Introduction: 

The management of patients with critical bleeding requires a multidisciplinary approach to achieve haemostasis, optimise physiology, and guide blood component use. The 2011 Patient blood management guidelines: module 1 — critical bleeding/massive transfusion were updated and published. Systematic reviews were conducted for pre‐specified research questions, and recommendations were based on meta‐analyses of included studies.

Main recommendations: The critical bleeding/massive transfusion guideline includes seven recommendations and 11 good practice statements addressing:

• major haemorrhage protocols (MHPs) facilitating a multidisciplinary approach to haemorrhage control, correction of coagulopathy and normalisation of physiological derangement;
• measurement of physiological, biochemical and metabolic parameters in critical bleeding/massive transfusion;
• the optimal ratio of red blood cells to other blood components;
• the use of tranexamic acid;
• viscoelastic haemostatic assays; and
• cell salvage.

Changes in management as a result of the guideline: 

The new guideline recommends MHPs be established as standard of care in all institutions managing patients with critical bleeding. In addition to routine physiological markers, the new guideline recommends temperature, biochemistry and coagulation profiles be measured early and frequently, providing parameters that define critical derangements. Ratio‐based MHPs should include no fewer than four units of fresh frozen plasma and one adult unit of platelets for every eight units of red blood cells. In the setting of trauma and obstetric haemorrhage, administration of tranexamic acid within three hours of bleeding onset is recommended. The use of recombinant activated factor VII (rFVIIa) is not recommended. There was insufficient evidence to make recommendations on the use of viscoelastic haemostatic assays or cell salvage as part of MHPs.