PBM: Massive bleeding

 

(Please note there are many embellishments to this summary)

 

List:

·         Massive transfusion protocol

·         Transfusion Numbers

 

Massive transfusion protocols

 

Damage control resuscitation principles:

1.       Damage control surgery

2.       Permissive hypotension

3.       Haemostatic resus

 

When to call it:

By scenario

·      Anticipate bleeding +++

·      Thorax, abdo, long bone trauma

·      Obstetric bleeding +++

·      GI bleeding +++

By volume

·      50% BV in 4h

·      100% BV in 24h

·      >150mL/min

 

What to do:

1.Activate

·      Call lab

·      Call for help

·      Allocate roles (incl getting, checking, giving blood)

2.Access

·      Big IVs

·      Arterial line

3.Test

·      t = 0 and q30-60

·      ABG, FBE, UEC, CMP, coag, BGHO

·      Viscoelastic if available

4.Stop bleeding

Anaesthesia:

·      Permissive hypotension (mAP 50-65, SBP 80-100 unless TBI)

Surgery:

·      Compression/tourniquets/packing

·      Ligation/diathermy/clamping

·      Angiography

Obstetric causes:

·      Tone: oxytocics

·      Thrombin: give substrates

·      Tissue: remove placenta

·      Trauma: repair

Obstetric procedures:

·      Bakri balloon

·      B-lynch suture

·      Internal iliac artery clamping

·      Interventional radiology

·      Caesarean hysterectomy

5.Replace blood

From the bank:

·      O negative if can’t wait

·      1st pack: 1:1:1 with TXA

·      2nd pack: 1:1:1 with cryo

From the cupboard:

·      Limit crystalloid

·      Consider albumin

From the patient:

·      Cell salvage if available

How to give it:

·      Give it rapidly

·      Give it warmed up

6.Promote clotting

1.Reverse anticoagulation:

·      Warfarin: VitK/PCC/FFP

·      Heparin: protamine

·      Dabigatran: idarucizumab

·      Xa inhibitors: andexanet alpha

·      Everything: ciraparantag

2.Give substrates:

·      FFP (INR <1.5, aPTT < 1.5x)

·      Cryoprecipitate (Fg >1.5 or >2 if obstetric)

·      Platelets (>80 unless neuro)

3.Support the substrates:

·      Temp >35 (forced air warmer + fluid warmer)

·      pH >7.2

·      iCa >1.1

7.Optimise DO2

Targets:

·      PaO2 >100

·      Hb >80

·      PPV <10% (surrogate)

·      pH >7.2

·      Lactate <4

8.Deactivate

·      Call lab when goals achieved

 

Transfusion Numbers

 

Doses and increments:

 

Dose and volume

Increment

RBC

1 bag at a time = 250-300mL

Paeds: ½ x desired ↑Hb x TBW

10g/L

FFP

15mL/kg = 3 bags = 1L

Paeds: 10-20mL/kg

-

Platelets

1 pooled bag = 300mL

Paeds: 10mL/kg

20-40 x 109 / L

Cryo

3-4g = 1 unit

10 bags whole blood cryo

5 bags apheresis cryo

Paeds: 5-10mL/kg

0.5-1g/L

TXA

1g over 10 mins load

1g over 8 hours infusion

-

rF7a

90mcg/kg

-

 

Ratios:

What we call it

1:1:1 units

What’s in the pack

4:2:1 bags

How much volume

1000mL:600mL:300mL

 

Hb threshold:

Population

Threshold

Most people

<70 yes (almost always)

70-100 maybe

<100 no

Acute coronary syndrome

<80 yes

80-100 maybe

>100 no (increases mortality)

Critically ill

<70 yes

70-90 maybe

>90 no

Children

<70 yes

70-90 maybe

>90 no

 

Platelet threshold:

Population

Threshold

Most

<50

Invasive procedures in ICU

<50

TBI

Brain surgery

Eye surgery

Neuraxial surgery

<100

Chemo and stem cell transplant

<10

<20 if risk factors i.e. bleeding, fever

Critically ill

<20

 

 

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