New British Guidelines for Haematological Management of Major Haemorrhage

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Beverley Hunt at al. have just published an excellent practical guideline for the haematological management of major haemorrhage which also serves a a great educational review on this topic… an excellent piece of work!

The authors look at this topic point for point and review current literature in an easy to understand sort of manor. They define major blood loss when it leads to a heart rte of >110/Min or a systolic blood pressure of less than 90mmHg, or simply said: when bleeding becomes haemodynamic relevant. In general it is recommended to have a major haemorrhage protocol at hand (1D) and all staff should be trained to recognise major blood loss early (1D).

Here’s a summary of the recommendations made by the British Committee for Standards in Haematology (BCSH):

In Major Haemorrhage….

Red Blood Cells RBC
– Hospitals must be prepared to provide emergency Group 0 red cells and group specific red cells (1C)
– Patients must have correctly labelled samples taken before administration of emergency Group 0 blood (1C)
– There is NO indication to request ‘fresh’ or ‘young’ red cells (under 7d of storage, 2B)
– Note: The optimum target haemoglobin concentration (Hb) in this clinical setting in general is NOT established. Current literature shows a tendency towards restriction towards 70-90g/L, but the BCSH makes no recommendations therefore (see blow)

Cell Salvage (e.g. cell saver)
– 24h access to cell salvage should be available in cardiac, obstetric, trauma and vascular centres (2b)

Haemostatic Monitoring
– Use haemostatic tests regularly during haemorrhage, every 30-60min, depending on severity of blood loss (1C)
– Measure platelet count, PT, aPTT (1C)
– Note: The BCSG does not recommend TEG and ROTEM at this stage

Fresh Frozen Plasma FFP
– Use FFP in a 1:2 ratio with RBC initially (2C)
– Once bleeding is under control administer FFP when PT and/or aPTT is >1.5 times normal (recommended dose 15-20ml/kg, 2C)
– The use of FFP should not delay fibrinogen supplementation if necessary (2C)

Fibrinogen
– Supplement fibrinogen when levels fall below 1.5g/L

Prothrombin Complex Concentrates PCC
– Do not use PCC

Platelets
– Keep the platelet count >50 x 10^9/L (1B)
– If bleeding persists give platelets if count falls below 100 x 10^9/L (2C)

Tranexamic Acid TA
– Give tranexamic acid as soon as possible to patients with, or at risk of major haemorrhage (Recommended dose: 1g IV over 10min, followed by 1g IV over 8h, 1A)
– Note: TA has no known adverse effects
– Note: Aprotinin is not recommended

Recombinant Activated Factor VIIa (Novo Seven)
– Do not use

Specific Clinical Situations

Obstetrics
– Fibrinogen levels increase during pregnancy to 4-6g/L
– In major obstetric haemorrhage fibrinogen should be given when levels are <2.0g/L (1B)

GI-Bleed
– Use restrictive strategy for RBC transfusion is recommended in most patients (1A)

Trauma
– Transfuse adult trauma patients empirically with a 1:1 ratio of FFP : RBC (1B)
– Consider early use of platelets (1B)
– Give tranexamic acid as soon as possible (Dose 1g over 10min and then 1g over 8h, 1A)

Prevention of Bleeding in High-Risk Surgery
– Use tranexamic acid (Dose 1g over 10min and then 1g over 8h, 1B)
Hunt B et al. British J Haemat, July 6 2015

Read more HERE:

Great Review on Transfusion, Thrombosis and Bleeding Management

Restricitve Transfusion Threshold in Sepsis, the TRISS Trial

Transfusion: Harmful for Patients Undergoing PCI?

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