MANAGEMENT OF MASSIVEBLOOD LOSS
Dr.Sripali Dassanayake
Massive blood loss
Jeopardise survival of patient
Doctors attempting to treat bleedingBlood bankLaboratoryDISCORD-waste of resourcesBad outcome
Under stres
s !
CHALLENGE
Definition
MASSIVE BLOOD LOSS = Loss of one blood volume within 24 hours ADULT-7% of ideal body weight
(70Kg;70*7/100=4.9l)
CHILDREN-8%-9%
OR
Loss of 50% blood volume within 3 hoursOR a rate of loss of 150ml/min
Clinical situations
Multiple trauma PPH Ruptured ectopic APH Injury to the highly vascular area;
involving lung,liver,spleen,prostate Any major Sx with prolonged
exposure Any surgical or obstetric emergency
Priorities of Rx
1.Restoration of blood volume to maintain tissue perfusion & oxygenation
2.Achieving haemostasis by;
Treating any traumatic, surgical or obstetric source of bleeding
Correcting coagulopathy by the judicious use of blood component therapy
OUTCOME
Early, Prompt action and Good communication between clinical specialities
Blood bank staff
Local blood centre
Diagnostic laboratories
Surgical team
Haematological team
Anaesthetic team
Templated Guidelines updated 2008,March(R/V in July)
Goal Procedure Comment
Restore circulating volume
Insert wide bore peripheral cannulaeGive adequate volumes of warmed crystalloids? Colloids
Blood
Aim to maintain normal blood pressure and urine output-30ml/hr
14G or larger
Monitor Central Venous Pressure
Blood loss is often underestimated
Keep patient warm
Contact key personnel Clinician inchargeDuty anaesthetistBlood bankDuty haematologist
Nominated co-odinator should take responsibility for communication and documentation
Goal Procedure Comment
Arrest bleeding Early surgical or obstetric intervention
Interventional radiology
Request laboratory investigations
FBC,PT,APTT,Thrombin time, fibrinogen(Clauss method);blood bank sample, biochemical profile, blood gases & pulse oxymetry
Ensure correct sample identity
Repeat FBC,PT,APTT,Fibrinogen 4hrly or after 1/3 of blood volume replacementRepeat after blood component infusion
Take samples at earliest opportunity as results may be affected by colloid infusion
Misidentification is the commonest transfusion risk
May need to give components before results available
Request suitable red cellsMaintain Hb>8g/dl
Assess degree of urgency
Un-crossmatched group O Rh negative in extreme emergencyNo more than 2 units
Un-crossmatched ABO group specific when blood group is known
Fully cross-matchedWhen irregular Ab presentWhen time permits
Use blood warmer and/or rapid infusion device
Employ blood salvage if available and appropriate to minimize allogenic blood use
Rh positive is acceptable if patient is a male or postmenopausal female
Laboratory will complete crossmatch after issue
Further cross-match not required after replacement of one blood volume(8-10 units)
Blood warmer indicated if flow rate>50ml/kg/hr in adultSalvage is contraindicated if wound is contaminated.Collection of split can be setup in <10min.
Request plateletsMaintain platelets >75,00o
Allow for delivery time from blood centreAnticipate platelet count <50,000 after 2* blood volume replacement
Target platelet count
100,000 for multiple /CNS trauma or if platelet function abnormal>50,000 in other situations
Request FFP(12-15ml/kg body weight=1L or 4 units for an adult<1u FFP=2-5mg fibrinogen/ml>
Aim for PT & APTT<1.5*control meanCritical level is 1g/l
Anticipate need for FFP after 1-1.5*blood volume replacement
Allow for ~30min thawing time
PT/APTT>1.5 of mean normal value- correlates with increased microvascular bleeding(<0.5 g/l of fibrinogen)
Keep ionized Ca+2 >1.13mmol/l
Maintain ffibrinogen 1.0g/l1.8g of fib/pool
If not corrected by FFP give cryoprecipitate(2 packs of pooled cryoprecipitate for an adult)Should be available on sideAllow for 30min thawing time
Cryoprecipitate rarely needed except in DIC
Suspect & Avoid DIC
Treating underlying causes;ShockHypothermiaacidosis
Although rare, mortality is high
Use of pharmacological agents to arrest bleeding
Antifibrinolytic drugs Tranexamic acid reverse
fibrinolysis Aprotinin
Recombinant factor viia-for haemophyliacs Where blood loss is>300ml/hr Where no effects of heparin/warfarin Where surgical control of bleeding is not possible After adequate replacement of coagulation factor
with FFP,cryoprecipitate and platelets After correction of acidosis
Disseminated Intra vascular Coagulation(DIC)
Microvascular oozing-cardinal clinical sign
Microthrombi in small vessels-end organ damage
DIC like syndrome:
Tissue trauma activation of coagulation cascade
Platelet +coagulation factor consumption
Patients at risk
prolonged hypoxia
Hypovolaemia
Hypothermia
Massive head injury
Extensive muscle damage
Tissue trauma
High mortality=difficult to reverse
Appropriate and aggressive Rx needed before microvascular bleeding is evident
based on laboratory evidence of consumption coagulopathy;
Prolongation of PT/APTT (more than accepted levels by dilution)
Significant thrombocytopenia Fibrinogen levels<1g/l Measurement of D-dimers
FFP and cryoprecipitate should be replaced “sooner rather than later "in sufficient dosage avoiding circulatory overload.
Risks of massive transfusion1 .Giving the wrong blood to the pt.-most frequent & hazardous-
must adhere to the protocols in whatever degree of emergency
2 .Transfusion related acute lung injury (TRALI) – *dyspnoea, fever & hypotension within hours of trnsfusion *Potentially life threatening
3 . Acute immunological mediated reactions-RareBUT 5-6times frequent in platelet &FFP transfusion compared to
red cell transfusion
4 .Transfusion associated haemodilution-suppress immune response-risk of post op infections
5 .Creutzfeldt-Jakob disease(vCJD):-rare, but invariably fatal
Metabolic consequences of massive transfusion
1.Ionized hypocalcaemia due to citrate toxicity 1. - commonest : in large volumes of plasma infusion-
specially with abnormal liver functions(slowed citrate metabolism)
-reduces myocardial contractility, vasodilation-exacerbate further bleeding & shock
*Measure Ca+2 –blood gas analyser
Rx –IV CaCl2 infusion(not gluconate-needs liver metabolism to release ionized Ca)
Dose 10ml of 10% CaCl2 IV OR 2.5-5mmol CaCl2 in divided doses over 10min.
2.Hyperkalaemia -high extracellular K+ in stored red cell
units-compounded by oliguria & metabolic acidosis associated with shock.
If >6mmol/l glucose insulin regime +
Bicarbonate(for acidosis)
In severe cases-haemofiltration
Patients survivaldepends on:-
**PROMPT ACTION ***GOOD COMMUNICATION **INVOLVEMENT OF SENIOR CLINICIANS
WITH NECESSARY EXPERTISE **Better understanding of the
associated physiological changes More aggressive resuscitation Effective blood component therapy guided by
lab/near patient testing Effective warming techniques
**PATIENT’S AGE & CO-MORBIDITY **DURATION & DEGREE OF SHOCK **DEVELOPMENT OF DIC
Any Questions……????
THANK YOU !