Altered Fibrinolysis during and after Surgery

Abstract

Major surgery induces hemostatic changes related to surgical stress, tissue destruction, and inflammatory reactions. These changes involve a shift of volume from extravascular space to intravascular and interstitial spaces, a “physiologic” hemodilution of coagulation proteins, and an increase of plasmatic fibrinogen concentration and platelets. Increases in fibrinogen and platelets together with a simultaneous dilution of pro- and anticoagulant factors and development of a hypofibrinolytic status result in a postoperative hypercoagulable state. This profile is accentuated in more extensive surgery, but the balance can shift toward hemorrhagic tendency in specific types of surgeries, for example, in prolonged cardiopulmonary bypass or in patients with comorbidities, especially liver diseases, sepsis, and hematological disorders. Also, acquired coagulopathy can develop in patients with trauma, during obstetric complications, and during major surgery as a result of excessive blood loss and subsequent consumption of coagulation factors as well as hemodilution. In addition, an increasing number of patients receive anticoagulants and antiplatelet drugs preoperatively that might influence the response to surgical hemostasis. This review focuses on those situations that may change normal hemostasis and coagulation during surgery, producing both hyperfibrinolysis and hypofibrinolysis, such as overcorrection with coagulation factors, bleeding and hyperfibrinolysis that may occur with extracorporeal circulation and high aortic-portal-vena cava clamps, and hyperfibrinolysis related to severe maintained hemodynamic disturbances. We also evaluate the role of tranexamic acid for prophylaxis and treatment in different surgical settings, and finally the value of point-of-care testing in the operating room is commented with regard to investigation of fibrinolysis.

Abnormal bleeding after lumbar vertebrae surgery because of acquired factor XIII deficiency: A case report and literature review

“…[13] Surgical stress, tissue destruction, and the release of inflammatory mediators lead to disruption of the physiological balance between coagulation and fibrinolysis. [15][16][17] Excessive bleeding and hemodilution similarly induce abnormalities in coagulation and fibrinolytic function. [18] Thrombosis can be attributed to postoperative hypercoagulability, blood stasis, and endothelial injury, whereas excessive bleeding is mostly due to secondary hyperfibrinolysis.…”

“…[21] Others, such as thromboelastograms, may also partially reflect fibrinolytic status but are not recommended for use alone to guide therapy. [22] For the treatment of hyperfibrinolysis, the 2 most widely used antifibrinolytic drugs for the treatment of hyperfibrinolysis are TXA and epsilon aminocaproic acid, [16,18] TXA is recommended within 1 hour after trauma for optimal clinical benefit. [21] Table 1 Routine laboratory investigations including liver and kidney function, electrolytes, blood routine, routine coagulation function on March 12, 2023 FXIII, also known as "fibrin factor," is distinct from other coagulation factors in that its potentially active subunit is present in a wide range of cells [23,24] and is activated by thrombin and calcium ions (Ca 2+ ) during the final stages of coagulation.…”

Genomic Analysis of Thrombophilia Variants in the General Population for the Creation of an Effective Preoperative Screening Tool

“…For most other cases, however, there is a relative perioperative prothrombotic state with elevated levels of factor VIII, fibrinogen, Table 1 Genes associated with thrombotic risk factors thrombin-antithrombin complex, and VWF, as well as decreased fibrinolysis and hyperactivity of platelet. 4 Impairment in fibrinolysis may persist for 3 to 5 days after surgery. 5 In the general population, with regard to VTE, one is more likely to develop a DVT between 2 and 10 days after surgery with a higher risk persisting for up to 3 months.…”

Impaired Whole-Blood Fibrinolysis is a Predictor of Mortality in Intensive Care Patients

“…Additionally, abnormalities in the fibrinolytic system have been described in other critically ill patient populations including trauma patients 11 , post-operative patients 12 and individuals with liver disease 13 . Currently, we have few, if any, options for assessing fibrinolysis in the routine diagnostic lab 14 .…”