Spinal and epidural sufentanil and fentanyl in early labour.

BACKGROUND AND AIM: The analgesic effect on labour pain of either spinal or epidural sufentanil or fentanyl was tested in a total of 80 primiparous parturients at an early phase of the delivery. The aim of the study was to compare the level of analgesia achieved within 20 minutes. METHODS: The parturients were randomly assigned to groups receiving either spinal sufentanil (5 µg), epidural sufentanil (20 µg), spinal fentanyl (20 µg) or epidural fentanyl (100 µg), whereafter the parturients were monitored for reported pain during contraction and side effects for 30 minutes. The primary outcome was the level of analgesia achieved within 20 minutes, while the secondary outcome was the time until the administration of the first epidural bolus. RESULTS: At baseline, the mean maximum pain VAS was 86 (84-89) mm. At 20 minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl or epidural fentanyl, the maximum VAS was 19 (7-31), 45 (32-59), 25 (10-39) or 52 (40-63) mm, respectively (P < .01 spin vs epid groups). There were no differences in efficacy between spinal or epidural sufentanil and fentanyl. The mean (95% CI) time to the activation of epidural analgesia was 151 (111-192), 130 (93-168), 177 (121-234) and 112 (80-143) minutes after spinal sufentanil, epidural sufentanil, spinal fentanyl and epidural fentanyl, respectively. CONCLUSIONS: In terms of a reduction of VAS score at 20 minutes, epidural sufentanil or fentanyl provide 63% and 60% of the analgesic effect of the corresponding spinal analgesia. Epidural sufentanil or fentanyl could be used in situations in which spinal/CSE administration is not possible or desired.

Cost analysis of a randomized stem cell mobilization study in multiple myeloma.

Upfront autologous stem cell transplantation (ASCT) is the standard therapy for younger multiple myeloma (MM) patients. MM patients usually undergo stem cell mobilization with cyclophosphamide (CY) followed by granulocyte colony-stimulating factor (G-CSF), or with G-CSF alone. A limited number of randomized studies are available comparing costs of different mobilization strategies. Eighty transplant-eligible patients aged up to 70 years with untreated MM were included in this prospective study. The patients were treated with RVD induction for three 21-day cycles and randomized 1:1 at inclusion into one of the two mobilization arms CY 2 g/m(2) + G-CSF [arm A] vs. G-CSF alone [arm B]. Plerixafor was given according to a specific algorithm if needed. Sixty-nine patients who received mobilization followed by blood graft collection were included in the cost analysis. The median total costs of the mobilization phase were significantly higher in arm A than in arm B (3855 € vs. 772 €, p ≤ 0.001). The cumulative median cost of the mobilization and collection phases was significantly lower in arm B than in arm A (8524 € vs. 11,622 €, p = 0.012). There was no significant difference between the arms in the total median costs of ASCT (n = 59) (34,997 € in arm A vs. 31,981 € in arm B, p = 0.118). Mobilization with G-CSF alone seems to be a preferable mobilization method for MM patients in terms of mobilization and apheresis costs. In addition, it requires less hospital resource utilization.

Patient-specific risk factors of adverse drug events in adult inpatients - evidence detected using the Global Trigger Tool method.

AIMS AND OBJECTIVES: To identify the prevalence, preventability, and severity of adverse drug events in randomly selected adult hospital inpatients, and to study the association between adverse drug events and patient-specific factors. BACKGROUND: Adverse drug events represent one of the major concerns in patient safety. DESIGN: A retrospective record review. METHODS: The study was conducted in an 800-bed university hospital in Finland within a 12-month period. Retrospective reviews of randomly selected discharged patients' (n = 463) records using the Global Trigger Tool method were undertaken. The prevalence, preventability, and severity of adverse drug events were studied, and the association between patient-specific factors and adverse drug events were examined using a binary logistic regression model and Pearson's chi-squared tests. RESULTS: A total of 180 adverse drug events were detected in 125 (27%) patients, of which 74 (41·1%) were preventable, and 94·4% caused temporary harm. An abnormal level of potassium in the blood was the most frequent adverse drug event (n = 37). The risk of adverse drug events increased with the length of hospital stay and the increased number of drugs patients used. The patients with coronary diseases (n = 130) had a 2·5 times higher risk of experiencing adverse drug events. In addition, the risk of adverse drug events during hospitalisation increased together with the co-morbidity of patients. CONCLUSIONS: Adverse drug events were experienced by a quarter of inpatients, while severe adverse drug events were rare. The risk of adverse drug events increased with patients' prolonged hospital stay, polypharmacy, and morbidity. In addition, information of the usefulness of the Global Trigger tool can be used for future development of the method. RELEVANCE TO CLINICAL PRACTICE: Patient-specific risk factors were identified using the Global Trigger Tool method revealing that more efficient monitoring of inpatients with these risk factors may be profitable for decreasing adverse drug events.

