Question 13.1

A 57-year-old female has the following haematological and coagulation profile post admission to the ICU after a laparotomy for intra-abdominal sepsis with significant blood loss.


Patient Value

Normal Adult Range


65 G/L*

115 – 165

White cell count

2.77 x 109/L*

3.5 – 11.0


14 x 109/L

150 – 400

Prothrombin Time

28.9 seconds*

12.0 – 15.0

International Normalised Ratio


0.8 – 1.1

Activated Partial Thromboplastin Time

122.5 seconds*

25.0 – 37.0


1.1 G/L*

2.2 – 4.3

a) List two likely causes of the coagulation abnormalities.

b) State how you would correct the coagulopathy and give your reasoning.

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College Answer


Haemodilution with inadequate replacement of blood and clotting factors



  • Ensure patient is normothermic amd correct acidosis
  • Platelets to increase platelet count
  • FFP to replace factors II, V, VII, IX, X, and XI.
  • Cryoprecipitate to replace factor VIII, and fibrinogen if FFP does not reverse INR.
  • Consider tranexamic acid and/or Activated Factor 7
  • Exclude on-going surgical haemorrhage


a) One does not need to degrade oneself with discussions of direct thrombin inhibitor toxicity and post-thrombolysis complications. The answer is obviously a massive transfusion associated with dilutional coagulopathy, with inadequate blood product replacement, and possibly also DIC.


A structured approach would resemble the following:

  • Establish that haemostasis has been achieved, and return to theatre if necessary
  • Control acidosis
  • Restore normothermia
  • Replace clotting factors and platelets:
    • FFP (APTT is high)
    • Cryoprecipitate (fibrinogen is low)
    • Platelets (they are low)
    • Factor VII can be considered
  • Replace RBCs (2 more uints of PRCBc)
  • Consider trahexamic acid

brief discussion of the clotting cascade and of the various factor replacement blood products is available elsewhere.


DeMuro, J. P., and A. F. Hanna. "Trauma Induced Coagulopathy: Prevention and Intervention."Scand J Trauma Resusc Emerg Med 20.47 (2014): 4.