Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC.
Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC.
Transfus Med Rev. 2017 Oct;31(4):258-263. doi: 10.1016/j.tmrv.2017.04.001. Epub 2017 Apr 25.
Patients who are critically ill following surgical or traumatic injury often present with coagulopathy as a component of the complex multisystem dysfunction that clinicians must rapidly diagnose and treat in the intensive care environment. Failure to recognize coagulopathy while volume resuscitation with crystalloid or colloid takes place, or an unbalanced transfusion strategy focused on packed red blood cell transfusion can all significantly worsen coagulopathy, leading to increased transfusion requirements and poor outcomes. Even an optimized transfusion strategy directed at correcting coagulopathy and maintaining clotting factor levels carries the risk of a number of transfusion reactions including transfusion-related acute lung injury, transfusion-related circulatory overload, anaphylaxis, and septic shock. A number of adjunctive strategies can be used either to augment a balanced transfusion approach or as alternatives to blood component therapy. Coupled with an appropriate and timely laboratory testing, this approach can quickly diagnose a patient's specific coagulopathy and work to correct it as quickly as possible, minimizing the requirement of blood transfusion and the pathophysiologic effects of excessive bleeding and fibrinolysis. We will review the literature supporting this approach and provide insight into how these approaches can be best used to care for bleeding patients in the intensive care unit. Finally, the increasing use of several novel oral anticoagulants, novel antiplatelet drugs, and low-molecular weight heparin to clinical practice has complicated the care of the coagulopathic patient when these drugs are involved. Many clinicians familiar with heparin and warfarin reversal are not familiar with the optimal way to reverse the action of these new drugs. Patients treated with these drugs for a wide variety of conditions including atrial fibrillation, stroke, coronary artery stent, deep venous thrombosis, and pulmonary embolism will present for emergency surgery and will require management of pharmacologically induced postoperative coagulopathy. We will discuss optimized strategies for reversal of these agents and strategies that are currently under development.
术后或创伤后危重症患者常伴有凝血功能障碍，这是临床医生必须在重症监护环境中快速诊断和治疗的复杂多系统功能障碍的一个组成部分。在进行晶体或胶体容量复苏的同时未能识别出凝血功能障碍，或者不平衡的输血策略侧重于输注浓缩红细胞，都会显著加重凝血功能障碍，导致输血需求增加和预后不良。即使是优化的输血策略，旨在纠正凝血功能障碍和维持凝血因子水平，也会带来许多输血反应的风险，包括输血相关性急性肺损伤、输血相关性循环超负荷、过敏反应和感染性休克。许多辅助策略可用于增强平衡输血方法，或替代血液成分治疗。结合适当和及时的实验室检测，这种方法可以快速诊断患者的具体凝血功能障碍，并尽快纠正，最大程度地减少输血需求和过度出血和纤维蛋白溶解的病理生理效应。我们将回顾支持这种方法的文献，并深入了解如何最好地将这些方法用于重症监护病房出血患者的护理。最后，几种新型口服抗凝剂、新型抗血小板药物和低分子量肝素在临床实践中的应用越来越广泛，当涉及这些药物时，增加了凝血功能障碍患者的护理难度。许多熟悉肝素和华法林逆转的临床医生不熟悉这些新药逆转作用的最佳方法。接受这些药物治疗的各种疾病，包括心房颤动、中风、冠状动脉支架、深静脉血栓形成和肺栓塞的患者，将需要进行急诊手术，并需要管理药物诱导的术后凝血功能障碍。我们将讨论这些药物的优化逆转策略和正在开发的策略。
