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Transfusion - Massive blood loss in the oncology patient

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Occasionally oncology patients can present with massive blood loss due to their primary tumour or complications of treatment. A successful outcome requires good communication between clinical specialties, the laboratory, blood bank and New Zealand Blood Service.

In New Zealand, many shared care centres have very limited stocks of platelets and therefore early involvement of blood bank is essential to ensure product is available promptly.

Transfusion Protocols for Starship Hospital can be found on the Starship Clinical Guidelines (/for-health-professionals/starship-clinical-guidelines/m/massive-transfusion-protocol/). The Christchurch Transfusion Protocol can be accessed at   http://www.cdhb.health.nz/Hospitals-Services/Health-Professionals/CDHB-Policies/Fluid-Medication-Manual/Documents/Paediatric-Massive-Transfusion-Protocol.pdf

% BV Loss Action 
< 15%  No need for urgent transfusion unless there is pre-existing anaemia or underlying cardiac or respiratory disease. Assess ongoing bleeding. 
15 - 30%  Initiate fluid resuscitation and assess need for red cells depending on pre-existing Hb, cardio-respiratory function and ongoing blood loss.
30 - 40%  Rapid fluid resuscitation followed by red cell transfusion. 
> 40%  Rapid fluid resuscitation with urgent RBC transfusion. 

Investigations

  • FBC
  • Coag screen (PT, APTT, fibrinogen)
  • Blood bank sample
  • Biochem
  • Blood gas

Repeat FBC and coags 4 hourly or after 1/3 blood volume replacement.

Treatment

  • Treat underlying cause of bleeding
  • Aim to keep Hb >80 g/L
  • Maintain platelets >75x109/L (platelets likely to be needed after 2 x blood volume replacement - 10 ml/kg for small children or 1 adult therapeutic dose (ATD) - bag)
  • Consider Fresh frozen plasma after 1.5 x blood volume replacement or cryoprecipitate for ongoing low fibrinogen. Both of these are frozen and need about 30 minutes to defrost so think ahead.

References

Guidelines for the management of massive blood loss. British committee on standards in haematology. BJH 2006 135(5):634-41.

NZBS Transfusion medicine handbook 2008.

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  • Date last published: 01 December 2010
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network