Pathophysiology and Treatment of Coagulopathy in Massive Hemorrhage and Hemodilution

Abstract

Fluid resuscitation after massive hemorrhage in major surgery and trauma may result in extensive hemodilution and coagulopathy, which is of a multifactorial nature. Although coagulopathy is often perceived as hemorrhagic, extensive hemodilution affects procoagulants as well as anticoagulant, profibrinolytic, and antifibrinolytic elements, leading to a complex coagulation disorder. Reduced thrombin activation is partially compensated by lower inhibitory activities of antithrombin and other protease inhibitors, whereas plasma fibrinogen is rapidly decreased proportional to the extent of hemodilution. Adequate fibrinogen levels are essential in managing dilutional coagulopathy. After extensive hemodilution, fibrin clots are more prone to fibrinolysis because major antifibrinolytic proteins are decreased.Fresh frozen plasma, platelet concentrate, and cryoprecipitate are considered the mainstay hemostatic therapies. Purified factor concentrates of plasma origin and from recombinant synthesis are increasingly used for a rapid restoration of targeted factors. Future clinical studies are necessary to establish the specific indication, dosing, and safety of novel hemostatic interventions.

A new structural biomarker that quantifies and predicts changes in clot strength and quality in a model of progressive haemodilution

“…[28][29][30] However, in surgery and trauma the fibrinogen concentration required to provide a stable haemostatic clot is uncertain. Several studies investigating the optimal fibrinogen concentration have recommended a range values (>1.0 g/L to <2.5 g/L).…”

Comparison of Thromboelastometry (ROTEM®) With Standard Plasmatic Coagulation Testing in Paediatric Surgery

“…1 As a result, early detection of signs of coagulopathy is a major issue and challenge for paediatric anaesthetists. Standard coagulation tests [prothrombin time (PT), activated partial thromboplastin time (aPTT), and plasma fibrinogen level] in the perioperative setting are time-consuming, 2 3 which delays prompt haemostatic therapy.…”

Literature Review for Management of Massive Hemorrhage

“…This may lead to further coagulopathy. Resuscitation with huge amount of crystalloid fluids and blood components can cause hemodilution, dilution coagulopathy, hyperfibrinolysis, decreased oxygen carrying capacity and delivery [8,9]. Hypothermia and metabolic acidosis may worsen the coagulopathy and lead to further hemorrhage, shock and may be death [10,11].…”