abe T, Ochiai H, Ashizuka S. Refractory Duodenal Bleeding Ulcers Successfully Treated with Factor XIII Transfusion. Intern Med 2021; 60:2217-2221. [PMID: 33583894 PMCID: PMC8355396 DOI: 10.2169/internalmedicine.6463-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 67-year-old woman with a history of autoimmune hepatitis was admitted for fever, acute hepatic dysfunction, and acute kidney injury. She was diagnosed with multiple duodenal ulcers. Despite the administration of proton pump inhibitor and red blood cells, her black stool and anemia progressed, and she was therefore transferred to our hospital. Despite hemostatic treatments, she continued to bleed. On the 21st day of admission, an endoscopic examination showed the oozing of blood from the duodenal mucosa. A low factor XIII (FXIII) activity level was detected, and she was administered FXIII concentrate. The bleeding stopped and she was thereafter discharged.
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Affiliation(s)
- Yusuke Yamada
- Department of Trauma and Critical Care Medicine, University of Miyazaki Hospital, Japan
| | - Tomohiro Abe
- Department of Trauma and Critical Care Medicine, University of Miyazaki Hospital, Japan
| | - Hidenobu Ochiai
- Department of Trauma and Critical Care Medicine, University of Miyazaki Hospital, Japan
| | - Shinya Ashizuka
- Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki, Japan
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Furtado SV, Hegde P, Palassery R, Karunakara BP. Factor XIII Deficiency and Intracranial Bleed: Surgical Management and Prophylaxis with Cryoprecipitate. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0041-1731026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractFactor XIII (FXIII) deficiency is a rare bleeding disorder with affected patients having high propensity for intracranial hemorrhage. A 12-year-old girl presented with severe headache, limb weakness, and rapidly worsening sensorium over 4 days. Magnetic resonance imaging of the brain and computed tomography (CT) of the head showed intraparenchymal bleed. Patient had normal coagulation profile and abnormal FXIII level. The perioperative management included cryoprecipitate transfusion to bring the FXIII value to 74%. She underwent craniotomy and evacuation of the hematoma. Postoperatively, she received prophylaxis against rebleed with cryoprecipitate. In the absence of FXIII concentrate, correction of FXIII deficiency is possible with cryoprecipitate in emergent situations.
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Affiliation(s)
- Sunil V. Furtado
- Department of Neurosurgery, Ramaiah Medical College Hospital, Bangalore, India
| | - Pranoy Hegde
- Department of Neurosurgery, Ramaiah Medical College Hospital, Bangalore, India
| | - Rasmi Palassery
- Department of Medical Oncology, Ramaiah Medical College Hospital, Bangalore, India
| | - B. P. Karunakara
- Department of Pediatrics, Ramaiah Medical College Hospital, Bangalore, India
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Nonimmune-acquired factor XIII deficiency: a cause of high volume and delayed postoperative hemorrhage. Blood Coagul Fibrinolysis 2020; 31:511-516. [PMID: 32852328 DOI: 10.1097/mbc.0000000000000953] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Factor XIII (FXIII) levels may decrease because of surgical consumption. Acquired FXIII deficiency could be a cause of postoperative hemorrhage usually underdiagnosed in clinical practice. To determine the diagnosis confirmation rate of acquired FXIII deficiency in postsurgical patients with clinical suspicion and to compare the characteristics and evolution of patients with or without FXIII deficiency. We performed a retrospective cohort study, which included 49 inpatients who were attended at our university hospital from 2014 to 2018 with suspicion of acquired FXIII deficiency because of disproportionate postoperative hemorrhage. FXIIIA levels less than 50% was considered a deficiency. Persistence of bleeding for more than 48 h, drop in hematocrit points, red blood cells transfused units, hemoglobin levels 12-36 h after bleeding, and time elapsed from the procedure to the bleeding were assessed as outcome variables. Logistic regression was employed for both univariate and multivariate analyses. Of the 49 patients included, 27(55%) had FXIII deficiency, with a median level of 34% [interquartile range (IQR) 19-42]. Abdominal surgery was the most common [n = 21 (43%)]. All patients had routine coagulation tests within the hemostatic range. FXIII deficiency was associated with a drop of more than 4 points in hematocrit [OR 59.69 (95% CI 4.71-755.30)], red blood transfused units >2 [OR 45.38 (95% CI 3.48-590.65)], and delayed bleeding >36 h after surgery [OR 100.90 (95% CI 3.78-2695.40)]. Plasma-derived FXIII concentrate was administered to eight patients with life-threatening bleeding with resolution within 24 h. Only one deficient patient died from bleeding. FXIII levels were measured 15 days after diagnosis or more in 20 out of 27 deficient patients, with normal results. Acquired FXIII deficiency may be a frequent underdiagnosed entity that should be considered when high-volume and delayed postoperative hemorrhage is present in patients with hemostatic routine coagulation test results.
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Haslinger C, Korte W, Hothorn T, Brun R, Greenberg C, Zimmermann R. The impact of prepartum factor XIII activity on postpartum blood loss. J Thromb Haemost 2020; 18:1310-1319. [PMID: 32176833 DOI: 10.1111/jth.14795] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/21/2020] [Accepted: 03/11/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postpartum hemorrhage (PPH), a major cause of maternal mortality, has several known risk factors but frequently occurs unexpectedly. PPH incidence and related maternal morbidity and mortality are rising worldwide. OBJECTIVE To evaluate the impact of defined prepartum blood coagulation parameters on postpartum blood loss. METHODS This single-center, prospective cohort study analyzed prepartum activities of coagulation factors II and XIII and fibrinogen levels in 1300 women. Blood samples were obtained at labor onset and analyzed only after the last patient had delivered, to prevent a potential treatment bias. Blood loss was quantified using a validated technique. The influence of coagulation factors on measured blood loss was assessed by continuous outcome logistic regression. RESULTS Prepartum factor XIII activity strongly influenced measured blood loss: every one unit (%) increase in prepartum factor XIII was associated with an odds ratio of 1.011 (95% confidence interval, 1.006-1.015; P < .001) to keep blood loss below any given cut-off level. For illustration, this suggests that a 30% increase in factor XIII activity increases the odds of not suffering PPH (defined as blood loss ≥500 mL) by 38.9%. This effect remained significant after stratification for the delivery mode, when correcting for other risk factors, and was independent of the statistical model used. Factor II but not fibrinogen had a partially comparable, but much less pronounced, effect. CONCLUSION In the largest population analyzed for the influence of prepartum coagulation factors on PPH to date, prepartum factor XIII activity had a strong impact on postpartum blood loss across every statistical model and clinical subgroup. Our hypothesis that early replenishment of factor XIII levels might constitute a new tool in the prevention and effective early treatment of PPH should be evaluated in future trials.
