From the Guidelines
Hemostatic resuscitation is a treatment approach for severely bleeding patients that focuses on restoring both blood volume and clotting function simultaneously, as recommended by the most recent European guideline on management of major bleeding and coagulopathy following trauma 1.
Key Components of Hemostatic Resuscitation
- Early and balanced administration of blood products, including packed red blood cells, plasma, and platelets in ratios that mimic whole blood
- Use of tranexamic acid to prevent fibrinolysis, as suggested by the guideline 1
- Maintaining normal body temperature and correcting acidosis to prevent impairment of blood clotting
- Monitoring coagulation with tests like thromboelastography (TEG) or rotational thromboelastometry (ROTEM)
Importance of Hemostatic Resuscitation
Hemostatic resuscitation is crucial in trauma, postpartum hemorrhage, and major surgical bleeding because traditional large-volume crystalloid resuscitation can worsen bleeding by diluting clotting factors, causing hypothermia, and contributing to acidosis—all of which impair blood clotting 1. The approach aims to break the "lethal triad" of hypothermia, acidosis, and coagulopathy that often leads to death in severely bleeding patients by addressing both volume replacement and hemostatic function from the beginning of treatment.
Additional Considerations
- Damage-control surgery should be employed in the severely injured patient presenting with deep hemorrhagic shock, signs of ongoing bleeding, and coagulopathy, as recommended by the guideline 1
- Early application of measures to reduce heat loss and warm the hypothermic patient should be employed to achieve and maintain normothermia, as suggested by the guideline 1
- Platelets should be administered to maintain a platelet count above 50×10^9/l in patients with ongoing bleeding and/or traumatic brain injury, as recommended by the guideline 1
From the Research
Definition of Hemostatic Resuscitation
Hemostatic resuscitation refers to a strategy used in the management of trauma patients with severe bleeding, focusing on early delivery of coagulation therapy combined with permissive hypotension to control coagulopathy and restore tissue perfusion [ 2 ].
Key Components
The key components of hemostatic resuscitation include:
- Early administration of blood products, such as packed red blood cells, fresh frozen plasma, and platelets, in a balanced ratio [ 3 ]
- Use of viscoelastic tests, such as ROTEM, to diagnose and monitor trauma-induced coagulopathy [ 3 ]
- Permissive hypotension to minimize further bleeding [ 2 ]
- Avoidance of dilutional coagulopathy by using a high ratio of fresh frozen plasma to red blood cells [ 4 ]
Benefits and Outcomes
Studies have shown that hemostatic resuscitation can improve outcomes in trauma patients with severe bleeding, including:
- Reduced mortality [ 4 ]
- Improved coagulation parameters [ 2 ]
- Reduced need for massive transfusion [ 5 ]
Next Generation of Hemostatic Resuscitation
The next generation of hemostatic resuscitation aims to apply a ratio-driven strategy, using antifibrinolytics, haemostatic monitoring, and avoiding critical fibrinogen deficiency by substitution [ 6 ].