Intraoperative bleeding is a major complication during and after surgery that often results in increased morbidity and mortality. Steps can be taken preoperatively to identify patients at higher risk and facilitate appropriate preparation. However, the surgical and anesthesia teams must be ready to intervene if severe bleeding does occur in surgery patients. 

Patients should be assessed for their bleeding risk in the preoperative period. A proper risk assessment should ascertain whether or not there is a prior history of bleeding after surgery or trauma, menorrhagia in female patients, drug history related to anticoagulant and antiplatelet medication, and a family history of any bleeding disorders (1). Increasingly, anticoagulant and antiplatelet medications are being continued into the perioperative period. Drug-induced coagulopathy and/or platelet inhibition are important risk factors in patients treated with anticoagulants or antiplatelet therapy (2). Therefore, an individualized assessment of the thrombotic risk of discontinuing these medications should be balanced against the risk of intraoperative bleeding (1). 

Traditionally, in the presence of severe bleeding in surgery patients, management involves replacement of the blood volume lost with allogeneic blood transfusions (ABT) and any missing coagulation factors. In severe trauma, following current guidelines, initial resuscitation usually involves the transfusion of balanced ratios of red blood cells, fresh frozen plasma (FFP), and platelets (2). However, it has become increasingly clear that ABT itself is an independent risk factor for poor clinical outcomes. Moreover, the cost of transfusion continues to escalate, as well as the gap between supply and demand of this precious resource. Consequently, it is important to utilize other methods to manage severe bleeding during surgery.  

Some pharmacological treatments have demonstrated benefit in reducing intraoperative blood loss. Epsilon aminocaproic acid (EACA) and tranexamic acid (TXA) are analogs of the amino acid lysine and reversibly inhibit fibrinolysis by binding the lysine-binding sites on plasminogen, limiting the activation of plasmin which degrades fibrin. Interestingly, a meta-analysis of EACA and TXA in the setting of elective surgery found that the evidence of hemostasis was stronger for TXA than for EACA with a relative risk reduction of 39% and 25%, respectively, in the need for blood transfusions (3). Additionally, early use of TXA in trauma has been associated with a reduction in mortality due to bleeding and all-cause mortality. Because the hemostatic responses to surgery and trauma are similar, TXA might reduce mortality due to bleeding in surgery patients. TXA can also be used in topical form — a systematic review showed that it reduced blood loss by 29% and the relative risk of receiving a blood transfusion by 45% in cardiothoracic, oral, orthopedic, otorhinolaryngeal, spinal, and urological surgery (4).  

Another method of managing severe bleeding in patients during surgery is cell salvage. Cell salvage is an established technique in cardiac, orthopedic, and vascular surgery and should be considered when the anticipated blood loss is >1000 mL (1). It is performed with the use of a double lumen suction device to collect blood. Blood is stored within a reservoir with added anticoagulant and once enough blood is collected, the RBCs are washed, filtered, and suspended in saline to be returned to the patient. It is important to note that re-transfused RBCs from cell salvage have no clotting factors, platelets, or plasma, and thus additional therapies may be required to achieve adequate hemostasis (1). However, use of cell salvage reduces the relative rate of ABT by 38%and improves cost effectiveness compared to ABT. Though there have been concerns about the potential harmful effects of bacteria and malignant cells aspirated from the surgical field, studies have shown that there is no increase in positive culture or postoperative infection despite the aspiration of blood contaminated with microorganisms which the washing process is unable to eliminate completely (1).  

References  

1. Desai N, Schofield N, Richards T. Perioperative Patient Blood Management to Improve Outcomes. Anesth Analg. 2018;127(5):1211-1220. doi:10.1213/ANE.0000000000002549 

2. Erdoes G, Faraoni D, Koster A, Steiner ME, Ghadimi K, Levy JH. Perioperative Considerations in Management of the Severely Bleeding Coagulopathic Patient. Anesthesiology. 2023;138(5):535-560. doi:10.1097/ALN.0000000000004520 

3. Henry DA, Carless PA, Moxey AJ, et al. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2007;(4):CD001886. Published 2007 Oct 17. doi:10.1002/14651858.CD001886.pub2 

4. Ker K, Beecher D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev. 2013;(7):CD010562. Published 2013 Jul 23. doi:10.1002/14651858.CD010562.pub2 

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