The factors associated with medication errors in adult medical and surgical inpatients: a direct observation approach with medication record reviews.

INTRODUCTION: Observing real situations in clinical practice can provide undetected information regarding problems in the medication process. AIMS: The aims of this study were to describe the frequency, types, and severity of medication errors in medical and surgical inpatients as well as to study the relationship between medication errors and associating factors. METHODS: A cross-sectional study using direct observations and medication record reviews was conducted to assess how 32 registered nurses administered 1058 medications to 122 inpatients in four medical and surgical wards at a university hospital in Finland between April and May 2012. Observations were recorded using a structured observation form and patients' medication record reviews (n = 122) before and after the observations were conducted. A multiprofessional team analysed and classified all of the detected errors and assessed their severity. A logistic regression was used to analyse the factors (work environment, team, person-specific, patient-specific or medication-related) associated with medication errors. RESULTS: At least one error was found in 22.2% (235/1058) of administered medications, 63.4% of which were medication administration errors and 18.3% of which were documentation errors. Of the medication administration errors, 59.1% involved an incorrect administration technique. 3.4% of errors caused harm to patients. Statistically significant factors that increased the risk of medication errors included every other weekday, except Sunday; morning shifts; increased rushes; nurses asking for help; and increased number of medications that patients used. Factors that decreased the risk of errors included administering medications through an oral route, double-checking the drugs, and additional people in the medication room at the same time. CONCLUSION: Medication errors in inpatient care are frequent, and improvements to increase safety are vital. More attention to medication administration techniques, administration instructions and attitudes toward safety are needed to prevent problems.

An observational study of how patients are identified before medication administrations in medical and surgical wards.

The aims of this study were to clarify how a patient's identity was verified before the administration of medication in medical and surgical wards in a hospital, as well as to study the association between patient identification and the registered nurse's work experience, observed interruptions, and distractions. The study material was collected during April and May 2012 in two surgical and two medical wards in one university hospital in Finland, using a direct, structured observation method. A total of 32 registered nurses were observed while they administered 1058 medications to 122 patients. Patients were not identified at all in 66.8% (n = 707) of medication administrations. Patient identifications were made more often by nurses with shorter work experience in the nursing profession or in the wards (4 years or less), or if distractions existed during medication administration. According to the results, patient identification was not adequately conducted. There is a need for education and change in the culture of medication processes and nursing practice.

[Glycocalyx and fluid therapy]. / Glykokalyksi ja nestehoito.

Glycocalyx consisting of proteins and carbohydrates is lining the complete healthy vascular endothelium. Being in continuous interaction with plasma proteins and other plasma components, the glycocalyx forms an endothelial surface layer playing an important role as protective mechanism of the vascular wall, in blood coagulation and regulation of permeability. Tissue swelling is a common problem in the treatment of surgical, trauma and intensive care patients. The extent of tissue swelling is also connected with morbidity and mortality. The question about the volume effect of infusion solutions and, on the other hand, prevention of permeability disturbance still remains highly actual.

Enhancement of GABAergic activity: neuropharmacological effects of benzodiazepines and therapeutic use in anesthesiology.

GABA is the major inhibitory neurotransmitter in the central nervous system (CNS). The type A GABA receptor (GABA(A)R) system is the primary pharmacological target for many drugs used in clinical anesthesia. The α1, ß2, and γ2 subunit-containing GABA(A)Rs located in the various parts of CNS are thought to be involved in versatile effects caused by inhaled anesthetics and classic benzodiazepines (BZD), both of which are widely used in clinical anesthesiology. During the past decade, the emergence of tonic inhibitory conductance in extrasynaptic GABA(A)Rs has coincided with evidence showing that these receptors are highly sensitive to the sedatives and hypnotics used in anesthesia. Anesthetic enhancement of tonic GABAergic inhibition seems to be preferentially increased in regions shown to be important in controlling memory, awareness, and sleep. This review focuses on the physiology of the GABA(A)Rs and the pharmacological properties of clinically used BZDs. Although classic BZDs are widely used in anesthesiological practice, there is a constant need for new drugs with more favorable pharmacokinetic and pharmacodynamic effects and fewer side effects. New hypnotics are currently developed, and promising results for one of these, the GABA(A)R agonist remimazolam, have recently been published.

