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Postinjury Coagulopathy Management: Goal Directed Resuscitation via POC Thrombelastography

Kashuk, Jeffry L. MD*; Moore, Ernest E. MD*; Sawyer, Michael MD†; Le, Tuan MD‡; Johnson, Jeffrey MD*; Biffl, Walter L. MD*; Cothren, C. Clay MD*; Barnett, Carlton MD*; Stahel, Philip MD§; Sillman, Christopher C. MD, PhD¶; Sauaia, Angela MD, PhD∥; Banerjee, Anirban PhD∥

doi: 10.1097/SLA.0b013e3181d3599c
Review

Progressive postinjury coagulopathy remains the fundamental rationale for damage control surgery, but the decision to abort operative intervention must occur before laboratory confirmation of coagulopathy. Current massive transfusion protocols have embraced pre-emptive resuscitation strategies emphasizing administration of packed red blood cells, fresh frozen plasma, and platelets in ratios approximating 1:1:1 during the first 24 hours postinjury, based on US military retrospective experience and recent noncontrolled civilian data. This policy, termed “damage control resuscitation” assumes that patients presenting with life threatening hemorrhage at risk for postinjury coagulopathy should receive component therapy in rations approximating those found in whole blood during the first 24 hours. While we concur with the concept of pre-emptive coagulation factor replacement, and initially suggested this in 1982, we remain concerned for the continued unbridled administration of fresh frozen plasma and platelets without objective evidence of their specific requirement.

A major limitation of current massive transfusion protocols is the lack of real time assessment of coagulation function to guide evolving blood component requirements.

Existing laboratory coagulation testing was originally designed for evaluation of hemophilia and subsequently used for monitoring anticoagulation therapy. Consequently, the applicability of these tests in the trauma setting has never been proven and the time required to conduct these assays is incompatible with prompt correction of the coagulopathy in the trauma setting.

This review examines the current approach to postinjury coagulopathy, including identification of patients at risk, resuscitation strategies, design and implementation of institutional massive transfusion protocols, and the potential benefits of goal-directed therapy by real time assessment of coagulation function via point of care rapid thromboelastography.

Despite its initial recognition over 25 years ago, postinjury coagulopathy continues to be a major cause of death from trauma. Rapid thrombelastography, a point of care assay of the visco-elastic properties of blood, provides a comprehensive analysis of hemostasis and potentiates goal-directed therapy for specific coagulation abnormalities noted after injury.

From the Departments of *Surgery, †Anesthesia, ‡Laboratory Medicine, §Orthopedic Surgery, ¶Pediatrics, and ∥Surgical Research, Denver Health Medical Center, University of Colorado Denver, CO.

Supported, in part, by award number P50GM049222 from the National Institute of General Medical Sciences The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIGMS or National Institutes of Health.

Jeffry L. Kashuk is currently at Division of Trauma, Acute Care, and Critical Care Surgery, Penn State Hershey College of Medicine, Hershey, PA.

Reprints: Jeffry L. Kashuk, MD, FACS, Division of Trauma, Acute Care, and Critical Care Surgery, Section Chief, Acute Care Surgery, Penn State Hershey College of Medicine, 500 University Dr MCH 075, Hershey, PA 17033-0850. E-mail: jkashuk@hmc.psu.edu.

© 2010 Lippincott Williams & Wilkins, Inc.