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Transfusion essay March 2009

Page history last edited by James Davies 8 years, 6 months ago

Discuss the management of massive blood loss in a hospital setting

 

Massive blood loss

Definition 

  • 1 blood volume within 24 hours (Adult blood volume 7% of ideal body weight ie. about 5 litres)
  • 50% blood volume within 3 hours 
  • >150ml/minute

 

General principles

  • Maintain tissue perfusion and oxygenation
  • Arrest bleeding
  • Correct coagulopathy with blood products 

 

Communication

  • Between haematology and clinical specialties (surgery, anaesthetics, interventional radiology for embolisation), lab, blood service, 
  • Dedicated team member to co-ordinate
  • Early senior involvement

 

Local protocols – role of the hospital transfusion committee

  • Other roles include analysis of events
  • Contingency plan for national blood shortage and emergencies

 

 General principles

  • Restore circulating volume / monitor signs of poor tissue oxygenation
    • Venous access
    • Warming of fluids and blood products (hypothermia increase coagulopathy)
    • Monitor UO/ BP
    • Treat acidosis
  • Arrest bleeding
    • Surgical/ obstetric / interventional radiology
  • Investigations
    • Group and Ab screen
    • Baseline haem, coag and biochemistry
    • Consider near patient testing such as TEG

 

Haematology targets 

 

1. HB >8

  • Consider cell salvage
  • O neg in emergency - ABO group specific – fully cross matched
  • Use blood warmer, rapid infuser (level 1)
  • HCT 0.35 may be required to sustain haemostasis in massive blood loss
  • 30-40% blood loss, PRCs usually required

2. Plts >75 (margin of safety, shouldn’t fall below 50)

  • Anticipate plt <50 after 2 x blood volume replacement

3. PTT and APTT <1.5

  • FFP 12-15mls/ kg (1L in adults)
  • Anticipate need after 1-1.5 x blood volume - now probably would instigate earlier particularly if there has been trauma or there is pre-existing coagulopathy.  Concept of 1:1 FFP to blood ratios.
  • Lasts for 24 hours once thawed, therefore should start to dethaw immediately
  • 30 minute thaw time

1. Fibrinogen >1

  • 2 packs for an adult, usually only needed if DIC
  • 30 minute thaw time

 

Other agents

  • PCC if secondary to warfarin
  • Not enough evidence to support antifibrinolytics
  • rVIIa – off license, consider if continued bleeding despite correction of other parameters
  • Fibrinogen concentrate

 

Risks

  • Wrong unit transfused
  • DIC – cardinal sign is microvascular oozing
  • Hypocalcaemia, hyperkalaemia, TRALI

 

 

 

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