From the Guidelines
Preoperative management of Factor V deficiency requires careful planning to minimize bleeding risk during surgery, and the most effective approach is to administer fresh frozen plasma (FFP) transfusions to achieve Factor V levels of at least 15-20% for minor procedures and 25-30% for major surgeries, as supported by the guidelines from the Association of Anaesthetists of Great Britain and Ireland 1. The typical dosing is 15-20 mL/kg of FFP initially, followed by 5-10 mL/kg every 12 hours during the perioperative period.
- Since Factor V has a half-life of 12-36 hours, FFP administration should begin immediately before surgery and continue postoperatively for 5-7 days for major procedures or 2-3 days for minor ones.
- Laboratory monitoring with Factor V activity levels and PT/PTT should guide therapy.
- Platelet transfusions may also be beneficial since platelets contain approximately 20% of circulating Factor V.
- Antifibrinolytic agents like tranexamic acid (10-15 mg/kg IV every 8 hours) can be added as adjunctive therapy to stabilize clots.
- Recombinant Factor VIIa may be considered in refractory bleeding at 90 μg/kg every 2-3 hours.
- Importantly, cryoprecipitate is not helpful as it contains minimal Factor V. A comprehensive preoperative assessment should include:
- Bleeding history
- Family history
- Medication review to discontinue antiplatelet or anticoagulant drugs
- Baseline coagulation studies This approach is necessary because Factor V is essential for both the extrinsic and intrinsic coagulation pathways, and no specific Factor V concentrate is commercially available, as noted in the Blood Reviews journal 1.
From the Research
Preoperative Management for Factor V Deficiency
The preoperative management for Factor V deficiency involves several key steps to ensure patient safety and prevent bleeding complications. Some of the strategies used include:
- Plasma exchange (PE) with fresh frozen plasma or solvent/detergent treated plasma (S/DP) to raise factor V levels quickly and sufficiently without volume overload 2
- Perioperative infusion of fresh frozen plasma (FFP) to maintain FV levels and prevent bleeding 3, 4, 5, 6
- Careful intraoperative operation and strict postoperative monitoring to minimize the risk of bleeding complications 4, 5
- A multidisciplinary approach to manage patients with severe factor V deficiency, including close cardiopulmonary monitoring in the intensive care unit 5
- Administration of 25 mL/kg body weight of fresh frozen plasma over 30 minutes to increase factor V activity before surgery 5
Specific Considerations
Some studies have reported the use of specific techniques, such as:
- Laparoscopic major hepatectomy, which can be safe and feasible for patients with hereditary FV deficiency under careful perioperative management 4
- Off-pump coronary artery bypass grafting, which can be successfully performed in patients with severe factor V deficiency with a transfusion of fresh-frozen plasma 6
- Burr hole craniostomy, which can be performed without perioperative complications in patients with severe factor V deficiency who have received preoperative fresh frozen plasma 5