Correction of hemostatic disorders
During massive blood loss, hemostasis is impaired due to the natural loss of coagulation factors, the development of dilutional coagulopathy, or DIC syndrome. Dilutional coagulopathy occurs when more than 100% of BV is replaced and manifests as a deficiency of plasma factors, and it is difficult to distinguish clinically from DIC syndrome. To reduce the risk of immune reactions, it is recommended to use leukoreduced blood components.
To normalize hemostasis, the following are used:
- Fresh frozen plasma (FFP): transfused when PT and aPTT are prolonged by more than 1.5 times or in stage II–III shock. The starting dose is 12–15 mL/kg at a rate of up to 1500 mL/h.
- Cryoprecipitate: prescribed if the fibrinogen level drops below 1 g/L (dosage — 1.0–1.5 IU per 10 kg of body weight).
- Platelet concentrate: indicated when platelet count drops below 50,000/µL in the presence of bleeding, or below 20,000–30,000/µL without it.
- Antifibrinolytics (Tranexamic acid, aprotinin): inhibit the primary activation of fibrinolysis.
- Antithrombin III concentrate: used when its activity drops below 70% to restore the anticoagulant system.
Maintaining balance and managing hypothermia
Developing hypothermia is extremely dangerous: it disrupts platelet function, depresses the cardiovascular system, impairs oxygen transport, and reduces the activity of liver enzymes. Every 1 °C decrease in body temperature reduces the rate of enzymatic coagulation reactions by 10%.
Main patient management rules:
- Mandatory warming of intravenous solutions.
- Maintaining central body temperature above 35 °C.
- Strict control to prevent hypercapnia, severe electrolyte shifts (hypokalemia and hypocalcemia), as well as excessive correction of acidosis with sodium bicarbonate.
Use of adrenomimetics and recovery phase
Vasopressors and inotropic drugs are used in parallel with blood volume replacement during regional anesthesia with sympathetic blockade, for a temporary bridging maneuver during catheter placement, or in hypodynamic shock. They are administered both as a bolus (Ephedrine, Phenylephrine, Epinephrine) and via continuous infusion (Dopamine, Dobutamine).
After hemorrhage arrest, therapy targets the restoration of tissue perfusion. Target parameters include:
- Systolic blood pressure above 100 mm Hg.
- Central body temperature above 36 °C.
- Urine output greater than 1 mL/kg per hour.
- Return of lactate levels and acid-base status to normal.
Briefly: answers to topical questions
Which crystalloid and colloid solutions are used for initial infusion therapy in blood loss?
- Initial solution — crystalloids, optimally polyelectrolyte and balanced solutions.
- If crystalloids are ineffective, colloids are added:
- synthetic — hydroxyethyl starch (HES), modified gelatin;
- natural — human albumin.
Which laboratory signs indicate the development of DIC syndrome in blood loss?
- Laboratory signs of DIC syndrome — a decrease in the levels of blood clotting factors and platelet count.
The three-temperature rule for shock: warm the solution, wrap the patient, keep the central temperature above 35 °C (and above 36 °C after bleeding stops) so that the coagulation cascade does not halt.
Class and exam questions
What are the main causes of hemostatic disorders during bleeding treatment?
Hemostasis is impaired due to direct loss of clotting factors with blood, the development of coagulopathy resulting from massive fluid dilution (when replacing >100% of blood volume), and secondary DIC syndrome.
What are the indications and initial dose of fresh frozen plasma?
FFP is transfused when PT and aPTT are prolonged by more than 1.5 times during bleeding, as well as in stage II–III hemorrhagic shock. The initial dosage is 12–15 mL/kg.
Why is hypothermia dangerous in massive blood loss?
Hypothermia suppresses the platelet link, reduces the rate of enzymatic coagulation reactions (by 10% for every 1 °C drop in temperature), impairs cardiac function, and disrupts oxygen transport.
What else to study on this topic
- Causes of hemorrhagic shock in obstetrics
- Methods for precise determination of blood loss volume
- Characteristics of blood loss and hemorrhagic shock classes
- Principles of intensive care at pre-hospital and hospital stages
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