Crystalloid resuscitation: coagulopathy

Administration of large volumes of fluid deficient in platelets and clotting factors will predictably lead to the development of a coagulopathy as a consequence of dilution. There has been much research into whether patients first become deficient in platelets of clotting factors during massive volume resuscitation. In the end, this question is not likely to be important. What is important is that after massive volume resuscitation, whether it be with PRBCs, crystalloid or colloid, your patient is likely to be thrombocytopenic and or deficient in clotting factors.

Most of the clotting factors are stable in stored blood except for factors V and VIII. These tend to decrease by up to 50% after 21 days of blood storage. PRBC’s have fewer of all the clotting factors.

Total platelet activity is only 50% to 70% of the original in vivo activity after 6 hours of storage in bank blood at 4°C. After 24 or 48 hours of storage, platelet activity is only about 10% or 5% of normal, respectively. Infusion of bank blood stored for longer than 24 hours dilutes the available platelet pool.

Clinically significant dilution of fibrinogen occurs after 1.4 blood volumes, factors II, V, and VII after 2 blood volumes and platelets after 2.3 blood volumes.

Platelets should not be given to treat laboratory evidence of thrombocytopenia unless clinical coagulopathy is also present. When the platelet count is less than 50,000 to 75,000/mm3, a bleeding problem is likely and is probably a combination of dilutional thrombocytopenia and DIC.