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Massive transfusion and coagulopathy: pathophysiology and implications for clinical management

[Transfusion massive et coagulopathie-: physiopathologie et implications cliniques]

From the Department of Anesthesiology, Centre Hospitalier de l’Université de Montréal,* Hôpital Notre-Dame, Montréal, Québec, Canada; the Hemostasis unit, Hôpital Universitaire de Genève, Genève, Suisse; and the Département d’anesthésie-réanimation, Hôpital Avicenne, Bobigny, France.

Address correspondence to: Dr. Jean-François Hardy, Département d’anesthésiologie, Porte AS-1115-3, Pavillon Lachapelle, CHUM Hôpital Notre Dame, 1560 rue Sherbrooke est, Montréal, Québec H2L 4M1, Canada. E-mail: jean-francois.hardy{at}umontreal.ca

Purpose: To review the pathophysiology of coagulopathy in massively transfused, adult and previously hemostatically competent patients in both elective surgical and trauma settings, and to recommend the most appropriate treatment strategies.

Methods: Medline was searched for articles on "massive transfusion," "transfusion," "trauma," "surgery," "coagulopathy" and "hemostatic defects." A group of experts reviewed the findings.

Principal findings: Coagulopathy will result from hemodilution, hypothermia, the use of fractionated blood products and disseminated intravascular coagulation. The clinical significance of the effects of hydroxyethyl starch solutions on hemostasis remains unclear. Maintaining a normal body temperature is a first-line, effective strategy to improve hemostasis during massive transfusion. Red cells play an important role in coagulation and hematocrits higher than 30% may be required to sustain hemostasis. In elective surgery patients, a decrease in fibrinogen concentration is observed initially while thrombocytopenia is a late occurrence. In trauma patients, tissue trauma, shock, tissue anoxia and hypothermia contribute to the development of disseminated intravascular coagulation and microvascular bleeding. The use of platelets and/or fresh frozen plasma should depend on clinical judgment as well as the results of coagulation testing and should be used mainly to treat a clinical coagulopathy.

Conclusions: Coagulopathy associated with massive transfusion remains an important clinical problem. It is an intricate, multifactorial and multicellular event. Treatment strategies include the maintenance of adequate tissue perfusion, the correction of hypothermia and anemia, and the use of hemostatic blood products to correct microvascular bleeding.

Abbreviations: aPTT activated partial thromboplastin time • BT bleeding time • DIC disseminated intravascular coagulation • FFP fresh frozen plasma • HES hydroxyethyl starch • MT massive transfusion • MVB microvascular bleeding • MWB modified whole blood • PRBC packed red blood cells • PT prothrombin time • RBC red blood cells

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