A Consultant Hematologist in Victoria, Australia agrees with sentiments expressed about lack of evidence and utility of automatic protocols. However, she wishes to comment on item #4 on the previous page, about the role of cryoprecipitate. She manages obstetric hemorrhage at a large hospital where the hematologist is part of the 'team' approach to management of this condition, and has a role in co-ordination of blood product support, interpretation of lab results and assisting the laboratory in work priorities during an emergency. She finds that cryoprecipitate has a definite role in some obstetric hemorrhage and that without aggressive and early replacement of fibrinogen in some clinical circumstances, things can "get away from you".

In her opinion, any protocol for massive transfusion should assess the likelihood of DIC. In obstetric hemorrhage DIC should be considered if: (i) the patient has had abruption and amniotic fluid embolism, or primary post partum hemorrhage. and (ii) clinical assessment reveals bleeding from everywhere (lines, endotracheal tube, mucous membranes, etc) versus bleeding from the uterus/surgical site only. With abruption and 'bleeding from everywhere' the Australian colleague recommends that cryo be used early. The same can apply to trauma management where cryo is more likely to be medically indicated for patients with obvious clinical coagulopathy or major head injury, severe acidosis, hypothermia etc.

Continued