Management Of Major Haemorrhage Research Articles

A guide to major haemorrhage management in paediatrics

A guide to major haemorrhage management in paediatrics

Should viscoelastic testing be a standard point-of-care test on all intensive care units?

Viscoelastic tests (VETs) have transformed assessment of haemostasis and transfusion practices in trauma, cardiac and liver transplantation centres. Impaired haemostasis is a common problem on the general intensive care unit (ICU), but routine use of VETs is rare. We have accordingly reviewed the evidence to determine whether there is evidence to support the use of VETs as a standard point of care test on all ICUs in assessing and managing patients. The benefits of using VETs in the management of major haemorrhage, namely faster identification of a coagulopathy, in particular early detection of fibrinolysis, and reduced transfusion requirements for blood products have been seen in the general ICU. Validation of treatments algorithms is now required to standardise practice. There is also emerging evidence to support the use of VETs to guide urgent treatment decisions in patients with a coagulopathy or in patients taking anti-coagulants or anti-platelet therapies. We recommend that departments independently review the feasibility of setting up a viscoelastic point of care service which considers the applicability to their patient cohort, the financial cost and the personnel required.

Contemporary management of major haemorrhage in critical care.

Haemorrhagic shock is frequent in critical care settings and responsible for a high mortality rate due to multiple organ dysfunction and coagulopathy. The management of critically ill patients with bleeding and shock is complex, and treatment of these patients must be rapid and definitive. The administration of large volumes of blood components leads to major physiological alterations which must be mitigated during and after bleeding. Early recognition of bleeding and coagulopathy, understanding the underlying pathophysiology related to specific disease states, and the development of individualised management protocols are important for optimal outcomes. This review describes the contemporary understanding of the pathophysiology of various types of coagulopathic bleeding; the diagnosis and management of critically ill bleeding patients, including major haemorrhage protocols and post-transfusion management; and finally highlights recent areas of opportunity to better understand optimal management strategies for managing bleeding in the intensive care unit (ICU).

Clinical decision support versus a paper-based protocol for massive transfusion: Impact on decision outcomes in a simulation study.

Management of major hemorrhage frequently requires massive transfusion (MT) support, which should be delivered effectively and efficiently. We have previously developed a clinical decision support system (CDS) for MT using a multicenter multidisciplinary user-centered design study. Here we examine its impact when administering a MT. We conducted a randomized simulation trial to compare a CDS for MT with a paper-based MT protocol for the management of simulated hemorrhage. A total of 44 specialist physicians, trainees (residents), and nurses were recruited across critical care to participate in two 20-min simulated bleeding scenarios. The primary outcome was the decision velocity (correct decisions per hour) and overall task completion. Secondary outcomes included cognitive workload and System Usability Scale (SUS). There was a statistically significant increase in decision velocity for CDS-based management (mean 8.5 decisions per hour) compared to paper based (mean 6.9 decisions per hour; p .003, 95% CI 0.6-2.6). There was no significant difference in the overall task completion using CDS-based management (mean 13.3) compared to paper-based (mean 13.2; p .92, 95% CI -1.2-1.3). Cognitive workload was statistically significantly lower using the CDS compared to the paper protocol (mean 57.1 vs. mean 64.5, p .005, 95% CI 2.4-12.5). CDS usability was assessed as a SUS score of 82.5 (IQR 75-87.5). Compared to paper-based management, CDS-based MT supports more time-efficient decision-making by users with limited CDS training and achieves similar overall task completion while reducing cognitive load. Clinical implementation will determine whether the benefits demonstrated translate to improved patient outcomes.

Correction to "Nonsurgical management of major hemorrhage".

Correction to "Nonsurgical management of major hemorrhage".

Nonsurgical management of major hemorrhage.

KEY POINTS Major hemorrhage is life-threatening and can occur in a variety of clinical settings. For the purpose of this review, we defined major hemorrhage as life-threatening bleeding that is likely to result in the need for massive transfusion (i.e., ≥ 10 units of red blood cells in 24 h).[1][1

Vascular clamps in perimortem caesarean delivery in parturients with placenta accreta spectrum: Case report and literature review

