What are the guidelines for administering fluids and blood products in a patient with hemorrhagic shock?

From the Guidelines

In hemorrhagic shock, rapidly administer crystalloid fluids (e.g., normal saline) at 1-2 L initially, followed by blood products as soon as possible, with a focus on maintaining a systolic blood pressure of 80-90 mmHg until major bleeding has been stopped, as recommended by 1. The initial management of hemorrhagic shock involves immediate control of obvious bleeding and fluid resuscitation to restore intravascular volume.

• Key principles include:
  • Immediate pelvic ring closure and stabilization in patients with pelvic ring disruption
  • Avoidance of hypotonic solutions such as Ringer’s lactate in patients with severe head trauma
  • Maintenance of a minimum target platelet count of 50×10^9/L in patients with ongoing bleeding and/or traumatic brain injury, as suggested by 1
  • Administration of fibrinogen and cryoprecipitate as needed to support coagulation Specific protocol:

1. Begin with 1-2 L crystalloid bolus
2. Transfuse packed red blood cells (PRBCs) and fresh frozen plasma (FFP) in a 1:1 ratio, as recommended by 1
3. Add platelets if count is <50,000/μL or for massive transfusion
4. Consider cryoprecipitate for fibrinogen <100 mg/dL Monitor response with vital signs, urine output, and serial hemoglobin/hematocrit levels, and adjust fluid and blood product administration based on ongoing losses and patient response, as guided by 1. This approach rapidly restores intravascular volume while addressing coagulation deficits, and is supported by the most recent and highest quality evidence from 1.

From the FDA Drug Label

Blood volume depletion should always be corrected as fully as possible before any vasopressor is administered. When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, LEVOPHED can be administered before and concurrently with blood volume replacement Whole blood or plasma, if indicated to increase blood volume, should be administered separately (for example, by use of a Y-tube and individual containers if given simultaneously).

The guidelines for administering fluids and blood products in a patient with hemorrhagic shock are:

• Blood volume depletion should be corrected as fully as possible before administering any vasopressor.
• Blood volume replacement can be done concurrently with vasopressor administration in emergency situations.
• Whole blood or plasma should be administered separately from the vasopressor, using a Y-tube or individual containers if given simultaneously 2.

From the Research

Guidelines for Administering Fluids and Blood Products

The administration of fluids and blood products in a patient with hemorrhagic shock is crucial for restoring tissue perfusion and achieving haemostasis in vital functions 3. The primary goals of treatment are to stop the bleeding and restore circulating blood volume 4.

Fluid Resuscitation

• Fluid replacement is aimed at normalization of hemodynamic parameters in controlled hemorrhagic shock (CHS) 5.
• In uncontrolled hemorrhagic shock (UCHS), fluid treatment is aimed at restoration of radial pulse, or restoration of sensorium or obtaining a blood pressure of 80 mmHg by aliquots of 250 ml of lactated Ringer's solution (hypotensive resuscitation) 5.
• Crystalloid solutions and blood transfusion are the mainstays of pre-hospital and in-hospital treatment of hemorrhagic shock 5.
• Isotonic crystalloid or colloid solutions can be used for volume replacement in hemorrhagic shock 6.

Blood Transfusion

• A hemoglobin level of 7-8 g/dl appears to be an appropriate threshold for transfusion in critically ill patients with no evidence of tissue hypoxia 4.
• Maintaining a higher hemoglobin level of 10 g/dl is a reasonable goal in actively bleeding patients, the elderly, or individuals who are at risk for myocardial infarction 4.
• Blood component transfusion is indicated when deficiencies have been documented by clinical assessment or hematological investigations 6.

Management of Hemorrhagic Shock

• Prompt recognition and arrest of the source of hemorrhage, while implementing resuscitative measures, is recommended 6.
• Resuscitation from hemorrhagic shock should include adequate oxygenation and restoration of circulating volume by placement of two large-bore IVs, and rapid infusion of a balanced crystalloid solution 6.
• Appropriate resuscitation requires ongoing evaluation of response to therapy, including clinical evaluation, and hematological, biochemical, and metabolic assessments 6.