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DOI: 10.1055/s-0037-1617077
Coagulation management in massive transfusion
Publikationsverlauf
Publikationsdatum:
23. Dezember 2017 (online)
![](https://www.thieme-connect.de/media/10.1055-s-00034925/2006S02/lookinside/thumbnails/10-1055-s-0037-1617077-1.jpg)
Summary
When 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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References
- 1 Lynn M, Jeroukhimov Klein Y. et al. Updates in the management of severe coagulopathy in trauma patients. Intensive Care Med 2002; 28: 241-247.
- 2 Kaufmann CR, Dwyer KM, Crews JD. et al. Usefulness of thrombelastography in assesment of trauma patient coagulation. J Trauma 1997; 42: 716-720.
- 3 Cosgriff N, Moore EE, Sauaia A. et al. Predicting life-threatening coagulopathy in massively transfused trauma patient: hypothermia and acidosis revisited. J Trauma 1997; 42: 857-862.
- 4 Gando S, Tedo I, Kubota M. Post-trauma coagulation and fibrinolysis. Crit Care Med 1992; 20: 594-600.
- 5 Kapsch DN, Metzler M, Harrington M. et al. Fibrinolytic response to trauma. Surgery 1984; 95: 473-478.
- 6 Gubler KD, Gentilello LM, Hassantash SA. et al. The impact of hypothermia on dilutional coagulopathy. J Trauma 1994; 36: 847-851.
- 7 Murray DJ, Pennell BJ, Weinstein SL. et al. Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg 1995; 80: 336-342.
- 8 Murray DJ, Olson J, Strauss R, Tinker JH. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology 1988; 69: 839-845.
- 9 Leslie SD, Toy PTCY. Laboratory hemostatic abnormalities in massively transfused patients given red blood cells and crystalloids. Am J Clin Pathol 1991; 96: 224-232.
- 10 McLoughlin TM, Fontana JL, Alving B, Mongan PD, Bünger R. Profound normovolemic hemodilution: hemostatic effects in patients and in a porcine model. Anesth Analg 1996; 83: 459-465.
- 11 Ciaverella D, Reed RL, Counts RB. et al. Clotting factor levels and the risk of diffuse microvascular bleeding in the massively transfused patient. Br J Haematol 1987; 67: 365-368.
- 12 Gentillelo LM, Pierson DJ. Trauma critical care. Am J Respir Crit Care Med 2001; 163: 604-607.
- 13 Spiess BD, Gillies BS, Chandler W, Verrier E. Changes in transfused therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth 1995; 9: 168-173.
- 14 Whitten CW, Greilich PE. Thrombelastography: past, present and future. Anesthesiology 2000; 92: 1223-1225.
- 15 Hartert H. Blutgerinnungsstudien mit der Thrombelastographie, einem neuen Untersuchungsverfahren. Klin Wochenschr 1948; 577-583.
- 16 Mallet SV, Cox DJA. Thrombelastography. Br J Anaesth 1992; 69: 307-313.
- 17 Haisch G, Boldt J, Krebs C. et al. The influence of intravascular therapy with a new hydroxyethyl starch preparation (6% HES 130/0.4) on coagulation in patients undergoing major abdominal surgery. Anesth Analg 2001; 92: 565-571.
- 18 Calatzis AN, Kling M, Calatzis AL. et al. Fast and specific coagulation monitoring through modified thrombelastography. Ann Hematol 1996; 72 Suppl I P92.
- 19 Valeri CR, Cassidy G, Pivacek LE. et al. Anemia induced increase in bleeding time: the implication for treatment of nonsurgical blood loss. Transfusion 2001; 41: 977-983.
- 20 Small M, Lowe GD, Cameron E, Forbes CD. Contribution of the haematokrit to the bleeding time. Haemostasis 1983; 13: 379-384.
- 21 Blajchman MA, Bordin JO, Bardossy L, Heddle NM. The contribution of the haematocrit to the thrombocytopenic bleeding in experimental animals. Br J Haematol 1994; 86: 347-350.
- 22 Santos MT, Valles J, Aznar J. et al. Prothrombotic effects of erythrocytes on platelet reactivity. Reduction by aspirin. Circulation 1997; 95: 63-68.
- 23 Peyrou V, Lormeau JC, Herault JP, Gaich C, Pfliegger AM, Herbert JM. 00. Thromb Haemost 1999; 81: 400-406.
