Hematological management of major haemorrhage: BSH Guideline

Given below are the general recommendations:

• Hospitals must have local MHPs in relevant clinical areas that include a clear mechanism for contacting all relevant team members and support staff.
• Clinical staff involved in frontline care must be trained to recognize major blood loss early, be familiar with the contents of MHPs, and know when to activate and deactivate the local MHP.
• Hospitals must have a strategy to ensure that emergency 'universal' RBCs are readily available for the treatment of life-threatening bleeding, including prompt access to group O RBC as emergency stock. Group O RhD- and K-negative RBCs should be prioritized for females of childbearing potential (aged <50 years) and in patients whose sex is unknown.
• The researchers recommend a standard threshold and target Hb range for RBC transfusion to provide critical life-saving support in major bleeding alongside clinical judgment on the severity of bleeding (threshold Hb 70 g/l, the target range for the post-transfusion HB level of 70–90 g/l.
• If major bleeding is ongoing and results of standard coagulation tests or near-patient tests are not available, we suggest that units of FFP be transfused in at least a 1:2 ratio with units of RBCs.
• If major bleeding is ongoing, and laboratory results are available, we suggest further FFP be administered aiming to maintain the PT ratio at <1.5-times mean normal (or equivalent).
• The researchers suggest that serial hemostatic tests should be checked regularly, every 30–60 min depending on the severity of the hemorrhage, to guide and ensure the appropriate use of hemostatic blood components.
• The researchers suggest fibrinogen supplementation should be given if fibrinogen concentrations fall below 1.5 g/l (non-pregnant women).
• If major bleeding is ongoing, we suggest using platelet transfusions to maintain platelet counts at >50 × 10⁹/l.
• The researchers suggest that VHAs are used to guide transfusion therapy in cardiac surgery, although for other clinical settings of major bleeding (e.g. trauma and PPH), hospitals should evaluate the costs and benefits of running these assays and ensure policies are in place to maintain these devices on a daily basis. 

Recommendations – alternatives to transfusion

• Tranexamic acid is recommended for patients with presentations of major bleeding due to trauma and PPH, but not gastrointestinal bleeding.
• Current evidence does not support the universal policy of 24-h cell salvage for patients with major bleeding and hospitals should evaluate the costs and benefits of running the cell salvage service.
• The use of cell salvage should be considered for patients who refuse to have a blood transfusion.
• The use of desmopressin, rVIIa or aprotinin is not recommended in the management of major hemorrhage unless as part of a clinical trial.

Recommendations – specific settings

Postpartum hemorrhage

• In patients with PPH, general recommendations for RBC and plasma transfusion should apply.
• Special attention should be paid to identifying women with PPH who develop coagulopathy and/or low fibrinogen levels. Use of fibrinogen supplementation is recommended in PPH, especially when there is ongoing bleeding and if fibrinogen levels are <2.0 g/l.
• The researchers recommend that an initial dose of TXA (1 g intravenously) is given to women with PPH within 3 h of bleed onset. If bleeding continues after 30 min, or it stopped and restarted within 24 h of the first TXA dose, a second dose of 1 g should be given.

Gastrointestinal bleeding

• In patients with gastrointestinal hemorrhage, general recommendations for RBC transfusion should apply.
• Special attention should be paid to heightened risks of raising vascular pressures with excessive plasma transfusions and the limitations of standard coagulation tests to monitor coagulation status in patients with liver disease.
• Tranexamic acid is not recommended for patients with acute gastrointestinal bleeding.

Trauma

• There are insufficient clinical data to support a role for pre-hospital transfusion resuscitation with RBCs and plasma, but if considered, it should not unduly add to transport delays to the hospital.
• The researchers recommend plasma should be given early as part of initial resuscitation in major hemorrhage due to trauma, and in a 1:1 (not >1:2 ratio) with RBCs, until results from coagulation monitoring are available.
• Fibrinogen supplementation should be given to patients with traumatic injury if fibrinogen levels fall to <1.5 g/l.
• Patients with traumatic injury (including mild-moderate TBI) should be given TXA as soon as possible after injury (and no later than 3 h); a suitable regimen includes 1 g bolus dose intravenously over 10 min, followed by a maintenance infusion of 1 g over 8 h should be used.

Surgical bleeding

• In major bleeding during/after surgery, general recommendations should apply, for RBC transfusion and other blood components.
• Timely and repeated access to laboratory coagulation monitoring should be available and inform the need for blood components including plasma.
• It is recommended that all patients having in-patient surgery should receive 1 gram of tranexamic acid prior to skin incision to reduce major surgical bleeding and reduce the need for blood transfusion.

Recommendations – mass casualty events

• The laboratory should have systems in place to identify and prioritize the testing of group and screen samples from major hemorrhage cases, patients receiving a pre-hospital transfusion, and severely injured patients during MCEs).
• Hospital Transfusion Teams should be engaged with local MCEs planning, scenario training, skills, and drills, which include effective policies for extended use of TXA.
• Effective systems should be in place for major hemorrhage management in the context of blood shortage and/or MCEs. Modified MHPs or tailored transfusion should be considered together with triage during blood shortage or MCEs to optimize the use of blood and support blood stock management.
• Transfusion Teams should be aware of their hospital's pre-determined casualty load and their regional incident response plan to aid with stock and staff planning. 

Reference:

Stanworth SJ, Dowling K, Curry N, Doughty H, Hunt BJ, Fraser L, Narayan S, Smith J, Sullivan I, Green L; Transfusion Task Force of the British Society for Haematology. A guideline for the haematological management of major haemorrhage: a British Society for Haematology Guideline. Br J Haematol. 2022 Jun 10. doi: 10.1111/bjh.18275. Epub ahead of print. PMID: 35687716.