Coagulation management in massive transfusion

SummaryWhen no fresh frozen plasma is available, acute major blood loss is compensated above all with crystalloids, colloids and red blood cell concentrates, meaning that all plasma clotting factors are diluted. So far, consumption coagulopathy is almost always accompanied by dilutional coagulopathy. Formulas for calculating critical blood loss and standard coagulation tests are often not helpful in the case of massive transfusion. On the other hand, systems suitable for point of care, such as thrombelastography, have important advantages. In the case of consumption and dilutional coagulopathy plasma coagulation is disturbed and critical values are first seen for fibrinogen. Not only is fibrin polymerization impaired by the bleeding-induced loss and dilution of fibrinogen, but also by interaction with artificial colloids, particularly hydroxyethyl starch and gelatin preparations. Neither fresh frozen plasma therapy nor treatment with clotting factor concentrates has been the subject of detailed clinical study. Large scaled studies are needed to work out guidelines for coagulation management in the case of massive blood loss.

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DIFFERENTIATED PRESCRIPTION OF HEMOSTATIC DRUGS AT ACUTE MASSIVE BLOOD LOSS

Тромбоз, гемостаз и реология ◽

10.25555/thr.2017.2.0778 ◽

2017 ◽

Author(s):

М. Глотов ◽

А. Биркун ◽

Е. Рябикина ◽

С. Самарин ◽

М. Федосов

Keyword(s):

Blood Loss ◽

Central Place ◽

Fresh Frozen Plasma ◽

Multiple Organ ◽

Basic Drugs ◽

Clotting Factors ◽

Massive Blood Loss ◽

Fresh Frozen ◽

Dilutional Coagulopathy ◽

Frozen Plasma

Острая массивная кровопотеря (ОМК) остается тяжелым осложнением с высокой летальностью. Центральное место в танатогенезе этого состояния занимают нарушения коагуляции. ДВС-синдром и дилюционная коагулопатия часто осложняют ОМК и приводят к развитию полиорганной недостаточности. В статье рассмотрены современные подходы к назначению гемостатических средств при ОМК, принятые на территории РФ. Базисными препаратами для лечения ОМК являются свежезамороженная плазма, тромбоцитный концентрат, криопреципитат, отдельные факторы свертывания крови, препараты кальция и транексамовая кислота. Правильное использование этих средств предполагает адекватный мониторинг коагуляции. Acute massive blood loss (AMBL) remains to be a severe complication with high mortality rate. Coagulation disorders take central place in tanatogenesis of this condition. DIC-syndrome and dilutional coagulopathy are often complicated by AMBL and lead to development of multiple organ failure. This article presents current approaches that are accepted in Russian Federation of hemostatic drugs prescription in AMBL treatment. Fresh frozen plasma, platelet concentrate, cryoprecipitate, some clotting factors, calcium and tranexamic acid are basic drugs for AMBL treatment. Adequate coagulation monitoring is required for correct use of these drugs.

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Emergency Oral Anticoagulant Reversal: The Relative Efficacy of Infusions of Fresh Frozen Plasma and Clotting Factor Concentrate on Correction of the Coagulopathy

Thrombosis and Haemostasis ◽

10.1055/s-0038-1655992 ◽

1997 ◽

Vol 77 (03) ◽

pp. 477-480 ◽

Cited By ~ 277

Author(s):

Mike Makris ◽

Mike Greaves ◽

Wendy S Phillips ◽

Steve Kitchen ◽

Frits R Rosendaal ◽

...