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Affiliation(s)
| | - Wolfgang Korte
- Center for Laboratory Medicine, Hemostasis and Hemophilia Center, St. Gallen, Switzerland
| | - Torsten Hothorn
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Romana Brun
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Charles Greenberg
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Roland Zimmermann
- Department of Obstetrics, University Hospital Zurich, Zurich, Switzerland
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Ito A, Iwashita Y, Esumi R, Sasaki K, Yukimitsu M, Kato T, Kawamoto E, Suzuki K, Imai H. Acquired factor XIII deficiency in two patients with bleeding events during veno-venous extracorporeal membrane oxygenation treatment. J Artif Organs 2019; 23:283-287. [PMID: 31834529 PMCID: PMC7458886 DOI: 10.1007/s10047-019-01148-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 12/03/2019] [Indexed: 11/30/2022]
Abstract
We report two cases of acquired factor XIII deficiency with bleeding events during veno-venous extracorporeal membrane oxygenation (ECMO). Case 1: A 76-year-old man diagnosed with aspiration pneumonia after near-drowning was started on ECMO. Later, the patient presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 29%. Although the patient recovered after receiving 1200 International Units of factor XIII concentrate, the patient had another episode of decreased factor XIII activity and bloody stool and was treated again with factor XIII concentrate. Case 2: A 48-year-old female diagnosed with pneumonia was started on ECMO. Soon after, she presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 39%. The patient was treated with 720 IU of factor XIII concentrate with good recovery. Acquired factor XIII deficiency cannot be detected by routine coagulation tests, therefore it may be under-diagnosed in the ICU. Detection of acquired factor XIII deficiency is essential when treating a bleeding ECMO patient.
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Affiliation(s)
- Asami Ito
- Mie University Hospital, Tsu, Japan.
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Recurrent Hematomas following a Revision Total Hip Arthroplasty in Acquired Coagulation Factor XIII Deficiency. Case Rep Orthop 2019; 2019:4038963. [PMID: 31396426 PMCID: PMC6668532 DOI: 10.1155/2019/4038963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/23/2019] [Accepted: 03/28/2019] [Indexed: 11/23/2022] Open
Abstract
Coagulation factor XIII (FXIII) is the final enzyme in the coagulation cascade and plays an important role in catalyzing the intermolecular cross-linking of fibrin polymers. FXIII deficiency is a rare disorder that presents with recurrent soft tissue bleeding. In this case report, we describe a patient with recurrent hematomas, following a revision total hip arthroplasty (THA). A 50-year-old female patient with no past history of bleeding and with a normal perioperative coagulation profile presented with recurrent hip joint hematomas. Her plasma FXIII activity showed a slight decrease (69%). Therefore, the patient was diagnosed with an acquired deficiency and was administered FXIII to correct it. The bleeding did not recur once the FXIII activity had returned to a normal level (76%). At 2 months after the second evacuation procedure, the patient was discharged from the hospital in an ambulatory state. There has been no recurrence of a hematoma since. We managed a rare case of acquired FXIII deficiency, which highlighted that a patient can present with an acquired bleeding disorder despite having a normal coagulation profile. An acquired FXIII deficiency should be suspected in patients with inexplicable, sudden-onset bleeding, as early diagnosis and treatment are important to prevent life-threatening complications.
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Wang C, Niu X, Ren Y, Lan Z, Zhang Y. Risk Factors for Postoperative Intracranial Hemorrhage After Resection of Intracranial Tumor in 2259 Consecutive Patients. World Neurosurg 2019; 129:e663-e668. [PMID: 31176060 DOI: 10.1016/j.wneu.2019.05.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative hemorrhage (POH), an uncommon complication after cranial operation, may result in prolonged postoperative hospitalization, severe neurologic impairment, or even death. Most models in studies detecting risk factors for POH include all kinds of cranial lesions; however, factors associated with POH may vary among intracranial diseases. There is a paucity of large sample studies focusing solely on POH after intracranial tumor surgery. Therefore, this study was designed to investigate the preoperative risk factors for POH after surgery for intracranial tumor. METHODS Medical records of 2259 adult patients who underwent primary surgical resection of single intracranial tumor between January 2017 and June 2018 at West China Hospital of Sichuan University were retrospectively studied. Univariate and multivariate analyses were performed to identify the risk factors for POH after resection of intracranial tumor. RESULTS POH (defined as postoperative hematoma requiring surgical evacuation) occurred in 40 of 2259 patients (1.8%). Univariate analysis revealed that older age (P = 0.037, Wilcoxon-Mann-Whitney test), higher international normalized ratio (INR) (P = 0.037, Wilcoxon-Mann-Whitney test), and larger tumor size (P = 0.001, Wilcoxon-Mann-Whitney test) were significantly associated with POH. Then it was confirmed by multivariate analysis that all of the 3 factors (older age: P = 0.033, higher INR: P = 0.044, larger tumor size: P = 0.002) were independent risk factors for POH after removal of intracranial tumor. CONCLUSIONS Older age, higher INR, and larger tumor size were identified as independent risk factors for POH after resection of intracranial tumor in adults.
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Affiliation(s)
- Chenghong Wang
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaodong Niu
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yanming Ren
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Zhigang Lan
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Yuekang Zhang
- Departments of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
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Javaherforoosh Zadeh F, Janatmakan F, Shafaee Tonekaboni M, Soltanzadeh M. The Effect of Fibrinogen on Blood Loss After Lumbar Surgery: A Double-Blind Randomized Clinical Trial. Anesth Pain Med 2019; 9:e91199. [PMID: 31497522 PMCID: PMC6712358 DOI: 10.5812/aapm.91199] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/22/2019] [Accepted: 04/26/2019] [Indexed: 12/16/2022] Open
Abstract
Background Spinal surgeries often have a high risk of hemorrhage during and after surgery, thus most patients require blood transfusions and blood products. Fibrinogen is used in different forms to control hemorrhage. Objectives The present study aimed to evaluate the outcomes of prophylactic fibrinogen administration in reducing hemorrhage after lumbar surgery. Methods This was a randomized clinical trial conducted on 30 patients undergoing lumbar surgery. The levels of fibrinogen, as well as hemoglobin (HB), hematocrit (HCT), prothrombin time (PT), partial thromboplastin time (PTT), and INR, were assessed preoperatively as the baseline values. The patients were divided into two groups: intervention (N = 15) and control (N = 15) groups. The intervention group received 1 g fibrinogen dissolved in 50 cc distilled water with surgical incision and the control group received 50 cc distilled water with the surgical incision. At the end of the operation, the volume of hemorrhage transfused blood products (fresh frozen plasma, packed cell, and platelet) was measured. In addition, at 0, 6, and 24 hours after the end of surgery and transfer to recovery, serum levels of fibrinogen, HB, HCT, INR, PT, PTT, and hemovac drain volume were measured. Results The hemorrhage during and after the operation in the control group was significantly higher than that of the intervention group (P < 0.05). There were no significant differences between hemoglobin and serum level of fibrinogen before and after surgery between the two groups. The postoperative hypotension showed no significant difference between the two groups. Conclusions The findings showed the effectiveness of fibrinogen in reducing acute hemorrhage. Considering the adverse consequences of hemorrhage and coagulopathy in patients undergoing surgery, using fibrinogen as prophylaxis is recommended in surgeries with high risks of hemorrhage.
