Massive Transfusion Coagulopathy
Coagulopathy following massive transfusion is a consequence of post-traumatic and surgical hemorrhage. Bleeding following massive transfusion can occur due to hypothermia, dilutional coagulopathy, platelet dysfunction, fibrinolysis, or hypofibrinogenemia. Transfusion of 15 to 20 units of blood products causes dilutional thrombocytopenia, and both antiplatelet agents (eg, clopidogrel [Plavix, Sanofi, Bridgewater, NJ]) and hemostatic inhibitors (eg, low-molecular-weight heparins, pentasaccharides, and direct thrombin inhibitors) are contributing factors to bleeding. Tests for platelet dysfunction are not readily available. Excessive fibrinolysis and low fibrinogen are also causes of bleeding in these patients. Currently, however, there are several agents that have been reported to be effective for the prophylaxis of hemorrhage in surgical patients, including aprotinin for cardiac surgery, orthopedic surgery, and hepatic transplantation, and the off-label use of recombinant activated factor VII (NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) as rescue therapy for life-threatening hemorrhage.
[Show abstract] [Hide abstract] ABSTRACT: Resuscitation of children and neonates with severe or refractory bleeding due to surgery or trauma often requires massive transfusion (MT). Findings from recent studies have led to a better understanding of the complex pathophysiology in massive haemorrhage and the effects of MT on haemostasis. Current management of the massively bleeding adult patient has evolved over the past few decades, shifting to early transfusion of products in a balanced ratio as part of MT protocols (MTPs). Paediatric data on successful management of MT are limited and the optimal transfusion approach is currently unknown, leading to practice variability among institutions, depending on resource availability and patients' needs. Here, we review new important concepts in the biology of massive bleeding and MT, outline important management principles and current practices, and highlight available relevant adult and paediatric data.0Comments 18Citations
- "Massive transfusion (MT) is a term that generally describes infusion of blood products in significant volumes over a short time period (Dehmer & Adamson, 2010). Several different definitions of MT for adult patients exist, based on absolute or relative volumes of transfused blood and blood products, and the time frame for these transfusions (Levy, 2006; Malone et al, 2006; Raymer et al, 2012). Three definitions of MT are commonly reported in adult literature (Raymer et al, 2012): 1-Transfusion of ! 10 units of red blood cells (RBCs) within 24 h, 2-Transfusion of >4 units of RBCs in 1 h with anticipation of continued need, 3-Replacement by transfusion of 50% total blood volume (TBV) in 3 h. "
[Show abstract] [Hide abstract] ABSTRACT: Abnormalities of the hemostasis can lead to hemorrhage, and on the other hand to thrombosis. Intracranial neoplasms, complex surgical procedures, and head injury have a specific impact on coagulation and fibrinolysis. Moreover, the number of neurosurgical patients on medication (which interferes with platelet function and/or the coagulation systems) has increased over the past years. The objective of this review is to recall common hemostatic disorders in neurosurgical patients on the basis of the "new concept of hemostasis". Therefore the pertinent literature was searched to provide a structured and up to date manuscript about hemostasis in Neurosurgery. According to recent scientific publications abnormalities of the coagulation system are discussed. Pathophysiological background and the rational for specific (cost)-effective perioperative hemostatic therapy is provided. Perturbations of hemostasis can be multifactorial and maybe encountered in the daily practice of neurosurgery. Early diagnosis and specific treatment is the prerequisite for successful treatment and good patients outcome.0Comments 34Citations
- "The level of fibrinogen required to maintain optimal hemostasis in the perioperative period has not yet been defined. Conservative algorithms suggest replacement of fibrinogen if fibrinogen concentration is below 1.0–1.5 g/l, levels that are far below normal values for fibrinogen [55, 182, 300]. In neurosurgical patients with postoperative bleeding complications, the preoperative fibrinogen was significantly lower compared to patients without bleeding. "
[Show abstract] [Hide abstract] ABSTRACT: Bleeding diathesis after aortic valve operation and ascending aorta replacement (AV-AA) is managed with fresh-frozen plasma (FFP) and platelet concentrates. The aim was to compare haemostatic effects of conventional transfusion management and FIBTEM (thromboelastometry test)-guided fibrinogen concentrate administration. A blood products transfusion algorithm was developed using retrospective data from 42 elective patients (Group A). Two units of platelet concentrate were transfused after cardiopulmonary bypass, followed by 4 u of FFP if bleeding persisted, if platelet count was < or =100 x 10(3) microl(-1) when removing the aortic clamp, and vice versa if platelet count was >100 x 10(3) microl(-1). The trigger for each therapy step was > or =60 g blood absorbed from the mediastinal wound area by dry swabs in 5 min. Assignment to two prospective groups was neither randomized nor blinded; Group B (n=5) was treated according to the algorithm, Group C (n=10) received fibrinogen concentrate (Haemocomplettan P/Riastap, CSL Behring, Marburg, Germany) before the algorithm-based therapy. A mean of 5.7 (0.7) g fibrinogen concentrate decreased blood loss to below the transfusion trigger level in all Group C patients. Group C had reduced transfusion [mean 0.7 (range 0-4) u vs 8.5 (5.3) in Group A and 8.2 (2.3) in Group B] and reduced postoperative bleeding [366 (199) ml vs 793 (560) in Group A and 716 (219) in Group B]. In this pilot study, FIBTEM-guided fibrinogen concentrate administration was associated with reduced transfusion requirements and 24 h postoperative bleeding in patients undergoing AV-AA.0Comments 174Citations
- "There are currently ongoing discussions in the literature concerning the critical level of plasma fibrinogen in relation to perioperative bleeding.12131920 There are experimental and clinical data describing a protective effect of high plasma fibrinogen levels. "