Keyword(s):

Vitamin K ◽

Fresh Frozen Plasma ◽

Factor Ix ◽

Clotting Factor ◽

Clotting Factors ◽

Anticoagulant Reversal ◽

Fresh Frozen ◽

Pre Treatment ◽

Clotting Factor Concentrates ◽

Frozen Plasma

SummaryHaemorrhage, including intracranial bleeding, is a common, potentially lethal complication of warfarin therapy and rapid and complete reversal of anticoagulation may be life-saving. Fresh frozen plasma (FFP) and vitamin K are most frequently administered. Because of the variable content of vitamin K-dependent clotting factors in FFP, and the effects of dilution, the efficacy of this approach is open to doubt. We have therefore compared the effects of FFP and clotting factor concentrates on the INRs and clotting factor levels of orally anticoagulated subjects requiring rapid correction of their haemostatic defect. In many, the pre-treatment INR was considered to be dangerously above the target therapeutic range. In the 12 patients given FFP, the INR did not completely correct (range 1.6-3.8, mean 2.3) indicating an ongoing anticoagulated state in all. In contrast, the INR in 29 subjects given clotting factor concentrates was completely corrected in 28 (range 0.9-3.8, mean 1.3). Following treatment, marked differences were observed in clotting factor IX levels between the two groups. The median factor IX level was 19 u/dl (range 10-63) following FFP infusion and 68.5 u/dl (range 31-111) following concentrate. In FFP treated patients, poorer responses were also observed for each of the other vitamin K-depen- dent clotting factors but these were less marked than for factor IX, which was present in low concentrations in some batches of FFP. Thus, haemostatically effective levels of factor IX cannot be achieved, in most instances, by the conventional use of FFP in patients requiring reversal of their anticoagulant therapy. Clotting factor concentrates are the only effective option where complete and immediate correction of the coagulation defect is indicated in orally anticoagulated patients with life or limb-threatening haemorrhage.

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Outcome of Major Hemorrhage at a Major Cardiothoracic Center in Patients with Activated Major Hemorrhage Protocol versus Nonactivated Protocol

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0040-1718869 ◽

2021 ◽

Vol 47 (01) ◽

pp. 074-083

Author(s):

Kathryn W. Chang ◽

Steve Owen ◽

Michaela Gaspar ◽

Mike Laffan ◽

Deepa R. J. Arachchillage

Keyword(s):

Fresh Frozen Plasma ◽

Electronic Records ◽

Blood Products ◽

Major Hemorrhage ◽

Fresh Frozen ◽

Dilutional Coagulopathy ◽

Baseline Characteristics ◽

The Impact ◽

Frozen Plasma ◽

Baseline Hemoglobin

AbstractThis study aimed to determine the impact of major hemorrhage (MH) protocol (MHP) activation on blood administration and patient outcome at a UK major cardiothoracic center. MH was defined in patients (> 16 years) as those who received > 5 units of red blood cells (RBCs) in < 4 hours, or > 10 units in 24 hours. Data were collected retrospectively from patient electronic records and hospital transfusion databases recording issue of blood products from January 2016 to December 2018. Of 134 patients with MH, 24 had activated MHP and 110 did not have activated MHP. Groups were similar for age, sex, baseline hemoglobin, platelet count, coagulation screen, and renal function with no difference in the baseline clinical characteristics. The total number of red cell units (median and [IQR]) transfused was no different in the patients with activated (7.5 [5–11.75]) versus nonactivated (9 [6–12]) MHP (p = 0.35). Patients in the nonactivated MHP group received significantly higher number of platelet units (median: 3 vs. 2, p = 0.014), plasma (median: 4.5 vs. 1.5, p = 0.0007), and cryoprecipitate (median: 2 vs. 1, p = 0.008). However, activation of MHP was associated with higher mortality at 24 hours compared with patients with nonactivation of MHP (33.3 vs. 10.9%, p = 0.005) and 30 days (58.3 vs. 30.9%, p = 0.01). The total RBC and platelet (but not fresh frozen plasma [FFP]) units received were higher in deceased patients than in survivors. Increased mortality was associated with a higher RBC:FFP ratio. Only 26% of patients received tranexamic acid and these patients had higher mortality at 30 days but not at 24 hours. Deceased patients at 30 days had higher levels of fibrinogen than those who survived (median: 2.4 vs. 1.8, p = 0.01). Patients with activated MHP had significantly higher mortality at both 24 hours and 30 days despite lack of difference in the baseline characteristics of the patients with activated MHP versus nonactivated MHP groups. The increased mortality associated with a higher RBC:FFP ratio suggests dilutional coagulopathy may contribute to mortality, but higher fibrinogen at baseline was not protective.

