Strategies to minimize intraoperative blood loss during major surgery

Abstract

Background Reducing operative blood loss improves patient outcomes and reduces healthcare costs. The aim of this article was to review current surgical, anaesthetic and haemostatic intraoperative blood conservation strategies. Methods This narrative review was based on a literature search of relevant databases up to 31 July 2019 for publications relevant to reducing blood loss in the surgical patient. Results Interventions can begin early in the preoperative phase through identification of patients at high risk of bleeding. Directly acting anticoagulants can be stopped 48 h before most surgery in the presence of normal renal function. Aspirin can be continued for most procedures. Intraoperative cell salvage is recommended when anticipated blood loss is greater than 500 ml and this can be continued after surgery in certain situations. Tranexamic acid is safe, cheap and effective, and routine administration is recommended when anticipated blood loss is high. However, the optimal dose, timing and route of administration remain unclear. The use of topical agents, tourniquet and drains remains at the discretion of the surgeon. Anaesthetic techniques include correct patient positioning, avoidance of hypothermia and regional anaesthesia. Permissive hypotension may be beneficial in selected patients. Promising haemostatic strategies include use of pharmacological agents such as desmopressin, prothrombin complex concentrate and fibrinogen concentrate, and use of viscoelastic haemostatic assays. Conclusion Reducing perioperative blood loss requires a multimodal and multidisciplinary approach. Although high‐quality evidence exists in certain areas, the overall evidence base for reducing intraoperative blood loss remains limited.

Hong Kong Society of Clinical Blood Management recommendations for implementation of patient blood management

“…Permissive hypotension refers to the lowering of mean arterial pressure to values between 50 and 65 mm Hg with the goal of reducing blood flow to the surgical field, thereby reducing blood loss and improving visibility in the surgical field. 50 Studies have shown that permissive hypotension during anaesthesia reduced blood loss in spinal surgery, radical prostatectomy, functional endoscopic sinus surgery, and orthopaedic surgery. [51][52][53] It can also reduce blood loss and blood product utilisation in adult trauma patients with haemorrhagic shock.…”

A Model to Predict the Probability for Intraoperative Blood Transfusion During Lumbar Spinal Stenosis and Femoral Fracture Surgeries in Aged patients

“…These clinical characteristics will affect the blood loss and hemostasis of patients and the changes of their vital signs during surgery, the length of time in surgery, and the size of the surgical wounds, but cannot predict accidents that may occur during surgery. These clinical features must be observed preoperatively, but not during or after surgery [5][6][7] . Moreover, the in uencing factors for different diseases may vary, so this scoring system is different from other preoperative scoring systems, such as the system proposed by the American Society of Anesthesiologists 8 .…”

Measurement of Intraoperative Blood Loss in Minimally Invasive Neurosurgery

“…Blood loss during any type of surgery is one of the biggest problems faced in the OR today. Out of the estimated 313 million surgical procedures that are done worldwide annually, recent estimates show that at least 4.2 million people die within the 30 days of surgery per annum, which accounts for 7.7% of all deaths [1]. Perioperative bleeding remains a major risk during and after surgery and is associated with a high rate of death, complications, and healthcare resource use.…”