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         HOW I AVOIDED A MASSIVE TRANSFUSION IN SEVERE TRAUMATIC SPLEEN RUPTURE. CASE REPORT.
Dimitris Bliamplias1, Polixeni Zografidou2, Maria Tsiotsiou2, Georgios Anagnostou2, Dimitrios Pinas2, Athanasios Mitsokapas, Kostas Fortounis4, Euaggelia Gkoutziomitrou3
Anesthesiology Department, «Papageorgiou» General Hospital. Thessaloniki. Greece 1 Consultant Anesthesiologist,
2 Resident-Anesthesiology,
3 Director-Anesthesiology,
4 Director-Surgery
     Introduction: Rotational thromboelastometry (ROTEM) is a point of care method, that was introduced a decade ago into extensive clinical practice. It helped clinicians to counterbalance the consequences of traumatic hemorrhage reducing both time to diagnosis and treatment, especially when factor concentrates are used. We present the clinical course of a patient with spleen rupture and severe hemorrhagic shock, emphasizing into hemostatic derangements and how they were approached and treated according to ROTEM exams intraoperatively.
Case Presentation: Male patient suffered a low velocity accident, driving his motorcycle without wearing any protective measures. He was brought to hospital immobilized in a long board with supplemental oxygen and crystalloid infusion. Initial clinical condition was good, with excellent level of consciousness, and normal vital signs except mild tachycardia (115/min). After detailed primary survey he undergone a computed tomography scan. Sudden deterioration of his clinical condition led him to the operating room were emergency laparotomy was performed. He was intubated, using rapid sequence technique, with airtraq device and gum elastic bougie, due to anatomical factors, suffering mild hypoxemia during the procedure. Initial vital were systolic blood pressure 70/30 mmHg, HR 125/min, noradrenaline was immediately deployed at dosing up to 1μγ/Kg/min. Initial pH was 7.048, Base Excess -17 meq/lt, lactate 8,86 mmol/lt and Hb 9.3 mg/dl One gram of tranexamic acid, and four grams (50 mg/Kg) of fibrinogen concentrate were given blindly, as of severe hemorrhagic shock. Spleen rupture was evident, spleen artery ligation was performed, and gradually vitals were normalized with parallel de-escalation of pressors. Two units of red packed cells were given along with fibrinogen. Before transferring to the ICU, a thromboelastographic study was performed. Normal width in FIBTEM (A10 16mm), normal Clotting Time in EXTEM (79 sec), A10 EXTEM 47 mm, exceedingly small increase in INTEM Clotting Time (258 sec), without evidence of hyper-fibrinolytic activity (ML 2%).
Conclusion: There is an ongoing debate as if factor concentrates can be used for treatment of trauma induced coagulopathy, replacing fresh frozen plasma ιn a massive transfusion protocol. This tactic is a ravishing alternative given the fact that factor concentrates are readily available, can be reconstituted with small amount of water for injection, thus avoiding volume circulatory overload and are more reliable as far as concentration of their active ingredients are concerned in comparison with labile blood products. There is also evidence that because fibrinogen concentration is the first and most rapidly falling coagulation factor, can be replaced without POC testing, based on knowledge from multifactorial models that calculate fibrinogen levels on arrival at ED, based on BE, Hb levels, and Injury Severity Score (ISS). The RETiC study compared first-line coagulation factor concentrates or fresh frozen plasma for reversal of trauma-induced coagulopathy. Their results underlined the importance of early and effective fibrinogen supplementation for severe clotting failure in multiple trauma.
Key Words: Trauma induced coagulopathy, rotational thromboelastometry, factor concentrates
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