- 24 Escolar G, Garrido M, Mazzara R, Castillo R, Ordinas A. Experimental basis for the use of red cell transfusion in the management of anaemic-thrombocytopenic patients. Transfusion 1988; 28: 406-411.
- 25 Hiippala ST. Dextran and hydroxyethyl starch interfere with fibrinogen assays. Blood Coagul Fibrinolysis 1995; 6: 743-746.
- 26 Gottumukkala VNR, Sharma SK, Philip J. Assessing platelet and fibrinogen contribution to clot strength using modified thrombelastography in pregnant women. Anesth Analg 1999; 89: 1453-1455.
- 27 Cochraine Injuries Group Albumin Reviewers.. Human albumin administration in critically ill patients. Systemic review of randomised controlled trials. Br Med J 1998; 317: 235-240.
- 28 Mortier E, Ongenae M, Baerdemaeker LD. et al. In vitro evaluation of the effect of profound haemodilution with hydroxyethyl starch 6%, modified gelatine 4%, and dextran 40 10% on coagulation profile measured by thrombelastography. Anaesthesia 1997; 52: 1061-1064.
- 29 Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solution in critically ill patients: a systemic review of randomized trials. Br Med J 1998; 316: 961-964.
- 30 Choi P, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation. A systemic review. Crit Care Med 1999; 27: 200-221.
- 31 Roberts I, Evans P, Bunn F, Kwan I, Crowhurst E. Is the normalisation of blood pressure in bleeding trauma patients harmful. Lancet 2001; 357: 385-387.
- 32 Ruttmann TG, James MFM, Viljoen JF. Haemodilution induces a hypercoagulable state. Br J Anaesth 1996; 76: 412-414.
- 33 Karoutsos S, Nathan N, Lahrimi A, Grouille D, Feiss P, Cox DJA. Thrombelastogram reveals hypercoagulability after administration of gelatin solution. Br J Anaesth 1999; 82: 175-177.
- 34 Ng KFJ, Lam CCK, Chan LC. In vivo effects of haemodilution with saline on coagulation: a randomized controlled trial. Br J Anaesth 2002; 88: 475-480.
- 35 Ruttmann TG, James MFM, Finlayson J. Effects on coagulation of intravenous crystalloid or colloid in patients undergoing peripheral vascular surgery. Br J Anaesth 2002; 89: 226-230.
- 36 Innerhofer P, Fries D, Klingler A, Streif W. In vivo effects of haemodilution with saline on coagulation. Br J Anaesth 2002; 89: 934-939.
- 37 Fries D, Innerhofer P, Klingler A, Berresheim U, Mittermayr M, Calatzis A, Schobersberger W. The effect of the combined administration of colloids and lactated Ringer’s solution on the coagulation system: an in vitro study using thrombelastograph coagulation analysis. Anesth Analg 2002; 94: 1280-1287.
- 38 Innerhofer P, Fries D, Margreiter J, Klingler A, Kühbacher G, Wachter B, Oswald E, Salner E, Frischhut B, Schobersberger W. The effect of perioperatively administered colloids and crystalloids on primary hemostasis and clot formation. Anesth Analg 2002; 95: 858-865.
- 39 Petroianu GA, Maleck WH, Koettner KP, Liu J, Schmitt A. Effect of in vitro hemodilution with hydroxyethyl starch and dextrans on the activity of plasma clotting factors. Crit Care Med 2003; 31: 250-254.
- 40 Mardel SN, Saunders FM, Allen H. et al. Reduced clot quality of clot formation with gelatin based plasma substitutes. Br J Anaesth 1998; 80: 204-207.
- 41 Engvall E, Ruoslahti E, Miller EJ. Affinity of fibronectin to collagens of different genetic types and fibrinogen. J Exp Med 1978; 147: 1584-1595.
- 42 Treib J, Baron JF, Grauer MT, Strauss RG. An international view of hydroxyethyl starches. Int Care Med 1999; 25: 258-268.
- 43 Vogt NH, Bothner U, Lerch G, Lindner KH, Georgieff M. Large dose administration of 6% hydroxyethyl starch 200/0.5 for total hip arthroplasty: plasma homeostasis, hemostasis and renal function compared to use of 5% human albumin. Anesth Analg 1996; 83: 262-268.
- 44 Entholzer EK, Mielke LL, Calatzis AN. et al. Coagulation effects of a recently developed hydroxyethyl starch (HES 130/0.4) compared to hydroxyethyl starches with higher molecular weight. Acta Anaesthesiol Scand 2000; 44: 1116-1121.
