Fibrinogen but not factor XIII deficiency is associated with bleeding after craniotomy

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

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.

Prophylactic administration of tranexamic acid combined with thromboelastography-guided hemostatic algorithm reduces allogeneic transfusion requirements during pediatric resective epilepsy surgery: A randomized controlled trial

Background: Intraoperative bleeding and allogeneic transfusion remain common problems in pediatric resective epilepsy surgery. Tranexamic acid (TXA) is a widely recommended antifibrinolytic drug that reduces blood loss and transfusion requirements for bleeding patients. Thromboelastography (TEG)-guided hemostatic algorithm is commonly used in bleeding management. This trial was designed to validate the efficacy of a multimodal coagulation therapy involving continuous TXA infusion with TEG-guided hemostatic algorithm in reducing allogeneic exposure risk in pediatric resective epilepsy surgery.

Methods: Eighty-three children undergoing resective epilepsy surgery were randomized into a treatment group (Group T; n = 42) and a control group (Group C; n = 41). Group T received prophylactic TXA (10 mg/kg followed by 5 mg/kg/h) with TEG-guided hemostatic algorithm, whereas Group C received conventional coagulation management. The primary outcome was allogeneic transfusion rate during surgery, and the secondary outcomes were intraoperative blood loss, incidence of postoperative seizures, and thromboembolic events during hospitalization.

Results: The incidence of intraoperative allogeneic transfusion reduced by 34.7% with the use of a multimodal coagulation therapy (19.0% in Group T vs. 53.7% in Group C; RR 0.355, 95% CI 0.179–0.704; p = 0.001). This was mainly triggered by a significant reduction (44.1%) in intraoperative plasma transfusion (7.1% in Group T vs. 51.2% in Group C; RR 0.139, 95% CI 0.045–0.432; p = 0.000). The risk of intraoperative RBC transfusion was lower in Group T than in Group C, but the difference was not statistically significant (14.3% in Group T vs. 29.3% in Group C; RR 0.488, 95% CI 0.202–1.177; p = 0.098). No platelets were transfused in both groups. Further, 19 (45.2%) patients in Group T received fibrinogen concentrates guided by TEG data, whereas 1 (2.4%) patient in Group C received fibrinogen concentrates empirically. There were no significant differences in estimated blood loss and postoperative seizures between the two groups, and no thromboembolic events were observed after surgery.

Conclusion: Prophylactic administration of TXA combined with TEG-guided hemostatic algorithm can be an effective multimodal coagulation strategy for reducing allogeneic transfusion requirements during pediatric resective epilepsy surgery.

Clinical Trial Registration:www.chictr.org.cn/index.aspx, identifier ChiCTR1800016188.

Mild Acquired Factor XIII Deficiency and Clinical Relevance at the ICU-A Retrospective Analysis

Acquired FXIII deficiency is a relevant complication in the perioperative setting; however, we still have little evidence about the incidence and management of this rarely isolated coagulopathy. This study aims to help find the right value for the substitution of patients with an acquired mild FXIII deficiency. In this retrospective single-center cohort study, we enrolled critically ill patients with mild acquired FXIII deficiency (>5% and ≤70%) and compared clinical and laboratory parameters, as well as pro-coagulatory treatments. The results of the present analysis of 104 patients support the clinical relevance of FXIII activity out of the normal range. Patients with lower FXIII levels, beginning at <60%, had lower minimum and maximum hemoglobin values, corresponding to the finding that patients with a minimum FXIII activity of <50% needed significantly more packed red blood cells. FXIII activity correlated significantly with general coagulation markers such as prothrombin time, activated partial thromboplastin time, and fibrinogen. Nevertheless, comparing the groups with a cut-off of 50%, the amount of fresh frozen plasma, thrombocytes, PPSB, AT-III, and fibrinogen given did not differ. These results indicate that a mild FXIII deficiency occurring at any point of intensive care unit stay is also probably relevant for the total need of packed red blood cells, independent of pro-coagulatory management. In alignment with the ESAIC guidelines, the measurement of FXIII in critically ill patients with the risk of bleeding and early management, with the substitution of FXIII at levels <50%-60%, could be suggested.

Factor XIII Deficiency and Intracranial Bleed: Surgical Management and Prophylaxis with Cryoprecipitate

Factor 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.

