Pain Management During Blood Loss

RUNNING HEAD: PAIN MANAGEMENT IN A PATIENT WITH MASSIVE BLOOD LOSS

Pain Management in a Patient with Massive Blood Loss Without the Use of Analgesia and Sedation due to Severe Hypovolemia

Mollie Meador

NSG 441

May 7, 2010

Introduction A twenty three year old female was admitted to the ICU at South Central Medical Center following uterine rupture and massive blood loss. The patient was ten weeks pregnant and experienced a miscarriage as evidenced by spontaneous vaginal bleeding and pain. Upon visitation of her doctor’s office, a D&C was performed to remove any fragments left from the abortion. During the procedure, the patient’s uterus ruptured due to previous caesarean section scar dehiscence. This is a relatively common occurrence due to the weakened structure of the uterus and vulnerability of the membranes at the site of scarring. The subsequent need for an emergency total hysterectomy put her at an increased risk for further hemorrhage. The client had experienced no complications with her previous two pregnancies in which both were delivered via cesarean section. The patient had an unremarkable health history, with no history of anemia, hematological anomalies or cardiac problems. Her medical diagnosis was hypovolemia, with using extensive to avoid hemorrhagic shock. During surgery, the patient received eight units of packed red blood cells, two units of fresh frozen plasma, two liters of Hespan, and eight liters of fluid. Her estimated blood loss throughout the procedure was 4500ccs. Prior to the emergent surgery, the patient’s vital signs and laboratory values were completely normal. Upon arrival to the ICU, her hemodynamic status was critical, with a red blood cell count of 3.5; Hemoglobin of 10.7; Hematocrit of 30.2, and Platelets were 142,000. Her blood pressure ranged from 56/30 to 80/62, and her heart rate fluctuated from 130 beats per minute to 153 beats per minute. Her oxygen saturation stayed relatively stable due to the mechanical ventilation she was receiving. Her skin was pale and cool to the touch, reflecting decreased tissue perfusion. The need for further blood and fluid replacements was essential. Throughout the night fourteen units of packed red blood cells were administered, two more units of fresh frozen plasma, one unit of platelets and two units of cryoprecipitate. These extensive fluid resuscitation measures reflect the severity of the patient’s condition. During the shift, her hemodynamic measures were critical, with every parameter significantly decreased, putting her particularly at risk for DIC. This is expected in a patient with massive hemorrhage due to the absence of essential clotting factors. The patient’s INR was 1.6; PT-19.1, PTT-47.9, Fibrinogen of 95, and a D-Dimer of 3147 on admittance to the ICU. These values represented the classic predisposition for DIC as evidenced by the massive bleeding and lack of appropriate clotting factors. After multiple transfusions, the final labs for the shift reflected no significant increase in hemodynamic parameters with a red blood cell count of 2.36, Hemoglobin of 6.9, and a hematocrit of 19.3. Throughout the night, the patient experienced severe anxiety and pain. The anxiety was primarily a result of mechanical ventilation she was receiving. The use of mechanical ventilation was necessary in ensuring adequate oxygenation while receiving blood products. The pain she was experiencing was due to the surgical incision on her abdomen and the uncomfortableness of mechanical ventilation. Because the patient’s blood pressure was so low throughout the process, analgesics and sedation was not an option, given they lower blood pressure and respirations even more. This proved to be a huge obstacle in her care because she was very anxious and would become agitated and upset, requiring the nursing staff to use non-pharmalocigal means of relaxation. Her pain was attempted to be controlled with the same measures. Extensive time was spent with the patient making her as comfortable as possible. Frequent suctioning of the oropharanyx provided her with some relief of the “choking” sensation she was feeling from the endotrachial tube. Visualization exercises were performed to try and distract her from her pain and anxiety. A cool compress was frequently applied to her head, face, and neck and significantly eased her discomfort. During times of severe distress from the anxiety and pain of her situation, verbal communication was a key tool that was used. Much time was spent explaining to the patient that the sensation of “choking” or feeling the need to vomit were complications of the endotrachial tube, and the patient was led through various relaxation techniques. Nursing care focused on consoling the patient and providing a relaxing environment and positive encouragement throughout the night. Constant monitoring was essential in the care of this patient given that alterations in hemodynamic parameters could reflect more blood loss. During the night, the patient’s blood pressure began to drop significantly from the consistent values and her heart rate significantly increased, with respirations increasing. These changes compelled the nursing staff to assess for any further bleeding that had occurred. Upon turning the patient, a massive pool of blood had collected under her back; proving the