Prescribing Appropriate Medicines to Older Adults: A Finnish Experience with the Web-Based Meds75+ Database.

The Finnish web-based Meds75+ database supports rational, safe and appropriate prescribing to older adults in primary care. This article describes the content and updating process of Meds75+ and demonstrates its applicability in everyday clinical practice. Meds75+ contains a classification (A-D) and recommendation texts for 450-500 drug substances when used in the treatment of older adults aged 75 years or older. The content of Meds75+ is continually updated. Each assessment of a drug substance begins with a structured collection of available information and research evidence. After that, an interdisciplinary expert panel discusses the classification and recommendation using a consensus method. A rolling 3-year updating cycle guarantees that all drug substances are reviewed regularly. Most drug substances are classified as class A (41%) (suitable, e.g. bisoprolol) or as class C (37%) (suitable with specific precautions, e.g. ibuprofen). One-fifth (20%) of the substances are in class D (avoid use, e.g. diazepam). Most commonly, older adults have purchased substances affecting the alimentary tract and metabolism (17%), the nervous system (16%) and the cardiovascular system (15%). In Finland, the proportion of older adults using class D substances (37%) has not changed between the years 2019 and 2022. Meds75+ has potential to support safer and more effective use of medications for older adults, since it offers up-to-date information on drug substances for healthcare professionals.

Potentially inappropriate drug use among older persons in Finland: application of a new national categorization.

PURPOSE: The Finnish Medicines Agency published a new consensus categorization for potentially inappropriate drug (PID) use among persons aged 75 years and older (A = suitable, B = limited evidence, C = suitable for use under certain conditions only, D = inappropriate) in 2010. We investigated factors associated with use of one or more Category D drugs. METHOD: Cross-sectional analyses were conducted using baseline data from the Geriatric Multidisciplinary Strategy for the Good Care of the Elderly (GeMS) Study collected in Kuopio, Finland, in 2004. From a random sample of 1000 persons aged 75 years and older, 781 persons provided consent to participate. Logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) and 95 % confidence intervals (95 % CIs) for factors associated with PID use. RESULTS: PIDs were used by 30 % (n = 234) of all participants on a regular or as-needed basis. Among the 764 persons (98 %) who used prescription or non-prescription drugs, PID use was associated with the number of drugs in use (adjusted OR 1.20; 95 % CI 1.13-1.28) and moderate self-rated health compared to good self-rated health (adjusted OR 1.74; 95 % CI 1.19-2.55). PID use was associated with poor maximum walking speed (adjusted OR 1.64; 95 % CI 1.10-2.45), poor Timed Up and Go (TUG) test scores (adjusted OR 1.66; 95 % CI 1.11-2.47), impaired instrumental activities of daily living (adjusted OR 1.50; 95 % CI 1.06-2.12) and Mini Mental State Examination scores <18 (adjusted OR 2.27; 95 % CI 1.41-3.65). CONCLUSION: PID use was highly prevalent and associated with impaired functional outcomes. This highlights the importance of clinicians conducting regular reviews of drug therapy.

Intravenous sulprostone infusion in the treatment of retained placenta.

OBJECTIVE: To analyze the effectiveness of intravenous sulprostone infusion for the treatment of retained placenta without massive primary hemorrhage among women at an university hospital over a three-year period. DESIGN: Retrospective observational study. SETTING: University teaching hospital. POPULATION: 126 consecutive women with placental retention and intravenous sulprostone infusion as primary treatment performed from October 2007 up to December 2011. METHODS: Hospital records of women who received sulprostone infusion to attempt placental expulsion were reviewed. MAIN OUTCOME MEASURES: Primary endpoints of the study were expulsion of placenta and the total amount of blood loss during delivery. RESULTS: The placenta was successfully expelled in 39.7% of cases, whereas 60.3% of women underwent manual removal of placenta. Blood loss was significantly lower in women with successful placental expulsion than in women who had manual removal of the placenta (582 ± 431 ml vs. 1275 ± 721 ml, p < 0.0001). Sulprostone infusion did not cause adverse effects or significant postpartum morbidity. CONCLUSIONS: Intravenous sulprostone infusion is safe and reduces both blood loss and the need for manual removal of the placenta.

