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Managing Coagulopathy in the Donor: When Clotting is Factor

Managing Coagulopathy in the Donor: When Clotting is Factor. Darren Malinoski, MD, FACS Assistant Chief of Surgery Chief, Section of Surgical Critical Care Portland VA Medical Center Associate Professor of Surgery Oregon Health & Science University 2013 Donor Management Summit.

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Managing Coagulopathy in the Donor: When Clotting is Factor

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  1. Managing Coagulopathy in the Donor:When Clotting is Factor Darren Malinoski, MD, FACS Assistant Chief of Surgery Chief, Section of Surgical Critical Care Portland VA Medical Center Associate Professor of Surgery Oregon Health & Science University 2013 Donor Management Summit

  2. Disclosure • No relevant financial commercial interests

  3. Presentation • 41 y.o. male, s/p MVC. No seatbelt, positive airbag, positive loss of consciousness. • Positive steering wheel damage. • No past medical/surgical history • Social history: denies • VS on arrival: 90 beats/min, 108/60, 18 reps/min, Temp 36.8 • Exam: Abdomen is soft, nontender. • FAST: Positive in Morrison’s pouch • ABG: 7.26/47/174/-6 • Hemocue upon arrival: 15.3. 10 min later: 12.1

  4. CT Scan Findings Summarized • Right liver lobe laceration extending to porta. • Hematoma in the greater omentum measuring 10cm. • Active extravasation from left gastric artery into lesser sac. • Heterogeneous spleen suggestive of injury. • No mention of the pancreas.

  5. Sequence • While in the scanner, there was an episode of hypotension, documented at 87/60 and 79/52 five minutes later. • This responded with a fluid challenge. • “BP labile (intermittently hypotensive)” while patient resuscitated and prepared for the OR

  6. Bleeding left gastric artery Liver laceration at the dome Gallbladder avulsion with underlying liver laceration Pancreatic transection at the neck and mild splenic laceration Ligated Surgicel and packed Cholecystectomy; argon beam coagulation, cautery and Surgicel Distal pancreatectomy with splenectomy Finding Treatment

  7. Intraoperatively • EBL: 2000ml • Blood products given: • PRBC 6 units • FFP 6 units • Plt 1 unit • Cryo 1 unit • UO: 4500ml • IVF: 3500ml

  8. Postoperatively • VS for first 8 hours: T 37.2; HR 90-110s; BP 110-140s/80-100s • Extubated 8 hours after end of surgery. • No further blood transfusions were required. • The patient was transferred to the floor the next day.

  9. Damage Control Resuscitation

  10. Initial Resuscitation Strategies WHAT TO USE: • Hypotension  2 liters of crystalloid • Colloids / Hypertonic saline • Blood products HOW TO GIVE: • Wide open through two large-bore IV’s • Enough, but not too much • Permissive hypotension / hypotensive resuscitation STOP THE BLEEDING!!!

  11. Bickell, et al. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. NEJM 1994

  12. The Coagulopathy of Trauma • Tissue injury • Shock • Hemodilution • Hypothermia • Acidemia • Inflammation • Hyperfibrinolysis • Hypocalcemia

  13. Early Massive Transfusion Protocols • Early resuscitation with crystalloid --- (ATLS) • Ten or more units of PRBC in first 24 hours • FFP transfusion initiation: • After 10 units of PRBC’s • When INR > 1.5 • 1 unit for every 4 units of PRBC’s • Platelet transfusion when count <50-100,000

  14. 16% vs 45%, early vs late period, P = .03

  15. Negative studies

  16. 1:1:1 vs. 1:1:2 (FFP, Plt, PRBC)

  17. TXA

  18. Damage Control Resuscitation • Permissive hypotension • Judicious use of crystalloid • Stop source of bleeding • Early use of blood products – massive transfusion protocols • 1:1 to 1:2 FFP:PRBC and Plt:PRBC •  6-6-1-1 +Calcium • Correct acidosis • Correct hypothermia • Adjuncts: TXA, Factor IX, Factor VIIa • Damage control surgery

  19. Considerations for Organ Donation • No guidelines with respect to transfusion triggers • PRBC, FFP, Plt, Cryo • Triggers: Hgb/Hct, INR, Plt, Fibrinogen • Mean Hgb in Region 5 = greater than 10 • Relationship between “clotting potential” and graft outcomes is unknown • Maybe a coagulopathy is beneficial

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