1. Brad Beckham T4

2. Definitions  Major blood loss Hemoglobin concentration below 6-10 g/dl  Massive transfusion in adults >9 erythrocyte units within 24h >5 erythrocyte units within 12h >50 units of any blood product within 24h

3. Hemostasis Monitoring  PT INR > 1.5 demonstrates 88% sensitivity and 88% specificity for at least one nonhemostatic coagulation factor level after trauma  aPTT >1.5x nl demonstrates sensitivity of 50% and specificity of 100% due to factor VIII release as acute phase reactant  ROTEM/TEG Coagulation time, clot formation time, clot firmness, lysis time

4. Causes  Hemodilution  Consumptive loss  Fibrinolysis  Anticoagulant use  Hypothermia  Metabolic derangements  Mechanical derangements

5. Initial Resuscitation  Initial usually crystalloids and colloids to restore volume Some colloids impair platelet function, inhibit fibrin polymerization, and induce aquired Von Willebrand syndrome Crystalloids induce dilution  Erythrocyte transfusion Improve oxygen carrying capacity Theorized to improve hemostasis

6. Hemostatic Products  FFP Guidelines recommend early initiation in massive transfusion protocol. No set FFP:RBC ratio, but studies suggest a 1:1 or greater likely to provide better survival rates Not to be used as volume replacement due to associated risk factors

7. Hemostatic Products  Cryoprecipitate Used to supplement FFP that is low in plasma fibrinogen 15ml / 10kg bodyweight increases plasma fibrinogen by 0.5g/L FFP requires 30ml / 1kg to increase by 1g/L High levels of fibrinogen associated with reduction in mortality of combat trauma pts

8. Hemostatic Products  Prothrombin Complex Concentrate Factors II, VII, IX, X, protein C and S Factors concentrated at 25x that of FFP Reduces risk of volume overload with FFP Limited data on usage Early data suggests reduced need for FFP with no change in survival Also used for acute reversal of coumarins

9. Hemostatic Products  Recombinant Activated Factor VII No difference in amount of transfusion within first 48h, but may reduce transfusions needed beyond this point May be associated with increased risk of thromboembolic complications  Platelet Concentrates Only recommended when platelet dysfunction is identified due to high risk of adverse post transfusion events

10. Conclusion  Use point-of-care testing to optimize dosing of appropriate products  Usage of newer concentrates to provide targeted therapy without risk of volume overload  Requires in depth knowledge of pathophysiologic changes occurring for optimal balanced approach

11.  Bollinger, Daniel M.D., et al. “Pathophysiology and Treatment of Coagulopathy in Massive Hemorrhage and Hemodilution” Anesthesiology: November 2010. Vol 113:5, pg 1205-1219.  American Association of Blood Banks, www.aabb.org