The increasing incidence of caesarean section (CS) increases the risk for placenta accrete spectrum (PAS) conditions in pregnancy. The aortic vascular clamps can be used in low resource settings to minimise major obstetric haemorrhage in a parturient with PAS. We report one case of major obstetric haemorrhage attributable to PAS and other cases that had the potential to bleed post-return of spontaneous circulation (ROSC). The first case had torrential bleed following classical CS done for percreta leading to severe haemodynamic instability and a near arrest situation despite standard protocolised management. As a last resort to control catastrophic bleeding, the aortic vascular clamp was used to avert an imminent cardiac arrest, which successfully lead to effective resuscitation and later uneventful recovery. The second case was a perimortem caesarean delivery in a diagnosed case of placenta percreta where we contemplated to use this clamp during resuscitative hysterotomy [Perimortem caesarean delivery (PMCD)] as its usage is likely to confer haemodynamic stability post-ROSC bleeding. However, the patient could not be revived. We have found that in addition to anaesthetic and major haemorrhage management skills in tackling a massive obstetric haemorrhage, the availability of trained surgical teams for controlling ongoing haemorrhage is crucial for effective resuscitation. Using aortic and common iliac vascular clamps as a damage control measure also plays a very important role in controlling catastrophic maternal haemorrhage. With the growing incidence of PAS and uncontrolled bleeding in these parturients, the skilled anaesthetic and resuscitative skills of anaesthesiologists are futile if haemorrhage is not controlled. We found that the availability and use of the vascular clamps at the time of PMCD are very useful to control bleeding and help in effective resuscitation. Its use has a short learning curve and the personnel can be trained easily.

Major haemorrhage: past, present and future.

Major haemorrhage is a leading cause of morbidity and mortality worldwide. Successful treatment requires early recognition, planned responses, readily available resources (such as blood products) and rapid access to surgery or interventional radiology. Major haemorrhage is often accompanied by volume loss, haemodilution, acidaemia, hypothermia and coagulopathy (factor consumption and fibrinolysis). Management of major haemorrhage over the past decade has evolved to now deliver a 'package' of haemostatic resuscitation including: surgical or radiological control of bleeding; regular monitoring of haemostasis; advanced critical care support; and avoidance of the lethal triad of hypothermia, acidaemia and coagulopathy. Recent trial data advocate for a more personalised approach depending on the clinical scenario. Fresh frozen plasma should be given as early as possible in major trauma in a 1:1 ratio with red blood cells until the results of coagulation tests are available. Tranexamic acid is a cheap, life-saving drug and is advocated in major trauma, postpartum haemorrhage and surgery, but not in patients with gastrointestinal bleeding. Fibrinogen levels should be maintained > 2 g.l-1 in postpartum haemorrhage and > 1.5 g.l-1 in other haemorrhage. Improving outcomes after major traumatic haemorrhage is now driving research to include extending blood-product resuscitation into prehospital care.

Foley Catheter Balloon Tamponade for Actively Bleeding Wounds Following Penetrating Neck Injury is an Effective Technique for Controlling Non-Compressible Junctional External Haemorrhage.

Thefoley catheter balloon tamponade (FCBT) has been widely employed in the management of trauma. This study reviews our cumulative experience with the use of FCBT in the management of patients presenting with a penetrating neck injury (PNI). A retrospective study was conducted at a major trauma centre in South Africa over a 9-year period from January 2012 to December 2020. All patients who presented with a PNI who had FCBT were included. A total of 1581 patients with a PNI were managed by our trauma centre, and 44 (3%) patients had an FCBT. Of the 44 cases of FCBT, stab wounds accounted for 93% (41/44) and the remaining 7% were for gunshot wounds. Seventy-five per cent of all FCBT (33/44) were inserted at a rural hospital prior to transfer to our trauma centre; the remaining 25% (11/44) were inserted in our resuscitation room. The success rate of FCBT was 80% (35/44), allowing further CT with angiography (CTA) to be performed. CTA findings were: 10/35 (29%) positive, 18/35 (51%) negative, and 7/35 (20%) equivocal. Fifteen patients required additional intervention (open surgery or endovascular intervention). The overall morbidity was 14% (6/44). Eighteen per cent required intensive care unit admission. The median length of stay was 1day. The overall mortality rate was 11% (5/44). FCBT is a simple and effective technique as an adjunct in the management of major haemorrhage from a PNI. In highly selective patients, it may also be used as definitive management.

