Management of major blood loss: An update

Editorial: Acta Anaesthesiol Sc
Fecha: 01/10/2010
P. I. JOHANSSON, S. R. OSTROWSKI and N. H. SECHER

Haemorrhage remains a major cause of potentially preventable deaths. Trauma and massive transfusion are
associated with coagulopathy secondary to tissue injury,
hypoperfusion, dilution and consumption of clotting factors
and platelets. Concepts of damage control surgery
have evolved, prioritizing the early control of the cause of bleeding by non-definitive means, while haemostatic control resuscitation seeks early control of coagulopathy.
Haemostatic resuscitation provides transfusions with
plasma and platelets in addition to red blood cells
(RBCs) in an immediate and sustained manner as part of
the transfusion protocol for massively bleeding patients.
Transfusion of RBCs, plasma and platelets in a similar
proportion as in whole blood prevents both hypovolaemia
and coagulopathy. Although an early and effective reversal
of coagulopathy is documented, the most effective means
of preventing coagulopathy of massive transfusion
remains debated and randomized controlled studies are
lacking. Results from recent before-and-after studies
in massively bleeding patients indicate that trauma
exsanguination protocols involving the early administration
of plasma and platelets are associated with improved
survival. Furthermore, viscoelastic whole blood assays,
such as thrombelastography (TEG)/rotation thromboelastometry(ROTEM), appear advantageous for identifying coagulopathy in patients with severe haemorrhage, as opposed to conventional coagulation assays. In our view,patients with uncontrolled bleeding, regardless of its cause, should be treated with goal-directed haemostatic control resuscitation involving the early administration of plasma and platelets and based on the results of the TEG/ROTEM analysis. The aim of the goal-directed therapy should be to maintain a normal haemostatic competence until surgical haemostasis is achieved, as this appears to be associated with reduced mortality.

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