4

Donat R Spahn MD FRCA Institute of Anesthesiology , University and University Hospital of Zurich , Switzerland

Bleeding and coagulopathy both increase mortality and morbidity of patients undergoing surgery or after trauma . 1 – 3 Therefore , the following aspects are key for the successful management of a bleeding patient : Early surgical or interventional source control within the concept of damage control surgery , understanding of the physiology and pathophysiology of haemostasis , early and repeated monitoring of coagulation and having an individualised goaldirected coagulation algorithm . 3

“ Severely injured patient presenting with deep haemorrhagic shock , signs of ongoing bleeding and coagulopathy to undergo damage control surgery ’’. 3 This situation is characterised by a core temperature below 34 ° C , a pH ≤ 7.2 and ongoing coagulopathy . 3 In this situation , fractures are stabilised with external fixators rather than primary definitive osteosynthesis , the aim being to arrive in the intensive care unit within 60 min for rewarming and further stabilisation . 3 , 4

Physiologically , the haemostasis process starts when the endothelial layer is disrupted and platelets become in contact with the sub-endothelial structures ; 5 they then become progressively linked to the subendothelium via von Willebrand factor and collagen and are activated . This activation results in an inside-out activation of glycoprotein 2b3a receptors that will serve as anchor points for fibrinogen . This fibrinogen platelet to platelet linking results in an initial platelet plug . 5 The activation of platelets

at the same time results in the secretion of thromboxane A2 , ADP and von Willebrand to recruit and activate additional platelets . Last but not least , the surface of these activated platelets provide the ideal internal milieu for the generation of a thrombin burst , which results in the transformation of fibrinogen into ( soluble ) fibrin and the activation of FXIII , which stabilises the fibrin . Fibrinogen therefore has a central role in coagulation because it is key in the stabilisation of the platelet plug and it is

“ We need to implement the coagulation algorithm with educational activities and monitor algorithm adherence to make patients benefit ”

also the substrate of the plasmatic coagulation . This is particularly important because fibrinogen is the ‘ coagulation element ’ that is the first factor to become critically low in many bleeding situations , particularly in trauma and post-partum haemorrhage . 3 , 6

Nevertheless , the individual coagulation situations are extremely variable and therefore early and repeated monitoring of coagulation and an individualised goal-directed coagulation algorithm is key for a successful management of any major bleeding following trauma , in surgery and post-partum . 3 , 7 In order to get coagulation results quickly , point-of-care technologies are key . 8 , 9

In this educational handbook , world-renowned experts review their field of expertise in a variety of clinical scenarios . It is extremely interesting to note , that today there is high-level scientific evidence that point-of-care and factor concentrate-based coagulation algorithms result in reduced :

• need for allogeneic blood products 10-16

10 , 12

• mortality

13 , 14

• incidence of acute kidney injury

• costs

10 , 11 , 17

• re-exploration rate 13 and

• length of stay . 11 These benefits have been

demonstrated in major trauma , 12 , 17 cardiac surgery , 10 , 11 , 13 , 14 , 17 paediatric surgery , 16 and post-partum haemorrhage . 15

The case therefore is clear . We are to introduce point-of-care and factor concentrate-based coagulation algorithms in the management of bleeding and haemostasis . However , creating such algorithms is not sufficient . We need to implement them and provide training in interdisciplinary situations , and monitor algorithm compliance to ensure that the patients benefit from the most advanced bleeding treatment concepts .

References 1 Ranucci M et al . Major bleeding , transfusions , and anemia : the deadly triad of cardiac surgery . Ann Thoracic Surg 2013 ; 96 ( 2 ): 478 – 85 . 2 Frith D et al . Definition and drivers of acute traumatic coagulopathy : clinical and experimental investigations . J Thromb Haemost 2010 ; 8 ( 9 ): 1919 – 25 . 3 Rossaint R et al . The European guideline on management of major bleeding and coagulopathy following trauma : fourth edition . Crit Care 2016 , 20 ( 1 ): 100 . 4 Shapiro MB et al . Damage control : collective review . J Trauma 2000 ; 49 ( 5 ): 969 – 78 . 5 Mannucci PM . Treatment of von Willebrand ’ s Disease . N Engl J Med 2004 ; 351 ( 7 ): 683 – 94 . 6 Collins PW et al . Fibrin-based clot formation as an early and rapid biomarker for progression of

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