Massive Intraoperative Bleeding Protocol - Anesthesia Management

1. Recognition and Triggers

• SBP <70 mmHg, OR SBP 71-90 mmHg with HR ≥108
• Combined with high-risk injury patterns (penetrating torso, major pelvic fracture, FAST positive in >1 region)
• Blood loss equivalent to circulating blood volume, or ongoing hemodynamic instability after initial resuscitation
• Clinical scoring tools: Assessment of Blood Consumption (ABC) score or Trauma-Associated Severe Hemorrhage (TASH) score

• Sabiston Textbook of Surgery, Table 33.1

2. Immediate Anesthesia Actions

• Insert 2+ large-bore IVs (16G minimum; 14G preferred)
• Establish arterial line for beat-to-beat BP and repeated blood draws
• Consider central venous access (MAC introducer/9Fr sheath > standard CVP line - for rapid volume)
• Consider rapid infusion catheter (RIC line) or Level 1 pressure infuser
• Foley catheter - urine output target >0.5 mL/kg/hr
• Continuous SpO2, ETCO2, temperature monitoring

• RSI if not already intubated; expect full stomach in trauma
• In uncontrolled hemorrhage with hemodynamic instability, use ketamine (maintains sympathetic tone) or etomidate for induction
• Avoid propofol as sole induction agent in severe hypovolemia - catastrophic vasodilation

• Use ketamine or high-dose volatile agent with caution (vasodilation)
• Reduce or eliminate volatile agent concentration during hypotension - rely on opioids and ketamine
• Avoid nitrous oxide (reduces FiO2, myocardial depressant, dilates bowel)
• Maintain FiO2 1.0 during hemorrhagic shock

3. Damage Control Resuscitation (DCR) - The Core Strategy

"DCR combines an empiric hemostatic resuscitation strategy in combination with permissive hypotension during surgical or angioembolization control of ongoing hemorrhage." - Miller's Anesthesia, 10e

Components of DCR (Sabiston Box 33.2):

1. Permissive hypotension until definitive surgical control
2. Minimize crystalloid use - crystalloids worsen the lethal triad
3. Initial use of 5% hypertonic saline if available
4. Early blood products (PRBCs, FFP, platelets, cryoprecipitate)
5. Tranexamic acid (TXA) - early administration
6. Prothrombin Complex Concentrate (PCC) as adjunct
7. Warm all fluids/blood products - target core temp >35°C

4. Permissive Hypotension

• Systolic BP: 80-100 mmHg
• Hematocrit: 25-30%
• PT/PTT within normal range
• Platelet count >50,000/µL
• Normal ionized calcium
• Core temp >35°C
• Prevent worsening acidosis (serum lactate trending down)

• Traumatic Brain Injury (TBI) - requires MAP ≥80 mmHg, CPP >60 mmHg
• Spinal cord injury
• Elderly patients (reduced physiologic reserve)
• Known ischemic coronary disease
• Miller's Anesthesia, 10e, Chapter 62

5. Massive Transfusion Protocol (MTP)

MTP Activation (Algorithm from Miller's / Schwartz's):

Blood Product Ratios:

• This approximates whole blood and corrects the coagulopathy of massive hemorrhage
• Empiric shipments (before lab results): Pack 1 = 4 PRBCs + 2 FFP; Pack 2 = 4 PRBCs + 2 FFP + 1 apheresis platelet unit + 10 units cryoprecipitate

1. Low-titer type O cold-stored whole blood (FDA approved, military preferred)
2. Fresh whole blood
3. PRBCs + Plasma + Platelets in 1:1:1
4. Plasma + PRBCs in 1:1
5. Plasma or PRBCs alone (last resort)

"Whole blood has been a component of transfusion for over 70 years... experience in Vietnam showed that typed and crossmatched warm whole blood was extremely effective in treating coagulopathy from massive transfusions." - Miller's Anesthesia, 10e

6. Viscoelastic-Guided Resuscitation (TEG/ROTEM)

• PT/PTT >1.5× control → 2 units thawed plasma
• Platelets <50,000/µL → 1 apheresis platelet unit
• Fibrinogen <100 mg/dL → 10 units pooled cryoprecipitate
• Schwartz's Principles of Surgery, 11e, Fig. 7; Miller's Anesthesia, 10e

7. Specific Blood Product Thresholds

8. Pharmacological Adjuncts

Tranexamic Acid (TXA)

