Blood Management in

Massively Bleeding Patients

Adhrie Sugiarto
Cipto Mangunkusumo Hospital

Case Illustration
G5P2A2 38wk pregnancy
Delivered the baby with the help
of forceps extraction
Bleeding profusely

Scope of this session

Massive transfusion protocol
Acute normovolemic hemodilution
Role of cell salvage in massive haemorrhagic
Management of peripartum haemorrhage: special population

Introduction
Uncontrolled and massive hemorrhage is still one of the major
challenges in the surgical and anesthesiological field
Trauma is one of the cause of hemorrhage and the leading cause of
death for individuals between the age of 18 and 45
Additional coagulopathy in the initial phase is induced by trauma
itself and aggravated by consumption and dilution of clotting factors
Resuscitation strategy to prevent hemodilution and to restore normal
coagulation function

Massive bleeding
Definitions of massive haemorrhage vary and have limited value
A loss of 1 blood volumes within a 24-h period
50 % blood volume loss within 3 hours
Rate of loss 150 ml/min

Massive Transfusion
Replacement of one entire blood volume within 24 h
Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h
Transfusion of >20 units of PRBCs in 24 h
Transfusion of >4 units of PRBCs in 1 h when on-going need is
foreseeable
Replacement of 50% of total blood volume (TBV) within 3 h

Raymer JM, Flynn LM, Martin RF. Massive transfusion of blood in the surgical patient. Surg Clin North Am. 2012;92:22134. vii
Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012;73:12737
Massive transfusion protocol (MTP) for hemorrhagic shock ASA committee on blood management. Available
from: https://www.asahq.org/For-Members/About-ASA/ASA-Committees/Committee-on-Blood-Management.aspx .

Damage control resuscitation

Developed based on experiences during Iraq and Afghanistan war
To prevent hypothermia, academia, coagulopathy and abdominal
compartment syndrome (ACS)
Agrressive strategy that delivers blood products before laboratory defined
anemia/coagulopathy Massive transfusion protocol
Permissive hypotension
Minimize crystalloid

Massive transfusion protocols

Activation criteria
Fixed ratio of blood components (PRC : Plasma : Platelets)
Pre-defined blood bank response
Streamline communication for preparation and delivery of blood
Management of non-blood components (eg: Calcium)

Options on management of expected

massive blood loss :
Acute Normovolemic Hemodilution
Cell Salvage

Acute Normovolemic Hemodilution (ANH)

A technique in which whole blood is removed from a patient, while
circulating volume is maintained with acellular fluid
Performed shortly before surgery
First goal was autologous transfusion
Hemodilution Blood fluidity cardiac output better
perfusion

Advantages of ANH
Reduces or eliminates the need for allogeneic blood transfusion
Provides fresh autologous blood product compared to stored blood. It has
functional platelets, normal levels of clotting factors and 2,3 DPG
It is the least costly method of autologous blood procurement
The blood does not require testing.
It decreases the risk of transfusion reaction due to wrong blood administration
error
Eliminates the risk of infection transmission associated with volunteer donor
blood
Can be used in presence of malignancy or infection
Can be used for emergent operations where preoperative autologous donation is
not possible.

Indications for ANH

Surgery associated with substantial blood loss (>750-1500mls)
Patient request for transfusion free management for religious/personal
reasons.
Surgical procedures where a benefit from ANH has been demonstrated :

Radical prostatectomy
Hip and knee arthroplasty
Elderly patients without cardiac disease
Cardiothoracic surgery
Vascular surgery (AAA repair and other vascular procedures)
Spine surgery
Liver resections

Contraindications for ANH

Anaemia (Hb under 9 g/dL)
Impaired renal function, (unable to excrete fluid load)
When increased cardiac output is undesirable (e.g. coronary artery
disease, aortic stenosis)
Clinically evident limitation of cardiac function
Clotting disorders
Significant pulmonary disease
Bacteraemia

Acute Normovolemic Hemodilution (ANH)

The volume of blood removed will depend upon the patients initial
Hb, estimated blood volume to be lost during the surgery, and the
haemodynamic status of the patient
Usually between 2 4 units (approx 400-500 mls /bag)
Maximum recommended volume 2000mls

The first 450 - 500 mls of blood can usually be withdrawn without the
need for fluid replacement, after that replace blood with fluid in the
ratio of 1 ml blood : 3 ml crystalloids or 1 : 1 ratio for colloids

Cell salvage

Cell salvage
Cell salvage and autologous transfusion is safe and effective at reducing
allogeneic blood transfusion requirements, and also being cost-effective in
cardiac and orthopaedic surgery.
Considered in all cases where significant blood loss is expected or possible, in
patients with preoperative anaemia, and who refuse allogeneic blood products.
Recent evidence has shown that cell salvage may be used in obstetrics or
malignancy.
Leukocyte Depletion Filters may provide an additional element of safety, and
should be used unless rapid re-transfusion is required
Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth
2010; 105: 401416.
Carless PA, Henry DA, Moxey AJ, OConnell D, Brown T, Fergusson DA. Cell salvage for minimising
perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2010; (4)CD001888.

Management of peripartum
haemorrhage

Peripartum haemorrhage (PPH)

Massive
Transfusion
Protocol

Summary
Damage Control Resuscitation to control bleeding is an essential part of
resuscitation.
Early administration of blood products should stimulate use of a balanced
administration strategy with PRBCs, FFP, and platelets given in equal proportions.
Massive transfusion reduces overall blood product requirements in patients with
rapid blood loss, but limited resuscitation and blood product conservation are
seen as appropriate in many injured patients
Blood management such as Acute Normovolemic Hemodilution and Cell salvage
are useful to reduce allogenic transfusion in expected massive blood loss
Post partum Hemorrhage management needs multidisciplinary and systematic
approach to restore the volume and coagulation system whilst controlling
bleeding is essential to improve outcome

Thank You