Factor XIII Measurement and Substitution in Trauma Patients after Admission to an Intensive Care Unit

Abstract

Trauma patients admitted to an intensive care unit (ICU) may potentially experience a deficiency of coagulation factor thirteen (FXIII). In this retrospective cohort study conducted at a specialized trauma center, ICU patients were studied to determine the dependency of FXIII activity levels on clinical course and substitution with blood and coagulation products. A total of 189 patients with a median injury severity score (ISS) of 25 (16–36, IQR) were included. Abbreviated injury scores for extremities (r = −0.38, p < 0.0001) but not ISS (r = −0.03, p = 0.45) showed a negative correlation with initial FXIII levels. Patients receiving FXIII concentrate presented with a median initial FXIII level of 54 (48–59)% vs. 88 (74–108)%, p < 0.0001 versus controls; they had fewer ICU-free days: 17 (0–22) vs. 22 (16–24), p = 0.0001; and received higher amounts of red blood cell units: 5 (2–9) vs. 4 (1–7), p < 0.03 before, and 4 (2–7) vs. 1 (0–2), p < 0.0001 after FXIII substitution. Matched-pair analyses based on similar initial FXIII levels did not reveal better outcome endpoints in the FXIII-substituted group. The study showed that a low initial FXIII level correlated with the clinical course in this trauma cohort, but a substitution of FXIII did not improve endpoints within the range of the studied FXIII levels. Future prospective studies should investigate the utility of FXIII measurement and lower threshold values of FXIII, which trigger substitution in trauma patients.

The potential impact of coagulation factor XIII in trauma-induced coagulopathy – a retrospective case series analysis

“…Following supplementation of FXIII (i.e., when patients were in the ICU), RBC transfusion was not significantly different between the groups, suggesting that treatment might have a positive effect in stabilizing the patients’ coagulation status. This finding is in line with observations made by Katzensteiner et al who reported a stongly negative correlation between FXIII levels and the amount of RBCs transfused prior to the first FXIII evaluation [ 17 ]. The observed necessity for an increased transfusion of FC, PC as well as additional supplementation of FXIII in some patients during the ICU stay might be related to prolonged bleeding due to more pronounced coagulopathy and prolonged vasopressor therapy in the FXIII group.…”

“…Notably, and comparable to other studies, e.g. Katzenstensteiner et al, the decision whether to substitute FXIII exclusively based on clinical judgment and independently from FXIII values [ 17 ].…”

“…The impact of FXIII activity in more complex, acute bleeding situations (as frequently observed in major trauma patients), is uncertain as no randomized controlled trials have specifically analyzed FXIII levels or the effects of FXIII replacement therapy. However, some trauma centers evaluated the effect of FXIII substitution in major bleeding situations/ after transfusion of a certain amount of RBCs [ 2 , 3 , 17 ] One major finding, observed in all these studies was a low FXIII activity. Thus, the aim of our current study was to further evaluate the effect and potential impact of coagulation FXIII substitution in patients with severe bleedings.…”

Perioperative Considerations in Management of the Severely Bleeding Coagulopathic Patient

“… 168 In a larger retrospective study in trauma patients, low factor XIII levels after hospital admission correlated with an adverse clinical course of patients. 169 Replacement of factor XIII levels with factor XIII concentrate failed to reduce transfusion demands. Further clinical studies are needed to clarify the population, dosing interval, and outcomes if using these agents for uncontrollable bleeding.…”