Canterbury DHB

Acute bleeding in the adult patient who declines blood products

Please refer to flowchart: Acute Bleeding in Patients who Decline Blood Products. After the individual’s particular views towards blood products etc have been established, and if the patient has refused to consent to the administration of various blood products and/or other interventions obtained, the medical management can be summarised as follows (adapted from [3]):

• Establish source of bleeding and perform local haemostatic strategies. This includes basic interventions, e.g. direct pressure, to more specialised input e.g. emergency arterial embolisation or surgical intervention in theatre as indicated by the clinical situation.
• Treat hypovolaemic shock (using intravenous fluids which may need to be warmed, supplemental oxygen, vasopressors if necessary). Relatively low volume and hypotensive resuscitation may be appropriate to reduce ongoing bleeding.
• Rule out abnormalities of haemostasis and correct any underlying coagulation defects without using blood products (check CBC, INR and aPTT, consider vitamin K 10 mg PO/IV if INR prolonged.)
• Consider prohaemostatic treatment. Tranexamic acid can be given orally or IV at a dose of 500 mg-1 g three to four times a day. The routine use of desmopressin is not supported by clinical evidence. The use of recombinant VIIa in this situation is off-label and has a very limited evidence base. It may be considered and individual circumstances should be discussed with the Haematologist on call.

Enhance haemoglobin production. Supplementation of vitamin B12 (e.g. 1000 mcg IM on days 1, 3 and 5), folic acid (5 mg PO daily) and intravenous iron (e.g. Iron polymaltose 1000 mg) can help to speed up the process of haemoglobin production. Anaemic patients with normal or even elevated endogenous erythropoietin levels may possibly benefit from high-dose Epo (up to 300-500 units/kg per day [3]). However, the use of Epo in this setting has been published in case reports and case series only and there is no evidence to recommend an optimal dose in this setting. Various regimens have been tried. A study looking at the effect of Epo on correcting anaemia post-peptic ulcer bleeding found a significant difference in median haematocrit after 14 days when erythropoietin (20,000 IU administered subcutaneously on days 0, 4, and 6) was given along with intramuscular iron compared with iron alone [12]. The rate of haemoglobin increase after Epo varies widely among patients. A study in orthopaedic patients reported an average increase on 14.4 g/L per week [13]. The haemoglobin, haematocrit and reticulocyte count can be used to assess response e.g. at day 7 and weekly thereafter.

• Limit blood tests to preserve blood volume. Paediatric sample pottles can be used.

Topic Code: 47848