Learning objectives

• Definition of coagulopathy
• Management of coagulopathy

Definition and mechanisms

• Coagulopathy is a condition in which the blood’s ability to coagulate (form clots) is impaired
• Leading to a tendency toward prolonged or excessive bleeding and occurring spontaneously or following an injury 
• Caused by:
  • Genetic conditions such as hemophilia and Von Willebrand disease
  • Acquired factors: anticoagulant medications (warfarin), the continued use of antibiotics, liver disease, or disseminated intravascular coagulation
• Activation of coagulation will lead to consumption of clotting factors, particularly factor V and fibrinogen, leading to a consumptive coagulopathy

Signs and symptoms

• Easy bruising
• Hemarthrosis (bleeding into a joint cavity)
• Hemorrhage after childbirth
• Accumulation of blood in the pleural cavity (hemothorax)
• Very heavy menstrual flow
• Loss of blood through the nose
• Anal bleeding
• Livedo reticularis
• Thrombocytopenia
• Gingival bleeding
• Rheumatisms
• Bloody gums
• Joint pain and swelling
• Blood in the urine
• Double vision
• Severe head or neck pain
• Repeated vomiting
• Difficulty walking
• Convulsions or seizures

Management

• Obtain a blood sample for a full coagulation screen
• Perform near-patient testing such as ROTEM or TEG
• Consider permissive hypotension in patients with moderate bleeding
• Perform massive volume resuscitation in a patient with severe hypovolemic shock
• Limit crystalloid and colloid infusions as this leads to acidosis, hypothermia and coagulopathy
• Transfuse red blood cells → hemoglobin target is between 7-9 dL/L
• Administer fresh frozen plasma, platelets, cryoprecipitate, and concentrated red cells, depending on clotting results and blood loss
• Correct hyperfibrinolysis with tranexamic acid (see also blood transfusion)
• Avoid volatile anesthetics as they lead to vasodilation
• Administer multimodal analgesia (opioids, NMDA glutamate receptor antagonists)
• Regional anesthesia is not indicated as it takes too much time and could mask compartment syndrome
• Avoid hypothermia as this worsens coagulopathy 
  • With passive rewarming, active external rewarming, and active internal rewarming
  • Hypothermia impairs thrombin generation
  • Hypothermia contributes to platelet dysfunction
• Consider complications associated with plasma administration such as TRALI, sepsis, and ABO incompatibility

Trauma-induced coagulopathy

TXA, tranexamic acid; PCC, Prothrombin Complex Concentrates

Suggested reading

• Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med. 2021;11(1):1.
• Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
• Simmons J, Powel M. 2016. Acute traumatic coagulopathy: pathophysiology and resuscitation. BJA: British journal of anaesthesia. 17;3:31-43.
• Gaunt, C., Woolley, T., 2014. Management of haemorrhage in major trauma. Continuing Education in Anaesthesia Critical Care & Pain 14, 251–255.
• Daniel Bolliger, Klaus Görlinger, Kenichi A. Tanaka, David S. Warner; Pathophysiology and Treatment of Coagulopathy in Massive Hemorrhage and Hemodilution. Anesthesiology 2010; 113:1205–1219.

Clinical updates

Deshpande et al. (A&A, 2025) review cancer-associated coagulopathy and highlight that malignancy confers a simultaneous high risk of thrombosis and bleeding, driven by tissue factor overexpression, tumor-derived microparticles, NETs, hypoxia-related endothelial dysfunction, and treatment-related effects. The review emphasizes that perioperative management should rely on structured risk assessment (e.g., Khorana, Caprini scores), early use of viscoelastic testing (TEG/ROTEM), and individualized anticoagulation and transfusion strategies rather than standard coagulation tests alone. 

• Read more about this study HERE.