Massive Haemorrhage

Abraham Tarekegn
Lecturer, Department of Anesthesia
CMHS, University of Gondar
 Outline
 Definition

 Factors to coagulopathy

 Prevention of coagulopathy

 Massive transfusion

 Management of massive hemorrhage

 Massive Haemorrhage
o Loss of entire blood volume equivalent within 24hrs

o Loss of 50% of blood volume within 3hrs

o Continuing blood loss of 150ml/min

o Continuing blood loss of 1.5ml/kg/min over 20 min

o Rapid blood loss leading to decompensation and circulatory failure

despite volume replacement and interventional treatment
Lethal triad: Bloody vicious cycle
 Factors contributing to the Coagulopathy of
Trauma

Acidosis

 Decrease coagulation factor activity

thrombin generation

platelet aggregation

 Enhanced fibrinolysis and depletion of plasma activator inhibitor-1

Factors contributing to the Coagulopathy of Trauma

Hypothermia
• Platelet dysfunction
• Reduced clotting factor activity

Dilutional Coagulopathy
• Factor deficiency
• Thrombocytopenia
• Anaemia
 Factors contributing to the Coagulopathy of
Trauma

Consumption:

• Platelets

• Fibrinogen

• Clotting factors

Crit Care Med 2008 Vol 36, No 7 (Suppl.)

 Prevent the Coagulopathy

• Most Rx arm of the lethal triad

• Appropriate choices of resuscitation fluids

• The amounts and ratio of these products to one another

• The timing of delivery of these products

• The use of adjuncts to resuscitation (recombinant Factor VIIa)

So how do we do this
o Replacement of each 1ml of blood lost with 3ml isotonic crystalloid

o Adult Hypotensive pt calls for a rapid infusion of 2L of an isotonic

crystalloid solution

o Red cells are recommended for transient or initial non-responders

o Time is of the essence

 Clarke et al. found that the probability of death increases approximately 1% for
each 3min spent in the emergency department in patients with major injuries.
J Trauma 2002;52:420-5
 Permissive Hypotension

• Allowing the BP of the patient who has the risk of major

ongoing bleeding to not return to normal values,

• But to stabilise at values around 75% of normal until surgical

control of bleeding is established

• Prevention of rebleeding syndrome

 Permissive Hypotension: When

• Ruptured AAA (Abdominal aortic aneurysm)

• Major vascular trauma to Non-compressible vessel

• Ongoing Intra Abdominal Haemorrhage

• Cold- coagulopathy- acidotic patient where temporising

surgery is planned
 Permissive Hypotension: When not /Contra-
indications

Use normal rules for Resuscitation:

• Hemodynamically stable patient

• Prior to exclusion of obstructive Shock

• Compressible bleed from isolated / external wounds

• Major head trauma

• Pregnant and childhood

• Burns
Massive Transfusion
o Massive transfusion is defined,

 In adults, as replacement of one entire blood volume within 24 h or >50%

of blood volume in 4 hours (adult blood volume is approximately 70
mL/kg).

 Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h

 In children, it is defined as transfusion of >40 mL/kg (blood volume in

children over 1 month old is approximately 80 mL/kg).
Massive Transfusion …
• Massive transfusion occurs in settings such as severe trauma, ruptured
aortic aneurysm, surgery and obstetrics complications.

• The goals to the management of massive transfusion include:

 early recognition of blood loss

 maintenance of tissue perfusion & oxygenation by restoration of blood volume &

haemoglobin (Hb)

 arrest of bleeding including with early surgical or radiological intervention, and

 judicious use of blood component therapy to correct coagulopathy.

 Management of massive
hemorrhage in general surgery
 Management of massive hemorrhage in
general surgery

o Major blood loss threatens the survival of patients in many

clinical settings and is a challenge for hematological and
blood transfusion services

o Tensions may arise between those attempting to treat

bleeding, those supplying blood and providing laboratory
services
MANAGEMENT OF MASSIVE HAEMORRHAGE

o Goals of management are:

 hemostasis,

 restoration of circulating blood volume, and

 blood component replacement.