- 45 Gallandat R, Siemons A, Baus D. et al. A novel hydroxyethyl starch (Voluven) for effective perioperative plasma volume substitution in cardiac surgery. Can J Anesth 2000; 47: 1207-1215.
- 46 Menzebach A, Cassens U, Van Aken H, Booke M. Strategies to reduce perioperative blood loss related to non-surgical bleeding. Eur J Anaesthesiol 2003; 20: 764-770.
- 47 Mortelsmans YJ, Vermaut GA, Van Aken H. A simple method for calculating component dilution during fluid resuscitation: the Leuven approach. J Clin Anesth 1994; 6: 279-287.
- 48 Stainsby D, MacLennan S, Hamilton PJ. Management of massive blood loss: a template guideline. Br J Anaesth 2000; 85: 487-491.
- 49 Reed RL, Ciavgerella D, Heimbach DM. et al. Prophylactic platelet administration during massive transfusion. Ann Surg 1986; 203: 40-48.
- 50 Hirshberg A, Dugas M, Banez Ei, Scott BG, Wall MJ, Mattox KL. Minimizing dilutional coagulopathy in exsanguinating hemorrhage: a computer simulation. J Trauma 2003; 54: 454-463.
- 51 Hiippala ST, Myllylä GJ, Vahtera EM. Hemostatic factors and replacement of major blood loss with plasma-poor red cell concentrates. Anesth Analg 1995; 81: 360-365.
- 52 Murray DJ, Pennel BJ, Weinstein SL, Olson JD. Packed red cells in acute blood loss: dilutional coagulopathy as a cause of surgical bleeding. Anesth Analg 1995; 80: 336-342.
- 53 Eika C, Havie O, Godal HC. The value of preoperative haemostatic screening. Scand J Haematol 1978; 21: 349-354.
- 54 Robbins JA, Rose SD. Partial thromboplastin time as screening test. Ann Intern Med 1979; 90: 796.
- 55 Lucas CE, Ledgerwood AM. Clinical significance of altered coagulation tests after massive transfusion for trauma. Ann Surg 1981; 47: 125-130.
- 56 Singbartl K, Innerhofer P, Radvan J. et al. Hemostasis and hemodilution: a quantitative mathematical guide for clinical practice. Anesth Analg 2003; 96: 929-935.
- 57 Vorstand und wissenschaftlicher Beirat der Bundesärztekammer.. Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten. Köln: Deutscher Ärzteverlag; 2001
- 58 Fries D, Innerhofer P, Reif C. et al. The effect of the fibrinogen substitution on dilutional coagulopathy – an in vitro model. Anesth Analg 2006; 102: 347-351.
- 59 Fries D, Krismer A, Schobersberger A. et al. The effect of fibrinogen on dilutional coagulopathy – a porcine model. BJA 2005; 95: 172-177.
- 60 Madjdpour C, Dettori N, Frascarolo P. et al. Molecular weight of hydroxyethyl starch: is there an effect on blood coagulation and pharmacokinetics?. BJA 2005; 94: 569-576.
- 61 Fries D, Haas T, Klingler A. et al. Efficacy of fibrinogen and prothrombin complex concentrate used to reverse dilutional coagulopathy-a porcine model. BJA 2006; 97: 460-467.
- 62 Escolar G, Garrido M, Mazarra M. et al. Experimental use of red cell transfusion in the management of anemic – thrombocytopenic patients. Transfusion 1988; 28: 406-411.
- 63 Blajchman MA, Bordin JO, Bardossy I. et al. The contribution of the hematocrit to thrombocytopenic and bleeding in experimental animals. Br J Haematol 194 86: 347-350.
- 64 Small M, Lowe GDO, Cameron E. et al. Contribution of the hematocrit to the bleeding time. Haemostasis 1983; 13: 379-384.
- 65 Santos MT, Valles J, Marcus AJ. et al. Enhancement of platelet reactivity and modulation of eicosanoid production by intact erythrocytes. J Clin Invest 1991; 87: 571-580.
- 66 Peyrou V, Lormeau JC, Herault JP. et al. Contribution of erythrocytes to thrombin generation in whole blood. Thromb Haemost 1999; 81: 400-406.
- 67 Valeri CJ, Cassidy G, Pivacek LE. et al. Anemia induced increase in the bleeding time: implications for treatment of non surgical blood loss. Transfusion 2001; 41: 977-983.