Blood transfusion and the anaesthetist: management of massive haemorrhage.

1. Hospitals must have a major haemorrhage protocol in place and this should include clinical, laboratory and logistic responses. 2. Immediate control of obvious bleeding is of paramount importance (pressure, tourniquet, haemostatic dressings). 3. The major haemorrhage protocol must be mobilised immediately when a massive haemorrhage situation is declared. 4. A fibrinogen < 1 g.l−1 or a prothrombin time (PT) and activated partial thromboplastin time (aPTT) of > 1.5 times normal represents established haemostatic failure and is predictive of microvascular bleeding. Early infusion of fresh frozen plasma (FFP; 15 ml.kg−1 ) should be used to prevent this occurring if a senior clinician anticipates a massive haemorrhage. 5. Established coagulopathy will require more than 15 ml.kg−1 of FFP to correct. The most effective way to achieve fibrinogen replacement rapidly is by giving fibrinogen concentrate or cryoprecipitate if fibrinogen is unavailable. 6. 1:1:1 red cell:FFP:platelet regimens, as used by the military, are reserved for the most severely traumatised patients. 7. A minimum target platelet count of 75 × 109 .l−1 is appropriate in this clinical situation. 8. Group-specific blood can be issued without performing an antibody screen because patients will have minimal circulating antibodies. O negative blood should only be used if blood is needed immediately. 9. In hospitals where the need to treat massive haemorrhage is frequent, the use of locally developed shock packs may be helpful. 10. Standard venous thromboprophylaxis should be commenced as soon as possible after haemostasis has been secured as patients develop a prothrombotic state following massive haemorrhage.