Massive blood loss and transfusion

Paediatric neurosurgical patients may be at a risk of massive blood loss. Th e most powerful approach to reduce transfusion is to minimise blood loss by preoperative optimisation of haemoglobin, limitation of blood sampling, positioning, surgical techniques to reduce bleeding, and cell salvaging. Th e fi rst step to decide when transfusion becomes essential is to calculate the maximal allowable blood loss, which evaluates the eff ects of patient age, weight, and starting haematocrit on blood volume. Th ere is little evidence available to guide paediatric care during massive blood loss: a haemoglobin level of at least 8 g/dL should be maintained during bleeding, and restrictive transfusion strategies (haemoglobin 7 g/dL) should be applied only when control of bleeding has been achieved. Bleeding and transfusion can induce coagulation abnormalities, which require meticulous diagnosis in children. Viscoelastic pointof-care tests are useful in detecting and guiding timely intervention to prevent and treat coagulation abnormalities, such as dilutional coagulopathy and hyperfi brinolysis.