Plasma therapy
and fibrinogen
supplementation
constitute the
initial steps
in the control
of a massive
haemorrhage,
but if
coagulation data
are available,
goal-directed
therapy should
be initiated
right away
hypothermia induces changes in platelet function
and fibrinolysis, ultimately requiring higher
amounts of blood products; in combination
with acidosis, it can be life-threatening. It is also
critical to immediately correct low levels of
fibrinogen, coagulation factors or platelet
counts. 2,4
Plasma therapy and fibrinogen
supplementation constitute the initial steps in
the control of a massive haemorrhage, but if
coagulation data are available goal-directed
therapy should be initiated right away.
Antifibrinolytic tranexamic acid should be
promptly and liberally administered to bleeding
patients or those at significant risk of bleeding
(for example, those receiving anticoagulation
therapy). This synthetic competitive inhibitor of
plasminogen can minimise perioperative blood
loss, and consequently transfusion needs, 2 and
it significantly reduces all-cause mortality and
mortality due to bleeding, with no apparent
increase in vascular occlusive events, when it
is administered early to patients undergoing
elective surgery. The observed reduction in the
risk of death due to bleeding is greater if the
agent is given within one hour from trauma,
whereas it actually increases if given more than
three hours after injury. 9,10 Tranexamic acid also
reduced mortality in a recent study that enrolled
women with post-partum haemorrhage provided
it was given soon after delivery with onset of
bleeding. 11
Goal-directed therapy with coagulation factor
concentrates, either containing fibrinogen or
prothrombin complex factors, allows for rapid
recovery of specific elements involved in
coagulation by avoiding unnecessary transfusions
and minimising variability, and may potentially
reduce transfusion needs and associated costs. 1,4
Goal-directed therapy with plasma versus
factor concentrates
Fresh frozen plasma (FPP) has been used for
decades for the correction of mild-to-moderately
elevated INR, and in many countries it is the only
therapeutic option available. However, FPP has to
be thawed, which may cause delays in therapy
implementation of about 45 minutes. In addition,
any viruses present in the plasma are not
inactivated, thus rendering it a risk factor for the
transmission of pathogens, and large volumes
have to be used in order to ensure its haemostatic
effectiveness (1ml plasma/kg body weight
increases coagulation factors by 1%). 2,4
For patients with an expected massive
haemorrhage, the current treatment guidelines
recommend a plasma/red blood cells ratio of at
least 1:2. 2 Therefore, 20-30ml/kg is necessary to
correct a clinical relevant coagulopathy, meaning
that the lower limit for transfusion is 5-7 units of
plasma, which can result in fluid overload. 12
A health economics evaluation of fluid overload in
patients receiving transfusions of FPP in hospitals
across in the US revealed an increased time of
hospitalisation and cost per visit. 13 Moreover,
a significant increase in complications, particularly
acute respiratory distress syndrome, was observed
in trauma patients who received plasma but did
not require massive transfusions; the incidence
of multiple organ dysfunction syndrome,
pneumonia, and sepsis actually increased with
13
HHE 2018 | hospitalhealthcare.com