Managing Active Hemorrhage ( Mt )

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Managing active hemorrhage is a particular challenge to the anesthesiologist due to derangements in hemodynamics, coagulopathy and electrolytes. These are further complicated by anesthesia, operational exposure and the need for intravascular volume support during resuscitation. In addition, the anesthesiologist must attempt to prevent post-operative morbidity, especially concerning end-organ dysfunction in patients with at-risk cardiovascular, neurovascular, pulmonary, hepatic or renal function.

With an aging population, higher use of anticoagulants and the development of novel drugs, a new degree of coagulopathy has been introduced previously unseen in resuscitation1. Historically, initial resuscitation centered on the use of
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Trauma patients transferred from the field often receive crystalloid infusion. In an analysis of 8700 patients of the German Trauma Registry in 2006, 34% were overtly coagulopathic at the time of presentation; the degree of derangement was proportional to the degree of prior crystalloid resuscitation4. Specifically, 10% of patients were coagulopathic after receiving 500 mL or less of crystalloid, which has been shown to be a product of both acute trauma response and factor dilution4. In trauma, abnormal coagulation panels at the time of presentation are associated with a 3-fold increase in mortality. Specifically, patients presenting with INR >1.5 have a mortality of 30% compared to 5% in those with normal INR4. Further research shows that factor-depleted infusions potentiate coagulopathy of trauma5.

MT is defined as > 10 u RBC in 24 h, > 4 u RBC in 4 hours with additional anticipated need, or replacement of 50% total blood volume (TBV) in 3 hours1. Of patients admitted to a civilian level I trauma center, 1- 5% require a MT1,4. An increase in transfusion requirement is associated with increased mortality. Patients receiving 10 u RBC1. Current evidence for MT practice stems from the past 15 years of research from military trauma literature and has been widely accepted for use in civilian trauma, obstetric emergencies, and major surgery.

Interpreted clinically to represent impending death, the lethal triad of
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