Massive transfusion and coagulopathy in a ruptured abdominal aortic aneurysm
A 71-year-old man presents with a ruptured abdominal aortic aneurysm. He is pale, confused, and has a blood pressure of 78/40 mmHg and a heart rate of 132/min. He has two 14-gauge IV cannulas and a rapid infuser. The blood bank has 4 units of red cells available and can deliver more in 30 minutes. His haemoglobin is 68 g/L, platelets 90 × 10⁹/L, and INR 1.6. He takes warfarin for atrial fibrillation, and his last dose was 3 days ago. The surgeon wants to open the abdomen immediately.
1. Outline your resuscitation and transfusion strategy before and during surgery.
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Before surgery:
- Activate the massive transfusion protocol and request a balanced ratio of red cells, plasma, and platelets (e.g., 1:1:1) as soon as possible.
- Give tranexamic acid 1 g IV over 10 minutes, then 1 g over 8 hours, if within 3 hours of injury or as per protocol for major haemorrhage.
- Warm the patient, use warmed fluids, and keep the theatre warm.
- Start vasopressor support (e.g., noradrenaline) to maintain a mean arterial pressure around 65 mmHg while accepting permissive hypotension until surgical control.
- Correct the warfarin effect: give prothrombin complex concentrate (e.g., 25–50 units/kg) plus vitamin K 5–10 mg IV, because the INR of 1.6 underestimates the true deficit and the patient is bleeding.
- Give calcium chloride or gluconate to counteract citrate-induced hypocalcaemia from stored blood.
During surgery:
- Monitor arterial pressure, capnography, temperature, and point-of-care coagulation (e.g., viscoelastic testing) if available.
- Replace fibrinogen if it falls below 1.5–2 g/L (cryoprecipitate or fibrinogen concentrate).
- Give platelets if the count falls below 50 × 10⁹/L with ongoing bleeding.
- Avoid over-transfusion of crystalloid, which worsens dilutional coagulopathy and hypothermia.
2. How would you monitor and treat the metabolic consequences of massive transfusion intraoperatively?
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Key complications to anticipate and treat:
- Hypothermia: use a forced-air warmer, warmed fluids, and a heated circuit; monitor core temperature continuously and keep it above 35 °C.
- Hypocalcaemia: citrate in stored blood binds calcium; monitor ionised calcium and give calcium chloride 10% 10 mL or calcium gluconate 10% 30 mL as needed. Signs include hypotension, prolonged QT, and arrhythmias.
- Hyperkalaemia: stored red cells leak potassium; monitor potassium and ECG, and treat with calcium, insulin–dextrose, or salbutamol if levels rise.
- Acidosis: monitor blood gases; treat the cause (hypoperfusion) rather than giving bicarbonate routinely.
- Coagulopathy: use viscoelastic testing or standard coagulation tests to guide plasma, platelet, and fibrinogen replacement; keep the fibrinogen above 1.5–2 g/L.
- Volume overload and pulmonary oedema: watch central venous pressure, urine output, and lung sounds, especially if renal function is impaired.
Document all blood products, fluids, and drugs given, and hand over the details to the intensive care team.