Best practice & research. Clinical anaesthesiology
-
Best Pract Res Clin Anaesthesiol · Mar 2010
ReviewPerioperative coagulation management--fresh frozen plasma.
Clinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. ⋯ FP24 and thawed plasma are alternatives to FFP with similar indications for administration. Both provide an opportunity for increasing the safe plasma donor pool. Although prothrombin complex concentrates and factor VIIa may be used as alternatives to FFP in a variety of specific clinical contexts, additional study is needed.
-
Perioperative coagulopathy impacts on patient outcome by influencing final blood loss and transfusion requirements. The recognition of pre-existing disturbances and the basic understanding of the principles of and dynamic changes of haemostasis during surgery are pre-conditions for safe patient management. The newly developed cellular model of coagulation facilitates the understanding of coagulation, thereby underscoring the importance of the tissue factor-bearing cell and the activated platelet. ⋯ Recent data from studies using viscoelastic coagulation studies confirm the central role of fibrinogen in stable clot formation and provide essential knowledge about its changes during blood loss and fluid administration. Besides early decrease in clot firmness during mild-to-moderate dilution, profound dilution results in a critical decrease in thrombin generation as well as a reduction in numbers and function of platelets. Although our knowledge of perioperative coagulopathy has dramatically increased over the past few years, several questions such as critical thresholds for fibrinogen, platelets, impact of FXIII and TAFI remain unanswered and need to be investigated further.
-
Best Pract Res Clin Anaesthesiol · Mar 2010
ReviewNew insights into acute coagulopathy in trauma patients.
Abnormal coagulation parameters can be found in 25% of trauma patients with major injuries. Furthermore, trauma patients presenting with coagulopathy on admission have worse clinical outcome. Tissue trauma and systemic hypoperfusion appear to be the primary factors responsible for the development of acute traumatic coagulopathy immediately after injury. ⋯ This coagulopathy can then be exacerbated by subsequent physiologic and physical derangements such as consumption of coagulation factors, haemodilution, hypothermia, acidemia and inflammation, all factors being associated with ongoing haemorrhage and inadequate resuscitation or transfusion therapies. Knowledge of the different mechanisms involved in the pathogenesis of acute traumatic coagulopathy is essential for successful management of bleeding trauma patients. Therefore, early evidence suggests that treatment directed at aggressive and targeted haemostatic resuscitation can lead to reductions in mortality of severely injured patients.
-
Recombinant activated factor VII (rFVIIa) is a haemostatic agent, which was originally developed for the treatment of haemophilia patients with inhibitors against factor FVIII or FIX. The efficacy of rFVIIa in preventing or stopping life-threatening bleeding for these patients has been demonstrated in several studies. ⋯ Conflicting results have been reported from various studies. Considering the lack of data and potential publication bias associated with case reports, this review summarises the clinical evidence of the efficacy and safety of rFVIIa in the perioperative period.