Recommended target trough levels in major surgeries for different RCDs
| Deficient factor . | Maintaining level . | Minor surgery . | Major surgery . |
|---|---|---|---|
| Fibrinogen | >1 g/L until wound healing | If necessary cryo, FFP, or specific missing factor should be considered for 1-3 d, based on the type of surgery; the use of TA may reduce the need for factor concentrates: the first dose should be given immediately before starting if IV or 2 h if oral | Fibrinogen concentrate: 50-100 mg/kg before surgery, daily, or every-other-day infusion in the first 4-6 d, then increase the interval (first 48 h requires daily evaluation; it is important not to exceed) |
| Prothrombin | >20% | PCC: 20-40 IU/kg before surgery with further 10-20 IU/kg/48 h (monitoring of coagulation is required in the first 48 h) | |
| FV | >15%-20% | FFP*: 15-25 mL/kg before surgery with further 10 mL/kg/12 h, if required (monitoring of coagulation is required in the first 48 h) | |
| FV and FVIII | FV > 20% FVIII > 50% | FV replacement as mentioned in Table 1 pd or rFVIII: 20-40 IU/kg or DDAVP 0.3 mg/kg | |
| FVII | >20% | rFVIIa: 15-30 mg/kg before surgery and every 4-6 h, in the first 24 h, then increase the interval to 8-12 h or pd-FVII concentrate: 10-40 IU/kg with similar intervals | |
| FX | >20%-30% | PCC: 20-30 IU/kg before surgery with further 10-20 IU/kg/24 h, if required or FFP*: 15-25 mL/kg/24 h pd-FX: data on 4 major and 3 minor surgeries were published by Escobar et al69 | |
| FXI | Not available | Antifibrinolytic agents in patients with no bleeding in previous surgery; pd-FXI concentrate: 10-15 IU/kg; a combination of FFP* 15-25 mL/kg and TA 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/d rFXIII: first data on minor surgery were recently published by Carcao et al96 | |
| Vitamin K dependent | — | 4-factor PCC: 20-30 IU/kg with vitamin K1 5-20 mg or virus-inactivated plasma: 15-25 mL/kg |
| Deficient factor . | Maintaining level . | Minor surgery . | Major surgery . |
|---|---|---|---|
| Fibrinogen | >1 g/L until wound healing | If necessary cryo, FFP, or specific missing factor should be considered for 1-3 d, based on the type of surgery; the use of TA may reduce the need for factor concentrates: the first dose should be given immediately before starting if IV or 2 h if oral | Fibrinogen concentrate: 50-100 mg/kg before surgery, daily, or every-other-day infusion in the first 4-6 d, then increase the interval (first 48 h requires daily evaluation; it is important not to exceed) |
| Prothrombin | >20% | PCC: 20-40 IU/kg before surgery with further 10-20 IU/kg/48 h (monitoring of coagulation is required in the first 48 h) | |
| FV | >15%-20% | FFP*: 15-25 mL/kg before surgery with further 10 mL/kg/12 h, if required (monitoring of coagulation is required in the first 48 h) | |
| FV and FVIII | FV > 20% FVIII > 50% | FV replacement as mentioned in Table 1 pd or rFVIII: 20-40 IU/kg or DDAVP 0.3 mg/kg | |
| FVII | >20% | rFVIIa: 15-30 mg/kg before surgery and every 4-6 h, in the first 24 h, then increase the interval to 8-12 h or pd-FVII concentrate: 10-40 IU/kg with similar intervals | |
| FX | >20%-30% | PCC: 20-30 IU/kg before surgery with further 10-20 IU/kg/24 h, if required or FFP*: 15-25 mL/kg/24 h pd-FX: data on 4 major and 3 minor surgeries were published by Escobar et al69 | |
| FXI | Not available | Antifibrinolytic agents in patients with no bleeding in previous surgery; pd-FXI concentrate: 10-15 IU/kg; a combination of FFP* 15-25 mL/kg and TA 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/d rFXIII: first data on minor surgery were recently published by Carcao et al96 | |
| Vitamin K dependent | — | 4-factor PCC: 20-30 IU/kg with vitamin K1 5-20 mg or virus-inactivated plasma: 15-25 mL/kg |
Recommended target trough levels in major surgeries for different RCDs.12 Each single case should be monitored and other therapeutic approaches may be adopted, taking into consideration cardiovascular risk and/or thrombotic history of the patient.
—, no data; cryo, cryoprecipitate. Other abbreviations are explained in Table 1.
Virus-inactivated plasma would be preferable.