• Antifibrinolytic - inhibits plasminogen activation and fibrin degradation
• Dose: 1g IV over 10 min, then 1g IV over 8 hours (CRASH-2 protocol)
• Must be given within 3 hours of injury - after 3 hours, mortality increases
• Indicated in trauma, obstetric hemorrhage, cardiac surgery
• "Tranexamic acid was associated with decreased death due to bleeding in a large, international, randomized trial, and its early use is now recommended." - Barash Clinical Anesthesia, 9e

Prothrombin Complex Concentrate (PCC)

• Contains factors II, VII, IX, X (± protein C/S)
• Rapid reversal of coagulopathy, particularly in anticoagulated patients
• 4-factor PCC preferred; dose 25-50 IU/kg

Vasopressors

• Norepinephrine first-line for refractory hypotension during active hemorrhage
• Vasopressin as adjunct (0.03-0.04 U/min) - especially if vasodilatory component
• Do NOT rely solely on vasopressors - address the underlying volume deficit

Recombinant Factor VIIa (rFVIIa)

• Last-resort option for uncontrolled hemorrhage refractory to standard therapy
• High cost, thrombotic risk
• Requires adequate platelets, fibrinogen, and temperature correction to work

9. The Lethal Triad - Prevention is Paramount

Hypothermia + Acidosis + Coagulopathy = "Bloody Vicious Cycle"

• Mulholland and Greenfield's Surgery, 7e; Miller's Anesthesia, 10e

10. Coagulation Complications to Recognize

• Platelets rarely fall as low as predicted by dilution alone (splenic/marrow release)
• Clinical bleeding usually at <50 × 10⁹/L for surgical bleeding; <10 × 10⁹/L for spontaneous bleeding
• Platelet count <75 × 10⁹/L is a reasonable guide for transfusion in massively bleeding patients

• Develops in prolonged hypotension + massive transfusion
• Signs: oozing into surgical field, hematuria, gingival bleeding, petechiae, venipuncture site bleeding
• Differential: dilutional thrombocytopenia, Factor V/VIII deficiency, true DIC, transfusion reaction
• Treat the underlying cause + component therapy guided by labs/TEG

• First coagulation factor to fall during hemorrhage
• Target fibrinogen >150-200 mg/dL
• Supplement with cryoprecipitate or fibrinogen concentrate (4-8 g)

11. Blood Conservation Strategies

1. Intraoperative Cell Salvage (ICS): Autotransfusion with washed RBCs - reduces allogeneic blood requirement. Avoid in contaminated field or malignancy (relative contraindication; use leukocyte depletion filter in cancer patients)
2. Deliberate hypotension where appropriate (not in TBI/spinal cord injury)
3. Antifibrinolytics: TXA or epsilon-aminocaproic acid (EACA) - particularly in cardiac surgery with CPB
4. Acute normovolemic hemodilution (ANH)
5. Topical hemostatic agents (fibrin glue, thrombin) in surgical field

12. Uncrossmatched Blood in Emergencies

• Type O Rh-negative PRBCs for women of childbearing age
• Type O Rh-positive for men and older women (less antigenic risk)
• After >2 units of type O whole blood given: do NOT switch to ABO-specific blood until bank confirms anti-A/anti-B titers have fallen sufficiently - risk of major hemolysis
• Miller's Anesthesia, 10e

13. Communication and Team Coordination

• Activate MTP early - do not wait for lab confirmation
• Clear communication between anesthesiologist, surgeon, blood bank, and nursing
• Assign one team member to track units transfused and document response
• Serial labs every 30-60 minutes during active MTP: CBC, PT/INR, PTT, fibrinogen, ABG, ionized calcium, lactate, temperature
• Deactivate MTP when hemorrhage is controlled and hemodynamics stabilize

Summary Algorithm

MASSIVE INTRAOPERATIVE BLEEDING
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1. CALL FOR HELP + ACTIVATE MTP
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2. ACCESS: Large-bore IV × 2, Art line, Foley
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3. AIRWAY: RSI if needed (Ketamine/Etomidate), FiO₂ 1.0
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4. PERMISSIVE HYPOTENSION: Target SBP 80-100 (NOT in TBI)
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5. EMPIRIC BLOOD: 4 PRBCs + 2 FFP → next pack + platelets + cryo
   CaCl₂ 1g IV immediately
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6. TXA 1g IV ASAP (within 3 hours)
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7. PREVENT LETHAL TRIAD: Warm fluids, warming blanket, correct pH
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8. TEG/ROTEM-guided: Titrate FFP, cryo, platelets, TXA
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9. REASSESS Q30 min: Labs, temp, lactate, urine output
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10. DEACTIVATE MTP when controlled