Skip to main content
SpringerLink
Log in

Disorders of Hemostasis in the Bleeding Intensive Care Unit Patient

  • Chapter
  • First Online:
Point-of-Care Tests for Severe Hemorrhage

  • 1259 Accesses

Abstract

Hemostasis disorders (coagulopathies involving both prothrombotic states and bleeding due to several pathological mechanisms) are common clinical conditions in critically ill patients admitted in the intensive care unit (ICU) [1, 2]. Different hemorrhagic scenarios represent a challenging aspect of daily practical activity of anesthesiologists and intensivists facing perioperative bleeding in major surgery, trauma, burns, obstetrical hemorrhage and even in medical and septic patients, all of these conditions involving possible life-threatening coagulation disorders. The management of bleeding in these patients involves outstanding clinical aspects, requiring a pathophysiological and, possibly, a clinicopathological approach together with diagnostic tools. These include conventional laboratory coagulation tests or, more recently, point-of-care (POC) devices (thromboelastography/thromboelastometry, TEG®/TEM®; platelet aggregometry), to ensure a rapid, appropriate and correct diagnosis to activate a theranostic approach (a term derived from the fusion of two words: thera-peutic and diag-nostic), in order to administer the appropriate and goal-directed treatment(s) [3, 4]. Coagulation disorders and severe bleeding conditions associated with postpartum hemorrhage (PPH), acute trauma with trauma-induced coagulopathy (TIC), and cardiac surgery-associated coagulopathy are treated in other chapters of this textbook. We will overview and summarize the pathophysiology of the coagulation disorders most frequently recorded in patients admitted to a general ICU after major surgery, polytrauma treated according to damage control surgery and “damage control resuscitation” with hemostatic control approach, burns, and severe sepsis/septic shock patients, looking at clinical and laboratory features of DIC (Disseminated Intravascular Coagulopathy). This chapter will focus on the more recent evidences regarding the costant relationships and cross talks between the coagulation and the inflammation systems, summarizing and outlining the importance of approaching these bleeding and unstable patients looking at a rapid, POC evaluation with viscoelastic hemostatic tests (VHT) such as TEG®/TEM®. Finally this chapter will report the principal therapeutically approaches, looking at the actual evidences, if any, to administer blood products and/or blood derivatives in a timely, goal-directed, and appropriated fashion.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
eBook
USD 16.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Levi M, Opal SM (2006) Coagulation abnormalities in critically ill patients. Crit Care 10:222

    Article  PubMed  PubMed Central  Google Scholar 

  2. Hunt BJ (2014) Bleeding and coagulopathies in critical care. N Engl J Med 370:847–859

    Article  CAS  PubMed  Google Scholar 

  3. Levy JH, Faraoni D, Sniecinski RM (2013) Perioperative coagulation management in the intensive care unit. Curr Opin Anaesthesiol 26:65–70

    Article  CAS  PubMed  Google Scholar 

  4. Kozek-Langenecker SA (2014) Coagulation and transfusion in the postoperative bleeding patient. Curr Opin Crit Care 20:460–466

    Article  PubMed  Google Scholar 

  5. Glance LG, Dick AW, Mukamel DB et al (2011) Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology 114:283–292

    Article  PubMed  Google Scholar 

  6. Toulon P, Ozier Y, Ankri A, Fléron MH, Leroux G, Samama CM (2009) Point-of-care versus central laboratory coagulation testing during haemorrhagic surgery. A multicenter study. Thromb Haemost 101:394–401

    CAS  PubMed  Google Scholar 

  7. Kozek-Langenecker SA, Afshari A, Albaladejo P et al (2013) Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 30:270–382

    Article  PubMed  Google Scholar 

  8. Haas T, Fries D, Tanaka KA, Asmis L, Curry NS, Schöchl H (2015) Usefulness of standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: is there any evidence? Br J Anaesth 114:217–224