Preoperative assessment

o A thorough pre-operative evaluation is fundamental for

 Stratifying hemorrhagic risk

 Predicting transfusion needs in relation to the type of surgical

intervention

 Evaluating the indications and eligibility of a patient for auto

transfusion procedures, and

 The need for any adjuvant therapies

Preoperative assessment …
o The pre-operative assessment must include:

 A careful review of the patient's clinical documentation,

 A thorough personal and family history,

 Focused particularly on revealing a suspected bleeding

disorder, as well as a control of the laboratory tests
Preoperative assessment …
Evaluation of haemorrhagic risk:

o A preoperative interview should elicit:

 Information on any spontaneous, post-traumatic or post-surgical bleeding

 Any use of anticoagulant and anti- aggregate drugs and include the family
history

o For those patients with a positive history of bleeding, it may be

helpful to use a structured questionnaire
 Preoperative assessment …
Questions to elicit bleeding disorder:
o Have you ever been told that you or your relative has a bleeding disorder?

o Have you ever had an abnormal result from a laboratory test on blood clotting
or had unexplained anemia?
o Have you ever had a bleeding problem:
 during or after an operation?
 after extraction of a tooth?
 after trauma?
 during childbirth or for heavy menses?
 with easy bruising or wounds that do not heal readily?
Preoperative assessment …
o Do you have or have you ever had a diseases of the liver or
kidney, any diseases of the blood or bone marrow, or low or high
numbers of platelets in your blood?

o Do you take aspirin, platelet anti- aggregate drugs, non-steroidal

anti- inflammatory drugs, vitamin K antagonists or heparin?

o [For the women]: Do you or did you have prolonged, very heavy
periods?
Preoperative assessment …

Laboratory tests

o CBC

o Coagulation profile (PT,PTT etc. )

o OFT (LFT, RFT)?

o Electrolyte?

o CX-R, U/S,ECG, echo ?

Preoperative preparation

o Adequate preoperative optimization

• Anemia -transfusion, pharmacological

• Coagulation disorder -correction

• Co-morbidities - Rx
Preoperative preparation …

o Resuscitation of the patient

o Adequate IV fluid prepared
o Adequate cross-matched blood
o Appropriate analgesia should be planned
o Warming devices
o IV access – two bore IV cannula (14G) on two hands,
o Multidisciplinary approach- anesthetists, surgeons, nurses and
other staffs
 Intraoperative Mx

Induction:

 Attach monitoring's -check V/S before induction

 Sympathomimetic drugs

 Cardio-stable drugs

 Combination: sympathomimetic + cardio-depressant?

• Emergency drugs ( titrated)

• Smooth induction
26
Intraoperative Mx ….

Maintenance of anaesthesia & monitoring

-Inhalational ? /Low MAC + intermittent bolus (sympathomimetics drugs)?

-Multi-modal analgesia

-Close monitoring of V/S- BP,PR, SPO2, EtCO,UOP, temperature,

CRT,peripheral skin temperature, glucose etc

-Adequate fluid resuscitation

-Keep pt warm –IV fluid & blood warming devices, blanket

-Good communication with surgical team

-Estimation of blood loss- suction, pack,gause,drapes, floor?

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Blood transfusion

 Check- pt identity, date of collection, cross-match paper

 Whole blood, packed RBC, platelets, fresh frozen plasma

 When?

 Adult: TEBL > 20% of TBV of the patient ( check V/S)

 Children: TEBL > 15% of TBV of the patient ( check V/S, age,
preoperative status)
 Postoperative Mx

• Preop medical problems

• Anesthesia, procedure

• Intraoperative V/S

• Amount of IV fluid given

• Analgesics used (opioid??)

• Transfusion (amount, CXN--)

• Incidents

• Emergence condition

• Postoperative concerns- oxygen, glucose, monitoring, pt

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position, ambulation, physiotherapy, investigations ---
Guideline for management of massive blood loss
Guideline for management of massive blood loss
Assessing degree of blood loss: physiological response

o Hypovolemic shock: inadequate tissue perfusion due to reduced

circulating blood volume.

o Normal blood volume is 70mls/kg.

o Loss of over 40% of blood volume is immediately life threatening

o Massive transfusion:
 An entire blood volume within a 24 hour period

 >50% of blood volume within 3 hours.

Assessing degree of blood loss: physiological response …

• Assessment is a combination of clinical signs and measured blood loss.

