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Treatment of coagulopathy in Massive hemorrhage and Hemodilution

Treatment of coagulopathy in Massive hemorrhage and Hemodilution. Brad Beckham T4. Definitions. Major blood loss Hemoglobin concentration below 6-10 g/dl Massive transfusion in adults >9 erythrocyte units within 24h >5 erythrocyte units within 12h

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Treatment of coagulopathy in Massive hemorrhage and Hemodilution

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  1. Treatment of coagulopathy in Massive hemorrhage and Hemodilution Brad Beckham T4

  2. Definitions • Major blood loss • Hemoglobin concentration below 6-10 g/dl • Massive transfusion in adults • >9 erythrocyte units within 24h • >5 erythrocyte units within 12h • >50 units of any blood product within 24h

  3. Hemostasis Monitoring • PT • INR > 1.5 demonstrates 88% sensitivity and 88% specificity for at least one nonhemostatic coagulation factor level after trauma • aPTT • >1.5x nl demonstrates sensitivity of 50% and specificity of 100% due to factor VIII release as acute phase reactant • ROTEM/TEG • Coagulation time, clot formation time, clot firmness, lysis time

  4. Causes • Hemodilution • Consumptive loss • Fibrinolysis • Anticoagulant use • Hypothermia • Metabolic derangements • Mechanical derangements

  5. Initial Resuscitation • Initial usually crystalloids and colloids to restore volume • Some colloids impair platelet function, inhibit fibrin polymerization, and induce aquired Von Willebrand syndrome • Crystalloids induce dilution • Erythrocyte transfusion • Improve oxygen carrying capacity • Theorized to improve hemostasis

  6. Hemostatic Products • FFP • Guidelines recommend early initiation in massive transfusion protocol. • No set FFP:RBC ratio, but studies suggest a 1:1 or greater likely to provide better survival rates • Not to be used as volume replacement due to associated risk factors

  7. Hemostatic Products • Cryoprecipitate • Used to supplement FFP that is low in plasma fibrinogen • 15ml / 10kg bodyweight increases plasma fibrinogen by 0.5g/L • FFP requires 30ml / 1kg to increase by 1g/L • High levels of fibrinogen associated with reduction in mortality of combat trauma pts

  8. Hemostatic Products • Prothrombin Complex Concentrate • Factors II, VII, IX, X, protein C and S • Factors concentrated at 25x that of FFP • Reduces risk of volume overload with FFP • Limited data on usage • Early data suggests reduced need for FFP with no change in survival • Also used for acute reversal of coumarins

  9. Hemostatic Products • Recombinant Activated Factor VII • No difference in amount of transfusion within first 48h, but may reduce transfusions needed beyond this point • May be associated with increased risk of thromboembolic complications • Platelet Concentrates • Only recommended when platelet dysfunction is identified due to high risk of adverse post transfusion events

  10. Conclusion • Use point-of-care testing to optimize dosing of appropriate products • Usage of newer concentrates to provide targeted therapy without risk of volume overload • Requires in depth knowledge of pathophysiologic changes occurring for optimal balanced approach

  11. Bollinger, Daniel M.D., et al. “Pathophysiology and Treatment of Coagulopathy in Massive Hemorrhage and Hemodilution” Anesthesiology: November 2010. Vol 113:5, pg 1205-1219. • American Association of Blood Banks, www.aabb.org

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