MANAGEMENT OF “MASSIVE” BLOOD LOSS-INCLUDING THE USE OF NOVO SEVEN (VIIa)
“Massive” Transfusions = 1 Whole Blood Volume/24 hours or 50% in 3 hours.
where 1 Whole Blood Volume = 60-80mls/kgm
where 1 Unit of Packed Cells (250 mls) is the equivalent of 420mls blood
By 4 Units of Packed Cells and Still Bleeding:
Coags & F.B.C. taken – labelled URGENT
Fresh Frozen Plasma should be started and Cryoprecipitate is recommended
Platelets should be given depending on F.B.C. or if patient is less than 4 hours post-pump irrespective of platelet count (longer if prolonged or deep hypothermic period).
By 6 Units of Packed Cells
Patient should have received at least 4 units of FFP & 2- 4 units of Cryoprecipitate.
Coags & F.B.C. should be repeated – Factor VIII & IX Concentrates, further FFP & Cryo, and platelets given as required.
By 10 Units of Transfusions the patient’s risks of coagulopathy, hypothermia and acidosis and general morbidity and mortality starts to rise sharply and every effort is required to bring the situation under control before this occurs.
The following questions and actions are required once 6 units has been reached:
Does the patient still have a coagulopathy – if so use the “Cocktail” (2000 Units Factor VIII Concentrate-as “Biostate”, 1000 Units Prothrombinex, 4 Bags of Cryoprecipitate).
If the patient has near normal coags and is still bleeding, then a “second” look procedure will generally be required to correct surgical bleeding. Surgical bleeding is generally defined as >200ml/hour blood loss from a single site.
If (a) the patient has near normal coagulation, or (b) if the coagulopathy is not controlled by with FFP, Cryoprecipitate, Biostate & Prothrombinex and platelets,
and
(b) the surgeon is confident that major bleeding sites are controlled as best as
possible.
And
(c) the patient is still bleeding heavily,
Then Novo Seven (Recombinant VIIa) should be given at a dose of 50µg/kgm (corrected up to the nearest mg)
In selected cases, such as acute aortic dissection, surgery for active endocarditis or complicated cardiac “redoes”, it may be appropriate to give Novo-Seven while the chest is still open if severe uncontrolled bleeding persists. In this situation appropriate fibrinogen top up with 2 to 4 units of cryoprecipitate and 2 units fresh frozen plasma may be given prior to administration of Novo Seven to ensure adequate substrate formation.
In the final analysis, the surgeon is ultimately responsible. If there is any disagreement, do not hesitate to involve a consultant.
J. Koutts. June 2009
Western Pathology Cluster