A practical guideline for the haematological management of major haemorrhage

The aim of this guideline is to provide recommendations for the haematological management of major haemorrhage in any clinical situation, with practical guidance for Clinical Haematologists and laboratory staff on the content and delivery of major bleeding protocols, including the use of blood components and transfusion alternatives. Management of major haemorrhage in any setting requires a multidisciplinary approach. There have been advances in techniques for resuscitation as well as surgical, radiological and endoscopy interventions, to control bleeding alongside critical care support, but these are beyond the scope of this document. These updated guidelines are based on new studies, which have provoked reassessment of the principles of managing major haemorrhage in all clinical situations, and which mandate much closer working between hospital blood banks and emergency departments to provide timely transfusion support for patients with major bleeding. Alongside changes in the use of blood component therapy, the importance of antifibrinolytics has been demonstrated in the study by the Clinical Randomization of Antifibrinolytics in Significant Haemorrhage (CRASH-2) collaborators (2010). The recognition that tranexamic acid (TA) benefited not only those with massive haemorrhage but also the larger number of patients with, or at risk of, significant haemorrhage (i.e. not only those fulfilling the criteria for massive bleeding) has led to an expansion of our guidelines from massive to major haemorrhage so that we can include this group. The writing group was representative of UK transfusion and haemostasis experts, and consultation within the specialities of anaesthesia, trauma and critical care was made. Relevant systematic reviews were identified by searching the National Health Service (NHS) Blood and Transplant Systematic Review Initiative Transfusion Evidence Library (http://www.transfusionevidencelibrary.com). A search was performed of PubMed and Embase using the term “bleeding” and “haemorrhage” combined with ‘management’ and “trials”. The search covered articles published up until April 2015. Only human studies were included and articles not written in English were excluded. The quality of evidence was judged by predefined Grades of Recommendation, Assessment, Development and Evaluation (GRADE) criteria (Guyatt et al, 2006). Strong recommendations, grade 1, are made when the group was confident that the benefits do or do not outweigh the harm and burden of cost of a treatment. Where the magnitude of benefit is less certain, grade 2, suggested recommendations are made. The quality of evidence is rated as A (high quality randomized control trial), B (moderate), C (low), D (very low, expert opinion only). The writing group produced a draft which was revised based on input from the British Committee for Standards in Haematology (BCSH) Transfusion and Thrombosis and Haemostasis Task forces, The Royal College of Anaesthetists and the Association of Anaesthetists; it was then circulated to a wider sounding board of 50 UK Haematologists and experts in bleeding management. The guidelines cover clinical management with an Appendix on logistics and laboratory management. While there are arbitrary definitions of massive blood loss, e.g., loss of one blood volume within a 24-h period, 50% blood volume loss within 3 h, loss of 150 ml/min, these may be difficult to apply in the acute situation. Indeed, standard definitions are not particularly helpful because they are retrospective. Our arbitrary definition of major haemorrhage is bleeding which leads to a heart rate more than 110 beats/min and/or systolic blood pressure less than 90 mmHg. Hospitals must have locally agreed triggers. It may not be straight forward to readily determine that major haemorrhage is occurring, for example post-partum; but early recognition of significant blood loss, ideally before major increments in pulse rate and falls in blood pressure, will allow prompt action to pre-empt shock. Medical, nursing and midwifery staff involved in frontline care must be trained to recognize major blood loss early, know when to activate/trigger the local major haemorrhage protocol and take prompt and appropriate action (1D). Whilst the focus is currently on practice recommendations for bleeding in trauma patients, the management of patients with bleeding in other clinical settings (e.g. gastrointestinal, obstetrical or surgical) also needs specific attention. The National Patient Safety Agency (NPSA) (2010) highlighted a recurring theme of delays in blood provision in emergencies resulting in unacceptable morbidity and mortality (NPSA/2010/RRR017). From October 2006 to September 2010, the NPSA received reports of 11 deaths and 83 incidents in patients as a result of such delays. The provision of emergency blood to a bleeding patient requires the use of specifically designed protocols, which include robust and clearly understood communication channels between clinical staff and those in the blood transfusion laboratory. Local protocols should enable the release of blood and blood components for initial resuscitation without the prior approval of a Haematologist. The Hospital Transfusion Committee (HTC) has a key role in overseeing protocol development and implementation (Department of Health, 2007). The smaller Hospital Transfusion Team (HTT) including the Haematology Consultant responsible for Transfusion, Transfusion Practitioner and Hospital Transfusion Laboratory Manager can help support various activities essential for effective implementation, e.g. training and audit, with clear and explicit input from leads in each clinical area required. The major haemorrhage protocols should be developed in collaboration with relevant teams managing haemorrhage and ratified by the HTC. While HTTs have a key supportive role, it is essential that each clinical area has a designated trainer responsible for ensuring on-going training for all relevant Hospitals must have local major haemorrhage protocols with for specific clinical (1D). laboratory and support staff must know to the haemorrhage protocol in relevant and be with the should be by training and (1D). communication is essential between teams to clinical or transfusion practice and component for the of bleeding is or or with specific may be should be to early to other to such the more difficult early action may be essential to and and major may be required. and/or also have in clinical care may be and early communication is to A designated Team the at the needs to be to and management. of the major haemorrhage protocol there must be a clear for all relevant and a designated Team should then management (1D). A Team should be and a specific clinical to communication with Transfusion Laboratory staff and support for the of the (1D). 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