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Coagulopathy and blood component transfusion in trauma R3.

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Presentation on theme: "Coagulopathy and blood component transfusion in trauma R3."— Presentation transcript:

1 Coagulopathy and blood component transfusion in trauma R3

2 Trauma –1 in 10 death worldwide –uncontrolled bleeding 40% of trauma-related deaths leading cause of potentially preventable and early in- hospital death life-threatening bleeding –vascular injury –coagulopathy consumption and dilution of coagulation factors and platelets, dysfunction of platelets and the coagulation system, increased fibrinolysis, compromise of the coagulation system by the infusion of colloid, hypocalcemia, and disseminated intravascular coagulation-like syndrome

3 Pathophysiology of coagulopathy in trauma 2) Consumption coagulopathy precise cause is difficult to identify and multifactorial

4 Pathophysiology of coagulopathy in trauma 3) Increased fibrinolysis trauma pts. demonstrate both hypofibrinolytic and hyperfibrinolytic states severity of injury, time from injury Simmons et al. –trauma : fibrinolytic activity increase –mild~moderate inj.: 24h normal –major inj.: remain elevated –hypothermia : fibrinolytic activity

5 Pathophysiology of coagulopathy in trauma 4) Hypothermia-induced coagulopathy significant risk factors for life-threatening coagulopathy –injury severity score > 25 –systolic BP < 70mmHg –acidosis with pH < 7.10 –hypothermia with BT < 34 lethal triad –hypothermia, metabolic acidosis, progressive coagulopathy

6 Pathophysiology of coagulopathy in trauma 4) Hypothermia-induced coagulopathy effect of hypothermia on coagulopathy is difficult to identify by routine coagulation screening tests (PT, aPTT) hypothermia –impairs thrombin generation and the formation of platelet plugs and fibrin clots –increase clot lysis –results in coagulopathy and uncontrollable bleeding

7 Pathophysiology of coagulopathy in trauma 5) Decreased levels of coagulation factors and platelets large volumes of crystalloid and colloid thrombocytopenia is seen commonly in pts. received massive blood transfusion platelets are present in whole blood RBC unit –negligible amounts of coagulation factors and platelets –thrombocytopenia and subnormal levels of coagulation factors often occur at early stage during massive RBC transfusion

8 Pathophysiology of coagulopathy in trauma 6) The effect of acute RBC loss on coagulation unclear as no data from trauma pts. are available, the effect of acute RBC loss on coagulation is unknown

9 Effect of massive RBC transfusion on coagulation whole blood, specific component therapy blood component therapy –optimizes the use of resources by allowing components to be used in different pts. –avoids potentially harmful effects caused by transfusion of surplus constituents –whole blood massive RBC transfusion earlier stage coagulopathy (low levels of platelets and clotting factors)

10 Effect of massive RBC transfusion on coagulation relationship between volume of blood loss, replacement volume and the reduction in coagulation factor and platelet levels are difficult to establish increased acid load from RBC units may also contribute to coagulopathy –pH of an RBC unit is low, and decreases progressively during storage from 7.0 to 6.3 –plasma high-buffering capacity acid-base disturbance –trauma pts. are already acidotic, massive transfusion of RBCs further increase acid load, exacerbate the ongoing coagulopathy

11 Unresolved issues regarding blood transfusion in trauma 1) Optimal replacement therapy for FFP and platelets massive RBC transfusion FFP, platelets, fibrinogen concentrate or cryoprecipitate universal guideline based on experts opinion or personal experience

12 Unresolved issues regarding blood transfusion in trauma 1) Optimal replacement therapy for FFP and platelets 1st approach –transfuse FFP and plts. prophylactically after a certain number of units of RBCs –FFP:RBC 1:10 ~ 2:3 –plt:RBC 6:10 ~ 12:10 –coagulopathy bleeding –benefit

13 Unresolved issues regarding blood transfusion in trauma 1) Optimal replacement therapy for FFP and platelets 2nd approach –transfuse FFP, plt, cryoprecipate only when there is clinical or laboratory evidence of coagulopathy microvascular bleeding PT or aPTT > 1.5 times normal value thrombocytopenia < fibrinogen concentration < 1g/L –occult site microvascular bleeding –lab. test may take 30~60min

14 Effect of RBC transfusion on longer-term outcome in trauma 1) Multiple organ failure (MOF) RBC transfusion has been to shown to be an independent risk factor for post-injury MOF 513 major trauma, severe bleeding and haemorrhagic shock injury MOF 12h RBC 13unit MOF 3.8unit decrease in volume of RBC transfused may decrease the risk and severity of MOF

15 Effect of RBC transfusion on longer-term outcome in trauma 2) Post-injury infection large amounts of foreign antigens may lead to downregulation of the immune system alternative non-immune-mediated mechanism –stored RBCs are less deformable and more rigid, once transfused they may obstruct capillary blood flow, predisposing tissue to ischemia and infection as well as poor delivery of prophylactic antibiotics

16 The need for haemostatic agents ideal hemostatic agent should be efficacious in a wide range of hemostatic dysfunctions, simple to store and use, and have a rapid action activated recombinant factor (rF a) is a potential candidate –effective hemostasis in a wide range of bleeding conditions –significantly dcreased RBC transfusion requirement in pts. with major trauma –optimal preconditions should be achieved before administration

17 The need for haemostatic agents optimal preconditions –fibrinogen concentration 0.5g/L –platelet count 50/L –pH 7.2

18 Conclusions non-surgically correctable bleeding remains a major challenge currently, blood component replacement therapy remains the mainstay of coagulopathy-related bleeding although RBC transfusion can be life-saving, its negative effects on post-injury outcome have been well documented hemostatic agents, which can effectively control bleeding and reduce the amount of RBC required, may decrease mortality and morbidity in trauma pts. but are unlikely to replace blood transfusion completely


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