    Article  CAS  PubMed  Google Scholar 

  9. Spahn D, Bouillon B, Cerny V et al (2013) Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 17:R76

    Article  PubMed  PubMed Central  Google Scholar 

  10. Schochl H, Schlimp CJ, Voelckel W (2013) Potential value of pharmacological protocols in trauma. Curr Opin Anaesthesiol 26:221–229

    Article  PubMed  Google Scholar 

  11. Levi M, van der Poll T (2013) Disseminated intravascular coagulation: a review for the internist. Intern Emerg Med 8:23–32

    Article  PubMed  Google Scholar 

  12. Gorlinger K, Bergmann L, Dirkmann D (2012) Coagulation management in patients undergoing mechanical circulatory support. Best Pract Res Clin Anaesthesiol 26:179–198

    Article  PubMed  Google Scholar 

  13. Esper SA, Levy JH, Waters JH, Welsby IJ (2014) Extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion. Anesth Analg 118:731–743

    Article  CAS  PubMed  Google Scholar 

  14. Kozek-Langenecker S (2007) Management of massive operative blood loss. Minerva Anestesiol 73:401–415

    CAS  PubMed  Google Scholar 

  15. Retter A, Barrett NA (2015) The management of abnormal haemostasis in the ICU. Anaesthesia 70(S1):121–127

    Article  PubMed  Google Scholar 

  16. Hartert H (1951) Thrombelastography, a method for physical analysis of blood coagulation. Z Gesamte Exp Med 117:189–203

    Article  CAS  PubMed  Google Scholar 

  17. Bolliger D, Seeberger MD, Tanaka KA (2012) Principles and practice of thromboelastography in clinical coagulation management and transfusion practice. Transfus Med Rev 26:1–13

    Article  PubMed  Google Scholar 

  18. Esmon CT, Xu J, Lupu F (2011) Innate immunity and coagulation. J Thromb Haemost 9(Suppl 1):182–188

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Fu BM, Tarbell JM (2013) Mechano-sensing and transduction by endothelial surface glycocalyx: composition, structure, and function. WIREs Syst Biol Med. doi:10.1002/wsbm.1211

    Google Scholar 

  20. Bianchi ME (2007) DAMPs, PAMPs and alarmins: all we need to know about danger. J Leukoc Biol 81:1–5

    Article  CAS  PubMed  Google Scholar 

  21. Levi M, van der Poll T (2010) Inflammation and coagulation. Crit Care Med 38(Suppl 2):S26–S34

    Article  CAS  PubMed  Google Scholar 

  22. Petaja J (2011) Inflammation and coagulation. An overview. Thromb Res 127(Suppl 2):S34–S37

    Article  PubMed  Google Scholar 

  23. Marik PE, Flemmer M (2012) The immune response to surgery and trauma: implications for treatment. J Trauma Acute Care Surg 73:801–808

    Article  CAS  PubMed  Google Scholar 

  24. Xiao W, Mindrinos MN, Seok J et al (2011) A genomic storm in critically injured humans. J Exp Med 208:2581–2590

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Maegele M, Lefering R, Yucel N et al (2007) Early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury 38:298–304

    Article  PubMed  Google Scholar 

  26. Sarani B, Dunkman WJ, Dean L, Sonnad S, Rohrbach JI, Gracias VH (2008) Transfusion of fresh frozen plasma in critically ill surgical patients is associated with an increased risk of infection. Crit Care Med 36:1114–1118

    Article  PubMed  Google Scholar 

  27. Watson GA, Sperry JL, Rosengart MR et al (2009) Inflammation and Host Response to Injury Investigators: fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma 67:221–227

    Article  PubMed  Google Scholar 

  28. Shere-Wolfe RF, Galvagno SM Jr, Grissom TE (2012) Critical care considerations in the management of the trauma patient following initial resuscitation. Scand J Trauma Resusc Emerg Med 20:68–83

    Article  PubMed  PubMed Central  Google Scholar 

  29. Moore FA, Moore EE, Sauaia A (1997) Blood transfusion. An independent risk factor for postinjury multiple organ failure. Arch Surg 132:620–624

