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Agreed local guidelines should be available which have been produced by a multidisciplinary team including an anaesthetist, acute pain nurse, pharmacist, physiotherapist, critical care clinicians, surgeons and other relevant specialties.¹⁰ These guidelines should cover at least the following:

• protocol for whom to call for problems with postoperative pain relief
• management of complications including high spinal block, accidental dural puncture...

For ongoing management of major trauma patients there should be clear guidelines regarding decisions to transfer for definitive specialist intervention in co-ordination with regional trauma networks.⁶⁷

Near patient testing for haemoglobin, blood gases, lactate, ketones and coagulation should be considered, particularly in areas where major blood loss is likely.¹⁶ If near patient testing is not available, laboratory testing should be readily and promptly available.

There should be a major haemorrhage protocol to cover the use of blood and blood products in appropriate proportions in a series of ‘shock packs’.⁸⁹

In MTCs and in other large acute hospitals, prethawed plasma should be immediately available with the initial shock pack.

Utilisation of blood and blood products should be guided by point of care testing together with methods to minimise blood loss.²⁴

There should be clear guidance on damage control resuscitation which is understood by all staff.⁹⁰

There should be clear guidelines on how to manage patients on anticoagulant therapy presenting with trauma or for elective orthopaedic surgery. Specific reversal agents may be required, such as prothrombin complex concentrate in the trauma setting in patients on warfarin. Direct oral anticoagulants (DOACs), patients on dual antiplatelet therapy (DAPT) and second generation drug eluting stents (DES) all require careful...

There should be a policy for the prevention of thromboembolic events postoperatively. This should include planning for anticoagulant prophylaxis in patients who are vulnerable to further bleeding.

NICE Guidance 157 provides clear guidelines for centres providing primary joint replacements we should be adhered to.⁷⁵ Additionally, enhanced recovery programmes should be promoted for the benefits of early mobilisation and reduced mortality associated with their use.