Massive transfusion and coagulopathy: pathophysiology and implications for clinical management

Hardy, Jean‐François; Moerloose, Philippe de; Samama, Charles Marc

doi:10.1007/bf03022251

Cited by 192 publications

(125 citation statements)

References 113 publications

(104 reference statements)

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“…Its origin is multicausal, and the main etiologic factors are hypothermia, fibrinolysis activated by tissular trauma and by endothelial damage, and dilution of coagulation factors and platelets [86][87][88][89][90][91]. Occasionally, a traumatized patient has a pre-existing condition such as liver or hematologic diseases or anticoagulant treatment that can predispose to bleeding [92], and must be identified in the anamnesis.…”

Section: Transfusion Threshold and Coagulopathy Correctionmentioning

confidence: 99%

“…The characterization of coagulopathy is made in most of the cases by simple laboratory tests: platelet count, activated partial thromboplastin time, prothrombin time-international normalized ratio, and fibrinogen concentration, which guide the administration of fresh frozen plasma, platelets, and cryoprecipitate [87][88][89][90][91]. Damage control surgery is a powerful ancillary tool in the coagulopathic patient who is being operated on.…”

Section: Transfusion Threshold and Coagulopathy Correctionmentioning

confidence: 99%

“…Prevention is accomplished by hypothermia prevention and treatment [93][94][95][96][97] (Box 1) and shock limitation, which in turn, is guaranteed by rapid interruption of the hemorrhage and aggressive hemodynamic resuscitation. Prophylactic administration of platelets or plasma usually do not prevent coagulopathy [98,99].The characterization of coagulopathy is made in most of the cases by simple laboratory tests: platelet count, activated partial thromboplastin time, prothrombin time-international normalized ratio, and fibrinogen concentration, which guide the administration of fresh frozen plasma, platelets, and cryoprecipitate [87][88][89][90][91]. Damage control surgery is a powerful ancillary tool in the coagulopathic patient who is being operated on.…”

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confidence: 99%

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Critical Care Issues in the Early Management of Severe Trauma

García

2006

Surgical Clinics of North America

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Violent trauma and road traffic injuries kill more than 2.5 million people in the world every year. It has been calculated by the World Health Organization that in 2002 there occurred 1.6 million violent deaths [1] and 1.2 million deaths from traffic injury [2], for a combined mortality of 48 deaths per 100,000 population per year.Most trauma deaths occur at the scene or in the first hour after trauma, with a proportion from 34% to 50% occurring in hospitals [3]. These deaths could be prevented by optimization of trauma care. Preventability of trauma deaths has been reported as high as 76% [4] and as low as 1% in mature trauma systems [5,6].Prehospitalization procedures, elapsed time to hospital arrival are, of course, vital to the whole trauma scenario, but errors made in the in-hospital phase of care are responsible for one third to two thirds of the reported by different authors [7,8]. Of these, intensive care unit (ICU) errors are among the most frequent and significant. Errors in the ICU management of trauma patients were studied by Duke and colleagues [9]. They reported 165 ICU trauma deaths. Two hundred fifty-eight errors occurred in 81 patients (52%), and 134 of them contributed to death in 52 patients (34%). ICU errors were classified as management errors (82%), diagnostic (9%), technique (5%), and system inadequacies (4%). Davis and colleagues [10] identified critical care errors in 30% of 125 trauma deaths with errors. These errors contributed to 48% of all preventable deaths.The most common critical care errors are related to airway and respiratory management, fluid resuscitation, neurotrauma diagnosis and support, and delayed diagnosis of critical lesions [9,10].It is imperative for the general surgeon who takes care of trauma patients to know how to deal with these critical aspects, to reduce preventable morbidity and mortality. In the next segment, the situations in which the participation of the surgeon is crucial, during the initial phases of reanimation and stabilization of the critically traumatized patient will be discussed. Airway and ventilation managementAirway and respiratory management errors are the most common of those identified by several authors [9][10][11] The cardinal manifestation is a sudden or a rapidly progressing desaturation, frequently accompanied by tachycardia and arrhytmias, and occasionally by agitation. Hypertension announces the cardiovascular collapse, and bradicardia appears immediately after the total collapse [12]. The symptoms should not be attributed to agitation when it is present, and other possible causes must be ruled out before. Diagnosing the complication involves a directed physical examination, the analysis of the airway pressures and ventilator volumes, chest radiographs, and sometimes the measurement of arterial blood gases (ABG), and the urinary bladder pressure ( Table 1).The emergency conditions in which the access to the airways must be gained, the displacement to diagnosis areas or operating room and the agitation, often present, make the critical...

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Section: Transfusion Threshold and Coagulopathy Correctionmentioning

confidence: 99%

Section: Transfusion Threshold and Coagulopathy Correctionmentioning

confidence: 99%

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confidence: 99%

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Critical Care Issues in the Early Management of Severe Trauma

García

2006

Surgical Clinics of North America

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“…Often, the results of routine hemostatic tests are generally available with a delay of at least 30-60 min; results, therefore, may not be able to provide an accurate picture of the current hemostatic physiology [22]. Hardy et al [23] concluded that bedside monitors of hemostasis are needed urgently for the management of operative and trauma-associated bleeding [10][11][12][13][14][15][16][17][18][19]. The bedside tests for PT and aPTT in whole blood using the CoaguCheck (Roche Diagnostics, Switzerland) attempted to overcome this limitation.…”

Section: Limitations Of Historical Coagulation Testingmentioning

confidence: 99%

Perioperative coagulopathy monitoring

et al. 2013

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Coagulopathy is common in orthopedic surgery patients either due to acquired factors, such as surgery, trauma, medications, or hemorrhage. Perioperative monitoring of blood coagulation is critical to diagnose the causes of hemorrhage, guide hemostatic therapies, predict the risk of bleeding during surgical procedures, and reduce risk of postoperative cardiac and thromboembolic events. In contrast to previous interventions that measure specific portions of the clotting cascade (such as intrinsic or extrinsic pathways or platelet aggregation), ''Point-ofcare'' coagulation monitoring devices assess the viscoelastic properties of whole blood. These techniques have the potential to measure the entire clotting process, starting with fibrin formation, clot retraction, and fibrinolysis. Furthermore, the coagulation status of patients is assessed in whole blood, allowing the plasmatic coagulation system to interact with platelets and red cells, and thereby providing useful additional information on platelet function. Improved monitoring of coagulopathy is particularly important as new anticoagulant drugs emerge that affect the clotting cascade in novel ways, including the inhibition of intrinsic and extrinsic pathways and platelet function. It is important for orthopedic surgeons to understand the pharmacology and reversal of these drugs in the perioperative setting. The purpose of this review is to review the current techniques to monitoring perioperative coagulopathy and to identify the manner in which novel anticoagulant medications affect the clotting cascade with particular interest in trauma and spine surgery.

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“…Massive transfusion has been defined loosely as the replacement of one blood volume in a 24-hr period. 6 Although, a more dynamic definition of massive transfusion includes the transfusion of at least four red cell concentrates within one hour and an ongoing need for blood replacement in the foreseeable future. 6 The management of a massively bleeding patient is complex and is aimed at concurrent hemorrhage control and blood volume replacement.…”

Section: Summary Reviewmentioning

confidence: 99%