Good Blood Management in Acute Haemorrhage and Critical Care
Murphy GJ., Curry N., Patel N., Walsh TS.
Good blood management is an important determinant of outcome in critically ill patients, trauma patients and those undergoing major surgery or treatment for postpartum or upper gastrointestinal (GI) haemorrhage. These patients have a high red cell requirement, a significant proportion of which is administered for the reversal of acute anaemia in nonbleeding patients. More liberal administration of red cells in acutely anaemic patients increases the risk of adverse events and randomized controlled trial (RCT) evidence indicates that restrictive transfusion thresholds of 7 g/dL are safe in patients without cardiovascular disease. Coagulopathy is common in these patients where it is associated with worse outcome. Existing laboratory and point of care tests that are used to direct the management of coagulopathy lack diagnostic or prognostic accuracy; treatment is often empiric, and these patients utilize a significant proportion of all non-red-cell components. The evidence base to support current practice is weak and this is an important and underresourced area of research. Critically ill patients and those undergoing major surgery are cared for in highly monitored and controlled environments and this facilitates the use of therapeutic adjuncts that can reduce bleeding and transfusion exposure. Systematic reviews demonstrate that intraoperative cell salvage is cost effective and improves outcomes when used in major surgery. In massive haemorrhage associated with trauma, better outcomes may be achieved by administration of higher ratios of fresh frozen plasma (FFP) and platelets to red cells. Recent evidence has also indicated a survival advantage with the use of tranexamic acid in major trauma. This edition first published 2013 © 2001, 2005, 2009, 2013 John Wiley & Sons Ltd.