A practical guideline for the haematological management of major haemorrhage.
Hunt et al. set the standards in a practical guideline from the British Committee for Standards in Haematology. Many guidelines have been published or updated recently, and this is one of the really good ones focusing on haematological management.
This document provides recommendations for early and readily available red blood cells (RBC), plasma and cell savers, general use of tranexamic acid, fresh frozen plasma (FFP) as part of intial resuscitation in at least a 1 unit:2 unit ratio with red cells (1:1 ratio and early consideration of platelet transfusion in trauma patients), fibrinogen supplementation at critical levels, VTE prophylaxis, and much more.
Unfortunately, RBC transfusion triggers are not established in general in the guideline. The knowledge from the RCT by Villanueva et al. (N Engl J Med 2013;368:11-21; see Dr. Carson’s Nataonline comment) looking at upper GI bleeding and showing that 7.0 g/dL is as good as or better than 9.0 g/dL, is only used for the GI population. This RCT tested a population where one-third of the patients were arriving in the emergency department with major bleeds (systolic BP <100mm Hg). Why should other populations with major bleeds be different? Some surprises emerge in this guideline: • Massive haemorrhage (or transfusion) protocols are graded 1D. It seems that the very low D is not deserved since many studies have evaluated a positive effect of implementing strict protocols. • The authors suggest that the use of TEG and ROTEM be confined to research, despite a Cochrane review on the topic and several RCTs showing reduced bleeding, transfusions, complications and maybe mortality as compared to conventional coagulation tests. Isn’t that good enough? And where is the evidence for conventional coagulation tests? • This guidance is developed by haematologists, endorsed by anaesthetists, but where are the surgeons? Management of major bleeding is in essence multidisciplinary. The word “surgeon” is only used once and the central principle of stopping the bleeding, which is properly the best way avoid transfusions and coagulopathy, is not stressed at all. We have a great new guideline even though some questions remain. British haematologists have shown us the way. – Jakob Stensballe