The role of recombinant activated factor VII in obstetric hemorrhage.

PURPOSE OF REVIEW: To review the literature regarding the use of recombinant activated factor FVII (rFVIIa) in the treatment of postpartum hemorrhage (PPH). RECENT FINDINGS: The previous and recent case reports and case series suggest a potential benefit of rFVIIa in the management of severe PPH refractory to standard treatment. However, the lack of randomized controlled studies limits the value of the available data. rFVIIa cannot work optimally if there is a shortage of the basic components of the coagulation cascade such as fibrinogen. New experimental data suggest that rFVIIa can relocate into the extravascular space and remain functionally active which may prolong its hemostatic effect longer than the short circulatory half-life indicates. SUMMARY: Although some preliminary guidelines have been published, the case reports and case series illustrate that the practice of using rFVIIa in PPH is far from uniform. rFVIIa should usually not be used to compensate for an inadequate transfusion therapy. Therefore, early and effective administration of red blood cells, fresh frozen plasma, fibrinogen concentrate (or cryoprecipitate), and platelets as well as the control of uterine atony are essential before considering administration of rFVIIa in the treatment of PPH.

[HELLP syndrome--severe complication during pregnancy]. / HELLP-oireyhtymä--raskauden vaikea komplikaatio.

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) is a severe microcirculatory disturbance during pregnancy, associated with pre-eclampsia, but it may occur also without it. In HELLP maternal morbidity and mortality have increased. Typical complications include coagulation disorder, acute respiratory failure, acute renal failure, infections, central nervous system symptoms, hepatic failure and bleeding, and premature ablation of the placenta. The only effective means to treat the syndrome during pregnancy is termination of pregnancy.

Alternatives to neuraxial analgesia for labor.

PURPOSE OF REVIEW: Although millions of parturients profit from neuraxial analgesia for labor, there are far more of those who do not have this choice for one reason or another. They need alternative ways to relieve labor pain. RECENT FINDINGS: Paracervical block gives less efficient analgesia compared with single-shot spinal in a sample of multiparae at active labor but is associated with better umbilical artery pH. Use of a neurostimulator may increase success in pudendal block. It is possible to reduce nitrous oxide occupational exposure by a developed scavenging system. Intravenous remifentanil gives less efficient pain relief than epidural analgesia. The maternal satisfaction, however, may be comparable. SUMMARY: Paracervical block with modern technique is a viable option for selected cases. It is rapid and does not affect the course of labor, but its efficacy is only modest. Pudendal block can be used in the second stage of labor or for episiotomy tear repair and pain. Intravenous remifentanil is currently becoming an established method, although its safety is still an issue. Nitrous oxide is a useful method to be used alone or together with the other methods.

The effective analgesic dose of dexamethasone after laparoscopic hysterectomy.

BACKGROUND: Apart from being antiemetic, glucocorticoids have an analgesic property. The optimal dose of dexamethasone in the management of pain after surgery has not been established. In this placebo-controlled, dose-finding study, we evaluated the analgesic effect of three doses of dexamethasone after laparoscopic hysterectomy. METHODS: We randomized 129 women scheduled for laparoscopic hysterectomy to receive placebo, dexamethasone 5 mg (D5), 10 mg (D10), or 15 mg (D15) IV before the induction of anesthesia. The patients were anesthetized with propofol and remifentanil in a standardized manner. Until the first postoperative morning, postoperative pain was managed with IV oxycodone using patient-controlled analgesia. The visual analog scale scores for pain and side effects, and the amounts of the analgesics were recorded for 3 days after surgery. RESULTS: The total dose of oxycodone (0-24 h after surgery) was smaller in the D15 (0.34 mg/kg [0.11-0.87]) group than in the placebo group (0.55 mg/kg [0.19-1.13]) (P = 0.003). The doses of oxycodone during Hours 0-2 after surgery were smaller in the D10 (0.17 mg/kg [0.03-0.36]) and D15 (0.17 mg/kg [0.03-0.35]) groups than in the placebo (0.26 mg/kg [0.10-0.48]) (P = 0.001, D10 versus placebo; P < 0.001, D15 versus placebo) group. During Hours 2-24 after surgery, however, the doses of oxycodone were equal in the placebo, D5, D10, and D15 groups (0.31 mg/kg [0.03-0.78], 0.22 mg/kg [0.03-0.92], 0.24 mg/kg [0.05-0.87], and 0.20 mg/kg [0-0.65], respectively). The visual analog scale scores for pain at rest, in motion, or at cough did not differ in the study groups. The incidence of dizziness was lower in the D15 group than in the placebo group (P = 0.001), the D5 group (P = 0.006), and the D10 group (P = 0.030) during the first 24 h after surgery. During the later course of recovery, the incidence of dizziness did not differ among the four study groups. CONCLUSIONS: IV dexamethasone 15 mg before induction of anesthesia decreases the oxycodone consumption during the first 24 h after laparoscopic hysterectomy. During first 2 h after surgery, dexamethasone 10 mg reduces the oxycodone consumption as effectively as the 15 mg dose.

