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1.15 Severe perioperative blood loss (Pathophysiology, clinical presentation and management)

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First, pathophysiology

This is the most important part. We have to break this cycle of bleeding:

  1. Blood loss causes hypothermia which causes the clotting factors to stop working.
  2. Next, because of this blood loss, the body tissues are not getting enough oxygen so they switch to anaerobic metabolism. This further destroys the clotting factors.
  3. Next, to recover the blood volume, we are giving more fluids or even packed red blood cells which further dilutes the clotting factors.

We define two types of bleeding:

  1. Severe bleeding: >700 to 900 ml blood lost.
  2. Massive bleeding: 5 - 6 l of blood lost in 24 hours so the entire blood volume essentially or >50% of the blood volume lost in 2 hours.

Management:

We essentially have to recontruct blood from its components:

  1. First thing is to provide red blood cells which are given by Packed Red Blood cells. The goal is to keep hemoglobin >80 g/l (normal is 120 - 160 g/l).
  2. Next, we need to provide clotting factors and plasma which are given by fresh frozen plasma.
  3. We also need to provide platelets if the platelet count drops below 50,000 /l.
  4. We need to provide fibrinogen so that it can be converted to fibrin to form clots. 2 - 4 g is enough.
  5. Lastly, cryoprecipitate which contains specific clotting factors for the patient if they have a specific clotting factor deficiency.

Transfusion complications:

We can remember them thinking about Anne who just starting working at the infusion shop as an automechanic. She is managing a car with excessive fuel loss and her boss reminds her: "You will TRIM the TROLLEY'S TRANSMISSION, ANNE."

  1. TRIM: Transfusion related immuno modulation which is the weakening of the immune system due to infusions.
  2. Trolley: this is actually TRALI which stands for Transfusion related acute lung injury.
  3. Transmission: transmission of hepatitis B/C or HIV. Rare, but still a risk.
  4. Anne: ABO blood type compatibility checking. If there is no time to check, just give O-

Clinical Protocol:

  1. First step is to stop the leak surgically.
  2. Then we should think about giving blood. Again, check the ABO blood type. Its always better to perform this blood test before surgery just in case.
  3. Now, if we do need to give blood, we need to warm it to 37 degrees.
  4. Hemoglobin should be maintained above 80 g/l of blood and hematocrit >20%.