START

❶ Call for help, inform theatre team of problem and note the time.

❷ Increase FiO₂ and consider cautiously reducing inhalational/intravenous anaesthetics.

❸ Check and expose intravenous access.

❹ Control any obvious bleeding (pressure, uterotonics, tourniquet, haemostatic dressings).

❺ Call blood bank (and assign one person in theatre to liase with them):

• Activate major haemorrhage protocol.
• Communicate how quickly blood is required.
• Communicate how much blood and blood product is required.

❻ Begin active patient warming.

❼ Use rapid infusion and fluid warming equipment.

❽ Discuss management plan between surgical, anaesthetic and nursing teams:

• Liaise with haematologist if necessary (Box A).
• Consider interventional radiology.
• Consider use of cell salvage equipment.

❾ Monitor progress:

• Use point of care testing: Hb, lactate, coagulation, etc.
• Use lab testing: including calcium and fibrinogen.

❿ Replace calcium and consider giving tranexamic acid (Box C).

⓫ If bleeding continues consider giving recombinant factor VIIa: liase with haematologist.

⓬ Plan ongoing care in an appropriate clinical area.

Box A: SPECIAL CASES

Seek advice from haematologist if: 

• Non-surgical uncontrolled bleeding despite PRBCs/FFP/platelets 
• Warfarin overdose 
• Newer oral anticoagulants (eg dabigatran/rivaroxaban)
• Inherited bleeding disorder (eg haemophilia, von Willebrand disease)

Box B: TRANSFUSION GOALS

• Maintain Hb > 80 g.l^-1 
• Maintain platelet count > 75x10⁹ l^-1 
• Maintain PT and APTT <1.5 x mean control (FFP) 
• Maintain fibrinogen >1.0 g.l^-1 (cryoprecipitate) 
• Avoid DIC (maintain blood pressure, treat/prevent acidosis, avoid hypothermia, treat hypocalcaemia and hyperkalaemia) 

Box C: DRUG DOSES

CALCIUM: (use either the chloride or gluconate) 

• Adult: 10 ml of 10% calcium chloride i.v.  
• Adult: 20 ml of 10% calcium gluconate i.v. 
• Child: 0.2 ml.kg^-1 of 10% calcium chloride i.v. 
• Child: 0.5 ml.kg^-1 of 10% calcium gluconate i.v.                 

TRANEXAMIC ACID: 

• Child: 15 mg.kg^-1 i.v. bolus then 2 mg.kg^-1.h^-1 until bleeding stops 
• Adult: 1 g i.v. bolus, then: 
  • Obstetric haemorrhage,  repeat dose 30 mins later 
  • Non-obstetric haemorrhage, 1 g i.v. infusion over next 8 h