• Tachycardia and pallor are key early signs of significant hemorrhage.
• Severe hemorrhage is indicated by hypotension, altered consciousness
and oliguria.
• Visible blood loss is often overestimated and non-visible blood loss such
as retroperitoneal or long bone bleeding can be difficult to quantify.
• In the operating theatre blood loss is monitored by close observation of
blood in suction equipment and on drapes, and is measured by
collection and weighing of blood soaked swabs.
 ANAESTHETIC CONSIDERATIONS
• High concentration oxygen therapy

• Fluid therapy is used to restore adequate circulating volume.

• 0.9% saline is a common choice of crystalloid in resuscitation (Start with

20mls/kg of crystalloid)

• Hb/Hct levels do not fall for several hours after acute major blood loss.

• Hb concentration of 7-9g/dl is acceptable for non-bleeding critically ill patients.

• Transfusing to a Hb concentration of 8-10g/dl provides a safety buffer for

further bleeding2
ANAESTHETIC CONSIDERATIONS …
o Drugs which cause vasodilation or reduce cardiac output may worsen
hypotension and further impair tissue oxygenation.

o Hypothermia is avoided through use of warmed IV fluids/blood, forced air

warmers, minimising patient exposure, a warm theatre environment and
warm surgical irrigation.

o Risk management needs to consider both the direct risk of hypovolemia

and the secondary risks of massive transfusion
ANAESTHETIC CONSIDERATIONS …
o Source control is often important in minimising the blood loss.

o If hemorrhage is ongoing, there should be no delay in achieving operative

assessment and operative control of bleeding.

o The optimal blood pressure to achieve prior to source control is a mean

arterial pressure (MAP) of 60-70mmHg.

o More aggressive restoration of normal blood pressure is achieved after

source control is established
BLOOD PRODUCTS

o Best practice will consider use of RBC, platelets, FFP and

cryoprecipitate to achieve Hct above 24%, platelets above 50
x109 litre-1 and fibrinogen above 0.5-1.0g litre-1.
Packed Red Blood Cells
o Packed red cells are produced by removing 150-200ml citrated
plasma from a whole unit of blood, and have a shelf life of
approximately 35 days.

o In extreme emergencies O Rh negative blood may be used while

awaiting a cross matched blood supply

o Blood group specific transfusion should be given at the earliest

opportunity
Whole Blood

o This is blood prior to fractionation into individual components

and it has a shelf life of 35 days.

o 70ml of citrate preservative is added to 420ml of blood.

o Whole blood for transfusion is generally only used in centers

where blood fractionation into component products is not possible.
Platelets
o Platelets are removed from the plasma component of whole blood and they have a shelf life of 3-

5 days.

o Platelets above 50 x109 litre-1 are required to prevent excessive bleeding risk and a higher level

of 100 x109 litre-1 has been recommended in patients with high energy trauma or CNS injury.

o Platelet count should be measured at least every 4 hours or after 1/3 blood volume replaced.

o Initial dose is 4-8 platelet concentrates.

o Six units usually increases the platelet count by 20-30 x109 litre-1.

o Anticipating platelet requirement and advance platelet request may be necessary to ensure

availability when required.

 Fresh Frozen Plasma
• FFP is produced by freezing plasma and it lasts for one year. It requires thawing prior to use. FFP contains

all the coagulation factors. Coagulation factor depletion is the primary cause of coagulopathy in the setting

of major haemorrhage. Fibrinogen falls first (reaching the critical level of 1.0 g litre-1 after 150% blood

loss) and later there is a fall in other clotting factors to 25% activity after 200% blood loss1. Use of FFP

should be considered after approximately one blood volume has been lost. Aim for PT and APTT <1.5 x

control mean. The recommended initial dose is 10-15mls/kg. Sufficient quantity of FFP will correct

fibrinogen and most coagulation factor deficiencies but large volumes are often required. If fibrinogen

levels remain critically low (below 1.0 g litre-1) after FFP has been given, cryoprecipitate infusion should be

considered.
Cryoprecipitate

• Cryoprecipitate is obtained by rapidly thawing FFP and

separation of cryoprecipitate from albumin/factor
IX/immunoglobulins. It is then stored frozen and thawed
immediately prior to use. Cryoprecipitate is rich
in factor VIII and fibrinogen. In acute haemorrhage, aim for
fibrinogen >1.0g litre-1.
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