Hairmyres Hospital Monklands Hospital Wishaw General Hospital Major Haemorrhage Protocol Commentary N.B. There is a separate NHSL protocol for the Management of Obstetric Haemorrhage Authors Dr Tracey Dunn, Consultant Anaesthetist, Monklands Dr Duncan Allen, Consultant Anaesthetist, Hairmyres Dr Donald MacLean, Consultant Anaesthetist, Wishaw Dr Pamela Paterson, Lead Clinician for Transfusion Review Date December 2009
Objective To ensure that a simple guideline exists to aid in the treatment of a major haemorrhage presenting to any NHS Lanarkshire acute hospital site. The protocol should run in accordance with previously established NHS Lanarkshire policies for the checking and administration of blood products. This commentary should be read in conjunction with the relevant site specific summarised protocol. Rationale Quality Improvement Scotland (QIS) recommend that protocols are in place in individual hospitals to facilitate a multidisciplinary approach to acute blood loss. The protocol is based on the guidelines produced by the British Committee for Standards in Haematology 1. This protocol is intended for use in Lanarkshire s Acute Hospitals for treating major haemorrhage in non-obstetric cases. A separate protocol is available for the Management of Obstetric Haemorrhage. It should be ensured that the patient does not have an advance directive refusing blood and blood products prior to transfusion. Resuscitate Recommendations Priority should be given to ensuring that patients are adequately resuscitated with patent airway, satisfactory ventilation and supplementary oxygen before assessment of circulation. Contact senior personnel Good communication is essential during a major haemorrhage. Trainees should contact their seniors early. Preferably one member of the clinical team should be identified as a coordinator to liaise with the blood bank and the Consultant Haematologist, allowing for more effective communication. Restore Circulating Volume/Laboratory Tests Circulatory support should be given as necessary, with a minimum of two large-bore peripheral cannulae being inserted to allow rapid fluid resuscitation (via a blood warmer). Estimated blood loss and physiological parameters including heart rate, blood pressure and peripheral perfusion should be used to guide initial fluid therapy. 2
Baseline observations should be undertaken and routine bloods sent (including FBC, U+Es, coagulation screen, ABGs and cross-match specimen, ensuring correct patient identification details). Recent studies show no survival benefit from colloids as opposed to crystalloids. 2 The volume of crystalloids needed to be administered is at least three times the blood volume lost. The volume of colloid needed is equivalent to the blood volume lost. Dextrose should never be used for fluid resuscitation in this situation. It is important at all times to ensure correct patient identification and to check the patient s wristband before administering blood products. For unidentified patients a minimum data set of gender and a unique identifier number is required. Throughout resuscitation, routine blood samples (as above) should be repeated at least every four hours and after every major therapeutic intervention. In addition, calcium should be measured after infusion of FFP (fresh frozen plasma), platelets and red cells as citrate anticoagulant may bind calcium, especially if hypothermic or acidotic. Treat hypocalcaemia with 10ml of 10% calcium gluconate as a slow IV bolus. Hypothermia should be prevented by blood warmers and warming blankets. Arrest Bleeding Senior staff from surgical, anaesthetic and haematological departments should be alerted early, allowing formulation of a management plan and surgical / radiological intervention as necessary. Time to definitive surgery should be minimised. Simple manoeuvres such as elevation of a limb and direct pressure should be considered. Institute Invasive Monitoring Invasive monitoring should be instituted as soon as practical and by those competent in doing so, with fluid replacement guided by pulse, blood pressure, CVP and urine output (aiming for >0.5ml/kg/hour.). Central venous access and arterial lines may be required. Consider transferring the patient to HDU/ITU/theatre as appropriate. Request suitable blood products: Red Cells (discuss with haematology BMS & declare major haemorrhage) No definitive Hb trigger value exists for transfusion in acute haemorrhage, but the American Society of Anaesthesiologists Task Force on Blood Component Therapy suggest transfusion is rarely indicated if Hb is >10g / dl, but is always indicated if Hb <6.0 3. Current consensus favours an Hb of >8.0. Allowances 3
must also be made for haemodilution, and Hb values may take some hours to drop post-haemorrhage. In extreme emergencies, uncross-matched group O blood may be needed but switch to group specific as soon as available. In pre-menopausal women only Rhesus negative blood should be used but Rhesus positive blood can be used in men and post menopausal women. If possible, ABO group specific blood should be given and preferably fully cross-matched blood (imposing delays of ~ 10 and 30 minutes respectively, not including transport times). Even in emergencies ensure correct patient identification, check the patient s wristband and complete the bag and tag for all transfused blood components. Fresh Frozen Plasma (discuss with Consultant Haematologist) Current red cell replacement is in the form of plasma-poor red cells, containing minimal coagulation factor activity. It is this coagulation factor deficiency which is the primary cause of coagulopathy after large volume blood transfusion. FFP is essentially plasma isolated by centrifugation of leucodepleted blood, and is thus rich in all clotting factors. It is, however, approximately five times more likely to cause a transfusion reaction than red cell concentrates. FFP should be given to those whose PT or APTT are 1.5 times normal, typically after 1-1.5 x blood volume loss, and also in those with pre-existing deranged clotting e.g. secondary to liver disease. The adult dose is 12 15mls/kg