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KEY POINTS
Bleeding disorders and hemorrhagic complications are common in ICU patients.
Bleeding disorders may be divided into thrombocytopenias, soluble coagulation factor deficiencies, and combined disorders.
Initial management approaches to thrombocytopenias vary considerably and require early recognition of distinct disorders including heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and other common thrombocytopenias.
Disorders of soluble coagulation factors are revealed by abnormal results in the prothrombin time/international normalized ratio (INR), activated partial thromboplastin time, fibrinogen level, and other tests including thromboelastography (TEG)/rotational thromboelastometry (ROTEM).
Factor deficiencies, factor inhibitors, von Willebrand disease, and other complex coagulopathies including disseminated intravascular coagulation, HELLP syndrome, massive transfusion, and anticoagulant-related syndromes have specific therapies to reduce the rate and risk of bleeding.
There are specific indications and appropriate applications for platelet transfusion, cryoprecipitate, fresh frozen plasma, concentrated and activated factors, as well as other medications, including inhibitors of fibrinolysis.
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Coagulation disorders and bleeding complications are very common in ICU patients. Furthermore, the coagulation abnormalities convey important prognostic information and a substantial number of patients will have clinically significant bleeding.1,2 Because of the high prevalence, morbidity and mortality seen with bleeding disorders in critically ill patients, prompt awareness and intervention is mandatory. Awareness and recognition of pathophysiology and evidenced-based guidelines is needed in order to manage the vast array of bleeding disorders seen in conditions such as massive transfusion and trauma, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and anticoagulant-related hemorrhage. This chapter will address bleeding disorders relevant to critically ill patients.
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CLINICAL ASSESSMENT OF BLEEDING IN CRITICALLY ILL PATIENTS
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Reliable monitoring of bleeding in ICU patients is essential for accurate safety and effective bedside care. Understanding the risk and magnitude of hemorrhage in these patients establishes a foundation for the choice of treatment strategies, particularly given the wide range of evidence quality in the literature. Furthermore, clinical studies utilizing bleeding assessment scales are usually constrained by application in homogenous, single-disease patients.3,4 More than four decades ago, the World Health Organization (WHO) developed standard grading scales for bleeding in patients undergoing cancer treatment.5 Though this scale (Table 93-1) is still used commonly, it is not particularly relevant to many critically ill patients with different pathophysiological conditions.
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In critically ill patients, it is major bleeding that is usually clinically relevant. Apart from intracranial hemorrhage, minor bleeding is rarely of great concern. Major bleeding is defined as bleeding leading to hemorrhagic shock, bleeding requiring administration of > 2 units of PRBCs, an intervention necessary to stop bleeding or bleeding affecting organ function.6 Hemoptysis ...