Department of Surgery, Denver Health Medical Center, University of Colorado Denver, CO, USA.
Ann Surg. 2010 Apr;251(4):604-14. doi: 10.1097/SLA.0b013e3181d3599c.
Progressive postinjury coagulopathy remains the fundamental rationale for damage control surgery, but the decision to abort operative intervention must occur before laboratory confirmation of coagulopathy. Current massive transfusion protocols have embraced pre-emptive resuscitation strategies emphasizing administration of packed red blood cells, fresh frozen plasma, and platelets in ratios approximating 1:1:1 during the first 24 hours postinjury, based on US military retrospective experience and recent noncontrolled civilian data. This policy, termed "damage control resuscitation" assumes that patients presenting with life threatening hemorrhage at risk for postinjury coagulopathy should receive component therapy in rations approximating those found in whole blood during the first 24 hours. While we concur with the concept of pre-emptive coagulation factor replacement, and initially suggested this in 1982, we remain concerned for the continued unbridled administration of fresh frozen plasma and platelets without objective evidence of their specific requirement. A major limitation of current massive transfusion protocols is the lack of real time assessment of coagulation function to guide evolving blood component requirements. Existing laboratory coagulation testing was originally designed for evaluation of hemophilia and subsequently used for monitoring anticoagulation therapy. Consequently, the applicability of these tests in the trauma setting has never been proven and the time required to conduct these assays is incompatible with prompt correction of the coagulopathy in the trauma setting. This review examines the current approach to postinjury coagulopathy, including identification of patients at risk, resuscitation strategies, design and implementation of institutional massive transfusion protocols, and the potential benefits of goal-directed therapy by real time assessment of coagulation function via point of care rapid thromboelastography.
进行性创伤后凝血病仍然是损伤控制性手术的基本原理，但必须在实验室确认凝血病之前决定停止手术干预。目前的大量输血方案采用了先发制人的复苏策略，强调在创伤后 24 小时内以 1:1:1 的比例输注浓缩红细胞、新鲜冷冻血浆和血小板，这一策略基于美国军事的回顾性经验和最近的非对照性平民数据。这种策略被称为“损伤控制性复苏”，它假设在有生命威胁性出血和创伤后凝血病风险的患者中，应在 24 小时内按照全血中发现的比例给予成分治疗。虽然我们同意预先补充凝血因子的概念，并在 1982 年最初提出了这一概念，但我们仍然担心在没有明确证据表明其具体需求的情况下，继续不受控制地输注新鲜冷冻血浆和血小板。目前大量输血方案的一个主要局限性是缺乏实时评估凝血功能以指导不断变化的血液成分需求。现有的实验室凝血检测最初是为评估血友病而设计的，随后用于监测抗凝治疗。因此，这些检测在创伤环境中的适用性从未得到证明，而且进行这些检测所需的时间与创伤环境中凝血功能的快速纠正不兼容。本综述探讨了创伤后凝血病的当前处理方法，包括识别高危患者、复苏策略、机构性大量输血方案的设计和实施，以及通过即时凝血功能评估（如即时血栓弹力图）实现目标导向治疗的潜在益处。
