The statements in the following section reflect current clinical guidelines and the views of clinicians with relevant clinical experience.
In a patient who is bleeding and has evidence of a coagulopathy (or is likely to develop a coagulopathy), it is sensible to give blood components before coagulation deteriorates and worsens the bleeding.
If the major source of bleeding has been controlled and there is no microvascular bleeding, there is no need to give blood components even if laboratory coagulation tests are abnormal.
Table 9 Use of blood components in the patient who is bleeding
Indication and target levels
Fresh frozen plasma
30 minutes to thaw
Dilutional coagulopathy with a PTR greater than 1.5 is likely after replacement of 1−1.5 blood volumes within six hours.
If bleeding continues, FFP may avoid a worsening coagulopathy and bleeding from the primary source, but it will not stop the primary cause of the bleeding.
An initial dose of 15 ml/kg is generally recommended (four or five donor units of FFP).
Further doses should only be given if bleeding continues and should be guided by the prothrombin time and activated partial thromboplastin time (APTT).
30 minutes to thaw
May be indicated when there is bleeding with a fibrinogen concentration below 1 g/l.
Two pooled units equivalent to 10 single donor units: 3−6 g fibrinogen in 200 to 500 ml should raise the plasma fibrinogen level in an adult by about 1 g/l (see Table 4).
Check delivery delay: may need to be transported from
Platelet count is unlikely to fall below a critical level of 50 x 109/l until 1.5−2.5 blood volumes have been replaced.
Count should be maintained above 75 x 109/l.
In multiple or CNS trauma above 100 x 109/l.
Adult dose unit: 2.5−3 x 1011 platelets should raise the platelet count by about 50 x 109/l, but less in consumptive coagulopathy, e.g. DIC.
If bleeding continues, monitor the platelet count as further transfusion may be needed to maintain target count.
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Recombinant factor VIIa (NovoSeven®) in haemorrhage
Criteria for use may include severe haemorrhage where there is a reasonable prospect of long-term recovery, e.g. multiple trauma, focal bleeding points have been dealt with and effective replacement of coagulation factors and platelets has been shown by laboratory tests (e.g. fibrinogen > 1 g, platelets > 50 PTR < 1.8).
Other adverse factors such as heparin, hypothermia, acidosis, hypocalcaemia, etc. should have been excluded or corrected, other available interventions, such as an antibrinolytic and local haemostatic agents, have been used, and the risk of thrombosis in critical small vessel anastomoses has been assessed.
Randomised controlled clinical trials have not yet established clear indications for recombinant factor VIIa in haemorrhage other than in some patients with intracranial haemorrhage.
Dose: Typical dose schedule is 90 micrograms/kg rounded up to a whole vial. Repeat at three hours if necessary.
Note: NovoSeven® is not licensed in the UK for this indication. Local procedures for documenting its use must be followed.
Anticipated massive transfusion
Patients such as those with ruptured aortic aneurysms often develop DIC as well as dilutional coagulopathy due to fluid resuscitation. Early administration of FFP may help to avoid this. The risks of administering FFP are likely to be small in relation to the patient’s overall risks and prognosis. Such use should be according to locally developed protocols that specify regular monitoring of coagulation.
Figure 9 - Blood components and haemorrhage
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