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Affiliation(s)
- Fatemeh Javaherforoosh Zadeh
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding Author: Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Farahzad Janatmakan
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Shafaee Tonekaboni
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mansoor Soltanzadeh
- Department of Anesthesia, Ahvaz Anesthesiology and Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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High-dose Factor XIII administration induces effective hemostasis for trauma-associated coagulopathy (TAC) both in vitro and in rat hemorrhagic shock in vivo models. J Trauma Acute Care Surg 2019; 85:588-597. [PMID: 29851904 DOI: 10.1097/ta.0000000000001998] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Trauma-associated coagulopathy (TAC) is an early and primary complication in severe trauma patients. Factor XIII (FXIII) is reported to stabilize a clot in the late phase of the coagulation cascade. The goal of this study was to investigate whether the administration of FXIII improves the condition of TAC both in vitro and in vivo. METHODS We evaluated the effects of different doses, including a very high dose of FXIII (3.6-32.4 IU/mL) on tissue-plasminogen activator-induced hyperfibrinolysis and the combined condition of dilutional coagulopathy and tissue-plasminogen activator-induced hyperfibrinolysis in vitro. The coagulation status was analyzed by rotational thromboelastometry (ROTEM) and Sonoclot. Then, we evaluated the effect of high-dose FXIII (300 IU/kg) for severe coagulopathy in vivo using a rat liver trauma model in which coagulopathy similar to TAC was observed. Survival time and the amount of intra-abdominal bleeding of rats were measured, and a coagulation test was also performed. Histologic evaluations of rats' lung and kidney after FXIII administration were completed. RESULTS High-dose FXIII significantly improved clot strength as well as increased resistance to hyperfibrinolysis in vitro which was confirmed by ROTEM. Platelet function on Sonoclot was significantly increased by FXIII in a dose-dependent manner. Factor XIII significantly decreased the total amount of bleeding and prolonged the survival time compared to control (control vs FXIII: 108.9 ± 11.4 vs 32.6 ± 5.5 mL/kg; p < 0.001; 26.0 ± 8.8 vs 120 minutes, p < 0.001) in a rat model. Rotational thromboelastometry parameters and platelet function on Sonoclot were significantly improved in the FXIII (+) group compared to control. No adverse effects of FXIII were detected histologically. CONCLUSION Factor XIII not only generated stable clot resistance to hyperfibrinolysis but also enhanced platelet function by facilitating clot retraction. High-dose FXIII administration therapy has significant clinical impact for severe trauma accompanied with TAC. STUDY TYPE Human in vitro and rat in vivo experimental study.
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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The impact of antenatal factor XIII levels on postpartum haemorrhage: a prospective observational study. Arch Gynecol Obstet 2018; 299:421-430. [DOI: 10.1007/s00404-018-4980-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/16/2018] [Indexed: 12/19/2022]
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Janatmakan F, Nassajian N, Sarkarian M, Ghandizadeh Dezfuli M, Salari A, Tabatabaei SK, Soltani F, Nassajian S. Effect of Local Fibrinogen Administration on Postoperative Bleeding in Open Prostatectomy Surgery. Anesth Pain Med 2018; 8:e73983. [PMID: 30214886 PMCID: PMC6119345 DOI: 10.5812/aapm.73983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/18/2018] [Accepted: 06/23/2018] [Indexed: 11/16/2022] Open
Abstract
Background Open prostatectomy is still accompanied by some postoperative bleeding. Prescribing fibrinogen to promote clot formation in patients with bleeding is of critical importance. This research studied the effects of local injection of fibrinogen on level of postoperative bleeding in open prostatectomy. Methods Overall, 44 patients were randomly entered in a study on open prostatectomy. Patients in the intervention group received local injections of 500 mg fibrinogen (20 mL) dissolved in distilled water, and the control group patients only received 20 mL of normal saline, where the injections were given by the surgeon at the prostatectomy operation site. All patients were tested for hemoglobin, hematocrit, PT, PTT, INR, and fibrinogen level. Also, the amount of blood loss and requirement for blood products were recorded. Results The study groups showed no difference regarding baseline variables. One patient in the fibrinogen group (1.66%) and four patients in the control group (6.66%) received blood products (P < 0.05), and the blood drainage tube at 24 hours after operation was 36.50) 18.70 (mL in the fibrinogen group and 151.36) 120.58 (mL in the control group (P = 0.005). There were no differences in hemoglobin, hematocrit, PT, PTT, INR, and serum fibrinogen level between the groups at any time. Conclusions The current study demonstrated that using fibrinogen in patients with high bleeding risk may effectively reduce the amount of bleeding and its subsequent blood transfusion requirement, after open prostatectomy surgery.
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Affiliation(s)
- Farahzad Janatmakan
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nozar Nassajian
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Sarkarian
- Department of Urology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammadreza Ghandizadeh Dezfuli
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Corresponding author: Mohammadreza Ghandizadeh Dezfuli, Anesthesia Department, Golestan Hospital, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. Tel: +98-9163052737; +98-6133743037, Fax: +98-6133743037, E-mail:
| | - Amir Salari
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyed Kamaleddin Tabatabaei
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Farhad Soltani
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Sheida Nassajian
- Department of Anesthesia, Pain Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Senders JT, Muskens IS, Cote DJ, Goldhaber NH, Dawood HY, Gormley WB, Broekman MLD, Smith TR. Thirty-Day Outcomes After Craniotomy for Primary Malignant Brain Tumors: A National Surgical Quality Improvement Program Analysis. Neurosurgery 2018; 83:1249-1259. [DOI: 10.1093/neuros/nyy001] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Affiliation(s)
- Joeky T Senders
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ivo S Muskens
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - David J Cote
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nicole H Goldhaber
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hassan Y Dawood
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William B Gormley
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marike L D Broekman
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Timothy R Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Godier A, Greinacher A, Faraoni D, Levy JH, Samama CM. Use of factor concentrates for the management of perioperative bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2018; 16:170-174. [PMID: 29168325 DOI: 10.1111/jth.13893] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/30/2022]
Affiliation(s)
- A Godier
- Department of Anesthesiology and Intensive Care Medicine, Fondation Adolphe de Rothschild and INSERM UMRS-1140 Faculté de Pharmacie, Descartes University, Paris, France
| | - A Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - D Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - J H Levy
- Departments of Anesthesiology, Surgery, and Critical Care, Duke University School of Medicine, Durham, NC, USA
| | - C M Samama
- Department of Anesthesiology and Intensive Care Medicine, Assistance Publique-Hôpitaux de Paris, Cochin University Hospital, Paris Descartes University, Paris, France
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Sanders JO, Friedrich K, Gerlach R, Platz J, Miesbach W, Hanke AA, Hofstetter C, Weber CF. Stellenwert der Thrombelastometrie für das Monitoring von Faktor XIII. Hamostaseologie 2017; 31:111-7. [DOI: 10.5482/ha-1132] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
SummaryRecently published studies give evidence, that an increased maximum lysis in the APTEM® – test (ML60 > 12%) of the ROTEM® (Tem International GmbH, Munich, Germany) might indicate a factor XIII deficiency (FXIII < 70%). It was the aim of this study to investigate the feasibility of thrombelastometric measurements with the ROTEM device to reflect the isolated influence of FXIII on clot stability and therefore to indicate potential factor XIII deficiencies. Patients, method: After approval by the local Scientific and Ethic Review Board, 26 consecutive patients, scheduled for elective craniotomy for tumour resection, were prospectively enrolled into this study. Blood samples were taken for conventional laboratory coagulation analyses, FXIII analyses and thrombelastometric measurements (EXTEM, FIBTEM and APTEM tests) after induction of general anaesthesia (T1), before skin incision (T2) as well as at (T3) and 24 hours after (T4) postoperative admission to ICU, respectively. Statistical analyses included Spearman rank order correlations and multiple linear regressions. Results: FXIII concentrations did not correlate with the ML60 in the APTEM test at any measuring point. Neither platelet count nor fibrinogen nor FXIII concentrations were of predictive value for ML60 of the APTEM test. Conclusion: The results lead to the assumption that thrombelastometric measurements may not be appropriate for the perioperative monitoring of FXIII concentration.
