Recently the fourth edition of the european guideline for the management of major bleeding and coagulopathy following trauma was published. We will try to provide you with an overview of it’s recommendations and discus the major changes compared to the 2013 guideline regarding the anesthetic and hemostatic management of these patients. Issues regarding imaging and surgical management are not discussed here.
Hb measurement
Where the 2013 guideline did not reccomend single Hb measurement as an isolated measure of bleeding, the 2016 guideline emphasizes that a low initial Hb is an indicator of severe bleeding and is associated with coagulopathy. It further recommends repeated Hb measurements as an initial value in the normal range may mask bleeding.
Fluid Therapy
The 2013 guideline emphasized that cristalloids be applied initially to treat the hypotensive bleeding patient where the 2016 guideline only reccommends the use of a restricted volume replacement strategy untill bleeding can be controlled. There is no mention of wich type of fluid to start with. Hypertonic solutions are no longer mentioned. Also the excessive use of 0,9 NaCl solution is to be avoided. Colloid solutions are mentioned to be “restricted“ because of its adverse affects on hemostasis. However there is no mention of what “restricted” really means.
Initial management of coagulopathy
It is now specifically mentioned that monitoring and measures to support coagulation be initiated immediately upon admission to the hospital whereas in the 2013 guideline it was said to be started as soon as possible. An increasing emphasis is placed on the early measurement of fibrinogen and the use of viscoelastic testing. Viscoelastic testing provides a more rapid assessment and early measures of clot firmness are associated with the need for massive transfusion although some controversy still remains.
For the initial management there are now 2 options: 1. RBC and plasma in a ratio of at least 1:2 or 2. RBC according to Hemoglobin level and fibrinogen concentrate. After the initial management it is recommended that resuscitation is continued using a goal-directed strategy using standard coagulation tests and/or viscoelastic tests. This two stage model is new for the 2016 guideline. Regarding the treatment of coagulopathy with fibrinogen concentrate, PCC’s, FFP etc. there are no changes in the 2016 guideline when compared to the 2013 guideline.
Novel Anticoagulants
For the management of the bleeding trauma patient on novel anticoagulants there are some changes regarding the reversal. First of all it is recommended to measure anti-factor Xa levels in patients treated with rivaroxaban, apixaban or edoxaban and in case of dabigatrian , dabigatran levels. For the reversal of the anti-Xa drugs with life-threatning bleeding use TXA 15mg/kg and high-dose PCC/aPCC (25-50U/kg) until specific antidotes are available. For the reversal of dabigatran it is recommended to use idarucizumab (5 g intravenously) or, if unavailable, high-dose (25–50 U/kg) PCC/aPCC, in both cases combined with TXA 15 mg/kg (or 1 g)
Conclusions
In the new 2016 guideline there were some significant changes made regarding fluid therapy and the management of coagulopathy. A new section has been added to specifically recommend a restricted volume replacement strategy and also a new section has been added to the chapter on the initial management of bleeding and coagulopathy that recommends either erythrocytes and plasma in a ratio of at least 1:2 or erythrocytes with fibrinogen concentrate. Further resuscitation should be guided by a goal-directed strategy with conventional blood products or factor concentrates.
Below you will find a link to the guideline (open acces) and also a list with all recommendations
Refrences:
Hb measurement
Where the 2013 guideline did not reccomend single Hb measurement as an isolated measure of bleeding, the 2016 guideline emphasizes that a low initial Hb is an indicator of severe bleeding and is associated with coagulopathy. It further recommends repeated Hb measurements as an initial value in the normal range may mask bleeding.
Fluid Therapy
The 2013 guideline emphasized that cristalloids be applied initially to treat the hypotensive bleeding patient where the 2016 guideline only reccommends the use of a restricted volume replacement strategy untill bleeding can be controlled. There is no mention of wich type of fluid to start with. Hypertonic solutions are no longer mentioned. Also the excessive use of 0,9 NaCl solution is to be avoided. Colloid solutions are mentioned to be “restricted“ because of its adverse affects on hemostasis. However there is no mention of what “restricted” really means.
Initial management of coagulopathy
It is now specifically mentioned that monitoring and measures to support coagulation be initiated immediately upon admission to the hospital whereas in the 2013 guideline it was said to be started as soon as possible. An increasing emphasis is placed on the early measurement of fibrinogen and the use of viscoelastic testing. Viscoelastic testing provides a more rapid assessment and early measures of clot firmness are associated with the need for massive transfusion although some controversy still remains.
For the initial management there are now 2 options: 1. RBC and plasma in a ratio of at least 1:2 or 2. RBC according to Hemoglobin level and fibrinogen concentrate. After the initial management it is recommended that resuscitation is continued using a goal-directed strategy using standard coagulation tests and/or viscoelastic tests. This two stage model is new for the 2016 guideline. Regarding the treatment of coagulopathy with fibrinogen concentrate, PCC’s, FFP etc. there are no changes in the 2016 guideline when compared to the 2013 guideline.
Novel Anticoagulants
For the management of the bleeding trauma patient on novel anticoagulants there are some changes regarding the reversal. First of all it is recommended to measure anti-factor Xa levels in patients treated with rivaroxaban, apixaban or edoxaban and in case of dabigatrian , dabigatran levels. For the reversal of the anti-Xa drugs with life-threatning bleeding use TXA 15mg/kg and high-dose PCC/aPCC (25-50U/kg) until specific antidotes are available. For the reversal of dabigatran it is recommended to use idarucizumab (5 g intravenously) or, if unavailable, high-dose (25–50 U/kg) PCC/aPCC, in both cases combined with TXA 15 mg/kg (or 1 g)
Conclusions
In the new 2016 guideline there were some significant changes made regarding fluid therapy and the management of coagulopathy. A new section has been added to specifically recommend a restricted volume replacement strategy and also a new section has been added to the chapter on the initial management of bleeding and coagulopathy that recommends either erythrocytes and plasma in a ratio of at least 1:2 or erythrocytes with fibrinogen concentrate. Further resuscitation should be guided by a goal-directed strategy with conventional blood products or factor concentrates.
Below you will find a link to the guideline (open acces) and also a list with all recommendations
Refrences:
- The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Rolf Rossaint, Bertil Bouillon, Vladimir Cerny, Timothy J. Coats, Jacques Duranteau, Enrique Fernández-Mondéjar, Daniela Filipescu, Beverley J. Hunt, Radko Komadina, Giuseppe Nardi, Edmund A. M. Neugebauer, Yves Ozier, Louis Riddez, Arthur Schultz, Jean-Louis Vincent and Donat R. Spahn
Critical Care 2016 20:100 DOI: 10.1186/s13054-016-1265-x
 | About the Author: Victor Viersen is an acute care anesthesiologist with special interest in trauma anesthesia, transfusion, coagulation management, medical education. He is one of the founders and editors of urgentiegeneeskunde.com. |
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