Algorithms for transfusion and coagulation management in massive haemorrhage

作者：Goerlinger K^*; Dirkmann D; Weber C F; Rahe Meyer N; Hanke A A

来源：Anasthesiologie & Intensivmedizin, 2011, 52: 145-+.

• Point-of-Care Testing
• Thromboelastometry
• Blood Transfusion
• Coagulation Factor Concentrates
• Cost Analysis

Massive bleeding as well as blood transfusion are associated with increased morbidity and mortality. In this context, blood transfusion increases the incidence of nosocomial infections, perioperative ischaemic events and acute lung injury.
Transfusion and coagulation management algorithms are capable for a significant reduction in perioperative transfusion requirements. However, different strategies to treat massive bleeding and haemostatic disorders are favoured in different countries.
"Damage control resuscitation" is based on transfusion of packed red blood cells, fresh frozen plasma (FFP), and platelet concentrates (PC) in a fixed ratio of 1:1:1. This concept is favoured by US Army for the treatment of patients with military trauma. It can be realised without any laboratory measurements and knowledge in haemostasis. However, this concept is based on prophylactic transfusion of FFP and PC in order to prevent coagulopathy and its efficacy in patients with already existing coagulopathy is controversial.
Algorithms to treat massive bleeding based on conventional laboratory tests are limited in their efficacy because PT, INR, and aPTT are not effective in predicting perioperative bleeding. Furthermore, disorders of primary haemostasis and hyperfibrinolysis can not be detected contemporarily by conventional laboratory tests and the turn-around time of conventional coagulation tests is too long to enable an early goal-directed therapy.
Early individualised goal-directed haemostatic therapy can only be done based on functional point-of-care (POC) methods such as thromboelastometry/graphy and impedance aggregometry (multiple electrode aggregometry (MEA)). POC coagulation diagnostics are most effective in connection with the use of immediately available haemostatic agents with a calculable effect and a low incidence of adverse events such as tranexamic acid, fibrinogen concentrate, prothrombin complex concentrate (PCC), and other specific coagulation factor concentrates. Implementation of evidence- or experience-based algorithms for POC coagulation management has already been shown to be effective in reduction of perioperative transfusion requirement and respective costs in several studies. This may also result in reduction of transfusion-related morbidity and mortality. Further prospective randomised studies are needed to confirm these data.

• 出版日期2011-2