Factor XIII Deficiency and Thrombocytopenia Are Frequent Modulators of Postoperative Clot Firmness in a Surgical Intensive Care Unit

Abstract

Objective: Fibrinogen and factor XIII (FXIII) have been shown to critically influence clot firmness in the intraoperative setting and thus likely influence intraoperative bleeding. We were interested to identify potential modulators of postoperative clot firmness in a tertiary care hospital surgical intensive care unit setting, independent of their clinical course during surgery. Methods: 272 day-shift consecutive patients were evaluated for whole blood clot firmness evaluated by the ROTEM® EXTEM thrombelastometric assay and various potential modulators of clot firmness upon arrival at the surgical intensive care unit (SICU). Results: Maximum clot firmness on the SICU was found to be independently influenced by the amount of colloids given during surgery as well as by platelet count, fibrinogen concentration, and FXIII activity at the time of SICU admission. In patients with lowest clot firmness, FXIII activity was the most important independent modulator of clot firmness; in patients with the highest clot firmness, platelet count and fibrinogen concentration were the most important modulators of clot firmness. Deficiencies (i.e., results below normal range) of these modulators of clot firmness were most prevalent for FXIII (activity < 70%: 45% of cases), which was significantly more frequent than thrombocytopenia (<150 × 10⁹/l: 32%) or fibrinogen deficiency (<1.5 g/l: 6%). Conclusions: Postoperative clot firmness as evaluated by whole blood thrombelastometry (ROTEM EXTEM assay) is independently and frequently modulated though FXIII activity and the platelet count, while fibrinogen concentration is also an independent but much less frequent modulator. Different modulators show different influences, depending on the clot firmness being present. Colloids infused during surgery also independently modulate postoperative clot firmness. Based on our data, strategies can be developed to improving postoperative care of patients with bleedings or at risk for bleeding.

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

“…Table 1 also includes the frequencies for the respective deficiencies if lower cut-off levels than regular reference range borders were used. Not unexpectedly, these results closely match ones in the early postoperative setting [ 16 ].…”

“…A very rare entity of acquired FXIII deficiency is a hemophilia-like disease caused by an anti-FXIII antibody, leading to potentially life threatening bleeding events [ 15 ]. By far the most prevalent reason for acquired FXIII deficiency is consumption in the surgical setting [ 16 ]. Treatment therefore mostly consists of FXIII substitution, sometimes in combination with immunosuppressive therapy if an autoimmune or specific inhibitory component is present.…”

“…In the immediate postoperative setting, clot firmness, as determined by thrombelastography, has been associated to the platelet count and the fibrinogen level [ 24 ]. On top of these observations, we identified FXIII as an independent predictor of overall clot firmness by multivariate analysis [ 16 ], again including platelet count and fibrinogen In that study, FXIII deficiency was very frequent immediately after surgery, as was thrombocytopenia. Fibrinogen deficiency was rather rare.…”

Hemostasis and Hemotherapy

“…However, only scarce knowledge on the relationship between thromboelastometry or thromboelastography and conventional parameters of hemostasis exists [2]. Thus, it is important to research such relationships; new research presented here shows that factor XIII, alone and in combination with other parameters, has a frequent and profound effect on postoperative clot firmness [3].…”

Thrombocytopenia: is it a prognostic factor for development of post-hemorrhagic hydrocephalus in neonates?

“…Various preclinical models of stroke have shown that rapid hematoma clearance after hemorrhagic stroke ameliorated inflammation and improved neurological deficits in the short and long terms [28]. Rappard et al [29] found that the blood clot firmness is highly depending on the platelet count and that thrombocytopenia results in a soft unstable clot. Similarly, thrombocytopenia may help in the decrease of clot formation with its sequelae of blockage, barrier impairment, and inflammatory reaction, and even if the intraventricular hematoma is formed it is not firm and usually resorbs faster.…”