The coagulopathy of massive transfusion

Recently, the Groupe d'Intérêt en Hémostase Périopératoire reviewed the pathophysiology of coagulopathy in massively transfused, adult and previously haemostatically competent patients in both elective surgical and trauma settings. In this article, we focus on our main observations. First, in most cases, the onset and severity of coagulopathy associated with massive transfusion differs depending on whether haemorrhage occurs as a result of trauma or elective surgery. In trauma patients, tissue trauma is uncontrolled, the interval between haemorrhage and treatment can vary widely, hypovolemia, shock and hypothermia are frequent, and coagulopathy is often related to the development of disseminated intravascular coagulation. Monitoring of haemostasis occurs late, when coagulopathy is installed, and treatment can be very difficult. In elective surgery patients, the situation remains controlled and, in most cases, a decrease in fibrinogen concentration is observed initially while thrombocytopenia is a late occurrence. Monitoring of haemostasis is ongoing and treatment is usually much simpler. Second, blood products have changed over time and this has affected the management of the bleeding patient. Contrary to the recommendations of studies published at a time when whole blood was readily available, the first line of treatment (at least in elective surgery patients) ought to be with fresh-frozen plasma to correct decreased levels of coagulation factors. The role of recombinant activated factor VII to treat bleeding that cannot be controlled by conventional measures remains to be clarified. Coagulopathy associated with massive transfusion remains an important clinical problem. Treatment strategies must be adapted to the context and to the blood products available. Nevertheless, the level of evidence supporting specific treatment options is low and more studies are required to guide our management of massively transfused patients.