Recomendaciones de consenso para el abordaje integral y manejo del sangrado en escenarios críticos

Hemostatic alterations in massive bleeding manifest in various ways, significantly increasing the risk of complications and mortality. The management of critical bleeding requires multidisciplinary teams and standardized approaches to enable rapid assessment, identification of root causes, precise interventions, and ongoing decision-making. Situations such as major surgery, trauma, and childbirth often involve multiple factors that contribute to hemorrhagic shock, characterized by tissue ischemia and endothelial dysfunction, hypofibrinogenemia and dysfibrinolysis. Acute reductions in erythrocyte mass couple with persistent hypotension further compromise hemostasis and oxygen delivery. This consensus document provides evidence-based recommendations the assessment and management of critical bleeding in three key areas: postpartum hemorrhage, trauma, and cardiovascular surgery. The primary objective is to deliver accessible guidance that prioritizes effective bleeding management in critical scenarios, wheter or not coagulopathy is present. This document also serves as a practical tool to support the implementation and optimization of «Patient Blood Management,» a framework endorsed by the World Health Organization to enhance patient outcomes through evidence-based clinical care.

The GRADE-based recommendations for managing critical bleeding are organized into four key areas: 1. Evaluation of coagulation in critical bleeding. Early and sequential assessment of hemostasis is recommended, incorporating viscoelastic or conventional tests. Special enphasis is placed on fibrinogen quantification and platelet function, with the integration of these tests into institutional protocols. 2. Management of postpartum bleeding. Recommendations highlight the importance of early bleeding identification, the use of uterotonics, tranexamic acid, fibrinogen replacement, comprehensive monitoring, and mechanical bleeding control. 3. Traumatic bleeding key mesures include administering tranexamic acid and implementing transfusion therapy tailored to individual needs. Massive transfusion protocols, is emphasized, alongside early coagulation assessment using conventional or viscoelastic tests to guide treatment. 4. Cardiovascular surgery. Recommendations focus on preoperative identification and correction of anemia and risk factors. The use of tranexamic acid, along with perioperative coagulation assessment guided by viscoelastic test-based algorithms, is adviced to minimize transfusions. Strategies also enphasize restrictive transfusion thresholds and targeted bleeding management during prolonged bypass procedures.