title: Decreased factor XIII availability for thrombin and early loss of clot firmness in patients with unexplained intraoperative bleeding.
abstract: To explore relevant changes in unexplained intraoperative bleeding, we evaluated elements of the final steps of the coagulation cascade in 226 consecutive patients undergoing elective surgery. Patients were stratified for the occurrence of unexplained intraoperative bleeding according to predefined criteria. Twenty patients (8.8%) developed unexplained bleeding. The median intraoperative blood loss was 1350 mL (bleeders) and 400 mL (nonbleeders) (P < 0.001). Fibrinogen and Factor XIII (F. XIII) were more rapidly consumed in bleeders (P < 0.001). Soluble fibrin formation (fibrin monomer) was increased in bleeders throughout surgery (P < or = 0.014). However, F. XIII availability per unit thrombin generated was significantly decreased in bleeders before, during, and after surgery (P < or = 0.051). Computerized thrombelastography showed a parallel, significant reduction in clot firmness. We suggest that mild preexisting coagulopathy is not rare in surgical patients and probably can result in clinically relevant intraoperative bleeding. This hemostatic disorder shows impaired clot firmness, probably secondary to decreased cross-linking (due to a loss of F. XIII, both in absolute measures and per unit thrombin generated). We suggest that the application of F. XIII might be worthwhile to test in a prospective clinical trial to increase clot firmness in patients at risk for this intraoperative coagulopathy.
authors.affiliation: *Institute for Anesthesiology and †Institute for Clinical Chemistry and Hematology, Kantonsspital, St. Gallen, Switzerland; and ‡Department of Clinical Research, University of Bern, Bern, Switzerland.
authors.forename: Patrick
authors.initials: P
authors.lastname: Wettstein
authors.forename: André
authors.initials: A
authors.lastname: Haeberli
authors.forename: Monika
authors.initials: M
authors.lastname: Stutz
authors.forename: Miriam
authors.initials: M
authors.lastname: Rohner
authors.forename: Cinzia
authors.initials: C
authors.lastname: Corbetta
authors.forename: Konrad
authors.initials: K
authors.lastname: Gabi
authors.forename: Thomas
authors.initials: T
authors.lastname: Schnider
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Korte
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001777:Blood Coagulation / Q000502:physiology*; D016063:Blood Loss, Surgical; D015992:Body Mass Index; D003627:Data Interpretation, Statistical; D005176:Factor XIII / Q000032:analysis / Q000378:metabolism*; D005260:Female; D005337:Fibrin / Q000378:metabolism; D005340:Fibrinogen / Q000378:metabolism; D006400:Hematocrit; D006801:Humans; D008297:Male; D008875:Middle Aged; D010949:Plasma; D013916:Thrombelastography; D013917:Thrombin / Q000378:metabolism*
chemical_list: D005337:Fibrin; D005340:Fibrinogen; D005176:Factor XIII; D013917:Thrombin