Journal: Eur J Anaesthesiol 25(7):538-543, 2008
Reprint: Department of Anesthesiology and Critical Care, Università degli Studi di Parma, Azienda Ospedaliera di Parma, Parma, Italy (S Ziegler, MD)
Faculty Disclosure: Abstracted by L. Easley, who has nothing to disclose.
Despite important advances in surgical techniques during the last 25 years and introducing vessel-and nerve-sparing methods, intra- and postoperative bleeding is still one of the most important complica¬tions associated with radical prostatectomy, due to the surgical trauma, release of urokinase, and the activation of the fibrinolytic system. Oncological sur¬gery patients are generally believed to be at high risk for thromboembolic complications. This prospective, observational multi-center study was conducted to assess changes in the coagulation status and define the degree of systemic fibrinolysis or hypercoagula¬tion in the perioperative period.
Forty-nine patients, 62±5 years of age, undergoing radical retropubic prostatectomy were prospectively included. Blood samples were taken before surgery (T1), at removal of the prostate (T2), 4-6 hr after surgery (T3) and then 1 day after surgery (T4). No evidence of hyperfibrinolysis was found at any stage. Values for lysis (LY) at 30 and 60 minutes decreased intraoperatively and returned in the following period until T4 to a value slightly higher than baseline. Both parameters showed a high correlation with partial thromboplastin time (aPTT) values. D-dimers increased significantly above the normal range until T3 and then decreased to the 1.7-fold basal value within the upper level of the normal range at T4. Preoperative PTT values were elevated, indicating hypocoagulation.
No clinically relevant activation of fibrinolysis was seen at any stage. Intraoperatively more activation of blood coagulation was found with the consumption of fibrinogen and a reduced thromboelastography (TEG) percentage clot lysis. Only at the first postoperative sample point did the authors see a trend to a more fibrinolytic state indicated by increasing PTT, LY-30 and LY-60 values and a peak of the fibrin degrada¬tion product D-dimers. No evidence was found for an uncontrolled activation of fibrinolysis on the day after surgery either. Platelets showed a constant reduction, probably due to consumption and hemodilution, but never fell below the critical level of 30,000 microliters.
These results are in accordance with the results of the TEG evaluation of coagulation in transurethral prostatectomy reported in an earlier study. In con¬trast, the hypercoagulable prothrombotic state associ¬ated with prostatectomy seems to have an important impact on the outcome after retropubic prostatec¬tomy. To balance the individual risk of bleeding with that of cardiac complications, it would be important to analyze the overall coagulation state of every single patient.
Neither standard coagulation parameters nor TEG values showed a significant activation of fibrinolysis or of hypercoagulation in the perioperative period. Hypercoagulation seems to have a substantial clinical impact resulting in fatal cardiovascular complica¬tions. This study showed that TEG values give a good estimation of the blood coagulation/fibrinolysis state during and in the first 24 hours after retropubic prostatectomy. |
