Management of the patient with potential for massive perioperative blood loss

What is massive blood loss?

Massive blood loss is defined variably as the loss of one blood volume within a 24-hour period, 50% volume blood loss within 3 hours or a rate of loss of over 150 ml/min. Normal blood volume is approximately 7% of ideal body weight in adults and 8–9% in children. It is often seen in the trauma setting or in emergency surgery but can also be anticipated in:

• patients undergoing cardiac surgery with cardiopulmonary bypass, obstetric procedures, organ transplantation, vascular or orthopaedic surgery;

• patients with pre-existing blood disorders or acquired coagulation deficiency;

• patients who elect not to undergo perioperative transfusion.

Preoperative evaluation

A thorough preoperative evaluation should be undertaken with enough time to allow preparation and optimisation should this be required. In addition to the routine history taking, examination and blood tests, it is worth considering a history of any previous blood transfusions, as the presence of red cell antibodies may affect the ability to have a rapid crossmatch. Any history of easy bruising or bleeding after dental procedures or minor operations may indicate a congenital coagulopathy and, in this situation, it may be appropriate to send off a full factor screen at the time of initial assessment. Drugs that may induce a coagulopathy should be considered, including herbal supplements that may inhibit clotting (chamomile) or platelet aggregation (garlic, ginger, fish oil). Consider risk factors for organ ischaemia, for example cardiac failure or ischaemic heart disease, which may alter the transfusion trigger threshold.

Treatment of anaemia

In an urgent situation, or when faced with an operation for a cancer diagnosis there is often not the time to treat with oral therapy. Treatment with erythropoietin [1] and/or intravenous (IV) iron [2] is effective at reducing the number of patients requiring allogeneic transfusions and the volume of blood transfused, and can be used to optimise iron stores and blood counts even if less than two weeks prior to surgery. The Centre for Perioperative Care Guidelines on the Management of Anaemia in the Perioperative Pathway [3] should be used if time allows.

Discontinuation of antiplatelet agents and anticoagulation

Ideally, all antiplatelet agents and anticoagulants should be discontinued prior to surgery with expected massive blood loss. This is not always possible, and liaison with specialists about appropriate management to balance bleeding risk with thrombotic risk is paramount.

Risks and consequences of massive perioperative blood loss

As part of the preoperative consultation, it is important to make the patient and family aware of the possible consequences of massive transfusion. Death as a result of massive perioperative blood loss is always a possibility and should be mentioned in the preoperative discussion. The morbidity of massive transfusion should be considered and discussed, including the need for invasive ventilation for lung injury and the risk of other organ failure requiring supportive management such as heart failure, renal failure, liver failure and the possibility of perioperative stroke.

The chances of these occurring will alter depending on age and other co-morbidities; scoring systems such as P-POSSUM consider blood loss as one of their surgical factors. Unfortunately, there is no way to quantify massive blood loss any further than as more than one litre in any perioperative risk scoring system and so, in these cases, it may not always be accurate. Surgical Outcome Risk Tool (SORT) mortality scoring and/or the National Surgical Quality Improvement Program should be used to allow communication of risks and allow a shared decision-making discussion, which is part of the NICE guidance [4].

Considerations for anaesthetic technique

Adequate large-bore IV access is essential to ensure fluids and blood products can be given quickly. Give consideration to a large-bore jugular sheath or vascath if at least two large-bore peripheral cannulae cannot be sited. Central line insertion is required to allow inotropes/vasopressors to be given according to measures of cardiac output and oxygen delivery. Arterial line insertion permits close blood pressure monitoring and allows regular sampling for thromboelastography (TEG) analysis and blood gases to monitor Hb and measures of organ perfusion (lactate and base deficit).

If appropriate, techniques to limit swings in blood pressure can be used, such as neuraxial block (either spinal or epidural) and remifentanil infusions. An infusion of metaraminol or noradrenaline (norepinephrine) can help to maintain perfusion pressure during periods of instability. This should be commenced at the start of surgery so that medication has passed through the dead space in the central line and is immediately available when required to maintain cardiovascular stability. Adrenaline in bolus and infusion concentrations should also be readily available.

A urinary catheter should always be inserted to monitor urine output and therefore renal perfusion. This also enables monitoring of complications, such as haematuria.

A rapid infusor system should be available to allow the quick administration of fluids and blood products. This should include a warming system to avoid intraoperative hypothermia.

Multidisciplinary approach

Management of massive bleeding intraoperatively requires a multidisciplinary approach [4]. Good communication between the surgical, anaesthetic and theatre teams is important. Should a large and rapid amount of blood loss be expected at any point during the surgery, communication of this is paramount, so that everyone can be prepared. This provides the opportunity to advise a ‘pause’ prior to performing any intervention that may result in significant loss. This allows ‘catch-up’ before proceeding with surgery. If significantly behind with resuscitation, then consideration should be given to packing the surgical site and carrying out resuscitation whilst minimising further blood loss before proceeding.

The hospital transfusion laboratory should be informed of the potential for massive blood loss before the case starts, so they can ensure that adequate transfusion products are available in an appropriate time frame. A major haemorrhage alert at the time of blood loss permits the appropriate allocation of staff in the laboratory to provide blood products as quickly as they are needed.

