Recommended target trough coagulation factor levels in surgeries
| Deficient factor . | Maintaining level . | Major surgery4 . | Minor surgery4 . | |
|---|---|---|---|---|
| Fibrinogen | >1 g/L until wound healing | Fibrinogen concentrate: | ||
| 50–100 mg/kg before surgery, daily or every other day infusion in the first 4-6 days and then increase the interval (first 48 hours requires daily evaluation) | ||||
| Prothrombin | >20% | PCC: | ||
| 20-40 IU/kg before surgery with further 10-20 IU/kg every 48 hours (first 48 hours requires daily evaluation) | ||||
| FV | >15-20% | Virus-inactivated plasma FFP: | ||
| 15–25 mL/kg before surgery with further 10 mL/kg every 12 hours, if required | ||||
| Consider additional platelet transfusion if virus-inactivated plasma or FFP is not enough | ||||
| FV and FVIII | FV >20% | Supplement FV replacement as mentioned in Table 1: | ||
| FVIII >50% | pd- or rFVIII: 20-40 IU/kg or DDAVP 0.3 μg/kg | |||
| FVII | >20% | rFVIIa: | For minor surgery, recommendation (2C) suggests to use tranexamic acid 15-20 mg/kg or 1 g 4 times daily or antifibrinolytics | |
| 15–30 μg/kg before surgery and every 4-6 hours, in the first 24 hours, and then increase the interval to 8-12 hours or | ||||
| pd-FVII concentrate: | If necessary cryo, FFP, or specific missing factor should be considered for 1-3 days, based on type of surgery | |||
| 10-40 IU/kg with similar intervals | ||||
| FX | >20-30% | PCC: | Each single case should be monitored and other therapeutic approach may be adopted, taken into consideration cardiovascular risk and/or thrombotic history of the patient | |
| 20-30 IU/kg before surgery with further 10-20 IU/kg every 24 hours, if required | ||||
| Virus-inactivated plasma FFP: | ||||
| 15-25 mL/kg per 24 hours | ||||
| FXI | No association between FXI clotting activity level and clinical bleeding severity | Antifibrinolytic agents in patients with no bleeding in previous surgery; | ||
| pd-FXI concentrate: | ||||
| 10-15 IU/kg. A combination of virus inactivated plasma 15-25 mL/kg and tranexamic acid 15-20 mg/kg or 1 g 4 times daily is an alternative to FXI concentrate | ||||
| FXIII | >20% | pd-FXIII concentrate: | ||
| 10-40 IU/kg per day | ||||
| Vitamin K dependent | — | Four-factor PCC (prothrombin, VII, IX, X): | ||
| 20-30 IU/kg with vitamin K1 5-20 mg; | ||||
| Virus inactivated plasma: | ||||
| 15-25 mL/kg is an alternative if 4-factor PCC is unavailable |
| Deficient factor . | Maintaining level . | Major surgery4 . | Minor surgery4 . | |
|---|---|---|---|---|
| Fibrinogen | >1 g/L until wound healing | Fibrinogen concentrate: | ||
| 50–100 mg/kg before surgery, daily or every other day infusion in the first 4-6 days and then increase the interval (first 48 hours requires daily evaluation) | ||||
| Prothrombin | >20% | PCC: | ||
| 20-40 IU/kg before surgery with further 10-20 IU/kg every 48 hours (first 48 hours requires daily evaluation) | ||||
| FV | >15-20% | Virus-inactivated plasma FFP: | ||
| 15–25 mL/kg before surgery with further 10 mL/kg every 12 hours, if required | ||||
| Consider additional platelet transfusion if virus-inactivated plasma or FFP is not enough | ||||
| FV and FVIII | FV >20% | Supplement FV replacement as mentioned in Table 1: | ||
| FVIII >50% | pd- or rFVIII: 20-40 IU/kg or DDAVP 0.3 μg/kg | |||
| FVII | >20% | rFVIIa: | For minor surgery, recommendation (2C) suggests to use tranexamic acid 15-20 mg/kg or 1 g 4 times daily or antifibrinolytics | |
| 15–30 μg/kg before surgery and every 4-6 hours, in the first 24 hours, and then increase the interval to 8-12 hours or | ||||
| pd-FVII concentrate: | If necessary cryo, FFP, or specific missing factor should be considered for 1-3 days, based on type of surgery | |||
| 10-40 IU/kg with similar intervals | ||||
| FX | >20-30% | PCC: | Each single case should be monitored and other therapeutic approach may be adopted, taken into consideration cardiovascular risk and/or thrombotic history of the patient | |
| 20-30 IU/kg before surgery with further 10-20 IU/kg every 24 hours, if required | ||||
| Virus-inactivated plasma FFP: | ||||
| 15-25 mL/kg per 24 hours | ||||
| FXI | No association between FXI clotting activity level and clinical bleeding severity | Antifibrinolytic agents in patients with no bleeding in previous surgery; | ||
| pd-FXI concentrate: | ||||
| 10-15 IU/kg. A combination of virus inactivated plasma 15-25 mL/kg and tranexamic acid 15-20 mg/kg or 1 g 4 times daily is an alternative to FXI concentrate | ||||
| FXIII | >20% | pd-FXIII concentrate: | ||
| 10-40 IU/kg per day | ||||
| Vitamin K dependent | — | Four-factor PCC (prothrombin, VII, IX, X): | ||
| 20-30 IU/kg with vitamin K1 5-20 mg; | ||||
| Virus inactivated plasma: | ||||
| 15-25 mL/kg is an alternative if 4-factor PCC is unavailable |