Major hemorrhage is an emergency with significant morbidity and mortality. The British Society for Haematology (BSH) has updated transfusion guidelines for management of major hemorrhage based on 96 new publications from 2014 to 2020. Key general recommendations from the BSH include training clinical staff to recognize major blood loss early and a succinct major hemorrhage protocol that expedites access to universal group O RBCs. The BSH also recommends a standard threshold and target hemoglobin of 70 g/l and a 1:2 ratio of fresh frozen plasma (FFP) to red blood cells (RBCs) if coagulation tests are not available. If coagulation tests are available, the BSH recommends transfusion of FFP to maintain a prothrombin time (PT) ratio at <1.5 times mean normal. Furthermore, they recommend serial hemostatic tests every 30-60 minutes, fibrinogen supplementation if levels fall below 1.5 g/l, and platelet transfusions to maintain platelet counts >50 X 109/l. Tranexamic acid is recommended for patients with major hemorrhage except for those with gastrointestinal bleeding. In addition, the BSH found insufficient data to support pre-hospital transfusions for trauma patients, but plasma should be given early. The BSH recommends that hospitals should also plan and implement drills for mass casualty events. Further recommendations are outlined including good practice statements for laboratory and organizational support as well as specific recommendations for patients with post-partum hemorrhage, gastrointestinal bleeding, trauma, and surgical bleeding.
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