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Watanabe N, Yokoyama Y, Ebata T, Sugawara G, Igami T, Mizuno T, Yamaguchi J, Nagino M. Clinical influence of preoperative factor XIII activity in patients undergoing pancreatoduodenectomy. HPB (Oxford) 2017; 19:972-977. [PMID: 28728890 DOI: 10.1016/j.hpb.2017.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/10/2017] [Accepted: 07/02/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The influence of decreased factor XIII (FXIII) activity on perioperative bleeding has been reported in some surgical procedures. The purposes of this study were to investigate the perioperative dynamics of FXIII in patients undergoing pancreatoduodenectomy and to clarify the effects of low preoperative FXIII activity on intraoperative bleeding and postoperative complications. METHODS Total of 43 patients who underwent a pancreatoduodenectomy were enrolled. The perioperative FXIII activities were measured, and their associations with intraoperative bleeding and postoperative outcomes were analyzed. RESULTS Fifteen patients (35%) had low FXIII activities (<70%, lower than the institutional normal range). The patients with preoperative FXIII activities <70% experienced significantly greater blood loss (median, 1309 mL) during surgery compared to those with FXIII levels of ≥70% (median, 710 mL) (p = 0.001). The postoperative morbidity rates, including pancreatic fistula, were comparable between the patients with FXIII activities <70% and those with FXIII activities ≥70%. The FXIII levels substantially decreased on postoperative day 1 and remained at low levels until postoperative day 7. CONCLUSION Unexpectedly high proportions of patients undergoing pancreatoduodenectomy had low preoperative FXIII activities. Preoperative FXIII deficiency may increase intraoperative bleeding but had no influence on the postoperative outcomes.
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Affiliation(s)
- Nobuyuki Watanabe
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yukihiro Yokoyama
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Tomoki Ebata
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gen Sugawara
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsuyoshi Igami
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Mizuno
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Junpei Yamaguchi
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masato Nagino
- Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Lillemäe K, Järviö JA, Silvasti-Lundell MK, Antinheimo JJP, Hernesniemi JA, Niemi TT. Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study. World Neurosurg 2017; 108:491-497. [PMID: 28893697 DOI: 10.1016/j.wneu.2017.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/30/2017] [Accepted: 09/01/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders. METHODS Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only). RESULTS The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy. CONCLUSIONS POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH.
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Affiliation(s)
- Kadri Lillemäe
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland.
| | - Johanna Annika Järviö
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Marja Kaarina Silvasti-Lundell
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland
| | - Jussi Juha-Pekka Antinheimo
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland
| | - Juha Antero Hernesniemi
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Neurosurgery, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland
| | - Tomi Tapio Niemi
- Department of Perioperative, Intensive Care and Pain Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, Töölö Hospital, Helsinki, Finland
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Maegele M. [Modern coagulation management in bleeding trauma patients : Point-of-care guided administration of coagulation factor concentrates and hemostatic agents]. Med Klin Intensivmed Notfmed 2017; 114:400-409. [PMID: 28849255 DOI: 10.1007/s00063-017-0337-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/12/2017] [Accepted: 08/01/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND Uncontrolled bleeding with trauma-induced coagulopathy (TIC) is still the leading cause of preventable death following severe multiple injury. Rapid diagnosis and treatment are associated with improved outcome. Early individualized goal-directed therapy and the use of point-of-care technology may be superior to empiric and ratio-based therapies with conventional blood products. MATERIALS AND METHODS Selective review of the literature considering current recommendations/expert opinion for coagulation management in bleeding trauma patients via individualized goal-directed therapy and the use of viscoelastic point-of-care (ROTEM®)-guided substitution of coagulation factor concentrates and hemostatic agents. RESULTS The administration of fibrinogen concentrate in bleeding trauma patients may be considered if ROTEM®-FIBTEM A10 < 10 mm (FIBTEM A5 < 9 mm; FIBTEM MCF < 12 mm) and EXTEM A10 < 45 mm (EXTEM A5 < 35 mm; EXTEM MCF < 55 mm); the administration of prothrombin complex concentrate (PCC) may be considered if signs of delayed coagulation initiation (ROTEM®-EXTEM CT > 80 s). At this stage, no concluding statement can be made for monitoring or treatment guidance with factor XIII by using point-of-care technology. Viscoelastic assays display high sensitivity and specificity for the detection of hyperfibrinolysis with subsequent administration of an antifibrinolytic. CONCLUSIONS Individualized therapeutic concepts based upon viscoelastic point-of-care (ROTEM®) assays present an alternative to empiric and ratio-based therapies with conventional blood products in bleeding trauma patients and may be associated with reduced need for allogenic blood products and morbidity.
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Affiliation(s)
- Marc Maegele
- Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Kliniken der Stadt Köln-Merheim, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland. .,Institut für Forschung in der Operativen Medizin (IFOM), Haus 38, Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland.
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Maegele M, Schöchl H, Menovsky T, Maréchal H, Marklund N, Buki A, Stanworth S. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017; 16:630-647. [PMID: 28721927 DOI: 10.1016/s1474-4422(17)30197-7] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 01/28/2023]
Abstract
Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.
