What are the guidelines for blood administration in a patient with a suspected brain bleed?

Blood Administration Guidelines for Suspected Brain Bleed

In patients with suspected brain bleed, platelets should be administered to maintain a platelet count above 50×10^9/L, while maintaining systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion. 1

Hemodynamic Management

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for suspected brain hemorrhage to ensure adequate cerebral perfusion 1
• Avoid hypotension as it adversely affects neurological outcomes in brain-injured patients 1
• Use 0.9% saline as the crystalloid of choice for fluid resuscitation in brain injury, as it is isotonic in terms of osmolality 1
• Avoid hypotonic solutions such as Ringer's lactate, Ringer's acetate, and gelatins as they can increase brain water content 1
• Avoid albumin and other synthetic colloids in the early management of brain-injured patients 1

Blood Component Administration

Red Blood Cells

• Transfuse red blood cells when hemoglobin level is <7 g/dL during interventions for brain hemorrhage 1
• Consider a higher transfusion threshold for elderly patients or those with limited cardiovascular reserve due to pre-existing heart disease 1

Platelets

• Maintain platelet count above 50×10^9/L in patients with ongoing bleeding and/or traumatic brain injury 1
• For patients requiring emergency neurosurgery (including ICP probe insertion), a higher platelet count is advisable 1

Coagulation Parameters

• Maintain prothrombin time (PT) and activated partial thromboplastin time (aPTT) at <1.5 times normal control during interventions for brain hemorrhage 1
• For patients on anticoagulants with intracerebral hemorrhage, rapidly reverse anticoagulation while limiting fluid volumes (e.g., using prothrombin complex concentrate rather than FFP, plus vitamin K to reverse warfarin) 1, 2
• Consider point-of-care tests (thromboelastography or rotational thromboelastometry) to assess and optimize coagulation function if available 1

Type-Specific Brain Bleed Management

Traumatic Brain Injury

• During massive transfusion protocol initiation, transfuse RBCs/plasma/platelets at a ratio of 1:1:1, then modify according to laboratory values 1
• Maintain cerebral perfusion pressure ≥60 mmHg when ICP monitoring is available 1
• Maintain PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg 1

Spontaneous Intracerebral Hemorrhage

• For patients presenting within 6 hours of symptom onset with systolic BP >150 mmHg, reduce blood pressure if immediate surgery is not planned 1
• Rapidly reverse anticoagulation in patients on antithrombotic or anticoagulant therapy 1, 2

Acute Ischemic Stroke

• Keep blood pressure <185/110 mmHg in patients who are candidates for or have received intravenous thrombolysis 1
• Avoid hypotension; systolic pressure <140 mmHg could be detrimental 1
• Use fluids and vasoconstrictors to raise blood pressure if necessary 1

Subarachnoid Hemorrhage

• Maintain euvolemia in patients with unsecured aneurysm 1
• Keep systolic blood pressure <160 mmHg but avoid hypotension (systolic <110 mmHg) 1

Monitoring and Special Considerations

• Implement mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings as soon as possible 1
• Consider pharmacological thromboprophylaxis within 24 hours after bleeding has been controlled 1
• In cases of cerebral herniation, use osmotherapy and/or temporary hypocapnia 1
• Maintain normothermia in patients with brain hemorrhage; hypothermia (33-35°C) may be applied in traumatic brain injury patients only after bleeding from other sources has been controlled 1
• Monitor for signs of hemorrhagic transformation, including changes in level of consciousness, elevation of blood pressure, deterioration in motor examination, onset of new headache, or nausea and vomiting 1