Management of massive blood loss

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

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Management of massive blood loss

  1. 1. MANAGEMENT OF MASSIVE BLOOD LOSS Dr.Sripali Dassanayake
  2. 2. Massive blood loss Jeopardise survival of patient Doctors attempting to treat bleeding Blood bank Laboratory DISCORD-waste of resources Bad outcome
  3. 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. 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. 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. 6. OUTCOME Early, Prompt action and Good communication between clinical specialities Blood bank staff Local blood centre Diagnostic laboratories
  7. 7. Surgical team Haematological team Anaesthetic team
  8. 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. 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. 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. 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. 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. 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. 14. Patients at risk  prolonged hypoxia  Hypovolaemia  Hypothermia  Massive head injury  Extensive muscle damage
  15. 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. 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. 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. 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. 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. 20.  **PATIENT’SAGE & CO-MORBIDITY  **DURATION & DEGREE OF SHOCK  **DEVELOPMENTOF DIC
  21. 21. Any Questions……????

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