Concentrates/blood products
surgical and trauma patients. 2,7 By
contrast, the incorporation of platelet
function assessment via aggregrometry
in blood management resulted in the
reduction in the number of patients
requiring massive transfusions or
transfusions of red blood cells compared
with conventional laboratory analyses,
thus leading to fewer transfusion-related
complications and reduced costs. 8
Initial management of
perioperative bleeding and
treatment escalation
The first measures to limit further loss of
blood include damage control surgery,
coiling, and packing strategies as well as
timely correction of acidosis and
hypothermia, hypocalcaemia, and
anaemia. In severely injured patients,
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
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
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 larger
volumes of transfused plasma. 14 FPP was
also associated with an increased risk of
hospitalph armacyeurope.com
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