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Time for changing coagulation management in trauma-related massive bleeding

Fries, Dietmara; Innerhofer, Petrab; Schobersberger, Wolfgangc

Current Opinion in Anesthesiology: April 2009 - Volume 22 - Issue 2 - p 267–274
doi: 10.1097/ACO.0b013e32832678d9
Trauma and transfusion: Edited by Thomas Weber

Purpose of review New insights into the pathophysiology of trauma-induced coagulopathy, the increasing availability of point-of-care devices and awareness of side effects of intravenous fluids and traditional fresh frozen plasma therapy has encouraged new concepts for managing massive blood loss.

Recent findings Trauma-induced coagulopathy primarily results from blood loss, hypovolemia-induced activation of the protein C system and consequent increase of the fibrinolytic potential, whereas hemodilution, localized consumption of clotting factors and platelets, hypothermia, acidosis, anemia and hypocalcemia further decrease the hemostatic potential. The widespread use of viscoelastic devices highlighted the importance of the contribution of fibrinogen to clot firmness, a precondition for cessation of bleeding. The evidence is growing that targeted therapy using coagulation factor concentrates guided by viscoelastic measurements enables effective correction of severe coagulopathy.

Summary During massive blood loss, viscoelastic measurements should guide aggressive treatment of deficiency or hyperfibrinolysis or both. In addition, the impact of contributing factors should be considered and as far as possible corrected. New data underscore the importance of avoiding hypoperfusion, and the use of coagulation factor concentrates should enable more effective correction of coagulopathy.

aDepartment of General and Surgical Critical Care Medicine, Innsbruck Medical University, Austria

bDepartment of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria

cInstitute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), Innsbruck and Hall, Innsbruck, Austria

Correspondence to Dr Petra Innerhofer, MD, Associate Professor, Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Anichstr. 35, A-6020 Innsbruck, Austria Tel: +43 512 504 80407; e-mail: petra.innerhofer@i-med.ac.at

This article is dedicated to our colleague and friend Professor Dr Josef Margreiter, who unexpectedly died on 7 November 2008.

© 2009 Lippincott Williams & Wilkins, Inc.