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Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.
| | - Herbert Schöchl
- Department for Anaesthesiology and Intensive Care Medicine, AUVA Trauma Academic Teaching Hospital, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tomas Menovsky
- Department for Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Hugues Maréchal
- Department of Anaesthesiology and Intensive Care Medicine, CRH La Citadelle, Liège, Belgium
| | - Niklas Marklund
- Department of Clinical Sciences, Division of Neurosurgery, University Hospital of Southern Sweden, Lund University, Lund, Sweden
| | - Andras Buki
- Department of Neurosurgery, The MTA-PTE Clinical Neuroscience MR Research Group, Janos Szentagothai Research Center, Hungarian Brain Research Program, University of Pécs, Pécs, Hungary
| | - Simon Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Foundation Trust, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Norton DG, Fan NK, Goudie MJ, Handa H, Platt MO, Averett RD. Computational imaging analysis of glycated fibrin gels reveals aggregated and anisotropic structures. J Biomed Mater Res A 2017; 105:2191-2198. [PMID: 28371216 DOI: 10.1002/jbm.a.36074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/02/2017] [Accepted: 03/24/2017] [Indexed: 11/09/2022]
Abstract
In this article, a computational imaging analysis method is presented for the evaluation of aggregation and anisotropy in both native (unglycated) and glycated fibrin matrix structures. The imaging analysis was used to test the hypothesis that glycated fibrin structures are more aggregated and anisotropic than unglycated (native) fibrin structures. Glycation of fibrinogen, and subsequently fibrin, occurs under normal physiological conditions; however, excess glycation due to disease states such as diabetes can disrupt the fibrin matrix and cause an abnormal structure and function. Studies that elucidate morphological changes in glucose incubated fibrin matrices are necessary to better understand thrombosis, which occurs due to hypercoagulable conditions. In this study, imaging algorithms were designed for the determination of aggregation of fibrin fibers within a matrix as well as preferential orientation (anisotropy) due to glycation. The results showed that glycated fibrin structures displayed an overall higher degree of aggregation and anisotropy as compared to unglycated fibrin structures. However, for glycated fibrin matrices that were polymerized utilizing extended incubation periods representative of physiological plasma glucose conditions, the results showed that fibrin aggregation and anisotropy decreased when compared to unglycated matrices. The algorithms showed that incorporation of the crosslinking agent FXIII into the fibrin matrix was shown to decrease both aggregation and anisotropy. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 2191-2198, 2017.
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Affiliation(s)
- David G Norton
- School of Medicine, Mercer University, Savannah, Georgia, 31404
| | - Natalie K Fan
- Department of Biomedical Engineering, The University of Texas at San Antonio, San Antonio, Texas, 78249
| | - Marcus J Goudie
- School of Chemical, Materials, and Biomedical Engineering, The University of Georgia, College of Engineering, Driftmier Engineering Center, Athens, Georgia, 30602
| | - Hitesh Handa
- School of Chemical, Materials, and Biomedical Engineering, The University of Georgia, College of Engineering, Driftmier Engineering Center, Athens, Georgia, 30602
| | - Manu O Platt
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology College of Engineering and Emory University School of Medicine, Atlanta, Georgia, 30332
| | - Rodney D Averett
- School of Chemical, Materials, and Biomedical Engineering, The University of Georgia, College of Engineering, Driftmier Engineering Center, Athens, Georgia, 30602
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Nilsson CU, Strandberg K, Engström M, Reinstrup P. Coagulation during elective neurosurgery with hydroxyethyl starch fluid therapy: an observational study with thromboelastometry, fibrinogen and factor XIII. Perioper Med (Lond) 2016; 5:20. [PMID: 27540479 PMCID: PMC4989364 DOI: 10.1186/s13741-016-0046-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 07/26/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Several studies have described hypercoagulability in neurosurgery with craniotomy for brain tumor resection. In this study, hydroxyethyl starch (HES) 130/0.42 was used for hemodynamic stabilization and initial blood loss replacement. HES can induce coagulopathy with thromboelastographic signs of decreased clot strength. The aim of this study was to prospectively describe perioperative changes in coagulation during elective craniotomy for brain tumor resection with the present fluid regimen. METHODS Forty patients were included. Perioperative whole-blood samples were collected for EXTEM and FIBTEM assays on rotational thromboelastometry (ROTEM) and plasma fibrinogen analysis immediately before surgery, after 1 L of HES infusion, at the end of surgery and in the morning after surgery. Factor (F)XIII activity, thrombin-antithrombin complex (TAT) and plasmin-α2-antiplasmin complex (PAP) were analysed in the 25 patients receiving ≥1 L of HES. RESULTS Most patients (37 of 40) received HES infusion (0.5-2 L) during surgery. Preoperative ROTEM clot formation/structure, plasma fibrinogen and FXIII levels were generally within normal range but approached a hypocoagulant state during and at end of surgery. ROTEM variables and fibrinogen levels, but not FXIII, returned to baseline levels in the morning after surgery. Low perioperative fibrinogen levels were common. TAT levels were increased during and after surgery. PAP levels mostly remained within the reference ranges, not indicating excessive fibrinolysis. There were no differences in ROTEM results and fibrinogen levels in patients receiving <1 L HES and ≥1 L HES. CONCLUSIONS Only the increased TAT levels indicated an intra- and postoperative activation of coagulation. On the contrary, all other variables deteriorated towards hypocoagulation but were mainly normalized in the morning after surgery. Although this might be an effect of colloid-induced coagulopathy, we found no dose-dependent effect of HES. The unactivated fibrinolysis indicates that prophylactic use of tranexamic acid does not seem warranted under normal circumstances in elective neurosurgery. Individualized fluid therapy and coagulation factor substitution is of interest for future studies.
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Affiliation(s)
| | - Karin Strandberg
- Department of Laboratory Medicine, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - Martin Engström
- Department of Anaesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Peter Reinstrup
- Department of Anaesthesia and Intensive Care, Skåne University Hospital, Lund University, Lund, Sweden
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Effects of Factor XIII Deficiency on Thromboelastography. Thromboelastography with Calcium and Streptokinase Addition is more Sensitive than Solubility Tests. Mediterr J Hematol Infect Dis 2016; 8:e2016037. [PMID: 27648200 PMCID: PMC5016016 DOI: 10.4084/mjhid.2016.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/05/2016] [Indexed: 11/29/2022] Open
Abstract
Background Homozygous or double heterozygous factor XIII (FXIII) deficiency is characterized by soft tissue hematomas, intracranial and delayed spontaneous bleeding. Alterations of thromboelastography (TEG) parameters in these patients have been reported. The aim of the study was to show results of TEG, TEG Lysis (Lys 60) induced by subthreshold concentrations of streptokinase (SK), and to compare them to the clot solubility studies results in samples of a 1-year-old girl with homozygous or double heterozygous FXIII deficiency. Case A year one girl with a history of bleeding from the umbilical cord. During her first year of life, several hematomas appeared in soft upper limb tissue after punctures for vaccination and a gluteal hematoma. One additional sample of a heterozygous patient and three samples of acquired FXIII deficiency were also evaluated. Materials and Methods Clotting tests, von Willebrand factor (vWF) antigen and activity, plasma FXIII-A subunit (pFXIII-A) were measured by an immunoturbidimetric assay in a photo-optical coagulometer. Solubility tests were performed with Ca2+-5 M urea and thrombin-2% acetic acid. Basal and post-FXIII concentrate infusion samples were studied. TEG was performed with CaCl2 or CaCl2 + SK (3.2 U/mL) in a Thromboelastograph. Results Prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time, fibrinogen, factor VIIIc, vWF, and platelet aggregation were normal. Antigenic pFXIII-A subunit was < 2%. TEG, evaluated at diagnosis and post FXIII concentrate infusion (pFXIII-A= 37%), presented a normal reaction time (R), 8 min, prolonged k (14 and 11min respectively), a low Maximum-Amplitude (MA) ( 39 and 52 mm respectively), and Clot Lysis (Lys60) slightly increased (23 and 30% respectively). In the sample at diagnosis, clot solubility was abnormal, 50 and 45 min with Ca-Urea and thrombin-acetic acid, respectively, but normal (>16 hours) 1-day post-FXIII infusion. Analysis of FXIII deficient and normal plasma mixtures (< 2–102% of pFXIII-A), showed that Ca-urea solubility was abnormal at pFXIII-A < 9%, thrombin-acetic acid at pFXIII-A<18%, but TEG MA and elasticity at 23% and Lys60 with SK at pFXIII-A< 40%. Conclusions TEG parameters MA and elasticity, and Lys 60 in TEG either with Ca2+ or Ca2+ and SK are more sensitive to low levels of pFXIII than solubility tests. The increased Lys60 induced by a subthreshold concentration of SK could probably reflect the clot characteristics “in vivo” in many patients with pFXIII levels between 5–40% and could be potentially considered as screening test.