Adequate personnel, both nursing and medical, should be present to monitor blood loss, prepare equipment and drugs, check transfusion products, keep records and monitor the patient. If cell salvage is being used, consideration should be given to having one person dedicated to the management of this. Keeping clear and contemporaneous records allows a check of the situation with a simple glance and an easier review after the event if any investigation follows. Electronic health records can assist with this, but still need to be kept up to date, with one person dedicated to recording the events, observations, medications and units transfused.

Thromboelastography (TEG)

Several randomised controlled trials have demonstrated reduced blood product use when thromboelastography is used to guide transfusion [5]. Thromboelastography is an assay that measures the properties of whole blood clot formation, showing the interaction of platelets, the coagulation cascade and fibrinolysis. It often does not correlate with standard tests such as International Normalised Ratio, activated partial thromboplastin time (aPTT) and platelet count and has the advantage that it can be done as a point of care test. Fresh-frozen plasma (FFP), platelets and cryoprecipitation can then be given according to the clotting ability of whole blood, rather than the individual numbers. This is particularly important in pro-thrombotic states such as cancer, for which the usual ‘trauma’ ratio of blood:FFP:platelets as 1:1:1 often is not required.

Tranexamic acid

The use of this antifibrinolytic before and/or during the procedure has been shown to be effective at reducing total perioperative blood loss and the number of patients transfused when used in major surgery [5]. There has been some concern that giving tranexamic acid may increase the risk of deep vein thrombosis or pulmonary embolism, especially in those with cancer. This does not appear to be the case if used when blood loss is expected to be more than 500 ml and its use is widely recommended [6]. In trauma, a tranexamic acid infusion is often used to minimise blood loss, there is no evidence on their use in the context of elective surgery.

Cell salvage

In appropriate cases, cell salvage can be used as a way of minimising allogeneic red cell transfusion. However, in cancer cases with massive and rapid blood loss, the need for a leucocyte depletion filter and the inability to put this cell-saved blood in a rapid infuser limit its usefulness.

Monitoring for blood loss

This consists of regular visual assessment of the surgical field, including the extent of blood present, presence of microvascular bleeding, surgical swabs/sponges and volume in suction canisters [3]. Theatre staff should be regularly weighing the swabs and visibly recording the amount. In certain procedures, e.g. orthopaedics/obstetrics, the amount in the swabs may significantly outweigh the amount in the suction. Blood loss can be visualised directly by seeing how much blood is in the suction canister or by keeping a tally of how much blood has been lost by weighing used surgical swabs (Fig. 1).

Figure 1 Blood loss can be visualised directly by keeping a tally of how much blood is lost by weighing used surgical swabs (a) or seeing how much blood is in the suction canister (b).

Allogeneic blood transfusion

In cases in which blood loss is expected to be more than 2–3 litres, it is sensible to start transfusion early rather than to stick to transfusion limits to avoid periods of under-resuscitation and hypotension. In cases with expected losses of 4–5 litres, it is almost impossible to avoid allogeneic transfusion. In these cases, starting red cell transfusion early in the blood loss results in more cardiovascular stability and maintenance of organ perfusion and, therefore, potentially, fewer complications. Once past the point of major blood loss, a more restrictive threshold depending on the age and co-morbidity of the patient can be used in accordance with transfusion guidelines and best practice. Organising blood products and other fluids in order provides good visualisation of what has been given to the patient and how much. Bundling units into groups of five makes them easier to count when giving significant amounts of blood (Fig. 2).

Figure 2 Organising blood products and other fluids in order, provides good visualisation of what has been given to the patient and how much of it (a). Bundling units into groups of five (b) makes them easier to count when giving significant amounts of blood.

Monitoring for the adverse effects of transfusions

It is necessary to monitor hypothermia [7] and the presence of haematuria may indicate a transfusion reaction. These should be managed as per guidelines, by stopping the transfusion and informing the blood bank. Additional serious complications, such as transfusion-related lung injury or transfusion-related circulatory overload, may become apparent through increasing oxygen requirements, increasing airway pressures or a fall in cardiac output or oxygen delivery.

Calcium levels should be monitored on regular blood gases and supplementation given if required. Multiple doses may need to be given. In patients with hyperkalaemia, insulin and dextrose infusions may be needed to treat and avoid cardiac arrhythmias.

Postoperative management

Regular monitoring of blood counts and gases should continue in either intensive care or high-dependency units. Further blood loss into drains should be expected and, in some cases with a large surgical field, can be expected to be another 1–2 litres in the first 24 hours.

Further transfusion may be required. Aim for adequate, but not overly high, coagulation parameters and platelet counts. Consider regular tranexamic acid to reduce microvascular bleeding.

It is important to consider the plan for thromboprophylaxis as, at some point, the risk of venous thromboembolism (VTE) will outweigh the risk of further bleeding. This decision should be taken after discussion with the surgical, anaesthetic and critical care teams, and should be reviewed on a regular basis.

Research ethics statement

Not applicable to this article.

Consent for publication statement

Narrative articles are based on clinical vignettes and created to provide a framework for discussion and maximise learning. These are not based on real individual patients and do not describe discrete patient interactions or outcomes. The objective is to summarise an interesting topic in perioperative medicine in response to a specific clinical question posed by the authors.

Conflicts of interest statement

The author declares no conflicts of interest with this work.