HPE CSL Managing Perioperative Bleeding handbook | Page 14

Concentrates / blood products
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acute lung injury in patients in the intensive care unit 15 and of multiple organ failure in patients with critical injuries . 16 In a study of patients undergoing coronary artery bypass , transfusion of FPP correlated with a higher long-term mortality . 17 Finally , FPP showed to be ineffective to correct mildly prolonged coagulation values in non-bleeding patients ; 18 , 19 however , another study showed that plasma therapy reduced mortality rates in cases of massive transfusions when it was implemented at an early stage . 20 These results were not verified by a meta-analysis of randomised controlled trials evaluating FPP for anticoagulation reversal or for the prevention and treatment of bleeding associated with invasive interventions or specific pathologies . 21
Whereas the transfusion of FPP is associated with increased incidence of nosocomial infections in patients undergoing surgery for conditions other than traumatic injuries , 22 goal-directed therapy with coagulation factor concentrates has a lower potential for infectiousness and incidence of multiple organ failure compared with FFP , although no significant differences in mortality rates have been observed with the two approaches . 23 Prothrombin complex concentrates ( PCCs ), traditionally used in the treatment of haemophilia and other congenital bleeding disorders , are recommended in the emergency reversal of vitamin K-dependent oral anticoagulants . 2 A recent systematic review and metaanalysis of randomised and observational studies demonstrated a lower rate of all-cause mortality and risk of posttransfusion volume overload , accompanied by rapid INR reduction , compared with FFP in patients receiving treatment with warfarin who experienced a major bleeding event or who needed urgent surgery . 24 Unlike FPP , PCCs require small infusion volumes and can be promptly administered to patients without the need for blood group matching or thawing , which can be particularly relevant is urgent cases of patients with intracranial haemorrhage who receive oral anticoagulants , 25 but their use is associated with an increased risk of thrombosis and should therefore be carefully analysed for trauma patients .
Fibrinogen supplementation , by contrast , is superior to FPP in the reversal of severe trauma-induced coagulopathy , but because fibrinogen is a critical
haemostatic factor for efficient local clot formation it reaches its critical lower reference values before all the other factors . 26 , 27 Rescue therapy with recombinant activated FVIIa , commonly used in the treatment of haemophilia , may be considered for life-threatening bleeding events that cannot be controlled with standard surgical interventions or coagulation therapy , although its cost and risk of arterial thromboembolic events associated with higher doses , especially among the elderly , should be taken into consideration in treatment decision making . Finally , replacement therapy with FXIII concentrate does not seem to have an effect in reducing transfusion needs . 2 , 4
Conclusions In light of the current evidence in the management of perioperative bleeding , prompt and goal-directed therapy is the key element in the implementation of haemotherapy for patients with coagulopathies . This involves a rapid and comprehensive diagnosis of the existing coagulation deficits and the use of coagulation factor concentrates to restore function . Nevertheless , the question of superiority of factor concentrates versus . allogenic blood products cannot be definitely answered at this time because allogenic blood products are still indicated for particular conditions , mainly for the management of extensive blood loss with massive transfusions , and in situations where the use of factor concentrates cannot correct the underlying pathology . In conclusion , goal-directed therapy with coagulation factor concentrates is preferred , but in some rare cases clinicians may have to resort to allogenic blood products .