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Abstract
Objective To describe the characteristics of patients who underwent a cranial operation and postoperatively suffered an intracranial hemorrhage significant enough to require evacuation. Materials & methods 3,109 cranial operations were performed at Houston Methodist Hospital (Texas Medical Center campus) between January 2009 and December 2013. Of these, 59 cases required a second operation for evacuation of an intracranial hemorrhage. The information gathered included the patients’ age, gender, past medical history, medications and laboratory data, initial diagnosis, date/type of first and second operations, duration of hospitalization, discharge condition, and discharge destination. Results The study found a 1.90% rate of a postoperative hemorrhage significant enough to require evacuation after a cranial operation. The average age in the cohort requiring reoperation was 63 +/- 14 years with 42 male and 17 female. Hematoma evacuations were performed at various time intervals depending on the pathology treated at the initial operation. The time to second operation was 2.7 days after intraparenchymal hematoma evacuation, 6.0 days after cerebrovascular surgery, 6.2 days after tumor surgery and 9.7 days after subdural hematoma evacuation. The rate of postoperative hematoma development was 9.1% after a subdural hematoma evacuation, while it was only 1.1% in all other operations. Overall, those requiring hematoma evacuation had a 15% mortality rate, 64% were non-ambulatory, and 54% were discharged to long-term acute care facility, skilled nursing facility, rehabilitation facility or hospice. Conclusions Neurological outcomes were poor in patients who underwent a cranial operation and required a second operation to remove a hematoma. This study suggests close observation of elderly males after a cranial operation, especially after subdural hematoma evacuation, and longer observation time for patients undergoing subdural hematoma evacuation than intraparenchymal hematoma evacuation, tumor surgery or cerebrovascular surgery.
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Preoperative plasma fibrinogen concentration, factor XIII activity, perioperative bleeding, and transfusions in elective orthopaedic surgery: A prospective observational study. Thromb Res 2016; 139:142-7. [DOI: 10.1016/j.thromres.2016.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 12/03/2015] [Accepted: 01/02/2016] [Indexed: 11/22/2022]
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Carvalho M, Rodrigues A, Gomes M, Carrilho A, Nunes AR, Orfão R, Alves Â, Aguiar J, Campos M. Interventional Algorithms for the Control of Coagulopathic Bleeding in Surgical, Trauma, and Postpartum Settings: Recommendations From the Share Network Group. Clin Appl Thromb Hemost 2016; 22:121-37. [PMID: 25424528 PMCID: PMC4741263 DOI: 10.1177/1076029614559773] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Several clinical settings are associated with specific coagulopathies that predispose to uncontrolled bleeding. With the growing concern about the need for optimizing transfusion practices and improving treatment of the bleeding patient, a group of 9 Portuguese specialists (Share Network Group) was created to discuss and develop algorithms for the clinical evaluation and control of coagulopathic bleeding in the following perioperative clinical settings: surgery, trauma, and postpartum hemorrhage. The 3 algorithms developed by the group were presented at the VIII National Congress of the Associação Portuguesa de Imuno-hemoterapia in October 2013. They aim to provide a structured approach for clinicians to rapidly diagnose the status of coagulopathy in order to achieve an earlier and more effective bleeding control, reduce transfusion requirements, and improve patient outcomes. The group highlights the importance of communication between different specialties involved in the care of bleeding patients in order to achieve better results.
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Affiliation(s)
- Manuela Carvalho
- Transfusion Medicine and Blood Bank Department, H. São João, Centro Hospitalar São João, Porto, Portugal
| | - Anabela Rodrigues
- Transfusion Medicine Department, H. Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Manuela Gomes
- Transfusion Medicine Department, H. Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Alexandre Carrilho
- Anesthesiology Department, H. São José, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - António Robalo Nunes
- Transfusion Medicine Department, H. Pulido Valente, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - Rosário Orfão
- Anesthesiology Department, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal
| | - Ângela Alves
- Anesthesiology Department, H. Santa Maria, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - José Aguiar
- Anesthesiology Department, H. Santo António, Centro Hospitalar do Porto, Porto, Portugal
| | - Manuel Campos
- Clinical Hematology Department, H. Santo António, Centro Hospitalar do Porto, Porto, Portugal
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Tone K, Lalu M, Kilty SJ, Rosenberg E, Tinmouth A. Airway Compromise and Perioperative Management of a Patient with Acquired Factor XIII Inhibitor. ACTA ACUST UNITED AC 2015; 4:120-4. [DOI: 10.1213/xaa.0000000000000130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
PURPOSE OF REVIEW Bleeding can be minimal, severe, life-threatening, or organ-threatening. Depending on the compensatory capacity of the patient, most bleeding events going beyond 20% blood volume may represent an emergency as well as a risk factor for anemia, transfusion, coagulopathy, and tissue hypoperfusion. All these factors are independent predictors for survival in postoperative critical care and are drivers for resource use and costs. RECENT FINDINGS A systematic literature search behind the guidelines from the European Society of Anesthesiology on the management of severe perioperative bleeding gives an up-to-date evidence-based summary of strategies intended to correct hemostasis, control bleeding, and increase patient safety. The current review discusses information, recommendations, and suggestions in the European Society of Anesthesiology guidelines, which appear applicable to the bleeding patient after the end of surgery. SUMMARY Individualized coagulation management guided by viscoelastic tests and restrictive transfusion behavior are encouraged in clinical practice of critical care. Potential fields of research are multifold, for example, thromboembolic adverse effects of hemostatic interventions in the isochronic postoperative acute-phase response, transfusion restrictions by increasing postoperative tolerance to anemia and erythropoiesis, and implementation of guidelines and institutional algorithms.
