HHE Sponsored supplement: Managing perioperative bleed - Page 13

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