    Article  CAS  PubMed  Google Scholar 

  30. Johansson PI, Stensballe J, Vindelov N, Perner A, Espersen K (2010) Hypocoagulability, as evaluated by thrombelastography, at admission to the ICU is associated with increased 30-day mortality. Blood Coagul Fibrinolysis 21:168–174

    Article  PubMed  Google Scholar 

  31. Johansson PI, Stissing T, Bochsen L, Ostrowski SR (2009) Thrombelastography and tromboelastometry in assessing coagulopathy in trauma. Scand J Trauma Resusc Emerg Med 17:45

    Article  PubMed  PubMed Central  Google Scholar 

  32. Levi M, Fries D, Gombotz H et al (2011) Prevention and treatment of coagulopathy in patient receiving massive transfusions. Vox Sang 101:154–174

    Article  CAS  PubMed  Google Scholar 

  33. Teodoro da Luz L, Nascimento B, Rizoli S (2013) Thrombelastography (TEG): practical considerations on its clinical use in trauma resuscitation. Scand J Trauma Resusc Emerg Med 21:29–36

    Article  Google Scholar 

  34. Jakoi A, Kumar N, Vaccaro A, Radcliff K (2014) Perioperative coagulopathy monitoring. Musculoskelet Surg 98:1–8

    Article  CAS  PubMed  Google Scholar 

  35. Farina JA Jr, Rosique MJ, Rosique RG (2013) Curbing inflammation in burn patients. Int J Inflam; Article ID 715645, http://dx.doi.org/10.1155/2013/715645

  36. Ong YS, Samuel M, Song C (2006) Meta-analysis of early excision of burns. Burns 32:145–150

    Article  PubMed  Google Scholar 

  37. Lavrentieva A, Kontakiotis T, Bitzani M et al (2008) Early coagulation disorders after severe burn injury: impact on mortality. Intensive Care Med 34:700–706

    Article  CAS  PubMed  Google Scholar 

  38. Lippi G, Ippolito L, Cervellin G (2010) Disseminated intravascular coagulation in burn injury. Semin Thromb Hemost 36:429–436

    Article  PubMed  Google Scholar 

  39. Niedermayr M, Schramm W, Kamolz L et al (2007) Antithrombin deficiency and its relationship to severe burns. Burns 33:173–178

    Article  CAS  PubMed  Google Scholar 

  40. Kowal-Vern A, Gamelli RL, Walenga JM, Hoppensteadt D, Sharp-Pucci M, Schumacher HR (1992) The effect of burn wound size on hemostasis: a correlation of the hemostatic changes to the clinical state. J Trauma 33:50–56

    Article  CAS  PubMed  Google Scholar 

  41. Sherren PB, Hussey J, Martin R, Kundishora T, Parker M, Emerson B (2013) Acute burn induced coagulopathy. Burns 39:1157–1161

    Article  CAS  PubMed  Google Scholar 

  42. King DR, Namias N, Andrews DM (2010) Coagulation abnormalities following thermal injury. Blood Coagul Fibrinolysis 21:666–669

    PubMed  Google Scholar 

  43. Garcia-Avello A, Lorente JA, Cesar-Perez J et al (1998) Degree of hypercoagulability and hyperfibrinolysis is related to organ failure and prognosis after burn trauma. Thromb Res 89:59–64

    Article  CAS  PubMed  Google Scholar 

  44. Lu RP, Ni A, Lin FC et al (2013) Major burn injury is not associated with acute traumatic coagulopathy. J Trauma Acute Care Surg 74:1474–1479

    Article  PubMed  PubMed Central  Google Scholar 

  45. Latenser BA (2009) Critical care of the burn patient: the first 48 h. Crit Care Med 37:2819–2826

    Article  CAS  PubMed  Google Scholar 

  46. Hendon DN (2003) Total burn care, vol 3. Saunders, London

    Google Scholar 

  47. Sterling JP, Heimbach DM (2011) Hemostasis in burn surgery: a review. Burns 37:559–565

    Article  PubMed  Google Scholar 

  48. Cartotto R, Musgrave MA, Beveridge M, Fish J, Gomez M (2000) Minimizing blood loss in burn surgery. J Trauma 49:1034–1049

