A talk by Anna Ågren at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. When not to simplify haemostasis management.
Case presentations
Anna Ågren
Associate professor
Senior consultant
Coagulation Unit,
Hematology Center,
Karolinska University
Hospital
Stockholm, Sweden

2. Conflict of Interest Disclosure
• Receipt of grants/research support CSL Behring
• Receipt of honoraria of consultation fees Octapharma
Novo Nordisk
CSL Behring

3. If TEG or ROTEM curves are normal and the patient is bleeding……
….is it true that there must be a surgical (and not a coagulopathic) bleeding?

4. A phone call to the coagulation consultant
at Karolinska University Hospital…..

5. A trauma patient
• 25 years old man
• Haemophilia B – FIX deficiency
• Head injury
• Abdominal injury
• Pelvic fractures
• Upper extremity fractures

6. 3 days later the patient is still bleeding……..
• Acute surgery of the abdomen
• Massive transfusions 4:4:1
• Tranexamic acid
• Fibrinogen
• Activated FVII

7. Didn´t you know that the patient had
Haemophilia?
Yes, we did…….
…but the ROTEM curve was normal……
Henri Matisse

8. The patient
received
FIX-concentrate…..
……and the bleeding stopped

9. Patients with hereditary
platelet dysfunction
Cyclooxygenase defect
• 35 years old woman
• Anemia during her whole life
due to bleeding;
gastrointestinal and
menorrhagia.
• Massiv surgical bleeding after
hysterectomi with
complications and reoperations.
ADP release defect
• 28 years old woman
• Bruises, epistaxis
• Bleeding in the mouth
while eating crisps and
bread.
• Bleeding after spinal
anesthesia during foot
fracture surgery.

11. • 1% of the population
• Blood group affects the level of
von Willebrand factor
Gill et al Blood 1987

12. Normal
• Less than 3 in males
• Less than 5 in females
von Willebrand patients
• 10-25 depending on von
Willebrand factor level.
Ågren Haemophilia 2017
Tosetto et al. J Thomb Haemost 2013

13. ROTEM did not discriminate patients with von
Willebrand disease
Ågren et al. Haemophilia 2017
Normal reference
intervals within
grey area
ROTEM: Rotational thromboelastometry

14. TEG Reaction-time was slightly prolonged in severe
von Willebrand disease
Ågren et al. Haemophilia 2017
Normal reference
intervals within
grey area
TEG; Thromboelastography
R-time: Reaction time

17. Citrate tubes….

18. If TEG or ROTEM curves are normal and the patient is bleeding……
….is it true that there must be a surgical (and not a coagulopathic) bleeding?

19. The answer is…………
No!

20. • Hemophilia disease
• Hereditary platelet function defects
• Von Willebrands disease
• Treatments with platelet inhibitors
• Some anticoagulant treatments
• Calcium imbalance
• Acid/Base imbalance
Josef Frank

21. Thank you!
Stina Wirsén