Management of Coagulopathy in Bleeding Patients

Abstract

Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.

Keywords: acquired coagulopathy; anticoagulation reversal; coagulation factor concentrate; goal-directed coagulation management; haemostasis; viscoelastic testing.

Figure 1

ROTEM-guided treatment algorithm for the management of trauma-induced coagulopathy. Adapted from Schochl et al., 2012 [6]. Reprinted from Springer Nature as indicated in the Terms and Conditions of the Creative Commons Attribution license. * For patients who are unconscious or known to be taking platelet inhibitor medication, Multiplate tests (adenosine diphosphate [ADP] test, arachidonic acid [ASPI] test, and thrombin receptor activating peptide-6 [TRAP] test) are also performed. ^† Any major improvement in APTEM parameters compared to corresponding EXTEM parameters may be interpreted as a sign of hyperfibrinolysis. ^‡ Only for patients not receiving TXA at an earlier stage of the algorithm. ^§ If decreased ATIII is suspected or known, consider co-administration of ATIII. ^¶ Traumatic brain injury: platelet count 80,000–100,000/μL. CA₁₀, clot amplitude at 10 min; BGA, blood gas analysis; BW, body weight; CT, clotting time; FFP, fresh frozen plasma; ISS, injury severity score; MCF, maximum clot firmness; ML, maximum lysis; PCC, prothrombin complex concentrate; TXA, tranexamic acid.

Figure 2

Simplified treatment algorithm for the initial assessment and management of trauma-induced coagulopathy without VET. Adapted from Casu S, 2021 [107]. Reprinted by permission from BMJ as indicated in the Terms and Conditions of the Creative Commons CC-NY license. BE; base excess; Ca, calcium; FFP, fresh frozen plasma; FXIII, factor XIII; Hb, haemoglobin; INR, international normalised ratio; PC, platelet concentrate; pRBC, packed red blood cells; rFVIIa, activated recombinant factor VII; TBI, traumatic brain injury.

Figure 3

Decision tree for dosing of haemostatic agents without the use of VET. Adapted from Casu S, 2021 [107]. Reprinted by permission from BMJ as indicated in the Terms and Conditions of the Creative Commons CC-NY license. BE, base excess; Fib, fibrinogen; FFP, fresh frozen plasma; Hb, haemoglobin; i.v., intravenously; rFVIIa, activated recombinant factor VII.