Patient Blood Management Guidelines: Module 1

Critical Bleeding Massive Transfusion

| Executive summary |

Summary of practice points

The CRG developed practice points where, as was commonly the case, the systematic review found insufficient high-quality data to produce evidence-based recommendations, but the CRG felt that clinicians require guidance to ensure good clinical practice. These points are based on consensus among the members of the committee.

No.	Practise Point	Relevant Section Of Document
PP1	In patients with critical bleeding requiring massive transfusion, the following parameters should be measured early and frequently: temperature acid–base status ionised calcium haemoglobin platelet count PT/INR APTT fibrinogen level. With successful treatment, values should trend towards normal. 4.1
PP2	Values indicative of critical physiologic derangement include: temperature < 35°C pH < 7.2, base excess > –6, lactate > 4 mmol/L ionised calcium < 1.1 mmol/L platelet count < 50 × 10⁹/L PT > 1.5 × normal INR > 1.5 APTT > 1.5 × normal fibrinogen level < 1.0 g/L. 4.1
PP3	In critically bleeding patients requiring, or anticipated to require, massive transfusion, an MTP^a should be used. A template MTP is provided within this module.^b ^a The use of the word ‘protocol’ in ‘massive transfusion protocol’ throughout this report is not strictly prescriptive. ^b The template MTP is intended for local adaptation. 4.2
PP4	In patients with critical bleeding requiring massive transfusion, insufficient evidence was identified to support or refute the use of specific ratios of RBCs to blood components. 4.2
PP5	In patients with critical bleeding requiring massive transfusion, haemoglobin concentration should be interpreted in the context of haemodynamic status, organ perfusion and tissue oxygenation. 4.3
PP6	In patients with critical bleeding requiring massive transfusion, the use of RBC and other blood components may be life saving. However, transfusion of increased volumes of RBC and other blood components may be independently associated with increased mortality and ARDS. 4.4
PP7	In patients with critical bleeding requiring massive transfusion, the use of an MTP to facilitate timely and appropriate use of RBC and other blood components may reduce the risk of mortality and ARDS. 4.4
PP8	An MTP should include advice on the administration of rFVIIa when conventional measures – including surgical haemostasis and component therapy – have failed to control critical bleeding. NB: rFVIIa is not licensed for this use. Its use should only be considered in exceptional circumstances where survival is considered a credible outcome (see Template MTP example). 4.6
PP9	When rFVIIa is administered to patients with critical bleeding requiring massive transfusion, an initial dose of 90 μg/kg is reasonable. 4.6
PP10	In patients with critical bleeding requiring massive transfusion, suggested doses of blood components are:^a FFP: 15 mL/kg platelets: 1 adult therapeutic dose cryoprecipitate: 3–4 g. ^a Or as directed by the haematologist/transfusion specialist in specific clinical situations, such as obstetrics. 4.8
APTT, activated partial thromboplastin time; ARDS, acute respiratory distress syndrome; FFP, fresh frozen plasma; INR, international normalised ratio; MTP, massive transfusion protocol; PT, prothrombin time; RBC, red blood cell; rFVIIa, recombinant activated factor VII

CRASH 2⁷
In trauma patients with or at risk of significant haemorrhage, tranexamic acid (loading dose 1 g over 10 minutes, followed by infusion of 1 g over 8 hours) should be considered. The CRASH 2 trial was published on 14 June 2010 after the cut-off date of the systematic review.⁷ No systematic review was conducted on tranexamic acid in critical bleeding/massive transfusion. The study population was not restricted to critical bleeding requiring massive transfusion. 4.9