Massive Hemorrhage – Patient and Doctor Induced Emergencies

00:06 Massive Hemorrhage is a amazingly common event in the operating room. It could be due to trauma or assault. It may be the result of vascular disease, such as a rupture of an abdominal aortic aneurysm or a dissection of a thoracic aortic aneurysm. It may be the result of a genetic disorder such as hemophilia. It may be drug induced, when it's secondary to anticoagulants or secondary to non-steroidal anti-inflammatories, such in the case of gastric hemorrhage induced by Diclofenac or any of the other NSAIDs that are out there.

00:48 It may be due to a surgical error when a major vessel is damaged during surgery. The treatment of massive bleeding has changed over the last 10 years.

01:00 From a fairly cautious approach where red blood cells were given and then, over a period of time, if there was evidence of ongoing micro bleeding or if clotting didn't seem to be occurring, you would call for additional substances such as plasma, which has clotting factors in it, or platelets which help form clot. We're now much more aggressive in our treatment of massive hemorrhage. And these are sometimes predictable situations such as cardiac surgery, vascular surgery, spine surgery. Or it may be hemorrhage that's completely unexpected such as when a bleeding disorder is not diagnosed prior to surgery. Your hospital should have a Massive Transfusion Protocol that is developed jointly by anesthesiologists, surgeons, emergency physicians, intensive care physicians, and blood bank physicians.

01:54 When the massive transfusion protocol is activated, the blood bank should provide product as quickly as possible. In my hospital, when we activate this protocol, the blood bank immediately sends up 5 units of red blood cells, 5 units of platelets and 2 units of frozen plasma. These can be administered together, all at one time or sequentially, which depends on the acuity of the bleed and how badly things are going. And while you're giving these products, the blood bank's in the process of collecting more product to send to you. So it becomes an automatic process. You use what you get, more comes right away. If the patient has been on Coumadin or Warfarin pre-operatively and wasn't able to discontinue the drug for a few days before surgery, because it's an emergency surgery they're having, they should be given Prothrombin Complex Concentrate or PCC, to review, to reverse the anticoagulants. And it's only one dose that's needed in the majority of people and it'll reverse the anticoagulants.

03:06 If Heparin's been given, it can be reversed with Protamine Sulfate. The newer low molecular weight Heparins, which have become extremely popular and are commonly used, are not as easy to reverse. We don't actually have a protocol for reversing them.

03:24 And the exact period before surgery where they should be stopped has not been well worked out yet. In most cases it's between 2 - 4 days before surgery, they stop their low molecular weight heparin. Antiplatelet drugs such as aspirin or Clopidrigel and non-steroidal anti-inflammatory drugs may be held before surgery, although there is little evidence that low dose aspirin increases bleeding. And my personal preference is to continue that right up until the day of surgery. But certainly, Clopidrigel should be stopped about 5 days before surgery. And non-steroidals, it's controversial. And your surgeons, in most cases, will insist that they be stopped.

04:12 If more than 2 units of red blood cells is transfused, all subsequent units have to be heated up to body temperature. And there are devices that have been designed that allow us to infuse blood very rapidly, and at the same time warm it up to body temperature so that the blood going into the patient is of appropriate temperature. Excessive bleeding can occur due to large volumes of stored blood being transfused. This is known as Disseminated Intravascular Coagulation. And in this situation, what happens is, the normal clotting factors in the blood are diluted out by large volumes of blood being given without clotting factors or even just large volumes of clear fluids such as normal saline. This is a serious complication of transfusion and of bleeding, and the patient's disease process, in some cases, can add to it. So patients with Preeclampsia in pregnancy are at high risk of developing DIC, Disseminated Intravascular Coagulation. It's difficult to reverse.

05:24 We're hoping that the use of the Blood Packages that I mentioned during the Massive Transfusion Protocol discussion, may reduce this problem. It's very easy to overload a patient when you're treating massive bleeding. And you should keep a close eye on the central venous pressure at all times and be prepared to treat pulmonary edema if it occurs. Keep an eye on saturation and make sure that you're maintaining saturation. If saturation starts to drop, check the lungs and make sure that you're not filling them with fluid.