Catastrophic Intraoperative Haemorrhage : A Surgeon’s Nightmare & An Anaesthetist’s Distress

If the surgeon cuts a vessel and knows the name of that vessel, the situation is serious; if the anaesthetist knows the name of the vessel, the situation is irretrievable.

Maldwny Morgan 1938, (Anaesthetist, London)

Catastrophic Intraoperative Haemorrhage is any surgeon’s Nightmare & An anaesthetist’s distress. Hemorrhage is the No. 1 killer in the operating room all over the world. Intraoperative critical events are found to occur in 6.85/10,000 anesthetic events. Hemorrhage is responsible for 33% of cardiac arrests and 47% of deaths. Massive hemorrhage can be defined as follows: (i) blood loss exceeding circulating blood volume within a 24-hour period, (ii) blood loss of 50% of circulating blood volume within 3-hour period, (iii) blood loss exceeding 150 ml/min, or (iv) blood loss that necessitates plasma and platelet transfusion. Some factors other than the volume or the speed of blood loss threaten surgical patient .Patient’s ischemic co-morbidity, preceding anemia, delay of blood transfusion, and delay of blood supply may make hemorrhage critical regardless of blood loss. Human factors affecting hemorrhagic critical events include inappropriate judgments (27%), poorly developed skills (26%), delay of recognizing bleeding during endoscopic procedures (3%), and incorrect handling of surgical devices (3%). However, communication between surgeons and anesthesiologists seems to be poor in 34% of the cases. Details of anesthetic management factors responsible for critical events are hypovolemia just prior to bleeding (12%), shortage of supportive anesthesiologists (10%), delay in ordering additional blood products (9%), shortage of rapid infusion/transfusion apparatus (8%), delayed judgment to start blood transfusion (7%), and delayed addition of venous routes (5%). Maximal speed of blood loss exceeds 120 ml/min in about half of the cases of critical hemorrhage,. Therefore maintaining multiple large-bore blood access is a prerequisite for saving a patient’s life. A 16 G (grey) and 18G (green) IV cannula provide a maximal flow rate of 180ml/min, and 160 ml/min respectively.

Anesthesiologists should be cautious when controlling anesthesia depth. Hypotension induced by anesthetic drugs affect critical events in 1.9% of patients developing life-threatening hemorrhage. More importantly hypertension, bucking, and patient movement, which are manifestations of light anesthesia or shortage of muscle relaxants, are reported to induce hemorrhage. Therefore, maintaining adequate levels of anesthesia depth is important to avoid anesthesia-related or anesthesia-induced critical haemorrhage.

The time required for emergency delivery of blood products from blood banks to OT seems to be between 30 and 45 min .Blood-type examination takes 9+/-7 min. Cross-matching takes 25+/-12 min.The time required for blood-type examination and cross-matching might be longer during nights or weekends. We should also consider the following points: (i) withdrawing blood samples from a patient and then transporting them to blood transfusion services will take about 15 min. Blood testing during nights or weekends by untrained staff can cause errors in blood-type judgment and in clerical work.

Anesthesiologists should also be cautious of complications caused by massive and/or rapid transfusion. Hypothermia and hyperkalemia, both of which might cause cardiac arrest, have been reported to complicate 2.9% and 1.2% of patients with massive hemorrhage, respectively. Mortality rate increases with increasing blood loss and with decreasing minimum intraoperative hemoglobin level. Therefore, a margin of safety in hemoglobin level should be considered in massive hemorrhage. In the British guidelines on massive hemorrhage, maintaining hemoglobin levels of more than 8 g/dl is recommended, while it is stated that the general indication of RBC transfusion is hemoglobin levels of less than 6 g/dl. We should also be aware that hemoglobin level is a poor indicator of blood loss in acute situations. Serum lactate levels (easily obtained by point of care ABG sampling) are useful in interpretation of Hb levels in the right perspectives. High lactate levels suggest haemoconcentration and hence false high Hb readings. If the S.lactate level is between 3-4 and Hb is 8gm%, the actual Hb could be just 6 gm%. The incidence of acute hemolytic reactions mainly due to major mismatch has also been reported to be 1/25,000-50,000 units.

The principal components of disaster medicine are summarized as CSCATTT: C for command, S for safety, C for communication, A for assessment, T for triage, T for treatment, and T for transport. To rapidly deal with critical bleeding in the operating room, effective communication among responsible staff is mandatory, especially between anesthesiologists and surgeons, between operating rooms and blood bank. When critical bleeding occurs, a commander, a person in charge, is appointed. Senior anesthesiologist or senior nursing incharge are candidates for commander.A commander comprehensively assesses hemodynamics, the hemostatic condition, and blood product supply system, and then consults the surgeon regarding the continuation of planned surgery or change of surgical procedure. A commander has to keep in mind the following points: prompt decision-making, concrete as well as concise instructions, following the rules of the game, watching for violations by medical staff, and confirmation of exact time recording. When the blood type is clear, but time is short, the cross-matching test is omitted, and the same ABO-type blood is used. When ABO-identical RBCs are not available, ABO-compatible, non-identical RBCs are transfused. When the patient’s blood type is AB, A- or B-type RBCs should be considered prior to O-type RBC transfusion. Delayed hemolysis may occur several hours to 3 weeks after transfusion. Symptoms are severer, the earlier the reactions occur. When hemolysis develops, a febrile reaction and hemoglobinuria may develop. Warming blood products with the exception of PC is mandatory when the transfusion speed exceeds 50 ml/kg/hr. Complications due to massive and rapid transfusion include metabolic changes (citrate intoxication, hyperkalemia, and hypothermia), dilution coagulopathy, and circulatory or iron overload.

A commander and a surgeon should discuss and decide surgical procedures: accomplishment of scheduled procedures, change to the minimum procedures, bimanual compression of the bleeding point, temporary packing fibrin glue, clamps of the artery or the aorta, or damage control surgery or interventional radiological procedures like arterial embolization. Hypothermia, acidosis, persistent hypotension, and shortage of blood products are the absolute indications for damage control surgery. It is desirable that the hospital transfusion committee prepares hospital regulations on “actions to be taken against critical bleeding”, and practices them in simulation. Establishing hospital actions enables a structured response against critical haemorrhage. In critical hemorrhage, a patient’s life mainly depends on manpower and the availability of blood products. In terms of manpower, the quantity as well as the quality is important. Anesthesiologists, surgeons, radiologists, nurses, and technicians in the operating room and staff of blood transfusion services are all essential to save a patient’s life. The survival rate after massive or critical hemorrhage might be higher in a hospital where surgeons can perform damage control surgery and radiologists can perform interventional radiology. Hemorrhagic mortality and morbidity in the operating room can be reduced by a systemic, not an individual approach.

In nutshell key action points in the management of bleeding catastrophes in the operating room include:

• Call for help, and request extra personnel.
• Activate a massive blood transfusion protocol.
• Communicate closely with the surgical team.
• Identify the source of bleeding, and try to achieve hemostasis as soon as possible, either temporarily or permanently.
• Obtain large, secure intravenous accesses and a rapid infusion system.
• Continuously monitor vital signs; consider invasive hemodynamic monitoring.
• Ensure the accuracy of the blood-checking process.
• Detect and treat complications of massive blood transfusion (eg, hypothermia, dilutional coagulopathy cardiac overload and hypocalcemia, hyperkalemia)
• Consider administration of recombinant coagulation factors and non-blood product hemostatic agents.
• Establishment of a postoperative care pathway after massive haemorrhage and massive blood transfusion.

Dr. A. K. Dewan
Director – Surgical Oncology