Acquired FXIII Deficiency is Associated with High Morbidity

BACKGROUND

 A factor XIII (FXIII) level >30% is considered necessary to prevent spontaneous bleeding. Bleeding is also a risk in patients with acquired FXIII deficiency, but the hemostatic level of FXIII in this context remains to be determined.

METHODS

 We retrospectively analyzed all patients diagnosed with acquired FXIII deficiency at a large hospital over 3 years (study ID NCT04416594, http://www.clinicaltrials.gov) and assessed clinical data to identify the best cut-off point for FXIII activity to distinguish between low and high risk of major bleeding in a mixed medical and surgical population.

RESULTS

 Of the 97 patients who experienced bleeding despite a normal coagulation test, 43.2% had FXIII activity <70%. FXIII activity was significantly lower in surgical patients and patients admitted to the intensive care unit (ICU). Low FXIII activity was significantly associated with long ICU stays and a high incidence of major bleeding.

CONCLUSION

 Acquired FXIII deficiency is associated with high morbidity. The hemostatic level of FXIII in the setting of acquired FXIII deficiency might be above 30%.

Elevated blood urea nitrogen is associated with recurrence of post-operative chronic subdural hematoma

Background

Chronic subdural hematoma (CSDH) is fundamentally treatable with about a 2–31% recurrence rate. Recently, there has been renewed interest in the association between Blood Urea Nitrogen (BUN) and intracranial lesion. Therefore, this paper attempts to show the relationship between BUN and CSDH recurrence.

Methods

A total of 653 CSDH cases with Burr-hole Irrigation (BHI) were enrolled from December 2014 to April 2019. The analyzed parameters included age, gender, comorbidities, laboratory investigations, medication use and hematoma location. The cases were divided into recurrence and non-recurrence groups while postoperative BUN concentration was further separated into quartiles (Q1 ≤ 4.0 mmol/L, 4.0 < Q2 ≤ 4.9 mmol/L, 4.9 < Q3 ≤ 6.4 mmol/L, Q4 > 6.4 mmol/L). Restricted cubic spline regressions and logistic regression models were performed to estimate the effect of BUN on CSDH recurrence.

Results

CSDH recurrence was observed in 96 (14.7%) cases. Significant distinctions were found between recurrence and non-recurrence groups in postoperative BUN quartiles of cases (P = 0.003). After adjusting for the potential confounders, the odds ratio of recurrence was 3.069 (95%CI =1.488–6.330, p = 0.002) for the highest quartile of BUN compared with the lowest quartile. In multiple-adjusted spline regression, a high BUN level visually showed a significantly high OR value of recurrence risk.

Conclusions

Elevated BUN at post-operation is significantly associated with the recurrence of CSDH, and it is indicated that high levels of serum BUN after evacuation may serve as a risk factor for CSDH recurrence.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-01985-w.

New Hemostatic Agents: Perioperative Anesthetic Considerations

AIM

Pharmacologic agents with procoagulant effects and antidotes against antithrombotic drugs play an important role in the prevention and management of perioperative coagulopathic bleeding. The aim of this narrative review is knowledge transfer from new and renewed hemostatic agents to anesthesiologists and other physicians involved in perioperative medicine.

METHODS

The literature search was performed on PubMed and the Summaries of Product Characteristics of 6 pharmacologic agents of interest: fibrinogen concentrate, vonicog alfa, susoctocog alfa, idarucizumab, andexanet alfa, and argatroban.

RESULTS AND DISCUSSION

This review highlights renewed interest in fibrinogen concentrate, an old prohemostatic drug, in correcting hypofibrinogenemia which is a leading pathomechanism of perioperative bleeding. This review describes clinically relevant aspects for brand new recombinant prohemostatic drugs for their use in critical clinical situations: vonicog alfa for the prevention and correction of bleeding in von Willebrand syndrome, and susoctocog alfa in acquired hemophilia A. Clinical experience and increasing evidence broadened the field of applications of the old antithrombotic drug argatroban to heparin resistance. New antidotes against new antithrombotic agents revolutionized the safety of chronic antithrombotic therapy in the emergency situations of acute and trauma surgery. Information on dosing and handling of new hemostatic drugs is summarized.

CONCLUSION

New and potent hemostatic agents exist for perioperative use and may enrich the armamentarium of anesthesiologists. Implementation into clinical practice requires their availability and user knowledge. Sustainability of these new drugs depends on post-licensing research, cost-effectiveness, and clinical experience.

