Includes a short descriptive type presentation with 2008 guidelines on management of massive blood loss and a little touch on management options.

1. MANAGEMENT OF
MASSIVE
BLOOD LOSS
Dr.Sripali Dassanayake

2. Massive blood loss
Jeopardise survival of patient
Doctors attempting to treat
bleeding
Blood bank
Laboratory
DISCORD-waste of resources
Bad outcome

3. 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 hours
OR a rate of loss of 150ml/min

4. 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

5. 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

6. OUTCOME
Early, Prompt action and Good
communication between clinical
specialities
Blood bank
staff
Local blood
centre
Diagnostic
laboratories

7. Surgical team
Haematological
team
Anaesthetic
team

8. Templated Guidelines updated
2008,March(R/V in July)
Goal Procedure Comment
Restore circulating volume Insert wide bore peripheral
cannulae
Give adequate volumes of
warmed crystalloids
? Colloids
Blood
Aim to maintain normal
blood pressure and urine
output-30ml/hr
14G or larger
MonitorCentralVenous Pressure
Blood loss is often
underestimated
Keep patient warm
Contact key personnel Clinician incharge
Duty anaesthetist
Blood bank
Duty haematologist
Nominated co-odinator should
take responsibility for
communication and
documentation

9. 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 replacement
Repeat 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

10. Request suitable red cells
Maintain Hb>8g/dl
Assess degree of urgency
Un-crossmatched group O
Rh negative in extreme
emergency
No more than 2 units
Un-crossmatched ABO
group specific when blood
group is known
Fully cross-matched
When irregularAb present
When 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
adult
Salvage is contraindicated if
wound is contaminated.
Collection of split can be
setup in <10min.

11. Request platelets
Maintain platelets
>75,00o
Allow for delivery time from blood
centre
Anticipate 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
mean
Critical 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 ionizedCa+2
>1.13mmol/l
Maintain f
fibrinogen 1.0g/l
1.8g of fib/pool
If not corrected by FFP give
cryoprecipitate(2 packs of pooled
cryoprecipitate for an adult)
Should be available on side
Allow for 30min thawing time
Cryoprecipitate rarely needed
except in DIC
Suspect & Avoid
DIC
Treating underlying causes;
Shock
Hypothermia
acidosis
Although rare, mortality is
high

12. 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

13. 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

14. Patients at risk
 prolonged hypoxia
 Hypovolaemia
 Hypothermia
 Massive head injury
 Extensive muscle damage

15. 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.

16. Risks of massive transfusion
1 .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-Rare
BUT 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

17. 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.

18.  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

19. Patients survival
depends on:-
 **PROMPTACTION
 ***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

20.  **PATIENT’SAGE & CO-MORBIDITY
 **DURATION & DEGREE OF SHOCK
 **DEVELOPMENTOF DIC

21. Any Questions……????