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.

Parameter

Patient Value

Normal Adult Range

Haemoglobin

65 G/L*

115 – 165

White cell count

2.77 x 109/L*

3.5 – 11.0

Platelets

14 x 109/L

150 – 400

Prothrombin Time

28.9 seconds*

12.0 – 15.0

International Normalised Ratio

2.7*

0.8 – 1.1

Activated Partial Thromboplastin Time

122.5 seconds*

25.0 – 37.0

Fibrinogen

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

a) 

Haemodilution with inadequate replacement of blood and clotting factors

DIC.

b)

  • 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

Discussion

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.

b)

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.

References

References

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