Abstract
Background: One cause of diffuse bleeding after cardiac operations may be a low plasma concentration of coagulation Factor XIII, which is essential for coagulation but is not covered by standard coagulation monitoring. Patients and Methods: In a prospective, randomized, double blinded study, 2500 units, 1250 units, and a placebo were administered in groups of 25 patients each, immediately after administration of protamine. Postoperative amount of blood loss and blood transfusion was recorded. Results: Patients were not statistically different with respect to the course of plasma levels of Factor XIII until administration of the study drug. In all groups Factor XIII fell from preoperative normal values to subnormal values after extracorporeal circulation. After administration of the study drug, Factor XIII increased to 71 %, 85 %, 103 % in the placebo, 1250 units, and 2500 units group, respectively, and these differences were statistically significant (p < 0.05). Postoperative blood loss was lowest in the 2500 units group and highest in the placebo group, however this was not significantly different. There was also no significant difference in the amount of blood transfusion. After differentiating all patients according to their post medication Factor XIII level into two groups with levels of < 70 % and ≥ 70 %, postoperative blood loss was found to be significantly higher in the < 70 % group as was the amount of blood transfusions. Conclusions: Factor XIII administration reduces postoperative blood loss and the extent of blood transfusion after coronary surgery, however administration is only helpful if plasma levels are below the normal value. Measurement of plasma levels is recommended before Factor XIII substitution.
Key words
Factor XIII - extracorporeal circulation - postoperative bleeding - blood transfusion
References
-
1
Wilhelmi M, Franke U, Cohnret T, Weber P, Kaukemuller J, Fischer S, Wahlers T, Haverich A.
Coronary artery bypass grafting surgery without the routine application of blood products: Is it feasible?.
Eur J Cardiothorac Surg.
2001;
19
657-661
-
2
McGill N, O'Shaughnessy D, Pickering R, Herbertson M, Gill R.
Mechanical methods of reducing blood transfusion in cardiac surgery: randomised controlled trial.
BMJ.
2002;
324
1299
-
3
Ferraris V A, Ferraris S P, Joseph O, Wehner P, Mentzer Jr R M.
Aspirin and postoperative bleeding after coronary artery bypass grafting.
Ann Surg.
2002;
235
820-827
-
4
Ray M J, Hales M M, Brown L, O'Brien M F, Stafford E G.
Postoperatively administered aprotinin or epsilon aminocaproic acid after cardiopulmonary bypass has limited benefit.
Ann Thorac Surg.
2001;
72
521-526
-
5
Troianos C A, Sypula R W, Lucas D M, D'Amico F, Mathie T B, Desai M, Pasqual R T, Pellegrini R V, Newfeld M L.
The effect of prophylactic epsilon-aminocaproic acid on bleeding, transfusions, platelet function, and fibrinolysis during coronary artery bypass grafting.
Anesthesiology.
1999;
91
430-435
-
6
Locker G J, Grimm M, Losert H, Stoiser B, Kofler J, Knapp S, Wilfing A, Knoebl P, Kapiotis S, Czerny M, Muhm M, Hiesmayr M, Frass M.
Prostaglandin E(1) does not influence plasmatic coagulation, hepatic synthesis, or postoperative blood loss in patients after coronary-artery bypass grafting.
J Clin Anesth.
2000;
12
363-370
-
7
Godje O, Haushofer M, Lamm P, Reichart B.
The effect of factor XIII on bleeding in coronary surgery.
Thorac Cardiovasc Surg.
1998;
46
263-267
-
8
Gerlach R, Raabe A, Zimmermann M, Siegemund A, Seifert V.
Factor XIII deficiency and postoperative hemorrhage after neurosurgical procedures.
Surg Neurol.
2000;
54
260-264
264-265 (discussion)
-
9
Wozniak G, Noll T, Akinturk H, Thul J, Muller M.
Factor XIII prevents development of myocardial edema in children undergoing surgery for congenital heart disease.
Ann N Y Acad Sci.
2001;
936
617-620
-
10
Shainoff J R, Estafanous F G, Yared J P, DiBello P M, Kottke-Marchant K, Loop F D.
Low factor XIIIa levels are associated with increased blood loss after coronary artery bypass grafting.
J Thorac Cardiovasc Surg.
1994;
108
437-445
-
11
Levy J H.
Efficacy and safety of aprotinine in cardiac surgery.
Orthopedics.
2004;
27
659-662
-
12 Vorstand und Wissenschaftlicher Beirat der Bundesärztekammer .Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten. Köln; Deutscher Ärzte-Verlag 1995
-
13
Gierhake F W, Papastavrou N, Zimmermann K, Bohn H, Schwick H G.
Prophylaxe postoperativer Wundheilungsstörungen durch Faktor XIII Substitution.
Dtsch Med Wschr.
1974;
99
1004-1009
-
14
Homann B, Blumenberg D, Lerner H.
Zum Einfluss der Narkose auf den Blutgerinnungsfaktor XIII.
Anaesthesist.
1984;
33
145-148
-
15
Schwarzt M L, Pizzo S V, Hill R L, McKee P A.
Human Factor XIII from plasma and platelets.
J Biol Chem.
1973;
248
1395-1407
-
16
Birnbaum D, Betz P.
Die extrakorporale Zirkulation als Risikofaktor der Herzchirurgie.
Z Kardiol.
1990;
79 (Suppl 4)
87-93
-
17
Tilsner V, Pokar H, Döring V, Reuter H, Marx G.
Nichtkardiale Risikofaktoren in der Herzchirurgie - Gerinnungssystem.
Z Kardiol.
1990;
79 (Suppl 4)
63-70
-
18
Boldt J, Schindler E, Welters I, Wittstock M, Stertmann W A, Hempelmann G.
The effect of the anticoagulation regimen on endothelial-related coagulation in cardiac surgery patients.
Anaesthesia.
1995;
50
954-960
-
19
Zilla P, Fasol R, Groscurth P, Klepetko W, Reichenspurner H, Wolner E.
Blood platelets in cardiopulmonary bypass operations.
J Thorac Cardiovasc Surg.
1989;
97
379-388
-
20
Holloway D S, Summaria L, Sandesare J, Vaagher J P, Alexander J C, Caprini J A.
Decreased platelet number and function and increased fibrinolysis contribute to postoperative bleeding in cardiopulmonary bypass patients.
Thromb Haemost.
1988;
59
62-67
-
21
Pleym H, Stenseth R, Wahba A, Bjella L, Tromsdal A, Karevold A, Dale O.
Prophylactic treatment with desmopressin does not reduce postoperative bleeding after coronary surgery in patients treated with aspirin before surgery.
Anesth Analg.
2004;
98
578-584
-
22 Centeon Pharma GmbH .Product Information Fibrogammin HS (Factor XIII). Hattersheim, Germany; 2004
-
23
Mishima Y, Nagao F, Ishibiki K, Matsuda M, Nakamura N.
Faktor XIII in der Behandlung postoperativer therapierefraktärer Wundheilungsstörungen.
Chirurg.
1984;
55
803-808
-
24
Baer U, Bauknecht J, Stangl T, Häring R.
Verminderung postoperativer Wundheilungsstörungen durch prä- oder postoperative quantitative Faktor XIII Substitution.
Zbl Chirurgie.
1980;
105
642-651
MD PhD Oliver Gödje Associate Professor of Cardiac Surgery
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88480 Stetten
Germany
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Fax: + 49 17 27 55 55 66
Email: goedje@pulsion.com