Challenges in the Management of Major Hemorrhage after Hemorrhoidal Banding

Hemorrhoidal banding is considered a safe, low-risk technique for the management of grade-I–III internal hemorrhoids. Furthermore, information in the literature regarding serious complications associated with banding is limited. Bleeding post hemorrhoidal banding is often considered minor and is expected to resolve spontaneously. Therefore, major hemorrhage post hemorrhoidal banding is often unexpected, recognized late, poorly managed, and may become life-threatening. In this case series, we present two unusual cases with rare, major, life-threatening hemorrhage post banding. Although it is rare, banding is shown to be associated with a risk of life-threatening bleeding, as this report highlights. Major hemorrhage is unusual because most bleeding after hemorrhoidal banding resolves spontaneously; however, as shown in this series, bleeding is a potential complication of hemorrhoidal banding. Thus, an appropriate index of suspicion is important to prevent serious morbidity and mortality. In this study, we discuss the factors associated with bleeding risk as well as surgical and management strategies to reduce the risk of major bleeding with hemorrhoidal banding.

Trends in pediatric traumatic major hemorrhage from a major trauma center.

Injury requiring management of major haemorrhage in paediatric trauma (called 'code red' at our institution) can result in critically injured children with high injury severity scores (ISS) and mortality. The rise in penetrating trauma in younger adolescents has led to an increase in major haemorrhage activations in injured children at this trauma centre. Criteria used to define a paediatric code red, at our institution, is non-compressible haemorrhage, obvious signs of bleeding, clinical signs of shock and/or cardiac arrest at scene.

A child in shock: carotid blowout syndrome

Paediatricians commonly encounter neck lumps during their routine clinical practice; vascular abnormalities, such as (pseudo)aneurysms, are a rare cause of these. Pseudoaneurysms of the carotid artery in children are usually...

Pre-hospital management of major haemorrhage following trauma: part one

Major haemorrhage remains the highest preventable cause of death following trauma, accounting for 30–40% of trauma mortality ( Kauvar et al, 2006 ). Therefore, pre-hospital intervention is a key aspect of paramedic practice. Paramedics are often first on the scene and have a range of local and systemic treatment options. Pre-hospital medical advances, such as the introduction of tranexamic acid, allow paramedics to deliver a higher standard of care. In addition, the number of patients on anticoagulants and antiplatelet drugs is increasing; therefore, knowledge of how these drugs interact with the haemostatic response would be beneficial. It is important that paramedics fully understand the mechanisms of drugs interacting with the haemostatic response, and the theory underpinning the management of major haemorrhage ( Kreuziger et al, 2012 ). This enables paramedics to understand why they are administering the care they are providing. This article gives a detailed overview of two physiological responses to major haemorrhage: haemostasis and blood pressure. This is followed by an explanation of how these systems are deranged and altered by major haemorrhage through pathophysiological consequences. Finally, recent research covering advances in the understanding of how deranged coagulation occurs is also discussed.

Management of injured patients who were Jehovah's Witnesses, where blood transfusion may not be an option: a retrospective review.

Management of major haemorrhage as a result of trauma is particularly challenging when blood is not an option (BNAO). Evidence on therapeutic strategies in this situation is limited. The aim of this study was to evaluate the management and outcomes of patients who identified themselves as Jehovah's Witnesses (who usually refuse blood products) with traumatic haemorrhage at an Australian major trauma centre. A retrospective review of patients from The Alfred Trauma Registry was conducted, including patients who were Jehovah's Witnesses presenting between January 2010 and January 2017. We examined demographics, injury characteristics, clinical progress, therapeutic interventions and outcomes at hospital discharge. There were 34 patients meeting inclusion criteria, with 50% suffering major trauma. Anaemia was a clinical problem for 13 (38·2%) patients, with haemoglobin levels reaching a nadir of 69·7 g/l (95% CI: 56·7-82·7) on average 5·1 days (95% CI: 2·5-7·7) post admission. Various strategies were employed to reduce blood loss including six (46·2%) patients receiving tranexamic acid, nine (29·2%) patients receiving oral or intravenous iron and five (38·5%) receiving erythropoietin. Three patients received packed red cells, and two patients received synthetic haemoglobin-based oxygen carriers. Numerous therapeutic strategies were employed inconsistently in this unique population of patients. Augmenting circulatory volume with an oxygen carrier acceptable to JW patients presents a novel approach to be considered in adjunct to other strategies. An international resource centre would assist clinicians faced with anaemia and BNAO.

A transfusion prescription template and other human factor interventions to improve balanced transfusion delivery in major haemorrhage due to trauma.

