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 !