Perioperative Bleeding - Factor Deficiencies

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Previously undiagnosed inherited factor deficiencies (such as hemophilia, von Willebrand disease and deficiencies of factors I [fibrinogen], II [prothrombin], VII, X and XIII) can present as perioperative bleeding. Perioperative bleeding can also occur from acquired factor deficiencies, either as a result of:
  • Massive bleeding and subsequent blood volume replacement with products that do not contain coagulation factors, leading to dilutional coagulopathy
  • Diseases that reduce the production of coagulation factors, increase the consumption of coagulation factors or inactivate coagulation factors, e.g. leukemia or liver disease
  • Treatment with drugs that reduce coagulation factor production, e.g. warfarin (Coumadin) therapy, which can lead to deficiencies of vitamin K-dependent coagulation factors
Acquired fibrinogen (factor I) deficiency - also known as hypofibrinogenemia - can cause severe perioperative bleeding 5 and is responsible for most cases of fibrinogen-deficiency–related severe bleeding. 6   It may emerge as a result of:
  • Disease that concurs with reduced levels of fibrinogen
  • Conditions where the fibrinogen molecule becomes dysfunctional (e.g. liver disease)
  • A profound loss of fibrinogen as a result of massive bleeding and blood dilution with volume expanders or massive transfusion   7
Possible causes of acquired fibrinogen deficiency and their associated conditions are shown in Table 1. Acquired fibrinogen deficiency is believed to be an early event in patients with serious bleeding, occurring before the depletion of other coagulation factors and platelets. 7

Table 1. Diseases and conditions associated with acquired fibrinogen deficiency 8
Possible cause Disease/condition
Fibrinogen loss
Volume resuscitation in trauma and elective surgery and in cardiovascular surgery because of priming of the cardiopulmonary bypass (CPB)
•  Massive transfusion
•  Blood dilution with volume expanders
•  Extended tissue injury
Consumption of fibrinogen
•  Disseminated Intravascular Coagulation (DIC) – the most common consumptive coagulopathy
•  Obstetric complications
•  Hemolysis
 Acute leukemia
•  Viper toxins
Hyperfibrinolysis – break down of fresh blood clots
•  Major trauma
 Surgery or injury of organs with profibrinolytic potential (e.g. liver, prostate)
•  Thrombolytic therapy
Impaired synthesis of fibrinogen
 Impaired liver function
 Hepatocellular carcinoma
 Therapy with asparaginase

CSL Behring products used in the treatment of perioperative bleeding associated with acquired fibrinogen (factor I) deficiency include:

CSL Behring's fibrinogen concentrate is licensed for acquired fibrinogen deficiency under the trade name Haemocomplettan® P in Austria, Brazil, Bulgaria, Czech Republic, Germany, Hungary, Iran, Israel, Kuwait, The Netherlands, Portugal, Romania, Switzerland, Taiwan, Turkey.Product availability varies from country to country, depending on registration status. Please contact your local CSL Behring representative.

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