The impact of acquired coagulation factor XIII deficiency in traumatic bleeding and wound healing

Kleber, Christian; Sablotzki, Armin; Casu, Sebastian; Olivieri, Martin; Thoms, Kai‐Martin; Horter, Johannes; Schmitt, Felix C. F.; Birschmann, Ingvíld; Fries, Dietmar; Maegele, Marc; Schöchl, Herbert; Wilhelmi, Michaela

doi:10.1186/s13054-022-03940-2

Cited by 24 publications

(17 citation statements)

References 90 publications

(137 reference statements)

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“…Blood loss and tissue trauma in severely wounded patients result in an activation of profibrinolytic pathways, glycocalyx damage, hypoperfusion-related acidosis and the dilution of the remaining coagulation factors mostly due to a crystalloid fluid-replacement therapy [ 5 ]. The above and an insufficient cross-linking of fibrin monomers due to an FXIII deficiency result in poor clot quality and higher susceptibility to clot lysis [ 11 , 12 ]. However, the impact of a low FXIII level on the blood loss in trauma is poorly understood.…”

Section: Discussionmentioning

confidence: 99%

“…A joint, trauma-specific European guideline on the management of major bleeding and coagulopathy following trauma has not yet identified any specific FXIII threshold value at which FXIII should be administered [ 16 ]. A recent review from a trauma expert group suggests that a cut-off for FXIII activity of ~60–70% is appropriate to diagnose an acquired FXIII deficiency [ 12 ].…”

Section: Discussionmentioning

confidence: 99%

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

Katzensteiner

Ponschab

Schöchl

et al. 2022

JCM

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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.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Katzensteiner

Ponschab

Schöchl

et al. 2022

JCM

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“…[550][551][552][553][554][555] In cases of severe haemorrhagic complications during major orthopaedic surgery that raise suspicion of accelerated factor consumption (acquired deficiency), especially in oncological or septic procedures, 556,557 it is suggested requesting a quantitative determination of FXIII activity (or antigen) 558 to determine if the patient has sufficient levels to achieve haemostasis (50 to 60%), which will also favour proper wound healing. 559 Replacement is suggested in cases of severe deficiency and risk of bleeding despite normal thrombo-elastometric or conventional coagulation variables. 560 Cell salvage Generally, cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion, but in major orthopaedic procedures, the clinical use of autologous reinfusion systems has decreased.…”

Section: Drainagementioning

confidence: 99%

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Kietaibl

Ahmed

Afshari

et al. 2023

European Journal of Anaesthesiology

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BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

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“…There is no clear threshold of FXIII activity after which there will be symptomatic bleeding events. Some research, however, suggested that at around 60–70% FXIII activity will be an increased bleeding risk after severe trauma or surgery [14], and a minimum of around 30% activity is thought to be necessary to prevent symptomatic bleeding [15]. Unlike other FXIII deficiency conditions, patients with aFXIII deficiency have lower FXIII activity, 8.5% on average, and more frequently (86%) have severe (grade III) bleeding episodes [3].…”

Section: Discussionmentioning

confidence: 99%

Management of autoimmune factor XIII deficiency in a frail, elderly patient

Kaneko

Ishimaru

Nakajima

et al. 2023

Blood Coagulation &Amp; Fibrinolysis

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Autoimmune factor XIII/13 deficiency (aFXIII deficiency) is a rare hemorrhagic disorder, for which typical guideline-directed treatment is aggressive immunosuppressive therapy. Approximately 20% of patients are over 80 years old; however, and optimum management of such patients has not reached consensus. Our elderly patient had massive intramuscular hematoma, and aFXIII deficiency was diagnosed. The patient opted against aggressive immunosuppressive therapy, so he was managed with conservative treatment only. Thorough survey of other correctable causes of bleeding and anemia is also required in similar cases. Our patient's serotonin–norepinephrine reuptake inhibitor use and multivitamin deficiency (vitamin C, B12 and folic acid) were revealed to be aggravating factors. Fall prevention and muscular stress prevention are also important in elderly patients. Our patient had two relapses of bleeding within 6 months, which were improved spontaneously by bed rest without factor XIII replacement therapy or blood transfusion. Conservative management may be preferred for frail and elderly patients with aFXIII deficiency when they opt against standard therapy.

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The impact of acquired coagulation factor XIII deficiency in traumatic bleeding and wound healing

Cited by 24 publications

References 90 publications

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

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

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

Management of autoimmune factor XIII deficiency in a frail, elderly patient

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