The aim of this guideline is to improve the management of massive haemorrhage and the communication between services. Massive haemorrhage jeopardises the survival of patients in many clinical settings and is a challenge for haematological and blood transfusion services. Tensions may arise between those attempting to treat bleeding and those supplying blood / providing laboratory services. Discord can waste scarce time, or, worse, result in a poor outcome for the patient (British Standards in Haematology (BSH) 2006). The speed with which massive haemorrhage can become life threatening emphasises the need for good communication between the Transfusion Laboratory and clinical areas.

Massive blood loss (MBL) related to trauma is uncommon in children. Major bleeding is more common in the surgical setting. The principles of massive blood loss management in adults can be broadly applied to the care of children. There is little research evidence available to specifically guide paediatric care. Children differ from adults in anatomy and physiology as well as in size and weight. These differences require specific modifications to the clinical care and transfusion support provided.

All triggers of the massive haemorrhage protocol will be reviewed 6 monthly by the PBM Team and presented at the next appropriate PBM/HT Committee.

A total blood volume of 80 ml/kg could reasonably be applied for all children. Massive blood loss may be defined as either 80 ml/kg in 24 h, 40 ml/kg in 3 h or 2–3 ml/kg/min. However, in clinical practice, haemodynamic changes compatible with hypovolaemia accompanying evidence or suspicion of serious haemorrhage are the usual triggers.

The following instructions relate to massive haemorrhage whatever the cause.

Recognise and Activate the Massive Haemorrhage Protocol

• Call Switchboard on 2222 and state ‘Massive haemorrhage on (relevant ward/department and the site if applicable)

• Switchboard will alert the appropriate senior members of staff. This group of professionals can vary depending on local practise but as a minimum will alert

  • Blood transfusion lab

  • Porters

  • On call senior Anaesthetist

  • Contact now needs to be made with the Transfusion Laboratory, they will ask for patient details so that they can start checking for samples, blood components already issued etc. The Transfusion Laboratory or the Clinical Communication Lead (CCL) can initiate this contact. The Transfusion Laboratory cannot help in any way until this contact has been made.

Release of blood components/products is not dependent on the approval of a consultant haematologist although they can be contacted for advice at any point.

• Team leader

• Clinical Communication Lead (CCL) role

• Sample taker / documenter

• Transporter of products/samples

Roles

Team Leader role

Who: Senior Doctor/Nurse Consultant with relevant authority, expertise and experience

Role: (the role indicated here is broadly defined only, as it is outside of the remit of the Transfusion Team)

• Lead, manage, and coordinate all patient requirements

• Communicate with CCL to ensure s/he aware of transfusion needs

• Ensure other relevant staff/teams are present/communicated with

• Alert relevant clinical areas (ICU/Theatre etc)

Clinical Communication Lead (CCL) Role

One of the most significant factors for ensuring blood components/products are ready as soon as possible is effective, timely, communication with Transfusion Laboratory. The language you use is pivotal to how your requests will be interpreted, i.e., if you ask for ‘cross matched blood’ this is generally not immediately available; if you ask for the blood components required and state how quickly you need it the Transfusion Laboratory staff will advise you of the options and how long each option takes.

Who: Senior registered professional, who can fully understand and communicate the clinical situation, requirements and progress.

Role: Critical role in communicating patient’s transfusion needs to Transfusion Laboratory

• Ring the Transfusion Laboratory asap

• Tell them ‘I am the communication lead for the massive haemorrhage on location’

• Give them patient identity & clinical details

• Give them your details and contact numbers/bleeps

• Inform them of any emergency O red cell units taken

Inform transfusion laboratory when further components are required. Maintain frequent/regular contact with transfusion laboratory re blood being ready / blood results

• Liaise with Team Leader re transfusion requirements

• Send staff to collect blood components

• Ensure sample taker is aware of samples required and samples taken meet all criteria*****

• Liaise with Consultant Haematologist if expert advice required

• If patient moves / bleeding resolves / patient dies tell the Blood Transfusion Laboratory

• Hand role over if patient moves / as appropriate

Unknown patients

Minimum identity requirements as per Trust identification policy (Best practice set out by NHS Improvement ‘Safer temporary identification criteria for unknown or unidentified patients’):

• Temporary number - prefix a randomly generated seven-digit number with the relevant standard NHS Trust code where possible.

• Gender – If gender cannot be identified default to female to ensure those of child-bearing age are given Rh D and K-negative red cells.

• Approximate age - 1 January plus estimated year of birth should be used.

*It is acknowledged that obtaining samples in massive haemorrhage situations can be very difficult. A lack of sample(s) should never delay provision of blood in a life-threatening massive haemorrhage as emergency red cell units are available in several locations (see Table G 6.1). However, fully serologically matched blood components are the ideal, so the Transfusion Laboratory will ask for a sample and will notify the clinical area of the requirement for a second group check if applicable. Please communicate clearly with the Blood Transfusion Laboratory if samples are not possible at this stage.

Sample Taker/Documenter

Who: Registered professional: e.g., Nurse / Midwife / ODP / FY1/2

This role encompasses ensuring that the samples sent are of sufficient quality to enable swift and accurate processing. This is a significant factor in ensuring blood components are ready as soon as possible; specifically ensuring the identification details are consistent and correct. It is recommended that if there is doubt about spellings of names/exact dates of birth then the patient should be treated as ‘unknown’ as traumatized relatives may not give consistent dates/spellings which can lead to sample rejection. Transfusion samples that are labelled incorrectly will NOT be used, as it is not legal to do so. If it is impossible to obtain a sample the Blood Transfusion Laboratory will supply emergency O red cells.