Acquired factor XIII deficiency: A review

Acquired factor XIII (FXIII) deficiency is a rare bleeding disorder that can manifest with spontaneous or delayed life-threatening hemorrhage. Causes of acquired deficiency include immune-mediated inhibition, as well as non-immune FXIII hyperconsumption or hyposynthesis. The occurrence of acquired FXIII deficiency can be idiopathic or may be associated with comorbidities, such as malignancies or autoimmune disorders. Recognition of acquired FXIII deficiency and its underlying cause is imperative, as treatment options vary depending on the etiology. Diagnosis requires quantitative FXIII testing in addition to supplemental inhibitor studies if the clinical situation suggests an immune-mediated pathophysiology. Treatment may involve FXIII replacement, antifibrinolytic administration, and/or inhibitor eradication. However, treatment targets and thresholds are undefined in acquired FXIII deficiency. This review will focus on the clinical characteristics, diagnostic issues and therapeutic options for both immune and non-immune acquired FXIII deficiency. Cases are described to illustrate the clinical features of acquired FXIII deficiency.

Clinical influence of preoperative factor XIII activity in patients undergoing pancreatoduodenectomy

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.

Crotalus atrox venom preconditioning increases plasma fibrinogen and reduces perioperative hemorrhage in a rat model of surgical brain injury

Perioperative bleeding is a potentially devastating complication in neurosurgical patients, and plasma fibrinogen concentration has been identified as a potential modifiable risk factor for perioperative bleeding. The aim of this study was to evaluate preconditioning with Crotalus atrox venom (Cv-PC) as potential preventive therapy for reducing perioperative hemorrhage in the rodent model of surgical brain injury (SBI). C. atrox venom contains snake venom metalloproteinases that cleave fibrinogen into fibrin split products without inducing clotting. Separately, fibrinogen split products induce fibrinogen production, thereby elevating plasma fibrinogen levels. Thus, the hypothesis was that preconditioning with C. atrox venom will produce fibrinogen spilt products, thereby upregulating fibrinogen levels, ultimately improving perioperative hemostasis during SBI. We observed that Cv-PC SBI animals had significantly reduced intraoperative hemorrhage and postoperative hematoma volumes compared to those of vehicle preconditioned SBI animals. Cv-PC animals were also found to have higher levels of plasma fibrinogen at the time of surgery, with unchanged prothrombin time. Cv-PC studies with fractions of C. atrox venom suggest that snake venom metalloproteinases are largely responsible for the improved hemostasis by Cv-PC. Our findings indicate that Cv-PC increases plasma fibrinogen levels and may provide a promising therapy for reducing perioperative hemorrhage in elective surgeries.

Insufficient fibrinogen response following free flap surgery is associated with bleeding complications

Background: Microvascular tissue transfer has become a safe and reliable tool in the reconstructive armamentarium, yielding high success rates. However, little is known about the changes in coagulation after free tissue transfer and their potential impact on morbidity. Methods: Fibrinogen concentration and platelet count among other values were available and assessed in 139 undergoing free tissue transfer before, immediately after, and 1-3 as well as 8-11 days after surgery. In patients undergoing urgent revision for either bleeding or microvascular thrombosis, blood samples were drawn directly before re-exploration. Results: In the patients without any surgical revision and in those with thrombosis of the microvascular pedicle, both fibrinogen concentration and platelet count increased significantly during the early and late post-operative window. Patients that developed bleeding necessitating re-exploration showed an inadequate increase in fibrinogen levels, resulting in significantly lower concentrations compared to the other two groups. There were no significant differences in platelet count or PTT between these groups. Conclusion: Free flap surgery induces acute and subacute changes in coagulation, comparable to other major surgeries and severe injuries. This leads to an increase in platelet count and fibrinogen over the post-operative course. Patients that developed bleeding requiring surgical re-exploration showed an insufficient increase in fibrinogen, resulting in significantly lower fibrinogen levels. Therefore, monitoring and correction of fibrinogen levels might aid in preventing or treating bleeding complications following free flap surgery.

Coagulation during elective neurosurgery with hydroxyethyl starch fluid therapy: an observational study with thromboelastometry, fibrinogen and factor XIII

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.

