Page 1250 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 90: Bleeding Disorders 857

and that 30 mL/kg is more likely to correct all individual coagulation fac- product transfusion, and few minor bleeding complications (defined as
tors. In an observational study, patients in whom the INR corrected oozing from the catheter insertion site). Finally, in 40 coagulopathic
165
172
received a median dose of 17 mL/kg, whereas those in whom the INR liver transplant patients (average PT 29% of control, aPTT 92 seconds,
failed to correct received only 10 mL/kg. 166 platelet count 47 × 10 /L) who underwent 259 catheterizations without
9
The clinical indication for fresh frozen plasma is to correct inadequate corrective transfusions, there were no serious bleeding complications.
173
hemostasis (INR >1.5-2 × control) in a bleeding patient. Fresh frozen The overall frequency of bleeding complications in 608 consecutive
plasma should not be used to correct specific and isolated factor defi- patients having thoracentesis or paracentesis was 0.2%. The mildly
ciencies in patients with congenital disorders or acquired coagulation coagulopathic group (average PT and aPTT less than twice normal
inhibitors. Prophylactic fresh frozen plasma may be administered for and platelet count 50 to 100 × 10 /L) did not have an increased risk of
9
high-risk procedures in the setting of coagulopathy. bleeding complications. Bedside line insertions, thoracentesis, and
174
The effect of FFP on coagulation times, bleeding risk, and clinical paracentesis are safe without increased risk of bleeding complications in
outcomes may be significantly less than assumed. A systematic review patients with mild coagulation abnormalities.
of 80 clinical trials of fresh frozen plasma in a wide range of clinical uses
demonstrated no benefit for either prophylactic or therapeutic use. An
167
important factor in reducing the potential benefit of plasma is the devel- KEY REFERENCES
opment of significant complications. Acute lung injury occurs more
frequently in patients receiving blood products and this risk is greatest • Arnold DM, Nazi I, Warkentin TE, et al. Approach to the diagnosis
with fresh frozen plasma. 168 and management of drug-induced immune thrombocytopenia.
■ CRYOPRECIPITATE • Bolliger D, Seeberger MD, Tanaka KA. Principles and practice
Transfus Med Rev. July 2013;27(3):137-145.
Cryoprecipitate is a dry powder which contains fibrinogen, fibronectin, of thromboelastography in clinical coagulation management and
von Willebrand factor, factor XIII, and factor VIII. Cryoprecipitate may transfusion practice. Transfus Med Rev. January 2012;26(1):1-13.
be reconstituted in very low volumes (10-15 mL) and thus has a sig- • Frank C, Werber D, Cramer JP, et al. Epidemic profile of Shiga-
nificant advantage over FFP in volume-overloaded patients. Each unit toxin-producing Escherichia coli O104:H4 outbreak in Germany.
contains the precipitate from the plasma of one donated blood unit. The N Engl J Med. November 10, 2011;365(19):1771-1780.
primary indication for cryoprecipitate is replacement of fibrinogen in • Holcomb JB, Wade CE, Michalek JE, et al. Increased plasma and
patients with hypofibrinogenemia caused by dilution, massive transfu- platelet to red blood cell ratios improves outcome in 466 mas-
sion, or consumptive coagulopathy. The dose of cryoprecipitate should be sively transfused civilian trauma patients. Ann Surg. September
titrated to maintain a target plasma level of fibrinogen above 100 mg/dL. 2008;248(3):447-458.
This usually requires 5 to 10 units of cryoprecipitate for the initial dose.
Fibrinogen levels should be reassessed frequently to determine optimal • Hui P, Cook DJ, Lim W, Fraser GA, Arnold DM. The frequency
dose and dosing interval. and clinical significance of thrombocytopenia complicating critical
illness: a systematic review. Chest. February 2011;139(2):271-278.
■ ACTIVATED RECOMBINANT FACTOR VIIA • Lauzier F, Arnold DM, Rabbat C, et al. Risk factors and impact

Recombinant, human activated factor VII (rVIIa) has been developed of major bleeding in critically ill patients receiving heparin
for the treatment of bleeding in hemophiliac patients with antibody thromboprophylaxis. Intensive Care Med. December 2013;39(12):
inhibitors to coagulation factors VIII and IX. Off-label uses have 2135-2143.
included correction of bleeding associated with trauma, intracranial • Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention
hemorrhage, liver disease, and warfarin, but clinical benefit has not been of heparin-induced thrombocytopenia: Antithrombotic Therapy
shown. A systematic review found no mortality reduction with fVIIa use and Prevention of Thrombosis, 9th ed: American College of Chest
in these off-label indications. Moreover, use is associated with increased Physicians Evidence-Based Clinical Practice Guidelines. Chest.
risk for thrombosis and thromboembolic disease. 169 February 2012;141(2 suppl):e495S-e530S.
■ TRANEXAMIC ACID AND AMINOCAPROIC ACID • Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A.
Evaluation of pretest clinical score (4 T's) for the diagnosis
Tranexamic acid acts by reversibly blocking binding sites on plasmino- of heparin-induced thrombocytopenia in two clinical settings.
gen and thus prevents fibrin binding and degradation. While tranexamic J Thromb Haemost. April 2006;4(4):759-765.
acid has been labeled for use in patients with hemophilia or menorrha- • Rice TW, Wheeler AP. Coagulopathy in critically ill patients: part
gia, reported unlabeled uses in the United States include prevention of 1: platelet disorders. Chest. December 2009;136(6):1622-1630.
surgical blood loss, particularly for uterine and cardiac surgery, and for • Vesely SK, George JN, Lammle B, et al. ADAMTS13 activity in
postpartum or posttrauma hemorrhage. Aminocaproic acid acts by the thrombotic thrombocytopenic purpura-hemolytic uremic syn-
same mechanism as tranexamic acid but has lower binding affinity to drome: relation to presenting features and clinical outcomes in a
plasminogen. 170 prospective cohort of 142 patients. Blood. July 1, 2003;102(1):60-68.
• Wheeler AP, Rice TW. Coagulopathy in critically ill patients: part
CORRECTION OF THROMBOCYTOPENIA AND 2-soluble clotting factors and hemostatic testing. Chest. January
COAGULOPATHY FOR ROUTINE BEDSIDE PROCEDURES 2010;137(1):185-194.

Evidence to support routine preprocedure transfusion for patients with • Williamson DR, Albert M, Heels-Ansdell D, et al. Thrombo-
mildly abnormal PT, aPTT, or platelet count is limited. In a cohort of cytopenia in critically ill patients receiving thromboprophy-
1825 patients undergoing central venous catheter insertion, the rate of laxis: frequency, risk factors, and outcomes. Chest. October
bleeding complications was 3 of 88 patients with uncorrected coagulop- 2013;144(4):1207-1215.
athy (range of platelet count 12 × 10 /L-46 × 10 /L, and INR 1.1-1.5).
9
9
There were no severe complications requiring transfusion or surgical
intervention. Similarly, a cohort of 76 patients with coagulopathy, REFERENCES
171
thrombocytopenia, or both undergoing central venous catheter inser-
tion had only one significant bleeding complication requiring blood Complete references available online at www.mhprofessional.com/hall

section07.indd 857 1/21/2015 7:42:45 AM