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Dickneite G, Herwald H, Korte W, Allanore Y, Denton CP, Matucci Cerinic M. Coagulation factor XIII: a multifunctional transglutaminase with clinical potential in a range of conditions. Thromb Haemost 2015; 113:686-97. [PMID: 25652913 DOI: 10.1160/th14-07-0625] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 11/27/2014] [Indexed: 12/28/2022]
Abstract
Coagulation factor XIII (FXIII), a plasma transglutaminase, is best known as the final enzyme in the coagulation cascade, where it is responsible for cross-linking of fibrin. However, a growing body of evidence has demonstrated that FXIII targets a wide range of additional substrates that have important roles in health and disease. These include antifibrinolytic proteins, with cross-linking of α2-antiplasmin to fibrin, and potentially fibrinogen, being the principal mechanism(s) whereby plasmin-mediated clot degradation is minimised. FXIII also acts on endothelial cell VEGFR-2 and αvβ3 integrin, which ultimately leads to downregulation of the antiangiogenic protein thrombospondin-1, promoting angiogenesis and neovascularisation. Under infectious disease conditions, FXIII cross-links bacterial surface proteins to fibrinogen, resulting in immobilisation and killing, while during wound healing, FXIII induces cross-linking of the provisional matrix. The latter process has been shown to influence the interaction of leukocytes with the provisional extracellular matrix and promote wound healing. Through these actions, there are good rationales for evaluating the therapeutic potential of FXIII in diseases in which tissue repair is dysregulated or perturbed, including systemic sclerosis (scleroderma), invasive bacterial infections, and tissue repair, for instance healing of venous leg ulcers or myocardial injuries. Adequate levels of FXIII are also required in patients undergoing surgery to prevent or treat perioperative bleeding, and its augmentation in patients with/at risk for perioperative bleeding may also have potential clinical benefit. While there are preclinical and/or clinical data to support the use of FXIII in a range of settings, further clinical evaluation in these underexplored applications is warranted.
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Affiliation(s)
- Gerhard Dickneite
- Prof. Dr Gerhard Dickneite, Preclinical R&D, CSL Behring, PO Box 1230, 35002 Marburg, Germany, Tel.: +49 6421 392306, Fax: +49 6421 394663, E-mail:
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Abstract
Fibrinogen is a critical protein for hemostasis and clot formation. However, transfusion guidelines have variable recommendations for maintaining fibrinogen levels in bleeding patients. An increasing number of studies support the practice of fibrinogen replacement therapy for acquired coagulopathies, and additional studies are underway. Fibrinogen therapy can be administered with cryoprecipitate or fibrinogen concentrates, and clinical practice varies according to their availability and licensing status. Fibrinogen concentrate therapy has been studied in animal models and clinical trials and supports the critical role of fibrinogen repletion in bleeding patients. Point-of-care testing will have an important role in guiding fibrinogen replacement for hemostatic therapy in clinical settings such as cardiovascular surgery, postpartum hemorrhage, and trauma. Fibrinogen therapy is an important component of a multimodal strategy for the treatment of coagulopathic bleeding.
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Kim SH, Lee JH, Joo W, Chough CK, Park HK, Lee KJ, Rha HK. Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery. Br J Neurosurg 2014; 29:243-8. [PMID: 25301742 DOI: 10.3109/02688697.2014.967749] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Post-operative extradural hematoma (EDH) is a relatively common complication in patients undergoing intracranial operations. The risk factors associated with the occurrence of EDH are not well described in the literature. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy or the craniectomy site. METHOD This was a retrospective study of 24 (2.6% of total) patients who underwent extradural hematoma evacuation after primary intracranial supratentorial surgery between January 2005 and December 2011. During this period, 941 intracranial operations were performed. The control group (72 patients) was selected on the basis of having undergone the same pre-operative diagnosis and treatment within 2 months of the operations for the 24 hematoma patients. The Glasgow Coma Scale score and operation character (emergency or elective) of the hematoma and control group were individually matched to minimize pre-operative conditional bias. The ages of both groups were individually matched with similar ages within 10 years of each other to minimize age bias. RESULT Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were an intra-operative blood loss of greater than 800 mL (p=0.007), maximal craniotomy length of greater than or equal to 100 mm (p=0.001), and craniotomy area of greater than or equal to 71.53 cm2 (p=0.018). In multivariate analysis, intra-operative blood loss exceeding 800 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH. CONCLUSION The data did not examine established risk factors for post-operative hematoma, such as thrombocytopenia, anti-coagulant and anti-platelet therapy, and a history of heavy alcohol consumption and/or tobacco intake. Recognizing the limitations of the study, large intra-operative blood loss and wide craniotomy area are implicated with an increased risk of post-operative EDH after intracranial surgery.
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Affiliation(s)
- Sang Hyo Kim
- Department of Neurosurgery, Yeouido St. Mary's Hospital, Neuroscience Center, College of Medicine, The Catholic University of Korea , Seoul , Republic of Korea
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Korte W. Catridecacog: a breakthrough in the treatment of congenital factor XIII A-subunit deficiency? J Blood Med 2014; 5:107-13. [PMID: 25031548 PMCID: PMC4096448 DOI: 10.2147/jbm.s35395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Circulating factor XIII (FXIII) consists of two active (A) and two carrier (B) subunits in tetrameric form. Congenital FXIII deficiency is a rare autosomal-recessive trait that mostly results from an FXIII A-subunit deficiency. Classic coagulation assays, such as prothrombin time or activated partial thromboplastin time, are not sensitive to FXIII; therefore, specific FXIII assays are necessary to detect the deficiency. The clinical picture of congenital FXIII deficiency comprises abortions, umbilical cord bleeding, increased surgical bleeding, intracerebral hemorrhage (which can, unfortunately, be the very first sign of severe FXIII deficiency), menorrhagia, and wound-healing disorders. Given the risk of intracranial hemorrhage, continued prophylaxis is to be recommended in severe deficiency, even in the actual absence of bleeding symptoms. Functional FXIII half-life decreases in consumptive processes (eg, surgery), explaining why increased dosing is needed in such situations. A recombinant FXIII (rFXIII) subunit-A molecule, which is expressed in Saccharomyces cerevisiae, has been evaluated for replacement therapy in congenital FXIII deficiency. The bleeding frequency under continued rFXIII prophylaxis during a year-long treatment period was significantly lower compared to on-demand treatment. Importantly, no severe spontaneous bleedings occurred, and bleeding requiring additional intervention only occurred after relevant trauma. Treatment with rFXIII proved to be safe: antibodies against rFXIII detected in four patients were not considered clinically relevant. No allergic reactions were observed. These data show that rFXIII can be used safely and effectively for continued prophylaxis in congenital FXIII deficiency; it is conceivable that this also holds true for treatment of acute bleeding, but clinical proof of this is pending.
