Prof.Mridul Panditrao dwells upon the peri-operative and emergency problem of massive bleeding, the physiology of coagulation, anf the role of recombinanat activated factor VII.
KUWAIT MEDICAL JOURNAL
Kuwait Medical Journal 2011; 43 (3): 176-188
Massive Bleeding in Trauma and Surgery: Role of rFVIIa
KEY WORDS: recombinant activated factor VII, recommendations
Mridul Panditrao1, 2, Minnu Panditrao1, Mohammed Shamsah2
1Department of Anesthesiology and Critical Care, Dr. D Y Patil Medical College (Deemed University), Pune, India
2Department of Anesthesia and Intensive Care, Al-Adan Hospital, Kuwait
Address correspondence to:
Prof. Dr. Mridul M. Panditrao, MD, DA, Senior Specialist, Department of Anesthesia and Intensive Care, Al-Adan Hospital, Kuwait.
Tel: 65 88 90 25, E-mail: drmmprao1@ gmail.com
Traumatic injury is the leading cause of death worldwide among persons between one and 44 years of age[1,2], fourth leading cause of death over all age groups and accounts for 10% of all deaths. In fact, Global Burden Diseases (GBD) Study has classifiedtheinjuriesasGroup-3,alongwithothertwo broader categories of diseases; communicable, and non-communicable. Despite improvement in care, uncontrolled bleeding contributes to 30 to 40% of trauma related deaths and is a leading cause of potentially preventable early in-hospital deaths[6 – 9].
PHYSIOLOGY OF BLEEDING AND HEMOSTASIS[10,11]
As a physiological response to an injury, whether, traumatic or planned (surgical), especially, if there is an integumental (skin or mucus membrane) breach then logically hemorrhage is the result. American College of Surgeons (Advanced Trauma Life Support (ATLS) Team) has classifiedbleeding/hemorrhage intofourclasses (Table1, Annexure1 ). This has further been modifiedrecentlytoincludesomemoreparameters (Table 2, Annexure1), Class I being, non-shock state, such as occurs when donating a unit of blood, whereas class IV being pre-terminal event requiring immediate therapy. Massive hemorrhage may be definedasloss of total EBV within a 24-hour period, or loss of half of the EBV in a 3-hour period. Bleeding secondary to surgical / traumatic cause is usually as a result of combination of vascular injury and coagulopathy.
STAGE I: VASOCONSTRICTION
As a response to hemorrhage, all the mediators of vasoconstriction: noradrenaline, thromboxanes (TBXs) and mediators of RA system are released, causing intense vasoconstriction.
Effects: The firstaidsystemcanlastfromminutesto hours.
1. Vasoconstriction minimizes vessel diameter and slows bleeding
2. TBXA2 leads to smooth muscle relaxation
3. The tamponade effect by the extravasated blood adds to vasoconstriction
STAGE II: PLATELET PLUG FORMATION
A complex phase formed by three sub-phases
1. Platelet adhesion
2. Platelet release reaction
Platelets create extensions and come in contact with each other. They release their contents i.e.,