The aim of this study is to improve practice in the management of major haemorrhage, particularly in red cell to plasma transfusion ratios. A review of the management of major haemorrhage in trauma in Newcastle Hospitals Trust in 2012-2013 showed good mortality outcomes but found that red cell:plasma transfusion ratios could be improved. Human factors techniques transferable from industry and the military were identified, and a package of interventions was implemented, including an intensive multidisciplinary team training programme and a new major haemorrhage prescription template. We reviewed the management of all 243 adult trauma patients admitted with major haemorrhage to the Emergency Department in the Newcastle Hospitals Trust in the 4-year period from April 2012. We analysed clinical details, blood components transfused and patient outcomes and used Trauma Audit and Research Network data to correlate with injury severity and predicted survival. Mean transfusion ratios of red cells to plasma improved from 1·5:1 and 1·6:1 in the first 2 years to 1·1:1 in the 2 years following implementation of the new measures. There was a statistically significant improvement in the delivery of a balanced transfusion, defined as a red cell:plasma ratio of <1·3:1 following the changes. Simple changes to procedures, specifically implementation of a new major haemorrhage prescription template and multidisciplinary team training, have resulted in marked improvement in the ratio of red cells to plasma transfused to trauma patients with major haemorrhage or requiring emergency blood. The package of changes could be easily replicated in other health-care settings.

The administration of blood components: a British Society for Haematology Guideline.

The administration of blood components: a British Society for Haematology Guideline.

Integrated major haemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility.

Major haemorrhage is a leading cause of death in critically ill or injured patients requiring medical retrieval and presents significant clinical and logistic challenges irrespective of patient location, primary pathophysiology or mode of transport. It is essential that all care providers involved in the retrieval patient pathway, including referring hospitals, ambulance services, retrieval teams and tertiary receiving centres, adopt a common approach to the management of this complex patient group through the use of retrieval-specific, integrated protocols. These should incorporate the latest clinical evidence base, recognise the differences between primary and inter-facility missions and clearly define the roles and responsibilities of the retrieval clinical coordinator. By unifying the response across services, the aim is to facilitate seamless transition of care with ongoing damage control resuscitation from point of referral, during transfer and on arrival at the receiving centre.

63: EVIDENCE BASED PRACTICAL GUIDELINE FOR THE MANAGEMENT OF MAJOR HEMORRHAGE IN CHILDREN AND TEENAGERS

Background and aims:Management of major hemorrhage in any setting requires a multidisciplinary approach. The aim of this guideline is to provide recommendations for the hematological management of major hemorrhage in...

The management of emergency blood transfusion including massive transfusion, emergency and massive transfusion

In order to prevent hypovolemic shock and its consequences early diagnosis and prompt treating of the patient is vital, as well as the urgent provision of blood. The most important aspects of effective blood supply are: 1) efficient communication (emergency physicians, surgeons, anesthesiologists, specialist in transfusion medicine, haematologist, support services); 2) documenting/investigating (reports of adverse reactions and errors or incidents associated with massive blood transfusions, evidence of harm; 3) implementation of national guidelines and local protocols for clinic and laboratory management of major haemorrhage; 4) pretransfusion testing (ABO group and RhD typing of patients red cells, full serological blood cross-matching which includes anti-human globulin phase AHG). In emergency situations the following can also be applied: a) O RhD-negative uncrossmatched blood; b) ABO and Rhesus-compatible uncrossmatched blood; c) ABO and Rhesus-compatible crossmatched blood (without AHG).

Anaesthesia for nephrectomy

### Key points This paper will summarize the perioperative anaesthetic considerations for patients undergoing nephrectomy for both non-neoplastic and neoplastic disease of the kidney. It does not include the management of patients undergoing living donor nephrectomy. Nephrectomy for patients with renal cell carcinoma (RCC) was first described in 1969.1 Surgical treatment varies with the pathology. Simple nephrectomy is the preferred option for those with non-neoplastic disease (e.g. trauma, non-functioning kidney with chronic infection) with radical nephrectomy being preferred in those with neoplastic disease. Radical nephrectomy implies resection of the whole of Gerota's fascia, including the perinephric fat, lymphatics, and the ipsilateral adrenal gland. The vast majority (∼90%) of solid renal masses are RCC; the remainder comprising mainly of transitional cell carcinoma or Wilm's tumour (in children). RCC accounts for between 1% and 3% of all visceral malignancies. It is twice as common in men when compared with women and most commonly presents in the seventh decade of life. The main environmental risk factor is cigarette smoking, contributing to one-third of all cases. Other important risk factors include obesity, hypertension, asbestos exposure, and acquired polycystic kidney disease. If symptomatic, presentation is usually with haematuria, loin pain, and a palpable mass. Non-specific symptoms such as malaise, …