Severe intraoperative haemorrhage Flashcards
When should a massive transfusion protocol be activated?
Complex question without a definitive answer
Suspect impending or actual haemorrhagic shock
Ongoing, difficult to control, surgical bleeding requiring more than 4U PRBC
When should severe haemorrhage be anticipated?
- Major trauma
- Obstetrics - placenta praevia, PPH esp
- Major vascular surgery
- Revision joint arthroplasty
- GI haemorrhage
- Anticoagulated patients
- Major head/neck or plastic surgery
How is blood loss assessed?
- Poorly!
- Regular assessment of suction bottles, swabs, bloody drapes and surgical field
- Hemocue can give an objective measure of [Hb] FBC
In an otherwise healthy individual how much blood is lost prior to developing hypotension?
40-50%
A surgeon sticks a laparoscope port through the abdominal aorta. What do you do?
- Swear at the surgeon
- Hit the emergency button and delegate jobs as help arrives
- Turn the patient onto 100% Oxygen
- Activate MTP
- Ensure surgeons are trying to stem the bleed
- Large bore IVC access x2 (could insert Vascath if difficulty with peripheral access)
- Send blood for X-match, coags, FBC and ABG (gives iCa & lactate)
- Warm fluid, warm theatre, warm patient
- Rapid fluid infusion while awaiting O- blood -> could label lines drugs & blood to ensure dedicated blood lines
- Get pressure infusers
- Establish monitoring - IDC, temp, art line, central line
- Consider cell saver if available
- Document transfusion of products
- Notify ICU
- Continue transfusion process until haemorrhage control is achieved
What IVC access device could be inserted if a 20G cannula is already insitu?
The guidewire for a RIC will fit through a 20G cannula
This would allow conversion from a small peripheral line into a rapid infusion cannula
What is permissive hypotension and which patient group/s should be excluded?
Permissive hypotension balances the goal of organ perfusion with the risk of rebleeding by accepting a lower-than-normal blood pressure - the goal is balance, not hypotension
In a normal healthy adult accepting an SBP of 80 should be OK
PH is contraindicated in head injury, and requires extreme caution in the elderly, cardiac disease and pregnant
What are the goals of management in severe blood loss?
Restoring blood volume to maintain tissue perfusion and oxygenation
Achieve haemostasis
What endpoints can be used to indicate ongoing appropriate management of a severe intraoperative haemorrhage?
- Temp >35’
- pH >7.2
- BE <-6
- INR 1.5
- Fibrinogen >1 g/L
- Ca > 1.1
- Lactate <4
- Platelets >75
- aPTT <1.5x normal
What is the fractionated equivalent of whole blood?
3U PRBCs, 6U FFP, 1bag Plts
Outline transfusion triggers for RBCs
Should be individualised, but - [Hb] 100 almost never
Also consider if - pt has persisting haemodynamic instability after 2L of Crystalloid (x2 20mL/kg bolus)
Earlier trigger if patient has IHD, renal impairment, severe resp disease
Inability to control bleed - bone, retroperitoneal
When should platelets be given?
Early
Indicated if plt count <75
What are the indications for FFP?
- As part of MTP
- Emergency reversal of Warfarin
- Correction of microvascular bleeding in presence of high aPTT/PT
- Patient transfused >1 blood volume
When is cryoprecipitate given?
Treatment of hypofibrinogenaemia (Fibrinogen <1g/L)
What other adjuncts could be given to assist in control of bleeding or coagulation deficits?
Tranexamic acid - fibrinolysis (best given early)
Calcium chloride - hypocalcaemia (10mLs 10%)
Prothrombinex - massive haemorrhage unresponsive
Recombinant factor VIIa - as for Prothrombinex
