Hardy Jean-François, De Moerloose Philippe, Samama Marc
Department of Anesthesiology, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montréal, Québec, Canada.
Can J Anaesth. 2004 Apr;51(4):293-310. doi: 10.1007/BF03018233.
To review the pathophysiology of coagulopathy in massively transfused, adult and previously hemostatically competent patients in both elective surgical and trauma settings, and to recommend the most appropriate treatment strategies.
Medline was searched for articles on "massive transfusion," "transfusion," "trauma," "surgery," "coagulopathy" and "hemostatic defects." A group of experts reviewed the findings.
Coagulopathy will result from hemodilution, hypothermia, the use of fractionated blood products and disseminated intravascular coagulation. The clinical significance of the effects of hydroxyethyl starch solutions on hemostasis remains unclear. Maintaining a normal body temperature is a first-line, effective strategy to improve hemostasis during massive transfusion. Red cells play an important role in coagulation and hematocrits higher than 30% may be required to sustain hemostasis. In elective surgery patients, a decrease in fibrinogen concentration is observed initially while thrombocytopenia is a late occurrence. In trauma patients, tissue trauma, shock, tissue anoxia and hypothermia contribute to the development of disseminated intravascular coagulation and microvascular bleeding. The use of platelets and/or fresh frozen plasma should depend on clinical judgment as well as the results of coagulation testing and should be used mainly to treat a clinical coagulopathy.
Coagulopathy associated with massive transfusion remains an important clinical problem. It is an intricate, multifactorial and multicellular event. Treatment strategies include the maintenance of adequate tissue perfusion, the correction of hypothermia and anemia, and the use of hemostatic blood products to correct microvascular bleeding.
回顾在择期手术和创伤情况下大量输血的成年且既往凝血功能正常患者发生凝血病的病理生理学，并推荐最合适的治疗策略。
检索Medline数据库中关于“大量输血”“输血”“创伤”“手术”“凝血病”和“止血缺陷”的文章。一组专家对研究结果进行了审查。
凝血病可由血液稀释、体温过低、使用成分血制品和弥散性血管内凝血导致。羟乙基淀粉溶液对止血作用的临床意义仍不明确。维持正常体温是大量输血期间改善止血的一线有效策略。红细胞在凝血中起重要作用，可能需要血细胞比容高于30%才能维持止血。在择期手术患者中，最初观察到纤维蛋白原浓度降低，而血小板减少是后期出现的情况。在创伤患者中，组织创伤、休克、组织缺氧和体温过低会导致弥散性血管内凝血和微血管出血。血小板和/或新鲜冰冻血浆的使用应取决于临床判断以及凝血检测结果，主要用于治疗临床凝血病。
与大量输血相关的凝血病仍然是一个重要的临床问题。它是一个复杂的、多因素和多细胞的事件。治疗策略包括维持足够的组织灌注、纠正体温过低和贫血，以及使用止血血液制品纠正微血管出血。
