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Anesth Analg 2004;99:1564-1569
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000134800.46276.21

GENERAL ARTICLES

Decreased Factor XIII Availability for Thrombin and Early Loss of Clot Firmness in Patients with Unexplained Intraoperative Bleeding

Patrick Wettstein, MD*,{dagger}, André Haeberli, PhD{ddagger}, Monika Stutz{ddagger}, Miriam Rohner{dagger}, Cinzia Corbetta{dagger}, Konrad Gabi, MD*, Thomas Schnider, MD*, and Wolfgang Korte, MD{dagger}

*Institute for Anesthesiology and {dagger}Institute for Clinical Chemistry and Hematology, Kantonsspital, St. Gallen, Switzerland; and {ddagger}Department of Clinical Research, University of Bern, Bern, Switzerland

Address correspondence and reprint requests to Wolfgang Korte, MD, Institute for Clinical Chemistry and Hematology, Kantonsspital, CH 9007 St. Gallen, Switzerland. Address e-mail to wolfgang.korte{at}ikch.ch

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 ≤ 0.014). However, F. XIII availability per unit thrombin generated was significantly decreased in bleeders before, during, and after surgery (P ≤ 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.

IMPLICATIONS: From a prospective study of 226 patients undergoing elective surgery, we suggest that unexplained intraoperative bleeding might occur secondary to a preexisting, nonovert coagulopathy with decreased Factor XIII availability and a consecutive reduction of clot firmness during surgical stress.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press
Copyright © 2004 by the International Anesthesia Research Society.