hypothesis correct. The increased flow of blood from her vagina continued for thirty minutes then subsided, returning to a scant to moderate flow. The pathophysiology of hypovolemic/hemmorragic shock is based around the premise of inadequate blood volume circulating throughout the body. Organ tissues require a continuous supply of oxygen, and experience a decreased perfusion due to the lack of blood volume. Any alteration in cardiovascular status such as an inability of the heart to pump efficiently, low blood volume, or increased resistance of blood flow can result in hypovolemic shock. With decreased organ perfusion, total body system failure is a concern. Shock progresses through four stages. The initial stage uses compensatory mechanisms such as vascular constriction and increased heart rate. Classic signs of shock are not notable in this stage. During the compensatory stage, the mean arterial pressure begins to drop 10 to 15 mm Hg from the patient’s baseline. The kidneys respond by causing widespread vessel constriction using renin, aldosterone, and ADH. The intermediate stage occurs with a 20 mm Hg or more decrease in mean arterial pressure. In this stage, vital organs develop hypoxia while non-vital organs become anoxic or ischemic. The final stage of shock, known as the refractory stage, is termed “irreversible” due to the extensive organ damage resulting from the lack of oxygen supply (Ignatavicius pp 822-832). A priority nursing diagnosis for this patient would be Deficient fluid volume related to active fluid volume loss secondary to hemorrhage. Expected outcomes for this patient would be hemodynamic parameters within normal limits, sufficient oxygenation to prevent organ tissue death, and no further volume loss. Sufficient volume replacement and hemodynamic stability would allow the patient to be extubated and relieve the anxiety and pain associated with mechanical ventilation. A biopsychosocial nursing diagnosis would be Anxiety related to discomfort and pain secondary to mechanical ventilation and abdominal surgical incision. Outcomes for this nursing diagnosis would be observable decreased levels of anxiety and pain as evidenced by no increases in vital signs representing pain or anxiety, verbalization of a decrease in anxiety, and the use of non-pharmacological measures to decrease the anxiety resulting from pain. The reduction in anxiety and pain would facilitate a faster recovery. The purpose of this scholarly paper is to examine the procedure and importance of rapid and effective fluid resuscitation while reducing anxiety and pain using non-pharmalogical measures. Review of Literature Literature for this scholarly paper was obtained through The University Of Southern Mississippi’s library’s database, using EBSCO host, Academic Search Premier which led me to various journal articles concerning massive blood loss and what it entails, an overview of hypovolemic shock, outcomes of massive transfusions, data discouraging the use of analgesics and sedatives in hypovolemia, and non-pharmalogical measures to decrease pain and anxiety. Each article reflects the importance of accurate and rapid blood transfusions due to the life threatening effects of a lack thereof. One article describes the hemodynamic effects of analgesia and sedation and solidifies the rationale behind not administering them to my patient. A final article explains the use of non-pharmalogical measures that decrease anxiety and pain. Overall, the articles combined related a strong relationship in the ultimate goal of decreased anxiety and pain with appropriate and rapid hemodynamic stabilization. Stainsby, MacLennan, Thomas, Isaac, and Hamilton (2006) thoroughly explain the importance of managing massive blood loss. The article clearly defines guidelines to follow while performing massive fluid recusitation. A main concept of the article is the necessity of prompt action and a good relationship between the physicians, nurses, and laboratory workers to ensure a rapid correction in the hemorrhage (Stainsby et.al, 2006, p 635). The article outlined specific parameters that must be met to meet the goal of rapid correction, starting from choosing appropriate resuscitation fluids and progressing through inhibition of further bleeding and maintaining normal laboratory values. Communication between healthcare personnel and accurate documentation of the transfusions is essential to fulfill the physical and legal parameters of the procedure (Stainsby et.al, 2006, p236). Indices for red blood cell transfusions are noted as greater than or equal to 40 percent of blood volume lost (Stainsby et.al, 2006, p. 637). The transfusion of fresh frozen plasma and cryoprecipitate are discussed and their importance is noted in their contribution to blood volume and the replacement of essential clotting factors that are diluted during fluid resuscitation (Stainsby et.al., 2006, p.638). Disseminated intravascular coagulation is a severe potential complication in a patient with massive bleeding and must be prevented at all costs and corrected if suspected. Monitoring PT and APTT along with assessments of platelet count and fibrinogen levels can alert health care personnel of this potential complication (Stainsby et.al., 2006, p. 239). Other potential complications of massive transfusions are discussed and include hypocalcaemia, and