[Thromboembolic complications in day case surgery]. / Tromboemboliset komplikaatiot päiväkirurgiassa.

Prevention of venous thrombosis in surgical hospital patients hasgained attention due to the fact that in spite of therapy, deep vein thrombosis and pulmonary embolism can cause long-term impediment and even mortality. In day case surgery, the threat of venous thrombosis has been considered low and few studies on the subject are available. On the other hand, increasingly diseased and aged patients are operated on day case surgery basis and more demanding procedures are performed for patients being discharged from the hospital during the same day. In addition, more information is constantly obtained concerning the significance of risk factors.

[Dinitrogen monoxide in the treatment of labor pains]. / Typpioksiduuli synnytyskivun hoidossa.

Self-administered nitrous oxide relieves labour pain in approximately two-thirds of women, and there is a dose-response with a maximum effect at a concentration of 70%. Nitrous oxide can be used during all stages of labour, and it has no impact on the progress of labour. Occupational exposure of health care workers to nitrous oxide has no adverse effects on their reproductive health if there is an adequate scavenging system in the delivery rooms. The greenhouse effect of the medical use of nitrous oxide is minimal and in future, its catalytic splitting to nitrogen and oxygen may overcome this adverse effect.

Medication reconciliation and review for older emergency patients requires improvement in Finland.

BACKGROUND: 10-30% of hospital stays by older patients are drug-related. The admission phase is important for identifying drug-related problems, but taking an incorrect medication history often leads to medication errors. OBJECTIVES: To enhance medication history recording and identify drug-related problems (DRPs) of older patients admitted to emergency departments (EDs). METHODS: DRPs were identified by pharmacists-led medication reconciliation and review procedures in two EDs in Finland; Helsinki University Hospital (HUS), and Kuopio University Hospital (KUH). One-hundred-and-fifty patients aged ≥65-years, living at home and using ≥6 medicines were studied. RESULTS: 100% of patients (N = 75) in HUS and 99% in KUH (N = 75), had discrepancies in their admission-medication chart recorded by the nurse or physician. Associations between admission-diagnosis and drug-related problems were found in 12 patients (16%) in HUS and 22 patients (29%) in KUH. Of these, high-alert medications (e.g. antithrombotics, cytostatics, opioids) were linked to eight patients (11%) in HUS and six patients (8%) in KUH. Other acute DRPs were identified in 19 patients (25%) in HUS and 54 patients (72%) in KUH. Furthermore, 67 patients (89%) in HUS and all patients in KUH had non-acute DRPs. CONCLUSIONS: Medication reconciliation and review at admission of older ED patients requires improvement in Finland.

Pharmacokinetic-pharmacodynamic relationship of dobutamine and heart rate, stroke volume and cardiac output in healthy volunteers.