    Article  CAS  PubMed  Google Scholar 

  49. O’Mara MS, Hayetian F, Slater H, Goldfarb IW, Tolchin E, Caushaj PF (2005) Results of a protocol of transfusion threshold and surgical technique on transfusion requirements in burn patients. Burns 13:558–561

    Article  Google Scholar 

  50. Johansson PI, Eriksen K, Nielsen SL, Rojkjaer R, Alsbjørn B (2007) Recombinant FVIIa decreases perioperative blood transfusion requirement in burn patient undergoing excision and skin grafting— results of a single centre pilot study. Burns 33:435–440

    Article  PubMed  Google Scholar 

  51. Schaden E, Kimberger O, Kraincuk P, Baron DM, Metnitz PG, Kozek-Langenecker S (2012) Perioperative treatment algorithm for bleeding burn patients reduces allogeneic blood product requirements. Br J Anaesth 109:376–381

    Article  CAS  PubMed  Google Scholar 

  52. Levi M (2008) The coagulant response in sepsis. Clin Chest Med 29:627–642

    Article  PubMed  Google Scholar 

  53. Meybohm P, Zacharowski K, Weber CF (2013) Point-of-care coagulation management in intensive care medicine. Crit Care 17:218, http://ccforum.com/content/17/2/218

    Article  PubMed  PubMed Central  Google Scholar 

  54. Adamzik M, Eggmann M, Frey UH et al (2010) Comparison of thromboelastometry with procalcitonin, interleukin 6, and C-reactive protein as diagnostic tests for severe sepsis in critically ill adults. Crit Care 14:R178

    Article  PubMed  PubMed Central  Google Scholar 

  55. Adamzik M, Langemeier T, Frey UH et al (2011) Comparison of thrombelastometry with simplified acute physiology score II and sequential organ failure assessment scores for the prediction of 30-day survival: a cohort study. Shock 35:339–342

    Article  PubMed  Google Scholar 

  56. Haase N, Ostrowski SR, Wetterslev J et al (2015) Thromboelastography in patients with severe sepsis: a prospective cohort study. Intensive Care Med 41:77–85

    Article  PubMed  Google Scholar 

  57. Perner A, Haase N, Guttormsen AB et al (2012) Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 367:124–134

    Article  CAS  PubMed  Google Scholar 

  58. Muller MC, Meijers JC, Vroom MB, Juffermans NP (2014) Utility of thromboelastography and/or thromboelastometry in adults with sepsis: a systematic review. Crit Care 18:R30

    Article  PubMed  PubMed Central  Google Scholar 

  59. American Society of Anesthesiologists Task Force on Perioperative Blood Management Practice Guidelines for Perioperative Blood Management (2015) An Updated Report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology 122:241–275

    Article  Google Scholar 

  60. Stanworth SJ, Walsh TS, Prescott RJ et al (2011) A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time. Crit Care 15:R108

    Article  PubMed  PubMed Central  Google Scholar 

  61. Vlaar AP, in der Maur AL, Binnekade JM, Schultz MJ, Juffermans NP (2009) A survey of physicians’ reasons to transfuse plasma and platelets in the critically ill: a prospective single-centre cohort study. Transfus Med 19:207–212

    Article  CAS  PubMed  Google Scholar 

  62. McIntyre L, Tinmouth AT, Fergusson DA (2013) Blood component transfusion in critically ill patients. Curr Opin Crit Care 19:326–333

    Article  PubMed  Google Scholar 

  63. Callum JL, Dzik WH (2010) The use of blood components prior to invasive bedside procedures: a critical appraisal. In: Mintz PD (ed) Transfusion therapy: clinical principles and practice, 3rd edn. AABB Press, Bethesda, pp 1–36

    Google Scholar 

  64. Yang L, Stanworth S, Hopewell S, Doree C, Murphy M (2012) Is fresh-frozen plasma clinically and effective? An update of a systematic review of randomized controlled trials. Transfusion 52:1673–1686