hyperkalemia due to the shifts and decreases in fluids. This article fully related the necessity of immediate action and rapid stabilization in a patient with massive blood loss. Having an awareness of these considerations can assist in early reversal of the medical complications of massive blood loss resulting in a decreased time spent on a ventilator and in the ICU, subsequently decreasing anxiety. Kelley (2005) specifically outlines the different components of hypovolemic shock in her article. As a registered nurse herself, she relates the article to nursing care and the understanding of blood transfusions in detail. She begins with stressing the importance of rapid identification of hypovolemia and justifies this by reinforcing the concept that without adequate blood volume, a cascade resulting in death can occur (Kelley, 2005, p. 2). She gives a case study in which a patient exhibits several characteristics of shock, making it easy to visualize an actual event. The article proceeds to identify the different types of shock and their signs and symptoms. Hypovolemic shock is discussed in detail, exploring the role of compensatory mechanisms such as vasoconstriction and its effects on other body systems. Acid base disturbances that could be expected in a patient with hypovolemic shock are discussed. Metabolic acidosis is a primary concern because of its effect on the heart and it’s ability to contract (Kelley, 2006, p.6). Precise and accurate fluid resuscitation should correct this metabolic disturbance. Kelley stresses the importance of immediate and continuous cardiac monitoring throughout the resuscitation. This includes continuous blood pressure monitoring, oxygen saturation, body temperature, and amount of urine output (Kelley 2005, p. 7). The kidneys are a very important indicator of perfusion and an output less than 1ml/kg per hour reflects poor perfusion and a need for increased resuscitation (Kelley 2005, p. 7). Fluid management is discussed from an ICU standpoint. Kelley identifies the role of fluid resuscitation as increasing preload and maintaining oxygenation (2005, p.9). Volumes of fluids are usually infused at maximum rate until a response is noted; however, normal vital signs are not the only sign of adequate fluid replacement (Kelley 2005, p. 9). Crystalloids are preferred because they pose no detrimental side effects, with normal saline being the crystalloid of choice given it is the only one suitable to be given with blood products (Kelley 2005, p. 9). According to Kelley, patients who have lost 40% or greater of circulating blood volume that has not responded to fluid replacement could benefit from blood transfusions (2005, p. 10). The article goes on to describe the procedure of a massive transfusion, noting the need for large bore catheters, IV tubes that can withstand high volumes, and rapid transfusion devices (Kelley 2005, p. 11). In hemorrhagic shock, packed red blood cells with component therapies is the standard (Kelley 2005 p. 11). Transfusion reactions, coagulation problems, and hypothermia are discussed to further the knowledge of the transfusion process. It is key for nurses to be alert to these potential complications of transfusions and be ready to reverse the problem. MODS and SIRS are other complications that are discussed and addressed as potentially fatal problems, and should be prevented at all costs. Kelley concludes her article by describing the signals for an end point in resuscitation. Vital signs, along with urinary output are obvious parameters that reflect improvement; however, other methods such as gastric tonometry, oxygen delivery index, and mixed venous oxygen saturation reflect a deeper level of tissue perfusion (Kelley 2005, p. 16,17). The information in this article is related directly from a nursing point of view. Preventing hypovolemic shock is very important in patients with massive blood loss. The fewer the complications that arise from the blood loss, the easier and faster the patient’s recovery will be, thus alleviating fear, anxiety, and pain. In his article, Bowdle describes the adverse effects of opioid agonist and agonist-antagonists in anesthesia. An adverse effect of opoids is respiratory depression and can be a serious problem in a critically ill patient (Bowdle 1998, p.176). He discusses the different types of opoids and their levels of respiratory depression, with Morphine contributing greatly to respiratory depression. The article implies that following a rapid and large administration of morphine, histamines are released. Histamines play a role in decreasing blood pressure and increasing the heart rate (Bowdle, 1998, p. 179). This is an undesirable effect in a patient who is severely hypotensive. Hypotension is a frequent result of fentanly analogues such as Morphine, but can usually be treated intravenous fluids (Bowdle 1998, p. 179). Administration of hypnosedatives and opioids concurrently can exacerbate cardiovascular effects (Bowdle 1998, p. 179). Another potential problem with large opoid administrations is muscle rigidity, and myoclonus, both of which usually occur during anesthesia but have been documented hours postoperatively (Bowdle 1998, p.179). Other effects of opoid administration include increased intracranial pressure because of their vasodilitary effects, decreased motility in the gastrointestinal tract, and nausea and vomiting (Bowdle 1998, p. 179-180). This article clearly defines reasons why morphine should not be used in a patient with a severely compromised cardiovascular status. Huber-Wagner, Qvick, Mussack, Euler, Kay, Mutschler, and Kanz provide a detailed look at the benefits of massive blood transfusions in patients experiencing massive blood loss. In their research, they studied 1062 polytrauma patients, most of which requiring massive blood transfusions. This article defines massive blood transfusions as greater than ten units of packed red blood cells (Huber-Wagner et.al, 2006, p69). In their study, the researchers also weighed the pros and cons of the expensive nature effecting hospitals and patients, justifying the study. If the results of the study reflected justification in performing massive blood transfusions, the pros of lifesaving measures outweigh the cons of the costs. Massive blood transfusions pose many complications. Early complications include leukopeina, hypothermia, acidosis, hyperkalcemia or hypo calcemia, immunodulation and hemodilution/coagulopathy (Huber-Wagner et.al., 2006, p. 70). The late complications are manifested as organ failure, multiorgan failure, systemic inflammatory response syndrome, and hepatitis or HIV (Huber-Wagner et.al., 2006 p. 70). A limit to the amount of blood transfused was another parameter of the research. Mortality from massive blood transfusions was assessed and determined. The results of the research proved that a massive blood transfusion was not the most significant determinant of mortality in patients who have sustained traumatic injury or massive hemorrhage (Huber-Wagner et.al., 2006, p. 74). Complications associated with massive blood transfusions were assessed and determined to be of low incidence. Acute lung injury occurred in one in eight thousand transfusions, and that delayed fluid resuscitation increased mortality (Huber-Wagner et.al., 2006, p. 74). However, coagulatory problems and failure occurred in a significant number of patients who received massive blood transfusions, supporting previous literature (Huber-Wagner et.al., 2006, p. 74). Systemic inflammatory response syndrome and sepsis were also complications that were present in a significant amount of patients receiving massive blood transfusions (Huber-Wagner et.al., 2006, p. 74). According to the article, 167 units of packed red blood cells was the largest documented massive blood transfusion that resulted in survival (Huber-Wagner et.al., 2006, p.74). The article concludes that massive blood transfusions are necessary for an increased chance of survival following massive blood loss, even with the incidences of sepsis and organ failure increasing with extensive transfusion amounts, and aggressive management of massive blood loss with packed red blood cells is justified in the critical care setting (Huber-Wagner et.al., 2006, p. 75). Complementary and alternative medicine is more widely used in recent years than ever. Many methods have been established as acceptable practice and are used daily. However, some people respond more to the use of alternative medicine than others. Owens et.al conducted a study to try and differientate between people who are more susceptible to the benefits of alternative medicine. Mind body therapies like hypnosis are being examined to understand why some people are more likely to benefit from hypnotism (Owens et.al., 1999, p. 530). The concept of absorption arose out of the study, stating that some people have a genetic and personality disposition to benefit from alternative medicine practices, and the level of absorption is scaled (Owens et.al., 1999, p. 530). In the study, the researchers used patients who were regularly visiting pain clinics for pain treatment. Many alternative methods were used in place of traditional pain management. The point of the article was that people suffering from chronic pain have been documented to have decreased levels of pain using non-pharmacological methods of alternative medicine. Examples of these therapies are relaxation tapes, massage, guided imagery, and meditation (Owens et.al., 1999, p. 531). In comparing and contrasting the literature used, the necessity for rapid and accurate fluid resuscitation following massive blood loss is essential. Each author demonstrated an awareness of the importance of knowing standard procedures and complications involving blood transfusions. The main concern in stabilizing a hemodynamically unstable patient is replenishing fluid volume, which directly correlates with subsequent medication administration. Evidence supporting the lack of using opiates in patients with severely depleted fluid volume was provided, and non-pharmacological measures to control pain were encouraged. This collection of literature as a whole reflects the need for rapid identification of volume loss, immediate and quick fluid resusisitation, and stabilization and monitoring of hemodynamic parameters in order to resolve hypovolemia and ensure adequate tissue perfusion, while taking care to consider the hemodynamic effects of the drugs that may be administered for pain or sedation. During the process of fluid resuscitation and mechanical ventilation, which are necessary to reverse hypovolemia, comfort should be ensured and no additional stressors should be added to the