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Reduction of Fresh Frozen Plasma Requirements by Perioperative Point-of-Care Coagulation Management with Early Calculated Goal-Directed Therapy

Transfusion Medicine and Hemotherapy ◽

10.1159/000337186 ◽

2012 ◽

Vol 39 (2) ◽

pp. 104-113 ◽

Cited By ~ 133

Author(s):

Klaus Görlinger ◽

Dietmar Fries ◽

Daniel Dirkmann ◽

Christian F. Weber ◽

Alexander A. Hanke ◽

...

Keyword(s):

Point Of Care ◽

Fresh Frozen Plasma ◽

Coagulation Management ◽

Goal Directed Therapy ◽

Fresh Frozen ◽

Frozen Plasma

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Perioperative coagulation management – fresh frozen plasma

Best Practice & Research Clinical Anaesthesiology ◽

10.1016/j.bpa.2009.09.007 ◽

2010 ◽

Vol 24 (1) ◽

pp. 51-64 ◽

Cited By ~ 43

Author(s):

Daryl J. Kor ◽

James R. Stubbs ◽

Ognjen Gajic

Keyword(s):

Fresh Frozen Plasma ◽

Coagulation Management ◽

Fresh Frozen ◽

Frozen Plasma

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The bleeding patient

The Complete Recovery Room Book ◽

10.1093/med/9780198846840.003.0026 ◽

2020 ◽

pp. 403-428

Author(s):

Anne Craig ◽

Anthea Hatfield

Keyword(s):

Blood Transfusion ◽

Blood Loss ◽

Disseminated Intravascular Coagulation ◽

Oxygen Supply ◽

Fresh Frozen Plasma ◽

Blood Transfusions ◽

Massive Blood Transfusion ◽

Intravascular Coagulation ◽

Fresh Frozen ◽

Frozen Plasma

Part one of this chapter tells you about the physiology of blood and oxygen supply, about anaemia and tissue hypoxia, and the physiology of coagulation. Drugs that interfere with clotting are discussed. Bleeding, coagulation, and platelet disorders are covered as well as disseminated intravascular coagulation. Part two is concerned with bleeding in the recovery room: how to cope with rapid blood loss, managing ongoing blood loss, and how to use clotting profiles to guide treatment. There is also a section covering blood transfusion, blood groups and typing. Massive blood transfusion is clearly described, there are guidelines about when to use fresh frozen plasma, when to use platelets, and when to use cryoprecipitate. The final section of the chapter is about problems with blood transfusions.

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Massive Transfusion

Anesthesiology: A Problem-Based Learning Approach ◽

10.1093/med/9780190850692.003.0019 ◽

2018 ◽

pp. 169-180

Author(s):

Jay Berger

Keyword(s):

Red Blood Cells ◽

Blood Volume ◽

Blood Cells ◽

Massive Transfusion ◽

Fresh Frozen Plasma ◽

Metabolic Complications ◽

Packed Red Blood Cells ◽

Fresh Frozen ◽

Life Threatening ◽

Frozen Plasma

Massive transfusion is defined as transfusion of 3 units of packed red blood cells in less than 1 hour in an adult, replacement of more than 1 blood volume in 24 hours, or replacement of more than 50% of blood volume in 3 hours. Massive transfusion protocols are implemented in cases of life-threatening hemorrhage after trauma, during a surgical procedure, or during childbirth. These protocols are intended to minimize the adverse effects of hypovolemia, dilutional anemia, metabolic complications, and coagulopathy with early empiric replacement of blood products and transfusion of fresh frozen plasma, platelets, and packed red blood cells in a composition that approximates that of whole blood.

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