Role:

• Ensure urgent transfusion samples taken as per policy: positive patient ID / label at bedside

• Minimum ID requirements

  • A unique number: NHS / hospital / A+E / Major incident / Military

  • First name and surname

  • Date of birth

  • Signature of person taking blood

  • Date and time blood taken

• UNKNOWN patients: unique number (avoid temporary numbers where possible) and gender

• Ensure CCL has told the Blood Transfusion Laboratory that samples are on the way

• Send samples to the Blood Transfusion Laboratory urgently

• Document blood components being used – drug chart / traceability tags / notes

Haemorrhage Transporter (including collection of blood components)

Who: Available trained and competent personnel; can be a porter

Role:

• Take samples to the Blood Transfusion Laboratory urgently

• Collect blood components as requested as per policy

• Check ID of patient / product details on blood component / blood label / patient ID document

• Document removal of blood component from blood fridge

• Return unused blood components/products to the Blood Transfusion Laboratory

Blood Transfusion Laboratory Role

The BMS receiving the call from the CCL will

• Undertake the role of Blood Transfusion Laboratory Communication Lead (LCL) or allocate it to a more appropriate BMS; this includes communicating effectively with the CCL to ensure the most appropriate blood components / products are issued as quickly as possible.

• Document the details on the Massive Haemorrhage communication sheet

• Alert senior colleague OR out of hours consider whether need to call second on call in

• Prioritise workload

• Issue blood components as per protocol or request; (Section G 8)

• Full details of the Blood Transfusion Laboratory response are outlined in ‘Guideline for the management of massive blood transfusion SOP’ (laboratory SOP quality management system Ipassport).

Transfusion Practitioner (TP) Role

The TP role is to improve practice through the:

• Collation of audit information regarding adherence to the protocol

• Provision of training in massive haemorrhage protocol

• Responding to any incident reports as a result of massive haemorrhage

• Where possible, and if required, the TP will visit the Blood Transfusion Laboratory and the clinical area during the MH to enhance communication and ensure protocol is working effectively

Good communication with the hospital Blood Transfusion Laboratory is essential, with the aim to transfuse age-appropriate components where possible. In emergency situations, it may not be possible to meet all the standard neonatal/paediatric specifications and the risks of delays in transfusion have to be balanced against the risk of using components of alternative specification.

Blood components have to be guided by the individual patient’s clinical situation (site of bleeding, aetiology, interventions planned).

If red cells are needed immediately, with no time for compatibility testing, emergency O red cells will be supplied.

• Group specific uncrossmatched red cells may be available

• Fully serologically matched red cells will be supplied as soon as possible

  (~ 60 minutes from receipt of sample if not blood group antibodies).

There are units of emergency group O RhD red cells on each site for use in an emergency. Please see Table G.6.1 for location of these units. It is the responsibility of the professional removing the Emergency group O red cells to inform the Transfusion Laboratory (or on-call haematology BMS if out of hours) as soon as possible so that the blood fridge can be restocked. Failure to inform the Transfusion Laboratory of the use of the emergency blood could leave the blood fridge without blood for subsequent life-threatening haemorrhages.

Table G.6.1 Emergency Blood Locations

Two units of Emergency blood can be removed at the same time.

Platelets

• 1 pool of platelets will be in stock for the purpose of the massive haemorrhage protocol.

• Once used the platelets will be restocked; however, delivery of stock comes from NHSBT (London/Oxford) so will not be immediate.

• In the event of a second Massive Haemorrhage happening shortly after or simultaneously then components will be WITHOUT platelets. In such an unlikely event, further platelets will be ordered from the NHSBT transfusion centre on a blue light request.

Tranexamic acid

Tranexamic acid (TXA) should be used where massive blood loss is anticipated in children presenting with major traumatic injuries (BSH 2016). Timely administration of TXA preferably within the first 3 hours of trauma for children is likely to be beneficial.

Dosage

Loading Dose – 15mg/kg (max 1g) diluted in a convenient volume of Sodium Chloride 0.9%, or Glucose 5% and given over 10 minutes

Maintenance Infusion – 2mg/kg/hour

Suggested dilution – 500mg in 500ml of sodium chloride 0.9% or glucose 5% given at a rate of 2mls/kg/hour for at least 8 hours or until bleeding stops.

Side Effects

• In general, the adverse effects of TXA are rare. They include gastrointestinal effects, malaise with hypotension (on rapid IV injection), arterial or venous thrombosis (see below), dizziness, fatigue, headache, muscle pain and spasms, convulsions, and hypersensitivity reactions including anaphylaxis.

• The use of TXA presents a potential risk of thrombosis. Studies into the use of TXA in paediatric cardiac surgery and spinal surgery did not find any increased rate of thromboembolic events. However, these studies did not have sufficient power to determine safety. An increase in seizure rate may be due to the antagonistic effect of TXA on GABA receptors.

For full guidance and details of research studies see Blood Transfusion Policy for Adult Patients with related guidelines document (Tranexamic Acid guideline).

This guideline has been registered with the Trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health NHS Foundation Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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