CLINICAL STRATEGIES FOR MANAGING HEMORRHAGE AND ANEMIA WITHOUT BLOOD TRANSFUSION IN CRITICALLY ILL PATIENTS* CONTENTS PAGE GENERAL ICU MANAGEMENT PRINCIPLES 1. PREVENTION AND ARREST OF 1. Exercising clinical judgment, be prepared to modify routine practice (e.g., extra vigilance, expeditious control of bleeding). BLEEDING A. Close Surveillance for Blood Loss ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 2 2. Formulate an individualized clinical management plan to facilitate rapid decision-making and avoid treatment delays. Prospective plan- B. Rapid Diagnosis and Control of Hemorrhage ˝˝˝˝˝ 2 ning includes prediction, prevention, prompt recognition, and treatment C. Expeditious Angiographic Embolization˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 3 of blood loss and anemia by the use of multiple appropriate therapeu- D. Permissive Moderate Hypotension During tic interventions. Bleeding ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 3 3. Discuss anticipated or potential procedures and their risks and E. Blood Pressure Management˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 3 benefits with the patient/substitute decision-maker. F. Pharmacological Enhancement of Hemostasis ˝˝ 3 4. Adopt an interdisciplinary and collaborative team approach among G. Autotransfusion/Blood Cell Salvage ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 4 involved clinical specialties (medicine, surgery, radiology, hematology, H. Rapid Warming/Maintenance of nursing, pharmacy) with active management by the lead clinician. Normothermia˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 4 5. Maintain ongoing communication regarding patient management I. Hemostasis/Anticoagulation Management ˝˝˝˝˝˝˝ 4 among members of the critical care team and consultants, especially J. Prophylaxis of Upper Gastrointestinal during transitions of staff. Where there are multiple conditions treated Hemorrhage˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 4 by multiple physicians, interspecialty collaboration and coordination is ˝˝˝˝˝˝˝˝ particularly important. K. Prophylaxis and Management of Infection 5 L. Blood Conservation in Burn Care ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 6. Consult with specialist physicians who have experience in the man- agement of patients without allogeneic blood transfusion. Recognition 2. MINIMIZATION OF IATROGENIC of risk factors for bleeding or anemia may help clinicians to predict/ anticipate the need for preventive or control measures. BLOOD LOSS A. Restricted Diagnostic Phlebotomy ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 7. Maintain continuous, close surveillance for signs and symptoms ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ of blood loss or deterioration. If a suspicion of bleeding arises from B. Reduce Nondiagnostic Blood Loss 5 either clinical or laboratory findings, promptly initiate diagnosis and C. Cautious Thromboembolic Prophylaxis ˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 5 appropriate management. D. Anticipation of Adverse Effects of Medications˝ 6 8. Prompt action to arrest blood loss and judicious volume manage- ment is lifesaving. The clinical urgency of low-level persistent bleed- 3. OPTIMIZATION OF OXYGEN ing may not be recognized until compensatory mechanisms fail and DELIVERY blood pressure falls. In the face of severe hemorrhage, early recourse A. Assess Perfusion and Tissue Oxygenation ˝˝˝˝˝˝˝ 6 to definitive measures to control bleeding is of paramount importance. ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ In general, avoid a watch-and-wait approach to the bleeding patient. B. Augment Cardiac Output 6 C. Early Enhancement of Oxygenation ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 9. Transfer a stabilized patient, if necessary, to a major center before the patient’s condition deteriorates. 4. MINIMIZATION OF OXYGEN GENERAL THERAPEUTIC PRINCIPLES IN ICU CONSUMPTION ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 1. Prevent and rapidly arrest any bleeding with decisive and immediate ac- A. Appropriate Analgesia 8 tion (e.g., surgery, hemostatic pharmacological agents). Avoid delays. B. Sedation and Muscle Relaxants ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 8 C. Mechanical Ventilation ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 9 2. Minimize iatrogenic blood loss (e.g., restrict phlebotomy for laboratory tests, cautious thromboembolic prophylaxis). D. Thermal Management ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 9 3. Optimize cardiac and respiratory support as soon as possible (e.g., early 5. OPTIMIZATION OF ERYTHROPOIESIS supplemental oxygen, individualized fluid therapy for adequate tissue ˝˝˝˝˝˝˝˝˝˝˝˝˝ perfusion, vasoactive agents). A. Early Erythropoiesis-Stimulant Therapy 9 B. Iron Replacement and Hematinic Support ˝˝˝˝˝˝˝ 10 4. Minimize oxygen consumption (analgesia, sedation). C. Nutrition ˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 10 5. Early aggressive treatment of anemia (e.g., erythropoiesis-stimulating agents, iron, nutrition). 