    Article  CAS  PubMed  Google Scholar 

  65. Arnold DM, Crowther MA, Cook RJ et al (2006) Utilization of platelet transfusions in the intensive care unit: indications, transfusion triggers, and platelet count responses. Transfusion 46:1286–1291

    Article  PubMed  Google Scholar 

  66. Nydam TL, Kashuk JL, Moore EE et al (2011) Refractory postinjury thrombocytopenia is associated with multiple organ failure and adverse outcomes. J Trauma 70:401–406

    Article  PubMed  Google Scholar 

  67. Gajic O, Dzik WH, Toy P (2006) Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: benefit or harm? Crit Care Med 34:S170–S173

    Article  PubMed  Google Scholar 

  68. Nascimento B, Rizoli S, Rubenfeld G et al (2011) Cryoprecipitate transfusion: assessing appropriateness and dosing in trauma. Transfus Med 21:394–401

    Article  CAS  PubMed  Google Scholar 

  69. Franchini M, Lippi G (2012) Fibrinogen replacement therapy: a critical review of the literature. Blood Transfus 10:23–27

    PubMed  PubMed Central  Google Scholar 

  70. Sorensen B, Spahn DR, Innerhofer P, Spannagl M, Rossaint R (2011) Clinical review: prothrombin complex concentrates – evaluation of safety and thrombogenicity. Crit Care 15:201

    Article  PubMed  PubMed Central  Google Scholar 

  71. Patanwala AE, Acquisto NM, Erstad BL (2011) Prothrombin complex concentrate for critical bleeding. Ann Pharmacother 45:990–999

    Article  CAS  PubMed  Google Scholar 

  72. Levy JH, Levi M (2014) New oral anticoagulant–induced bleeding. Clinical presentation and management. Clin Lab Med 34:575–586

    Article  PubMed  Google Scholar 

  73. Moorman ML, Nash JE, Stabi KL (2014) Emergency surgery and trauma in patients treated with the new oral anticoagulants: dabigatran, rivaroxaban, and apixaban. J Trauma Acute Care Surg 77:486–494

    Article  PubMed  Google Scholar 

  74. Yank V, Tuohy CV, Logan AC et al (2011) Systematic review: benefits and harms of in-hospital use of recombinant factor VIIa for off-label indications. Ann Intern Med 154:529–540

    Article  PubMed  PubMed Central  Google Scholar 

  75. Korte W (2010) FXIII in perioperative coagulation management. Best Pract Res Clin Anaesthesiol 24:85–93

    Article  CAS  PubMed  Google Scholar 

  76. Shander A, Van Aken H, Colomina MJ et al (2012) Patient blood management in Europe. Br J Anaesth 109:55–68

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. ICU “Bozza” – 1st Service Anesthesia and Intensive Care, Ospedale Niguarda Ca’ Granda, Milan, Italy

    Lucio Bucci MD

  2. UOC Anesthesia and Intensive Care, A.O. Ospedale dei Colli Presidio Monaldi, Naples, Italy

    Luca Monastra MD

  3. 2nd Service Anesthesia Critical Care Medicine, Ospedale Niguarda Ca’ Granda, Milan, Italy

    Andrea De Gasperi MD

Authors
  1. Lucio Bucci MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luca Monastra MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrea De Gasperi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Lucio Bucci MD .

Editor information

Editors and Affiliations

  1. Department of Anaesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Italy

    Marco Ranucci

  2. Department of Medicine Hemorrhagic and Thrombotic Diseases Unit, University of Padua Medical School, Padua, Italy

    Paolo Simioni

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Bucci, L., Monastra, L., De Gasperi, A. (2016). Disorders of Hemostasis in the Bleeding Intensive Care Unit Patient. In: Ranucci, M., Simioni, P. (eds) Point-of-Care Tests for Severe Hemorrhage. Springer, Cham. https://doi.org/10.1007/978-3-319-24795-3_11

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-24795-3_11

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-24793-9

  • Online ISBN: 978-3-319-24795-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation