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

[cite]