References 1 Tanaka KA et al . Blood coagulation : hemostasis and thrombin regulation . Anesth Analg 2009 ; 108 ( 5 ): 1433 – 46 . 2 Rossaint R et al . The European guideline on management of major bleeding and coagulopathy following trauma : fourth edition . Crit Care 2016 ; 20 ( 1 ): 100 . 3 Grottke O et al . Perioperatively acquired disorders of coagulation . Curr Opin Anestesiol 2015 ; 28 ( 2 ): 113 – 22 . 4 Kozek-Langenecker SA et al . Management of severe perioperative bleeding : guidelines from the European Society of Anaesthesiology : First update 2016 . Eur J Anaesthesiol 2017 ; 34 ( 6 ): 332 – 95 . 5 Glance LG et al . Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery . Anesthesiology 2011 ; 114 ( 2 ): 283 – 92 . 6 Koch CG at al . Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting . Crit Care Med 2006 ; 34 ( 6 ): 1608 – 16 . 7 Weber CF , Zacharowski K . Perioperative point of
care coagulation testing . Dtsch Asztebl Int 2012 ; 109 ( 20 ): 369 – 75 . 8 Straub N et al . Cost-effectiveness of POC coagulation testing using multiple electrode aggregometry . Clin Lab 2016 ; 62 ( 6 ): 1167 – 78 . 9 CRASH-2 trial collaborators , et al . Effects of tranexamic acid on death , vascular occlusive events , and blood transfusion in trauma patients with significant haemorrhage ( CRASH-2 ): a randomised , placebo-controlled trial . Lancet 2010 ; 376 ( 9734 ): 23 – 32 . 10 Gayet Ageron A et al . Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage : a meta-analysis of individual patient-level data from 40 138 bleeding patients . Lancet 2018 ; 391 ( 10116 ): 125 – 32 . 11 WOMAN trial collaborators . Effect of early tranexamic acid administration on mortality , hysterectomy , and other morbidities in women with post-partum haemorrhage ( WOMAN ): an international , randomised , double-blind , placebocontrolled trial . Lancet 2017 ; 389 ( 10084 ): 2105 – 16 . 12 Chowdary P et al . Efficacy of standard dose and 30 ml / kg fresh frozen plasma in correcting laboratory parameters of haemostasis in critically ill patients . Br J Haematol 2004 ; 125 ( 1 ): 69 – 73 . 13 Magee G , Zbrozek A . Fluid overload is associated with increases in length of stay and hospital costs : pooled analysis of data from more than 600 US hospitals . Clinicoecon Outcomes Res 2013 ; 5:289 – 96 . 14 Inaba K et al . Impact of plasma transfusion in trauma patients who do not require massive transfusion . J Am Coll Surg 2010 ; 210 ( 6 ): 957 – 65 . 15 Khan H et al . Fresh-frozen plasma and platelet transfusions are associated with development of acute lung injury in critically ill medical patients . CHEST 2007 ; 131 ( 5 ): 1308 – 14 . 16 Johnson JL et al . Effect of blood products transfusion on the development of postinjury multiple organ failure . Arch Surg 2010 ; 145 ( 10 ): 973 – 7 . 17 Bjursten H et al . Increased long-term mortality with plasma transfusion after coronary artery bypass surgery . Intensive Care Med 2013 ; 39 ( 3 ): 437 – 44 . 18 Abdel-Wahab OI et al . Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities . Transfusion 2006 ; 46 ( 8 ): 1279 – 85 . 19 Muller MC et al . Fresh frozen plasma transfusion fails to influence the hemostatic balance in critically ill patients with a coagulopathy . J Thromb Haemost 2015 ; 13 ( 6 ): 989 – 97 . 20 Riskin DJ et al . Massive transfusion protocols : the role of aggressive resuscitation versus product ratio in mortality reduction . J Am Coll Surg 2009 ; 209 ( 2 ): 198 – 205 . 21 Yang L et al . Is fresh-frozen plasma clinically effective ? An update of a systematic review of randomized controlled trials . Transfusion 2012 ; 52 ( 8 ): 1673 – 86 . 22 Sarani B et al . Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection . Crit Care Med 2008 ; 36 ( 4 ): 1114 – 18 . 23 Nienaber U et al . The impact of fresh frozen plasma vs coagulation factor concentrates on morbidity and mortality in trauma-associated haemorrhage and massive transfusion . Injury 2011 ; 42 ( 7 ): 697 – 701 . 24 Chai-Adisaksopha C et al . Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal . A systematic review and meta-analysis . Thromb Haemost 2016 ; 116 ( 5 ): 879 – 90 . 25 Imberti D et al . Emergency reversal of anticoagulation with a three-factor prothrombin complex concentrate in patients with intracranial haemorrhage . Blood Transfus 2011 ; 9 ( 20:148 – 55 . 26 Innerhofer P et al . Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma ( RETIC ): a single-centre , parallel-group , open-label , randomised trial . Lancet Haematol 2017 ; 4 ( 6 ): e258 – 71 . 27 Hiippala ST et al . Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates . Anesth Analg 1995 ; 81 ( 2 ): 360 – 5 .
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