units (approximately 4 units for an average adult). Allow 20 minutes for the FFP to be thawed in the laboratory. The appropriate component will be supplied by the laboratory but this may not be the same group as the patient. Occasionally it may be necessary to administer FFP before clotting results are available. This should be done in liaison with the Consultant Haematologist. It should, however, be ensured that an urgent sample has been sent for a coagulation screen to guide further management. Platelets (discuss with Consultant Haematologist) Allow margin of safety to ensure platelet count is maintained >50x10 9 / L in acutely bleeding patients 1,4. A platelet count of 50x10 9 / L may be anticipated when approximately 1.5-2 x blood volume has been lost although there is marked individual variation. Platelets should be requested if it is anticipated that the count may fall below 50x10 9 / L and administered early to ensure the count is maintained above this critical level at all times. Platelets should be maintained >100x10 9 / L in patients with multiple and CNS trauma and those with impaired platelet function 4 (despite a normal platelet count) e.g. due to antiplatelet agents and uraemia. The adult dose is one pool and should preferably, but not necessarily, be ABO compatible. 4
One pool of platelets is stocked at Wishaw. Platelets are not stocked at Monklands and Hairmyres and usually need to come from the Blood Transfusion Centre at Gartnavel Hospital. A delay of at least 45 minutes is, therefore, expected and the need for platelets should be anticipated in advance to take this delay into account. Cryoprecipitate (discuss with Consultant Haematologist) High molecular weight proteins (fibrinogen, von Willebrand factor and factor VIII) are precipitated from plasma to form cryoprecipitate. Cryoprecipitate should be given when fibrinogen is below 1.0g/L despite administration of FFP which contains significant amounts of fibrinogen. Adult dose is 1.5 units / 10kg (approximately 2 pools). Each pool contains products from five donors with an associated increased risk of transfusion reactions. Consider Other Agents and Pre-existing Coagulation Disorders (discuss with Consultant Haematologist): Baseline coagulation screen and medical / drug history should suggest the possibility of a pre-existing coagulation disorder. Seek the advice of haematology staff and ensure coagulation screen is repeated regularly after intervention. Liver disease - Vitamin K (10mg in 1ml) should be administered as slow IV bolus in addition to blood products. Warfarin therapy - Guidelines are on the Lanarkshire Intranet 5 - Stop warfarin. Give 5mg Vitamin K as IV bolus. - Administer Prothrombin complex concentrate (Factors II, VII, IX and X.) - FFP can be used if Prothrombin complex concentrate is contraindicated. Heparin therapy - Stop heparin. - Give protamine as IV injection over 10 minutes. - 1mg protamine reverses 80-100 units heparin. - Reduce protamine if >15 minutes after heparin infusion stopped. - Do not exceed a dose of 50mg protamine in a 10 minute period. - Caution with LMWH, which is not fully reversed by protamine. - Protamine side effects include hypotension. - Overdose of protamine sulphate may cause bleeding. Protamine has a weak anticoagulant effect due to an 5
interaction with platelets and with many proteins including fibrinogen. Post-thrombolysis - Stop thrombolysis. - Consider antifibrinolytics e.g. aprotinin and tranexamic acid. - Coagulation factors e.g. cryoprecipitate, may be required. Antiplatelet therapy - Stop infusion. Consider platelet transfusion. Haemophilia - Seek haematological advice. Recombinant Factor VIIa Recombinant factor VIIa is thought to cause a supra-physiological surge in thrombin generation on the surface of aggregated platelets, which is site specific and thus limited to areas of vessel damage 8. Its use in major haemorrhage, in the absence of haemophilia, is unlicensed and there is, as yet, only limited case reports to suggest it may be of benefit in this group of patients,6,7. The BCSH guidelines suggest it should be considered in diffuse coagulopathic bleeding with blood loss >300mls/hr where there is no heparin or warfarin effect, acidosis has been corrected and surgical intervention has failed to control haemorrhage 1. Major crush injury is a relative contra-indication as thrombotic sequelae may occur. The recommended dose is 90mcg / kg as an IV bolus over 2-5 minutes. Clinical signs indicating reduction in rate of haemorrhage should be sought. A further dose of 90mcg / kg can be considered after 2 hours if major blood loss persists. Liaison between responsible Consultant and Consultant Haematologist is required as currently rfviia is unlicensed. Suspect Disseminated Intravascular Coagulation (DIC) DIC is suggested by prolongation of PT and APTT, thrombocytopenia and a low or falling level of fibrinogen. It carries a high mortality and requires aggressive treatment with further FFP, platelets and cryoprecipitate 1. Prevention of DIC requires early, aggressive treatment of shock, hypoxia, acidosis and hypothermia. References 6
1. British Committee for Standards in Haematology. Guidelines on the management of massive blood loss. D Stainsby et al. British Journal of Haematology, 135: 634-641. 2. Alderson P, Schierhout G, et al. Colloids versus crystalloids for resuscitation in acutely ill patients. Cochrane Library, 2001; issue 1. 3. American Society of Anesthesiologists Task Force. Practice guidelines for blood component therapy. Anesthesiology, 1996; 84: 732-747. 4. Hoffman M, Dutton R, et al. Excessive bleeding in surgery and trauma. Surgical Rounds, 2002; 10: 5-16. 5. Management of over anticoagulation with warfarin NHS Lanarkshire intranet - Acute Division - Hospital - Policies and Procedures Clinical guidelines, policies and procedures - Haematology. 6. Perez F, et al. Successful treatment of intra-abdominal bleeding associated with DIC using rfviia. British Journal of Haematology, 2001; 114: 174-176. 7. Hedner U. NovoSeven as a universal haemostatic agent. Blood coagulation and Fibrinolysis, 2000; 11:107-111. 7