situation. Using non-pharmacological methods of pain and anxiety control prove to suffice. Nurses involved in massive fluid replacements should be aware of the procedures and undesirable and desirable outcomes, while being attentive to client needs and providing care that will not further deteriorate the condition. As evidenced by the literature, blood administration and fluid volume replacement are delicate practices. Nurses typically institute these practices and should be aware of the extent of knowledge required to perform them successfully. Application to Clinical Setting The 23-year-old patient discussed previously experienced massive transfusions and benefitted from health care providers’ awareness of the severity of the situation and the discomforts associated with it. This important aspect of massive fluid replacement was evident in the article written by Stainsby et.al. She received twenty-one units of blood along with other blood products and tolerated them well. She did not experience any complications associated with massive transfusions and did not exhibit any signs of volume overload, representing a successful fluid resuscitation. The patient’s subsequent survival after the massive transfusion supports the assumption in the article by Huber-Wagner, et.al that a massive blood transfusion alone is not a definitive predictor of mortality. Her vital signs directly correlated with those in the literature experiencing hypovolemic shock. Nursing care was instituted by keeping the patient warm and cooling the patient when deviations in her temperature were noted, slowing the progression of shock. Warmed fluids were administered with consideration to hypovolemic shock. Vital signs and hemodynamic measures were carefully monitored and documented. Kelleys article addressed the need for these measures in a patient with hypovolemic shock. The physician made the judgment to restrict morphine or versed until the patient’s blood pressure had improved and heart rate had stabilized based on the knowledge of the potential cardiovascular effect of the drugs in further lowering blood pressure. The literature supporting this choice provided a logical rationale for withholding the analgesic and sedative drugs. IV normal saline was used as the fluid of choice in resuscitation, directly adhering to the standard of care in this patient. It was essential for the patient to remain calm to ensure proper oxygenation and no decline in vital signs, making non-pharmacological means of relaxation an essential tool in her care. Expected outcomes for this patient were met after meticulous nursing care and monitoring. The patient exhibited hemodynamic measurements that were improving throughout resuscitation, maintained sufficient oxygenation, and no further volume loss. This ultimately resulted in being able to administer Morphine and Versed by the end of the shift. The patient’s level of anxiety was significantly decreased along with her pain. Throughout the night, periodic increases in respirations, blood pressure, and heart rate reflected pain, but were controlled soon thereafter by non-pharmacological means of relaxation. When questioned as to whether or not her anxiety and pain were decreased, the patient responded by nodding her head. In conclusion, the patient responded well to fluid resuscitation and the expected outcomes related to her nursing diagnosis of fluid volume deficit were met. The improvement in her hemodynamic parameters allowed her to eventually receive pharmacologic relief of her anxiety and pain, while ensuring her return to normal health. During the time in which the patient could not receive medications to help with her anxiety and pain, she exercised the use of non-pharmacological methods to decrease these feelings. Visualization and focused breathing along with application of cool compresses alleviated those feelings and resulted in a positive outcome. This patient was a challenge on many levels. The blood loss she sustained put her in a life-threatening situation that could have ended unfavorably, and her unstable vital signs resulting from the blood loss prevented her from receiving traditional methods of anxiety and pain relief through medications. Nursing care had to be balanced between the delicate procedure of blood transfusions and the unusual need for extensive non-pharmacological therapeutic responses. Opportunities for Teaching and Quality Improvement This patient had many opportunities for teaching due to the technical aspects of her care that was delivered. She needed instructions for post-operative care, such as splinting her incision site, monitoring for any changes in the character of the incision, and infection control of the incisional site. This education will prevent further complications that could potentially cause her to suffer from infection or dehisinance, deterring her from subsequent hospital stays. The patient needed clarification concerning what went on during her time spent on the ventilator and blood transfusions. Going over what happened and explaining the technicalities of the process gives the patient a sense of control after an uncontrollable situation. Her need for a re-established control is important at this time. Discussions concerning the occurrence of her total hysterectomy should be aimed at providing the patient with answers as to why