BACKGROUND AND OBJECTIVE: Dobutamine causes an increase in cardiac output (CO) by augmenting stroke volume (SV) through enhanced left ventricular contractility and by decreasing systemic vascular resistance. However, in some patients, the dominant mechanism by which dobutamine improves left ventricular performance is an increase in the subject's heart rate (HR). We therefore decided to evaluate the pharmacokinetic-pharmacodynamic relationship of dobutamine plasma concentrations and heart rate, SV and CO in healthy volunteers. METHODS: We enrolled 23 subjects who received dobutamine at a dose of 2.5, 5 and 10 microg/kg/min for three consecutive periods of 60 minutes each. Dobutamine plasma concentrations were determined from 22 blood samples drawn during each study session. Echocardiography was used to measure CO before administration of dobutamine and once during each infusion period. RESULTS: There was a clear linear relationship between dobutamine plasma concentrations and CO (r(2) = 0.628; p < 0.001). In most subjects, HR remained stable at dobutamine plasma concentrations produced by the lowest infusion rate but increased markedly thereafter so that overall there was a linear relationship between dobutamine plasma concentrations and HR (r(2) = 0.540; p < 0.001). However, SV increased significantly at the dobutamine plasma concentrations produced by the lowest infusion rate but remained mostly stable or even decreased thereafter. Although clinically slight, the overall increase in SV was statistically significant (r(2) = 0.062; p < 0.05). CONCLUSION: Low plasma concentrations of dobutamine resulted in an increase in CO almost solely due to improved left ventricular contractility. However, at higher plasma concentrations of dobutamine, SV remained stable or even decreased, and the linear increase in CO was entirely based on increased HR.

Use of recombinant activated factor VII in primary postpartum hemorrhage: the Northern European registry 2000-2004.

OBJECTIVE: To collect data from nine European countries for cases of obstetric hemorrhage between 2000 and 2004 in which recombinant activated factor VII (rFVIIa) was used. METHODS: The cases were identified through national surveys. Standardized case report forms included sociodemographic details, past medical and obstetric history, and details of the progress and management of labor in which the postpartum hemorrhage occurred. Clinicians were asked to describe subjectively the effect of rFVIIa administration using two mutually exclusive categories: 1) bleeding reduced or 2) bleeding unchanged or worse. RESULTS: A total of 113 forms were returned (88%) with 97 (86%) classified as treatment, and 16 (14%) as "secondary prophylaxis." Clinicians noted improvements after a single dose for 80% of women in the treatment group, and for 75% in the secondary "prophylaxis" group. However, rFVIIa failed in 15 cases (13.8%). Few serious adverse events were noted related to rFVIIa administration; there were four cases of thromboembolism, one myocardial infarction, and one skin rash. CONCLUSION: Clinical reports and hematologic data suggest improvement for more than 80% of women after rFVIIa administration and few adverse effects. LEVEL OF EVIDENCE: II.

Factor XIII deficiency enhances thrombin generation due to impaired fibrin polymerization - An effect corrected by Factor XIII replacement.

INTRODUCTION: Factor XIII (FXIII) cross-links fibrin, completing blood coagulation. Congenital FXIII deficiency is managed with plasma-derived FXIII (pdFXIII) or recombinant FXIII (rFXIII) concentrates. AIM: As the mechanisms protecting patients with low FXIII levels (<5IU/dL) from spontaneous bleeds remain unknown we assessed the interplay between thrombin generation (TG), fibrin formation and clot kinetics before and after FXIII administration in three patients with FXIII deficiency. METHODS: Patients received initially rFXIII (35IU/kg, A-subunit) following with pdFXIII at 1250IU or 2500IU (12-30IU/kg) monthly. TG (CAT), thromboelastometry (ROTEM), prothrombin fragments F1+2, fibrinogen and FXIII activity (FXIII:C) were measured at baseline and one-hour recovery. RESULTS: FXIII was at the target level of 20±6IU/dL at the 4-week trough. rFXIII corrected FXIII to 98±15 and high-dose pdFXIII to a level of 90±6, whereas low-dose/half dose pdFXIII reached 45±4IU/dL. Although fibrinogen (Clauss Method) was normal, coagulation in FIBTEM was impaired, which FXIII administration tended to correct. CAT implied 1.6- to 1.9-fold enhanced TG, which FXIII administration normalized. Inhibition of fibrin polymerization by Gly-Pro-Arg-Pro peptide mimicked FXIII deficiency in CAT by enhancing TG both in control and FXIII recovery plasma. Antithrombin, α2-macroblobulin-thrombin complex and prothrombin were normal, whereas F1+2 were elevated compatible with in vivo TG. DISCUSSION: FXIII deficiency impairs fibrinogen function and fibrin formation simultaneously enhancing TG on the poorly polymerizing fibrin strands, when fibrin's antithrombin I -like function is absent. Our study suggests an inverse link between low FXIII levels and enhanced TG modifying structure-function relationship of fibrin to support hemostasis.