Massive Blood Loss

OVERVIEW

Definitions of massive blood loss vary

• = loss of one blood volume within a 24 hr period
• = blood loss > 150mL/min
• = 50% blood volume loss in 3 hours

GOALS

(1) stop bleeding
(2) rapid and effective restoration of an adequate blood volume
(3) maintain blood composition -> haemostasis, O2 carrying capacity, oncotic pressure and biochemistry

MANAGEMENT

(1) Restore circulating volume

• wide bore IV access -> send initial bloods to lab including cross match
• access to adequate volumes of pre-warmed crystalloid & colloid
• synthetic colloids -> max 1.5L in 24 hours

(2) Contact key personnel

• surgeon
• OT
• haematologist
• blood bank

(3) Stop bleeding

• OT
• interventional radiology
• damage control surgical management

(4) Request laboratory investigation

• full set of bloods with correct ID information
• may need to give products before results available
• repeat full set of bloods every 30min

(5) Activate the Massive Transfusion Protocol (example shown below)

• 3U of whole blood
• Box 1: 2 RBC, 2 FFP
• Box 2: 4 RBC, 4 FFP, 1 adult platelets
• Box 3: 4 RBC, 4 FFP, 3 Cryo
• consider FVIIa 90mcg/kg if indicated
• Box 4: 4 RBC, 4 FFP, 1 adult platelets
• subsequent boxes alternate Box 3 and 4
• repeat coag’s, platelets, FBC, ABG, Ca2+ Q30min

RATIONALE FOR BLOOD PRODUCTS

RBC

• Hb > 80 g/L
• may need O Rh -ve
• can use O Rh +ve for male or post menopausal female
• lab needs 45 minutes or longer to complete full cross match
• use blood warmer
• consider cell salvage
• 1U raises Hb for 10 g/L

PLATELETS

• Plt > 100 for multi or CNS trauma
• Plt > 50 for others
• platelet count will be less < 50 after x 2 blood volume replaced
• neonate or small child 10mL/kg
• 1 adult unit = 5 standard units raises count by 30

FFP

• aim for INR 1.5 & APTT 75
• child’s dose = 15mL/kg
• adult dose = 4 U
• allow 30min to thaw

CRYOPRECIPITATE

• aim = fibrinogen > 1.0 g/L and FVIII replacement
• child’s dose = 5mL/kg
• adult dose = 1 pack/30 kg

RECOMBINANT FACTOR VIIa

• need to triage patients to ensure that only potentially salvageable patients receive rFVIIa
• need to have at least reached massive transfusion criteria
• consider if =

• 10U RBC
• 10U FFP
• 2U PLT
• 2U Cryo
• reversed warfarin (vit K, prothrombin X)
• reversed heparin (protamine)
• considered anti-fibrinolytic agents (tranexamic acid or aprotinin)

If ongoing bleeding:

(1) pH <7.2 or T < 35 C -> Damage Control Surgery

(2) otherwise rFVIIa 100mcg/kg, wait 20 min and repeat -> needs platelets > 100 and fibrinogen >1

• Damage control surgery = abandonment of definitive surgery, rapid haemostasis, packing and closure -> transfer to ICU for warming, correction of coagulopathy and inotropes -> definitive treatment undertaken later

COMPLICATIONS (HI ESTI VO) -> MANAGEMENT

Haemostatic Failure

• dilution (especially platelets)
• depletion
• consumption
• decreased production
• DIC

-> early monitoring, bed side testing
-> replace with appropriate products

Impaired O2 Transport

• fluid over/underload
• defective RBC function
• impaired Hb function
• DIC
• ALI/ARDS
• MODS
• microaggregates

Electrolytes and Metabolic Disturbance

• hyperkalaemia/hypokalaemia -> use younger blood + specific therapy
• sodium overload
• acid-base disturbances
• citrate toxicity (hypocalcaemia) -> replace Ca2+
• hypothermia
• metabolic acidaemia
• fever from foreign proteins in donor plasma
• iron overload

Serological Incompatibility

• immediate generalized reaction (anaphylaxis, TRALI, ABO and Rh incompatibility)
• delayed transfusion reaction (Rh, Kidd, low AB titres) -> haemolysis

-> avoid cross-match issues
-> allocate sufficient resources (staff and protocols)
-> TRALI prevention (leukodepletion, filters)

Transmission of Infection

• viral (hepatitis, HIV, CMV)
• bacterial (Yersinia, Treponema palladium, Pseudomonas, Staphylococcus)
• parasites (malaria, toxoplasmosis)

-> blood bank precautions
-> monitoring for and antibiotics

Impaired reticuloendothelial Function

Vasoactive Reactions

• kinin activation
• damaged platelets and granulocytes

Others

• transfusion-associated circulatory overload (TACO)
• air embolism
• thrombophlebitis
• distraction from stopping bleeding
• graft vs host disease
• immunomodulation (increased risk of infection, tumour recurrence, activation of latent viral infections, recurrent miscarriage)

References and Links

CCC Transfusion Series
Blood Products	Cryoprecipitate, Fresh Frozen Plasma (FFP), Platelets, Red Cells (RBCs) Concentrates: Prothrombinex, Factor VIIa, Fibrinogen Concentrate
Reversal	Rivaroxaban / Apixaban / Enoxaparin: Andexanet Alfa, Rivaroxaban and Bleeding Dabigatran: Idarucuzimab, Dabigatran and bleeding Heparin: Protamine Warfarin: Vitamin K / FFP / PTx, Warfarin Reversal, Warfarin Toxicity
Testing	Coagulation Studies, TEG / ROTEM (Thromboelastography), Platelet function assays
General Topics	Acute Coagulopathy of Trauma, Blood Bank, Blood conservation strategies, Blood Product Compatibilities, Blood transfusion risks, Disseminated Intravascular Coagulation, Massive blood loss, Massive transfusion protocol (MTP), Modifications to blood components,Procedures and Coagulopathy, Storage Lesions, TRALI, Transfusion Literature Summaries, Transfusion Reactions

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