Hematologic and Coagulation Disorders
Transfusion
Restrictive thresholds are supported for most critically ill patients (hemoglobin 7 g/dL), with a higher trigger (8 g/dL) for active ischemia or ongoing bleeding. Platelet prophylaxis at 10 × 10^9/L, 20 before procedures, and 50 before major surgery or neuraxial instrumentation. Plasma is for bleeding with documented coagulopathy, not for isolated abnormal INR.
Massive hemorrhage
Use a balanced resuscitation ratio (approximately 1:1:1), activate the protocol early, give tranexamic acid within 3 hours in trauma, and use viscoelastic testing (TEG/ROTEM) to guide product choice. Correct calcium, temperature, and pH alongside clotting factors.
Specific disorders
DIC: consumptive coagulopathy with prolonged PT/aPTT, low fibrinogen, thrombocytopenia, elevated D-dimer; treat the cause. HIT: use the 4Ts score, stop heparin, start argatroban or bivalirudin, avoid warfarin until platelets recover and avoid platelet transfusion. TTP: microangiopathic hemolysis with schistocytes, low platelets, neurologic and renal findings; urgent plasma exchange plus steroids, and platelets only for life-threatening bleeding. Warfarin reversal: four-factor PCC plus vitamin K. Dabigatran: idarucizumab. Anti-Xa inhibitors: andexanet or PCC where unavailable.
Traps
- Giving platelets in suspected TTP.
- Using recombinant factor VIIa as a universal rescue.
- Failing to reverse anticoagulation before emergent neurosurgery.
- Confusing liver disease coagulopathy with DIC.
- Missing heparin-induced thrombocytopenia because the platelet fall is modest.
Rule of thumb
In a bleeding patient on warfarin with an intracranial hemorrhage, give PCC and vitamin K immediately and do not wait for lab results.