Reduction of fresh frozen plasma requirements by perioperative point-of-care coagulation management with early calculated goal-directed therapy.

This review article is presented by the European protagonists in the field of goal-directed, differentiated coagulation therapy in bleeding patients. In the first part of their manuscript, the authors describe the different strategies available to stabilize coagulation in the massively bleeding patient: 1) the formula-driven transfusion protocol based on a fixed ratio of packed red blood cells (pRBC), fresh frozen plasma (FFP) and platelet concentrates (PC) e.g. 1:1:1; 2) the PT-, aPTT- and platelet count-driven protocol; and 3) a protocol based on the results of point-of-care (POC) coagulation monitoring with thrombelastometry (ROTEM®) and platelet aggregometry (Multiplate®). At least in some parts of Europe, a paradigm shift has become apparent, clinicians moving away from the formula- and laboratory test-driven protocols towards the goal-directed administration of factor concentrates and pro-coagulant drugs (e.g. fibrinogen, prothrombin complex concentrate, tranexamic acid, desmopressin).

In the second part of the manuscript, the authors report their own retrospective experience with the POC-driven pro-coagulant therapy, nicely showing a significant decrease in the administration of FFP (overall –90%), pRBC (overall –62%) and PC (overall –72%) in three different institutions in Germany and Austria. In the meantime, the first prospective data to support these experiences have been published (Weber et al, Anesthesiology 2012;117:531-47). The cost-savings occurring in the allogeneic transfusion sector seem to over-compensate the simultaneous rise in costs for fibrinogen and prothrombin complex concentrate.

– Oliver Habler