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Affiliation(s)
- Wolfgang Korte
- Center for Laboratory Medicine, St Gallen, Switzerland ; Center for Hemostaseology and Hemophilia, St Gallen, Switzerland
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Gertler R, Martin K, Hapfelmeier A, Tassani-Prell P, Braun S, Wiesner G. The perioperative course of factor XIII and associated chest tube drainage in newborn and infants undergoing cardiac surgery. Paediatr Anaesth 2013; 23:1035-41. [PMID: 23668424 DOI: 10.1111/pan.12193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Perioperative acquired factor XIII deficiency has been looked upon as a potential cause of postoperative bleeding in adult cardiac surgery. METHODS Forty-four infants were prospectively studied for the time course of factor XIII in plasma and the effect on chest tube drainage (CTD) and transfusion requirements in the first 24 h after surgery. A reconstituted blood prime (RBP) with fresh-frozen plasma (FFP) and packed red blood cells (PRBC) was used. Samples were taken at baseline, after cardiopulmonary bypass and upon arrival in the ICU. Differences in blood loss and transfusion requirements based on a cutoff value of 70% factor XIII activity at the time of ICU admission were also calculated. RESULTS Baseline factor XIII activity was 79%, decreased to 71% after CPB (P = 0.102) and increased back up to 77% at ICU arrival (P = 0.708). There was no significant correlation between factor XIII, CTD, age, cyanosis, platelet count, and transfusion requirements at any time point. Only preoperative fibrinogen levels correlated significantly with factor XIII activity. Perioperative blood transfusions (PRBC P = 0.712, FFP P = 0.909, platelets P = 0.807) and chest tube losses (P = 0.424 at 6 h and P = 0.215 at 24 h) were not significantly different above or below a 70% factor XIII activity at ICU arrival. CONCLUSION Factor XIII activity in infants with congenital heart defects is within the lower range of normal adults, independent of patient's age and the presence of cyanosis. Reconstituted blood prime maintains factor XIII activity at sufficient levels during pediatric cardiac surgery. We could not detect a correlation between FXIII and CTD.
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Affiliation(s)
- Ralph Gertler
- Institut für Anästhesiologie, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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Hanna J, Winstedt D, Schött U. Fibrinogen and FXIII dose response effects on albumin-induced coagulopathy. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 73:553-62. [DOI: 10.3109/00365513.2013.821710] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Gerlach R, Raabe A, Scharrer I, Meixensberger J, Seifert V. Post-operative hematoma after surgery for intracranial meningiomas: Causes, avoidable risk factors and clinical outcome. Neurol Res 2013; 26:61-6. [PMID: 14977059 DOI: 10.1179/016164104773026543] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Intracranial meningiomas are mainly benign lesions amenable for surgical resection. However, removal of an intracranial meningioma carries a higher risk of post-operative hemorrhage compared to surgery for other intracranial neoplasms. Because avoidance of post-operative hematoma is of vital interest for neurosurgical patients, the aim of this retrospective study was to analyze risk factors of post-operative hematoma associated with meningioma surgery. Two hundred and ninety six patients with intracranial meningiomas, operated between June 1998 and June 2002, were included in this study. Patients who developed a space-occupying post-operative intracranial hemorrhage and were treated surgically were identified. Data of patients with and without hematoma were retrospectively analyzed to identify risk factors associated with post-operative hematoma. Variables analyzed included patients' age, invasion of venous sinus by the meningioma, tumor vascularization, arachnoidal infiltration, pre-operative prophylaxis of thromboembolic events, peri-operative coagulation abnormalities, residual tumor, location and histology of the tumor. Outcome of patients with post-operative hematoma was assessed according to the Glasgow Outcome Scale (GOS) at discharge and at three months. 21 patients (7.1 %) of 296 patients developed a post-operative intracranial hematoma requiring surgical evacuation. Age was significantly higher in the hematoma group 62.4 +/- 14.0 years compared to patients without post-operative hematoma 56.1 +/- 12.0 (p < 0.05; t-test). Patients older than 70 years had a six-fold increased risk to develop a post-operative hematoma (Chi2 test, 95% CI 1.949-13.224). Patients with post-operative hemorrhage had significant lower post-operative prothrombin time, fibrinogen and platelets immediately after surgery and lower platelets at day 1. None of the other parameters, including pre-operative routine coagulation values, differed significantly between patients with and without post-operative hemorrhage. Three patients with post-operative hematoma showed platelet dysfunction and three patients showed decreased FXIII activity. Of those patients with post-operative hemorrhage at three months follow up three patients (13%) succumbed from reasons not directly related to hemorrhage, one patient remained GOS 2 (4.3%), four patients (17.4%) were GOS 3 and 15 (65.4%) patients had favorable outcome (GOS 4 [one patient] and GOS5 [14 patients]). Meningioma surgery carries a higher risk for post-operative hematoma in the elderly. Thrombocytopenia and other hemostatic disorders were frequently associated with post-operative hemorrhage after meningioma surgery, while no surgical factors could be defined. Extending coagulation tests and specific replacement therapy may prevent hematoma formation and improve the patients outcome.
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Affiliation(s)
- Rüdiger Gerlach
- Department of Neurosurgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
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Hanafusa N, Hamasaki Y, Kawarasaki H, Kido R, Shibagaki Y, Ishikawa A, Enomoto Y, Fujita T, Noiri E, Nangaku M. The effect of different apheresis modalities on coagulation factor XIII level during antibody removal in ABO-blood type incompatible living related renal transplantation. Transfus Apher Sci 2013; 49:254-8. [PMID: 23827327 DOI: 10.1016/j.transci.2013.06.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Revised: 03/07/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023]
Abstract
Apheresis therapy is used to remove pathogenic antibodies within the recipient blood during ABO-incompatible living related renal transplantation (LRRT). Factor XIII (FXIII) is a coagulating factor. Its deficiency reportedly engenders perioperative bleeding. This study compared apheresis modalities from the perspective of the FXIII level. Cases 1-3 were treated only with double-filtration plasmapheresis (DFPP) without (case 1) or with (cases 2 and 3) fresh frozen plasma (FFP) supplementation. Cases 4 and 5 were treated with simple plasma exchange (PEx) with FFP supplementation for the last session. Cases 1-3 showed a marked (case 1, 8.6%) or moderate (case 2, 26.2%; case 3, 28.4%) decrease in FXIII on the day before the procedure after the last apheresis session, although cases 4 (81.9%) and 5 (66.2%) did not. Case 1 experienced perioperative bleeding. The last session is usually performed the day before the surgical procedure. Therefore, FXIII elimination by DFPP might cause bleeding complications because of its slow recovery. The fact warrants that the last apheresis modality during the course might be PEx from the viewpoint of FXIII depletion.
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Affiliation(s)
- Norio Hanafusa
- Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Japan.
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