it was necessary and the life changes it precipitates. Grieving the loss of the potential for the birth of another child could be very hard for the patient to deal with and education concerning coping skills is essential. The patient was educated to rest as much as possible, avoiding strenuous activities. Since the patient had two young children, recommendations for help with childcare were given. The family required an extensive amount of education because the nature of the patient’s condition was so critical. Understanding the sequence of events that led to the patient’s delicate physical status was essential for the family to understand. Sometimes it is hard for the family of the patient in such a critical condition to understand how the patient deteriorated so quickly. Blood transfusions were explained and any questions the family had were answered directly. The family was concerned because the patient was receiving such an extensive amount of blood products. They needed to be reassured that the administration of blood had clear rationales behind it and was guided by laboratory values and response of the patient. The family had many questions concerning recovery of the patient and the questions were answered by encouraging rest and the need for their help in her recovery. Her husband asked if a total hysterectomy truly meant they would have no more children and was disheartened by the answer of yes. He was then educated on coping skills that would be necessary to exercise while grieving the loss of never having another child. This was very important information for him to be educated on not only for his mental well being, but also for his wife’s. Referrals Referrals for this patient may be made as needed. If the patient exhibits signs of poor coping skills regarding her total hysterectomy, psychological counseling may be needed. If she experiences any other problems associated with her surgery, she may be referred to a specialist regarding gynecological problems. Quality Improvement The nursing care that was delivered to this patient was concise and aggressive. However, the communication between the nurses in the ICU, doctors, and laboratory workers was less than desirable. The process could have moved much more quickly had this been addressed. Non-pharmacological methods of anxiety and pain reduction were not readily practiced and somewhat ignored by the staff. This was not done out of malice, but done because it required extra time from the staff. Nurses should be prepared to go to any extent to ensure optimal patient comfort, even if the means of doing so are unconventional. Significant Learning Any patient suffering massive blood loss and undergoing massive blood transfusions should be cared for very carefully. Close attention should be directed on monitoring the patient’s status, and deviations from the normal should be promptly evaluated and corrected. Blood transfusions are a delicate process that requires close attention to detail and necessitates a thorough understanding of the procedure. A thorough knowledge of medications that are ordered to be administered and their potential side effects should be a standard in nursing to prevent further deterioration of the problem. Learning how to communicate with a patient on a mechanical ventilator and being able to distinguish their needs through non-verbal communication is a very important skill. Therapeutic communication, including responses to sensitive questions and assertiveness while maintaining compassion, do not occur without conscious efforts to do so, and nurses should remain conscious of their responses to patients and patients’ family. The importance of pain management and anxiety control is a huge lesson in dealing with a patient in a helpless situation, such as being on mechanical ventilation. Attentiveness to the patient and patient’s needs should be the priority in care during a medical emergency such as this. Nursing is not simply caring for the physical needs of a patient, but the psychological and emotional needs too. Nurses can tend to forget that while practicing; therefore, every shift that is worked should be focused on the patient as a human, caring for all of mankind’s needs.

Resources Bowdle, T. (1998). Adverse Effects of Opioid Agonists and Agonist-Antagonists in
Anesthesia. Drug Safety, 19(3), 173-189. Retrieved from Academic Search Premier database. Huber-Wagner, S., Qvick, M., Mussack, T., Euler, E., Kay, M., Mutschler, W., et al.
(2007). Massive blood transfusion and outcome in 1062 polytrauma patients: a prospective study based on the Trauma Registry of the German Trauma Society. Vox Sanguinis, 92(1), 69-78. doi:10.1111/j.1423-0410.2006.00858.x.

Kelley, D. (2005). Hypovolemic shock: an overview. Critical Care Nursing Quarterly, 28(1), 2-19. Retrieved from MEDLINE database.

Owens, J., Taylor, A., & Degood, D. (1999). Complementary and Alternative Medicine and Psychologic Factors: Toward an Individual Differences Model of Complementary and Alternative Medicine Use and Outcomes. Journal of Alternative & Complementary Medicine, 5(6), 529. Retrieved from Academic Search Premier database.

Stainsby, D., MacLennan, S., Thomas, D., Isaac, J., & Hamilton, P. (2006). Guidelines on the management of massive blood loss. British Journal of Haematology, 135(5), 634-641. doi:10.1111/j.1365-2141.2006.06355.x.