Postoperative care of the neurosurgical patient

PURPOSE OF REVIEW

Monitoring and therapy of patients in neurocritical care are areas of intensive research and the current evidence needs further confirmation.

RECENT FINDINGS

A consensus statement of the Neurocritical Care Society and the European Society of Intensive Care Medicine provided pragmatic guidance and recommendations for multimodal monitoring in neurocritical care patients. Only a minority of these recommendations have strong evidence. In addition, recent multicenter randomized controlled trials concerning the therapy of subarachnoidal hemorrhage and traumatic brain injury could not show decreased mortality or improved functional neurologic outcome after the interventions. The current evidence for monitoring and medical therapy in patients after traumatic brain injury and aneurysmal subarachnoid hemorrhage is highlighted in this review.

SUMMARY

Although strong evidence is lacking, multimodal monitoring is of great value in neurocritical care patients and may help to provide patients with the optimal therapy based on the individual pathophysiological changes.

Topiramate as concomitant antiepileptic treatment; an isolated perioperative hypofibrinogenaemia

A description of a case is presented of an isolated hypofibrinogenaemia acquired in relation to taking topiramate used as concomitant treatment of a drug resistant epilepsy. The hypofibrinogenaemia developed in the course of a month after the introduction of the drug, and was diagnosed in the perioperative period.

Risk Factors for Postoperative Fibrinogen Deficiency after Surgical Removal of Intracranial Tumors

Higher levels of fibrinogen, a critical element in hemostasis, are associated with increased postoperative survival rates, especially for patients with massive operative blood loss. Fibrinogen deficiency after surgical management of intracranial tumors may result in postoperative intracranial bleeding and severely worsen patient outcomes. However, no previous studies have systematically identified factors associated with postoperative fibrinogen deficiency. In this study, we retrospectively analyzed data from patients who underwent surgical removal of intracranial tumors in Beijing Tiantan Hospital date from 1/1/2013to12/31/2013. The present study found that patients with postoperative fibrinogen deficiency experienced more operative blood loss and a higher rate of postoperative intracranial hematoma, and they were given more blood transfusions, more plasma transfusions, and were administered larger doses of hemocoagulase compared with patients without postoperative fibrinogen deficiency. Likewise, patients with postoperative fibrinogen deficiency had poorer extended Glasgow Outcome Scale (GOSe), longer hospital stays, and greater hospital expenses than patients without postoperative fibrinogen deficiency. Further, we assessed a comprehensive set of risk factors associated with postoperative fibrinogen deficiency via multiple linear regression. We found that body mass index (BMI), the occurrence of postoperative intracranial hematoma, and administration of hemocoagulasewere positively associated with preoperative-to-postoperative plasma fibrinogen consumption; presenting with a malignant tumor was negatively associated with fibrinogen consumption. Contrary to what might be expected, intraoperative blood loss, the need for blood transfusion, and the need for plasma transfusion were not associated with plasma fibrinogen consumption. Considering our findings together, we concluded that postoperative fibrinogen deficiency is closely associated with postoperative bleeding and poor outcomes and merits careful attention. Practitioners should monitor plasma fibrinogen levels in patients with risk factors for postoperative fibrinogen deficiency. In addition, postoperative fibrinogen deficiency should be remediated as soon as possible to reduce postoperative bleeding, especially when postoperative bleeding is confirmed.

Interferência e características do edema periorbital no exame pupilar após craniotomia

Objetivo Avaliar a interferência e características do edema periorbital no exame pupilar, em pacientes submetidos a craniotomia por via anterior. Métodos Estudo de coorte prospectivo realizado em pacientes no pós-operatório na unidade de terapia intensiva e internação de neurocirurgia. A interferência e características do edema periorbital no exame pupilar foram avaliados da admissão do paciente até sétimo dia de pós-operatório. O exame pupilar foi realizado por enfermeiros. Resultados Foram avaliados 100 pacientes e a incidência de edema periorbital foi de 80%. O enfermeiro não realizou o exame pupilar em 24 (30%) pacientes. As características que influenciaram na realização do exame pupilar foram coloração arroxeada e intenso edema periorbital. Conclusão O edema periorbital estava presente na maioria dos pacientes no pós-operatório de craniotomia e o exame pupilar não foi realizado em 30% dos pacientes. A presença de intenso edema periorbital e de coloração arroxeada foram características que prejudicaram o exame pupilar.