Massive Intraoperative Bleeding Protocol

1. Classification of Hemorrhage (ACS)

• Class IV hemorrhage = Trauma-Induced Coagulopathy (TIC) will be present; massive transfusion is required; death risk is extremely high without immediate intervention. - Morgan & Mikhail's Clinical Anesthesiology, p. 1841

2. Triggering Criteria for Massive Transfusion Protocol (MTP)

Clinical Criteria (Admission/OR)

• SBP ≤ 70 mmHg
• Estimated blood loss > 1000 mL
• SBP < 90 mmHg despite initial crystalloid resuscitation
• Temperature < 34°C
• ABC score ≥ 2 (SBP < 90 mmHg + penetrating injury + HR > 110 + positive FAST)
• Intraoperative: nonsurgical hemorrhage or EBL > 150 mL/min

Laboratory Criteria

• Base excess > -10
• INR > 1.4
• PT > 18 seconds
• PTT > 60 seconds
• Admission Hct < 30
• Miller's Anesthesia 10e, Fig. 62.9

3. The "Lethal Triad" - What You Are Fighting

• Hypothermia - radiant heat loss, cool resuscitation fluids, exposed peritoneal surfaces, anesthetic suppression of shivering - directly impairs platelet function and reduces coagulation factor activity
• Acidosis - from prolonged tissue hypoxia and lactate accumulation - worsens coagulation factor function
• Coagulopathy - from dilution (crystalloids), consumption, hyperfibrinolysis, and ATC mechanisms

Crystalloid volumes > 4 L prehospital raised the risk of coagulopathy regardless of arrival lactate - Miller's Anesthesia 10e, p. 9388

4. Immediate Team Roles (Code Hemorrhage / Crisis Activation)

5. Damage Control Resuscitation (DCR) - Core Principles

5a. Permissive Hypotension

• Target SBP 90 mmHg (MAP ~60 mmHg) until definitive hemorrhage control
• Rationale: aggressive normalization "pops the clot" and worsens hemorrhage
• Exception: NOT used in traumatic brain injury, elderly patients, blunt trauma, or cardiac/carotid disease - Mulholland & Greenfield Surgery 7e, p. 1592

5b. Limit Crystalloids

• Minimize isotonic fluids - they cause dilutional coagulopathy and hypothermia
• Use blood products as primary resuscitation fluid

5c. Hemostatic Resuscitation - Blood Product Ratios

• 1:1:1 ratio of RBC : FFP : Platelets (approximates whole blood)
• Evidence: PROPPR trial - 1:1:1 achieved hemostasis more rapidly and fewer exsanguination deaths by 24h compared to 1:1:2
• Uncross-matched (type O) RBCs and FFP until cross-match available
• Miller's Anesthesia 10e, p. 9413

6. MTP Pack Protocol

1. Contact blood bank; activate MTP
2. Send runner to blood bank; wait for Pack 1
3. Submit specimen for cross-match immediately
4. Draw: coagulation studies, fibrinogen, CBC (consider viscoelastic testing if available)

• Administer in 1:1:1 ratio (RBC : FFP : Platelets)
• Consider tranexamic acid (TXA) 1 g over 10 min, then 1 g infusion over 8 hours
• Blood bank prepares next pack

• Repeat coagulation studies + fibrinogen + CBC after each pack
• If fibrinogen < 100-150 mg/dL: add cryoprecipitate (10 bags raises fibrinogen ~100 mg/dL) or fibrinogen concentrate (25-50 mg/kg)
• Reassess: bleeding controlled? - Rosen's Emergency Medicine, p. 2617

7. Pharmacologic Adjuncts

• Miller's Anesthesia 10e; Rosen's Emergency Medicine

8. Blood Product Dosing Reference

• Rosen's Emergency Medicine, p. 2609-2611

9. Surgical Damage Control (DCL)

• Rapid midline laparotomy (xiphoid to suprapubic)
• Evacuate hemoperitoneum with salvage devices; pack all four quadrants tightly
• Unpack one quadrant at a time, controlling each bleeding source
• Options: packing, vessel ligation, vascular shunts (temporary), bowel stapling without anastomosis
• Allow anesthesia to "catch up" on resuscitation while quadrants packed

• Reverse hypothermia, coagulopathy, acidosis
• Goal: temp > 35°C, pH > 7.35, INR < 1.5, fibrinogen > 150 mg/dL

• Return to OR at 24-72 hours for anastomosis, vascular repair, abdominal closure
• Fischer's Mastery of Surgery 8e; Current Surgical Therapy 14e

10. Hemostatic Surgical Adjuncts

• Fischer's Mastery of Surgery 8e, Table 275.4

11. Monitoring During MTP

12. Viscoelastic Testing (TEG/ROTEM) - Goal-Directed Approach

• Are performed at physiologic pH/temp (do not reflect actual in vivo coagulopathy)
• Take 45-60 minutes (results may be irrelevant by the time they return)

• Clotting factor deficiency vs. platelet dysfunction vs. fibrinolysis
• Hyperfibrinolysis (critical for TXA decision)
• Functional platelet dysfunction even with normal platelet counts

13. Special Considerations

• Warfarin: PCC + Vitamin K 10 mg IV
• Dabigatran: Idarucizumab (Praxbind) 5 g IV
• Factor Xa inhibitors (rivaroxaban, apixaban): Andexanet alfa or 4F-PCC

Summary Algorithm

MASSIVE BLEEDING RECOGNIZED
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CALL FOR HELP + ACTIVATE CODE HEMORRHAGE / MTP
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SURGICAL: Pack/compress bleeding source immediately
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ANESTHESIA: Permissive hypotension (SBP 90) + limit crystalloids
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BLOOD BANK: O-negative RBC + FFP (uncrossmatched) immediately
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PACK 1: 6 RBC : 6 FFP : 6 Platelets + TXA 1g IV
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LAB: ABG + TEG/ROTEM + fibrinogen + CBC
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REASSESS every pack: fibrinogen low → cryoprecipitate/fibrinogen conc
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SWITCH TO GOAL-DIRECTED THERAPY once controlled
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DAMAGE CONTROL SURGERY if lethal triad present

• Miller's Anesthesia 10e (Hemostatic Resuscitation, Trauma-Induced Coagulopathy chapters)
• Mulholland & Greenfield Surgery 7e (Damage Control Resuscitation chapter)
• Rosen's Emergency Medicine (Massive Transfusion Protocols)
• Fischer's Mastery of Surgery 8e (Operative hemorrhage control)
• Current Surgical Therapy 14e (Damage Control Laparotomy)
• APSF: Management of Massive Intraoperative Hemorrhage
• ISBT: Massive Bleeding Protocols (updated Jan 2026)