6. TOLERANCE OF ANEMIA A. Compensatory Mechanisms in Normovolemic 6. Maintain normovolemia in the anemic patient. In the presence of uncon- Anemia˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝˝ 10 trolled hemorrhage, consider permissive moderate hypotension and con- trolled fluid resuscitation until bleeding is promptly arrested. B. Acceptance of Normovolemic Anemia ˝˝˝˝˝˝˝˝˝˝˝˝ 10 C. Effects of Storage on Red Blood Cells ˝˝˝˝˝˝˝˝˝˝˝ 11 * This Clinical Strategies document is an informational resource and reference for medical practitioners only. It provides neither medical advice nor treatment recommendations and does not substitute for an appropriately qualified health-care professional. The editor does not recommend or endorse any test, physician, product, or procedure, and has endeavored to include accurate, timely information. However, not all listed strategies are appropriate or acceptable to all patients. It is the responsibility of each provider to maintain awareness of new information, discuss options for care, and assist patients in making choices in accord with their wishes, values, and beliefs. Patients should always seek the advice of a qualified health-care professional regarding a medical condition or treatment. Distributed by Hospital Information Services for Jehovah’s Witnesses http://www.jw.org/en/medical-library 1 1. PREVENTION AND ARREST OF BLEEDING A. Close Surveillance for Blood Loss1,2 c. Determine if bleeding is localized or due to a systemic coagulation defect 1. Clinical diagnosis of bleeding (1) The most common causes of bleeding a. Pain, wound swelling, or firmness at surgical site after surgery or trauma are technical (e.g., hematoma) (e.g., incomplete surgical hemostasis due to an b. Saturation of surgical dressings; oozing; tube unligated vessel or an drainage uncontrolled/unrecognized arterial injury). Do not assume that excessive bleeding is the c. Hematemesis, bloody nasogastric aspirate, result of a coagulopathy melena/hematochezia (2) Causes of systemic coagulation defects d. Hemodynamic instability; spontaneous drop in include thrombocytopenia, platelet dysfunction, blood pressure excessive fibrinolysis, dilution of clotting e. Clinical examination (e.g., pallor, ecchymosis, components, excessive anticoagulation, dyspnea, tachycardia, tachypnea, diaphoresis, inadequate heparin neutralization, disseminated decreased level of consciousness, oliguria) intravascular coagulation, congenital deficiencies (e.g., protein C, protein S, Factor V f. Perfusion markers/metabolic variables (See 3.A.) Leiden)10,11 g. Declining serial hemoglobin or platelet count 3. Prompt intervention to stop bleeding h. Fluid/volume status (ongoing bleeding should be suspected when a patient shows evidence of a. Control blood loss as quickly as possible by hypovolemia despite reasonable hydration) any means necessary. Temporizing measures should not delay definitive interventions to stop Notes: bleeding12 1. Avoid delay in identification or localization of bleeding by close monitoring and frequent serial clinical examinations b. Consider less invasive approaches to control by the same examiner.3 bleeding13,14 (e.g., angiographic, pharmacological, 2. The observation protocol should include regular serial endoscopic) monitoring of vital signs, urine output, hematocrit, and c. Early surgical exploration is mandatory, even if blood gases. the patient is anemic, if there is evidence of 3. The clinical urgency of low-level persistent blood loss ongoing bleeding or potential bleeding that can (e.g., bleeding from small vessels, capillaries) from be controlled operatively or if imaging procedures potentially multiple sites may not be recognized until compensatory mechanisms fail and blood pressure falls. are unsuccessful or may delay definite diagnosis and result in prolonged blood loss15-19 d. Employ techniques to control hemorrhage that B.Rapid Diagnosis and Control of 20,21 4-7 can be rapidly applied. Use a combination of Hemorrhage bleeding control strategies22,23 (e.g., pelvic sheet, 1. Maintain a high level of clinical suspicion damage control surgery, packing, external fixation, angiography and embolization, skeletal a. Maintain acute clinical awareness of potential traction) bleeding 4. “Damage control” strategy for massive (1) Any drop in hemoglobin/hematocrit, platelet 24 count, or blood pressure, and any increase in blood loss heart rate requires urgent clarification a. Damage control as a therapeutic procedure should be anticipated and implemented as early b. Adopt a lower threshold for intervention as possible. Surgical intervention should be (i.e., consider surgical exploration/reexploration 25 on less clear-cut indications) simple, quick, and well performed. Damage control laparotomy includes limited surgery (e.g., 2. Systematic screening/diagnosis of staples, clamps, rapid sewing) for control of