How I Treat How I treat patients with massive hemorrhage

Death from injury has increased by 20% over the last decade and accounts for more death than malaria, tubercolosis, and HIV combined. Hemorrhage requiring massive transfusion secondary to trauma and major surgery remains a major cause of potentially preventable deaths, and development of coagulopathy further substantiallyincreases the mortality rates of hemorrhaging patients. Classically, massive transfusion has been defined as receiving .10 red blood cell (RBC) units in 24 hours, although recently, a change toward applying the rate of transfusion in a shorter time frame such as 2 or 6 hours has been broadly accepted. Historically, treatment of massive hemorrhage with blood products has been based on the “Berne” concept, dictating that resuscitation should occur in successive steps starting with RBCs and followed by plasma when ;1 blood volume was substituted and including platelets when .2 blood volumes were substituted. This approach was incorporated into transfusion guidelines as exemplified by guidelines from the American Society of Anesthesiologists (ASA). Early in the new millennium, however, this transfusion paradigm was challenged mainly based on the results from the US Military in Iraq, where thawed AB fresh frozen plasma (FFP) was administered together with RBCs, as well as platelet concentrates (PCs) from the start of resuscitation. This resuscitation regimen was based on the notion that it was problematic to dilute the concentration of platelets and coagulation factors by RBCs before administering platelets and plasma to massively bleeding patients. Another concern regarding the transfusion guidelines was that conventional coagulation tests, like prothrombin time and partial thromboplastin time, were applied to identify patients in need of plasma substitution. However, the conventional plasma based tests only describe isolated fragments of the hemostatic process and are poorly associated with bleeding and transfusion requirements, as well as the platelet count itself does not reflect whether the platelets are hemostatically intact. The criticism of using the conventional coagulation tests were inspired by a new understanding of the hemostatic process, introduced by Hoffman and colleagues in the mid-1990s. A final major problem with the conventional coagulation analysis is that the time from blood sampling to availability of the results is too slow to be of clinical relevance in the massively bleeding patient.