Haematological management of major haemorrhage: a British Society for Haematology Guideline

METHODOLOGY

This updated guideline¹ was compiled by a writing group selected to be representative of UK haematology/transfusion experts, according to the British Society for Haematology (BSH) process at [https://b-s-h.org.uk/media/16732/bsh-guidance-development-process-dec-5-18.pdf].² An updated search (PubMed and Embase) for articles (in English, only human studies) published from July 2014 up to March 2020 was undertaken by the BSH information specialist using the terms ‘bleeding’ and ‘haemorrhage’ combined with ‘management’ and ‘trials’. Systematic reviews were identified³ and cross-checked by searching the National Health Service Blood and Transplant Systematic Review Initiative Transfusion Evidence Library. A total of 530 citations were screened (L.G., S.J.S.) of which, 365 citations were excluded as they were narrative reviews, case-reports, case series (without comparator groups), and studies of anticoagulation reversal; 65 citations were trial protocols; and four citations were duplicates. A total of 96 citations were included and reviewed by the members of the writing group. We reviewed a recent clinical practice guideline from the European Society of Intensive Care Medicine,⁴ and recent UK Serious Hazards of Transfusion (SHOT) haemovigilance reports.⁵ The writing group focused on systematic reviews and randomised controlled trials (RCTs) to formulate recommendations, although recognising that the literature underpinning laboratory and organisational aspects would likely be based on observational studies and descriptions of practice, rather than interventional trials. In areas where the evidence base was limited, the writing group presented pragmatic guidance. The following areas were considered beyond the scope of this guideline: techniques for resuscitation, surgical, radiological and endoscopic interventions to control and monitor bleeding, the use of crystalloids and colloids for fluid resuscitation. Recommendations on thromboprophylaxis were also not considered in this guideline, but the authors recognised the importance of this topic, noting that trauma patients have high rate of hospital-acquired venous thromboembolism. The scope of this guideline included the emerging practice of pre-hospital transfusion and emergency transfusion in the context of mass casualty events (MCEs).

The Grading of Recommendations Assessment, Development and Evaluation (GRADE) nomenclature was used to evaluate levels of evidence and to assess the strength of recommendations (http://www.gradeworkinggroup.org).⁶ The guideline was reviewed by the BSH Guidelines Committee Transfusion Task Force, and Thrombosis & Haemostasis Task Force, and placed on the members section of the BSH website for comments. Readers are referred to linked BSH guidelines on transfusion support in children and the use of viscoelastic haemostatic assays (VHAs).^7, 8