Consumptive coagulopathy from massive transfusion: Clinical sciences

Massive transfusion refers to the rapid administration of blood products to patients suffering from life threatening hemorrhagic shock or severe coagulopathy caused by trauma, major high risk operations, obstetric complications, or disseminated intravascular coagulopathy or DIC.

Massive transfusion protocol, or MTP for short, is a systematic approach in providing a balance of blood products, such as packed red blood cells or PRBC, fresh frozen plasma or FFP, and platelets in a 1 to 1 to 1 ratio.

Remember, platelets and fibrinogen play an important role in primary hemostasis by forming a platelet plug. Then, the clotting factors through the coagulation cascade help to form a blood clot to stop the bleeding. In the setting of massive hemorrhage, the body consumes as much of these factors as it can in an attempt to stop the bleeding. Without proper replacement, coagulopathy can worsen and become fatal very quickly.

So, it’s very important to determine which factors are deficient so that proper balance of blood products can be given. Balanced transfusion decreases the risk of serious transfusion-related complications, such as consumptive coagulopathy; this occurs when one type of blood product is given in excess, causing dilution and consumptive depletion of platelets and clotting factors, and ultimately leading to worsening coagulopathy and bleeding.

Now, when a patient presents with chief concerns suggestive of consumptive coagulopathy from massive transfusion, the first step is to perform a focused history and physical. Keep in mind that patients who are unstable, intubated, or have altered mental status might not be able to provide history. So, make sure to check their medical chart to determine the injury, estimated loss of blood, as well as the type and amount of blood products transfused.

Typically, the history will include a recent massive transfusion, which may have been given following trauma, high-risk surgery like cardiac or aortic procedures, massive hemorrhage, or DIC.

On physical exam, you might notice altered mental status, hypotension, fever, tachycardia, and dyspnea. These are signs of shock! Additionally, you might see jaundice, petechiae, purpura, or ecchymoses, as well as hematuria or hemoptysis, all signs of coagulopathy. With these clinical features, you should suspect consumptive coagulopathy from a massive transfusion right away.

Alright, once you suspect coagulopathy from massive transfusion, your next step is to order labs like CBC, PT/INR, aPTT, fibrinogen, and D-Dimer, as well as a peripheral blood smear to determine the type of coagulopathy.

CBC provides information on red blood cells through hemoglobin and hematocrit, in addition to serum platelet levels. On the other hand, PT/INR and aPTT give us information about the clotting factors and their efficacy. For example, elevated PT/INR and aPTT means that the body is taking longer to form clots, which can happen when there’s a deficiency of the clotting factors.

Next, fibrinogen and D-Dimer give us information on the patient’s thrombolytic pathway.

Fibrinogen is a protein that converts into fibrin to form a mesh-like structure to stabilize the blood clot. So, decreased fibrinogen level means that the body might not be able to stabilize the clots and temporize the bleeding.

Conversely, D-dimer is a product of clot degradation. Remember that clot degradation, or fibrinolysis,occurs as soon as the clot is formed.

This prevents the clots from becoming too large. An elevated D-dimer indicates excessive fibrinolysis, which can occur when the body forms increased amounts of blood clots. Keep in mind, D-dimer is not specific to certain types of coagulopathies, and can be elevated in a wide array of medical conditions like deep vein thrombosis and pulmonary embolism.