The Need for Red Cell Support During Non-Cardiac Surgery Is Associated to Pre-Transfusion Levels of FXIII and the Platelet Count.

Silke Listyo,Eric Forrest,Lukas Graf,Wolfgang Korte

doi:10.3390/jcm9082456

Silke Listyo, Eric Forrest + Show 2 more

Open Access

https://doi.org/10.3390/jcm9082456

Copy DOI

Abstract

Unexpected intraoperative bleeding is associated with a reduced availability of crosslinking capacity (provided through factor XIII (FXIII)) per unit of generated thrombin. Furthermore, FXIII deficiency and thrombocytopenia (but not fibrinogen deficiency) are the most prevalent modulators of clot firmness in the immediate postoperative setting. In this study, we therefore evaluated whether levels of FXIII, fibrinogen, or the platelet count influenced the probability of intraoperative red cell transfusions in patients in the operating theatre. This retrospective study was comprised of 1023 patients, which were in need of blood product support in the operating theatre and of which 443 received red cell transfusions. Due to standard operating procedures, FXIII activity, fibrinogen concentration, and platelet count were measured before transfusion took place, but without influencing the decision to transfuse. FXIII deficiency was frequent (50%), as was thrombocytopenia (49%), but not fibrinogen deficiency (9%). FXIII deficiency was associated with a significantly increased probability to receive red cell transfusions (OR 4.58, 95% CI 3.46–6.05) as was thrombocytopenia (OR 1.94, 95% CI 1.47–2.56), but not fibrinogen deficiency (OR 1.09, 95% CI 0.67–1.76). Similar results were seen for cut-off independent evaluations (receiver operating characteristics (ROC) curves, using continuously distributed variables), where the areas under the curves (AUC) of red cell transfusion for FXIII activity was 0.744 (95% CI 0.716–0.770)/0.632 (95% CI 0.601–0.661) for the platelet count, and 0.578 (95% CI 0.547–0.609) for fibrinogen concentration. All AUCs were significantly different from each other (p < 0.0001 and p = 0.0106, respectively), indicating that FXIII activity was a significantly better predictor of red blood cell (RBC) transfusion than platelet count and fibrinogen concentration. These results suggest that pre-transfusion FXIII activity and to a lesser extent the platelet count influence the probability of intraoperative red cell transfusions. Modifying FXIII activity and/or the platelet count might influence the need for downstream red cell transfusion, thus potentially reducing transfusion associated morbidity. This, however, needs confirmation in future studies.

Highlights

Unexpected and unexplained intraoperative coagulopathies and bleeding continue to be a diagnostic and therapeutic dilemma
Using a look back analysis, we evaluated the potential association of pre-transfusion factor XIII (FXIII) activity, fibrinogen level, and platelet count with intraoperative red cell transfusion in a routine surgical setting
Data were evaluated in three ways: first, the prevalence of the respective coagulation factor deficiencies alone or in combination were determined; second, odds ratios for the transfusion of red cell concentrates in the whole cohort depending on whether or not a deficiency was present, were calculated; third, from continuously distributed data, receiver operating characteristics (ROC) curves were constructed on the use of red cell concentrates for every variable; and ROC curves’ areas under the curves (AUC) were compared to the number of red cell concentrates transfused if one abnormality was present (Mann–Whitney testing)

Summary

Introduction

Unexpected and unexplained intraoperative coagulopathies and bleeding continue to be a diagnostic and therapeutic dilemma. Our group has previously shown that patients undergoing elective surgery (and in which unexplained and unexpected intraoperative bleeding occurs) exhibit a higher degree of prothrombin conversion as well as reduced availability of crosslinking capacity (most likely due to reduced FXIII activity) per unit of generated thrombin. This leads to reduced clot firmness and higher blood loss [17]. It seems reasonable to believe that the conditions found very early postoperatively might be similar to the ones present during surgery

Methods

Results

Conclusion