gms | German Medical Science

Objective: Decompressive craniectomy (DC) is a life-saving procedure and performed in patients suffering from space-occupying lesions of various underlying pathologies. An effective coagulation management is essential for prevention of an excessive blood loss and surgical morbidity in these patients. Therefore we introduced an institutional coagulation management protocol (ICMP) focusing on the reduction of transfusions of allogeneic blood products. The aim of this study was to evaluate the utilization of blood products in patients with DC after implementation of ICMP.

Methods: In this study, we analyzed the data of patients who underwent DC from a prospective conducted DC-database from 2012 to 2015. The ICMP was introduced in 07/2014. The period from 03/2012 to 06/2014 (epoch A) included 157 patients with DC. The period from 07/2014 to 10/2015 (epoch B) included 100 patients who underwent DC. The number of red blood cells units (RBCU) and platelet units (PU) given perioperatively was analyzed in each epoch. Further analysis focused on the occurrence of bleeding complications. In evidence of intake of antiplatelet drugs (APD), the platelet testing was performed with PFA-100™ test or aggregometry on whole blood. In evidence of intake of vitamin K antagonists (VKA) or novel oral anticoagulants (NOAC), international normalized ratio (INR), anti-factor-Xa activity level or thrombin clotting time were analyzed. According to our ICMP we started the reversal of APD with intra-venous (i.v.) bolus application of 1 g tranexamic acid (TXA) followed by continuous i.v. application of TXA in a dosage of 20 mg/kg during 8 h. For procedures with a higher risk for bleeding, Minirin® (DDAVP) was administered with a dosage of 0.3 μg/kg as an i.v. bolus additionally. The reversal of VKA was managed by administration of prothrombin complex concentrates (PCC). The reversal of NOAC was started with i.v. bolus application of 1 g TXA followed by continuous i.v. application of TXA in a dosage of 20 mg/kg of body weight. Furthermore, PCC were administered with a dosage of 50 IE/kg.

Results: The overall proportion of patients who received transfusion of RBCU and/or PU was significantly reduced in epoch B compared to epoch A (25% vs. 46%, p=0.0009). Even in patients with a preexisting history for the use of antithrombotic drugs prior to DC, no transfusion of allogeneic blood products was necessary in 17 of 28 (epoch B) vs. 20 of 63 (epoch A, p=0.01) patients. There was no significant difference regarding the rate of bleeding complications between epoch A and epoch B (9.5% vs. 10%).

Conclusion: Our ICMP was highly efficient in reducing the transfusion of allogeneic blood products in patients who underwent DC.