Massive transfusion

 

Preparation: some hard-won knowledge

Summary*

·     Access

·     Warming

·     Products

If it could bleed^

If:

·     Sharp object

·     Inside a body cavity

Then:

·     A: decent cannula

·     W: forced air

·     P: blood available (BGHO), albumin available

If it could hose^

If:

·     Sharp object

·     Near a great vessel

Then:

·     A: huge cannula

·     W: fluid and forced air

·     P: blood ready, albumin in room

Blood ready means

·     No testing delay (= Crossmatched)

·     No transport delay (= Close by)

·     No paperwork delay (= Checked)

A big gun is useless without ammo

A big drip is useless without products

*Yes, that acronym is a gun in CS-GO
^These are your assessments. You must not rely on your surgeon.

 

Administration: some hard won knowledge

Fast bleeding (minutes)

·     Volume: fractional losses

o   RBCs: % ↓Volume = %↓Hb

o   Rest: if ↓Volume 1.5L ≈ 30%

·     Speed: vital signs

·     Ratio: as if whole blood. TEG/ROTEM if time.

Slow bleeding (hours)

·     Volume: blood tests

·     Ratio: blood tests

Medium bleeding

·     Volume: bit of both

·     Ratio: bit of both

 

 

 

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Indications for MTP:

By volume

·     50% BV in 4h

·     100% BV in 24h

·     >150mL/min

By scenario

·     Anticipate bleeding +++

·     Thorax, abdo, long bone trauma

·     Obstetric bleeding +++

·     GI bleeding +++

 

1.Haemostasis

Goals

·     Plt >50

·     INR <1.5

·     aPTT <1.5x

·     Fib >1.5*

·     T >35

·     iCa >1.1

a.Stop bleeding

·     Permissive hypotension: mAP >50, SBP >80

·     Temporising: compression, tourniquets, packs

·     Definitive: ligation, clamping, diathermy

·     Obstetric: Bakri balloon, B-lynch suture, DSA, hysterectomy

b.Promote clotting

·     Reversal: e.g. protamine

·     Substrate: FFP, platelets, cryo

·     Adjuncts: TXA, CaCl2

·     Heat: air warmer + fluid warmer

*Fib >2 if pregnant

^SBP >100-110 if brain trauma

 

2.Resuscitation

Goals

·     mAP >65

·     Hb >80

·     PaO2 >100

·     pH >7.2

·     Lac <4

a.Access

·     2 x IVC + rapid infuser

·     A-line

·     IDC

b.Warming

·     Forced air warmer

·     Blood warmer

c.Products

·     Crystalloid: 1.5L max

·     Blood: O-neg / cross-matched / cell salvage

·     1:1:1 ratio (4 red, 2* yellow, 1 white)

·     Targeted: formal ± viscoelastic

*4 yellow bags in Victoria

 

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