o Thromboelastogram (TEG)

o Kaolin: Activates intrinsic pathway

o Tissue Factor: Activates extrinsic pathway
o Heparinase: Enzyme that degrades heparin
 o

o Coagulopathy of Trauma
Acute coagulopathy present 1 in 4 trauma patients
Associated with 4 fold increase in mortality
Dysfunction
Fibrin activation and/or generation
Platelets
Endothelium
o Multifactorial
Tissue trauma
Shock
Hemodilution
Hypothermia
Acidemia
Inflammation

Effects of tranexamic acid on death, vascular occlusive events, and blood

transfusion in patients with significant haemorrhage (CRASH-2 Trial) Shakur
Lancet 2010

o Background: Tranexamic acid reduced need for blood transfusions

Hyperfibrinolytic during surgery
Trauma and surgery share similar hemostatic responses
o Tranexamic acid (TXA) MOA: inhibits fibrinolysis by blocking lysine binding
on plasminogen
o Objective: Does tranexamic acid, when given within 8 hours to patients with
or at risk of significant bleeding reduce death within 4 weeks of injury

o
o Coagulation Cascade: amplification system to accelerate thrombin generation
from inactive precursor (prothrombin)
Product Components mL/unit Storage 1 unit (70kg
pt)
PRBC 190 mL RBC 350 mL Hgb 1g/dL
25 mL plasma
100 mL saline/additive
FFP 400-800 mg fibrinogen 200 mL coag factors
200 units other coag ~ 7% (10-15
factors mL/kg)
Cryo 200-300 mg fibrinogen 15 mL -20 C fibrinogen ~
80-100 units FVIII 10 mg/dL
(Factor 8, 13, 80 units vWF (10 PACK
fibrinogen, 40-60 units FXIII 100 mg/dL)
vWF,
fibronectin)
Platelets 3.3 x 10^11 platelets/6 300 mL 30-60K
pack

Components KCentra FFP

500 units/20 mL 1 unit/200 mL
FII 380-800 200
FVII 200-500 200
 FVIII N/A 200
FIX 400-620 200
FX 500-1020 200
Protein C 420-820
Protein S 240-680

o KCentra Pearls:
Ensure adequate platelets and fibrinogen
Fibrinogen goal ~ 150 mg/dL (cryo)
Platelet goal ~ 50k
Give with IV vitamin K 5-10 mg in patients treated for warfarin
bleeding
Jehovahs witness
Ensure patient is okay with receiving albumin
Avoid in history of HIT

Transfusion Thresholds:

General ICU Patients:

o TRICC, NEJM 1999, Hebert et al, Transfusion Requirements in Critical Care: Multicentre
Canadian trial of 838 normovolaemic patients (ie not bleeding) randomised, excluding routine
cardiac patients. No change in mortality if transfused at 70 rather than > 100 (p=0.10, liberal group
higher), and significantly transfusions. Mortality difference in favour of restrictive in the less
sick cohort (APACHE < 20) and age < 55. Prior to universal leucodepletion and includes
significant biases. Not powered to look at cardiovascular disease, severe sepsis or acute
cerebrovascular disease. More modern issues are the age of blood and the use of erythropoietin
o CRIT study, Crit Care Medicine 2004, Corwin et al, prospective observational study of 4892
patients showed mean pre-transfusion threshold was 8.6 g/dl (ie still high) and the number of units
transfused was an independent predictor of worse outcome. Same finding as JAMA 2002 Vincent
JL. Other studies differ
o RELIEVE Study: Transfuse at 70 or 90 in patients aged > 55 years and < 4 days ventilation
trend to higher mortality in threshold of 90, Walsh et al, Crit Care Med 2013
o Post hip surgery: FOCUS study, Carson et al, NEJM 2011, Liberal vs Restrictive transfusion
strategy following hip surgery in patients with cardiovascular risk. 2016 patients age > 50 in 47
Canadian and US hospitals, transfusion thresholds of 100 mg vs < 80 or symptoms of anaemia. No
difference in outcomes (3 year mortality 42% in both arms)
o Septic patients: Holst et al, TRISS Trial Group, multi-centre RCT, n = 1005, NEJM Oct 2014, 9 g
vs 7 g in patients with septic shock. Transfused one unit at a time. Lower group received median
of 1 unit, higher group median of 4 units. 90 day mortality 43 vs 45%
o Post-Cardiac Surgery: TITRE2 Study, 90 vs 75 post-cardiac surgery, n = 2007, Transfusion in
92% vs 53%, similar outcomes (mortality 2.6 vs 4.2%, p = 0.045). No difference in costs. Murphy,
NEJM 2015
o

PROPPR Trial: 1:1:1 vs 1:1:2 (plasma:platelets:rbc) in n = 680 trauma patients likely to require massive
transfusion. No significant difference in 24 hour mortality (12.7% vs 17%) or 30 days (22.4 vs 26.1%).
Exsanguination as cause of death lower in 1:1:1 group, Holcomb, JAMA 2015. Study criticised for not
monitoring core temperature and low use of tranexamic acid

o Resources:
TEG Explanation: https://www.youtube.com/watch?v=SjH05uGSGv0
o References:
Hess JR, Brohi K, Dutton RP, et al. The coagulopathy of trauma: a
review of mechanisms. J Trauma. 2008;65(4):748-54.
Luddington RJ. Thrombelastography/thromboelastometry. Clin Lab
Haematol. 2005;27(2):81-90.
Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on
death, vascular occlusive events, and blood transfusion in trauma
patients with significant haemorrhage (CRASH-2): a randomised,
placebo-controlled trial. Lancet. 2010;376(9734):23-32.

Standard blood tubing is 170 microns removes macroaggregates

but microaggregate filter needed to prevent ALI/ARDS