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Intraoperative clotting factor dilution and activated hemostasis in children with Ewing's sarcoma or osteosarcoma: a
U Nowak-Göttl1, E Schaudin, C Hoffmann
1Department of Pediatric Hematology and Oncology, University Hospital Münster, Germany.
Insights
Major surgery in young cancer patients causes significant changes in blood clotting and fibrinolysis. Monitoring these hemostatic parameters, especially with hematocrit correction, is crucial for managing bleeding risks and guiding treatment.
Area of Science:
- Oncology
- Hematology
- Surgical Research
Background:
- Investigated intraoperative coagulation and fibrinolysis in pediatric patients with Ewing's sarcoma and osteosarcoma undergoing major surgery.
- Focused on young patients (n=12 each) to understand surgical impacts on hemostasis.
Purpose of the Study:
- To prospectively evaluate intraoperative hemostatic changes in pediatric sarcoma patients.
- To correlate these changes with hematocrit (HCT) readings.
- To assess the impact of surgery and transfusion on coagulation and fibrinolysis.
Main Methods:
- Collected blood samples at multiple time points: pre-anesthesia, 2 & 4 hours post-anesthesia, post-surgery, and first postoperative day.
- Measured various hemostatic markers including von Willebrand factor, fibrinogen, antithrombin III, D-dimer, and others.
- Adjusted intraoperative and postoperative hemostatic parameters based on preoperative HCT readings.
Main Results:
- Major surgery led to dilution coagulopathy due to blood product transfusion.
- Postoperatively, von Willebrand factor and fibrinogen levels significantly increased, while antithrombin III decreased.
- D-dimer levels significantly rose post-incision, indicating clot formation; T-PA and PAI 1 also increased during surgery.
- 25% of patients required re-operation for severe hemorrhage within 36 hours.
Conclusions:
- Hemostatic parameters are valuable for monitoring surgery- and transfusion-induced hemostatic imbalance.
- Hematocrit (HCT) correction is essential for accurate interpretation of plasma protein concentrations.
- HCT correction influences decisions regarding the necessity and frequency of protein concentrate substitution therapy.
Background:
The study was designed to evaluate prospectively intraoperative changes in coagulation and fibrinolysis in young patients with Ewing's sarcoma (n = 12) or osteosarcoma (n = 12) who underwent major surgery, and to relate them to hematocrit (HCT) readings.
Materials And Methods:
Blood samples (von Willebrand factor, fibrinogen, antithrombin III, protein C, plasminogen, t-PA ag, PAI 1 activity, F1+2, D-dimer, PAP) were obtained immediately prior to starting anesthesia, two and four hours later, immediately after surgery and on the first postoperative day. Intra- and postoperative hemostatic parameters were adjusted to preoperative HCT readings.
Results:
Major surgery induced dilution coagulopathy due to blood product transfusion to support the patient's vascular volume. Postoperatively, VWF (0.01) and fibrinogen (0.007) were found to be significantly enhanced, whereas antithrombin III levels were significantly (0.007) decreased. D-dimer formation showed a clear, significant (0.0019) rise two hours after skin incision and remained elevated through the first postoperative day. F1+2 and PAP showed only minor deviations. T-PA (0.012) and PAI 1 (0.001) rose during the operation and normalized on the first postoperative day. Within 36 hours of the initial operation, six of the 24 patients (25%) returned to surgery to stop severe hemorrhage.
Conclusions:
These findings indicate that hemostatic parameters may be useful when monitoring surgery- and transfusion-induced hemostatic imbalance. Furthermore, the significant differences between the HCT-uncorrected concentration of the various plasma proteins clearly demonstrated the need to use HCT correction factors which may influence the necessity for and/or the frequency of substitution therapy with protein concentrates.