Guidelines. Blood transfusion and the anaesthetist: management of massive haemorrhage.
Thomas D, Wee M, Clyburn P, Walker I, Brohi K, Collins P, Doughty H, Isaac J, Mahoney PM, Shewry L.
1. Hospitals must have a major haemorrhage protocol in
place and this should include clinical, laboratory and
2. Immediate control of obvious bleeding is of paramount
importance (pressure, tourniquet, haemostatic
3. The major haemorrhage protocol must be mobilised
immediately when a massive haemorrhage situation is
4. A fibrinogen < 1 g.l)1 or a prothrombin time (PT) and activated partial thromboplastin time (aPTT) of > 1.5 times normal represents established haemostatic
failure and is predictive of microvascular bleeding.
Early infusion of fresh frozen plasma (FFP;
15 ml.kg)1) should be used to prevent this occurring
if a senior clinician anticipates a massive haemorrhage.
5. Established coagulopathy will require more than
15 ml.kg)1 of FFP to correct. The most effective way
to achieve fibrinogen replacement rapidly is by giving
fibrinogen concentrate or cryoprecipitate if fibrinogen
6. 1:1:1 red cell:FFP:platelet regimens, as used by the
military, are reserved for the most severely traumatised
7. A minimum target platelet count of 75 · 109.l)1 is
appropriate in this clinical situation.
8. Group-specific blood can be issued without performing
an antibody screen because patients will have
minimal circulating antibodies. O negative blood
should only be used if blood is needed immediately.
9. In hospitals where the need to treat massive
haemorrhage is frequent, the use of locally developed
shock packs may be helpful.
10. Standard venous thromboprophylaxis should be
commenced as soon as possible after haemostasis has
been secured as patients develop a prothrombotic
state following massive haemorrhage.