Introduction
Bleeding during surgery is a significant complication that could increase morbidity risk. The major causes of bleeding could be a prevailing bleeding disorder that was not detected preoperatively, the type of surgery, and acquired abnormalities related to clotting. Various hemostatic changes occur post-trauma and certain complicated surgeries like cardiac surgery and liver transplantation. The standard approach to treating such a patient includes the following:
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Administration of blood from a compatible donor (allogeneic blood).
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Use of certain drugs.
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Use of recombinant hemostatic factors.
The pharmacological drugs used for perioperative bleeding control are:
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Desmopressin.
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Fibrinogen.
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Tranexamic acid.
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Prothrombin complex concentrates.
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Testing the patient for clotting disorders with the help of rotational thromboelastometry, thromboelastography, and platelet function assays has shown that targeted therapy can be used for hemostasis (stoppage of bleeding).
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To improve the management of such conditions, a strategic plan is needed to reduce the risk of blood transfusion and the use of blood products.
What Causes Heavy Bleeding During Surgery?
Several factors can result in bleeding in patients undergoing surgery, and they include:
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Blood loss.
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Hemodilution.
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Dysfunction of the platelets.
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Activation of fibrinolytic.
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Inflammatory pathways.
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Hypothermia (reduced temperature).
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Bleeding after surgery consists of both preoperative and acquired (due to prescribed anticoagulants) hemostasis defects.
What Are the Perioperative Strategies Used To Manage Bleeding?
The strategies for managing bleeding complications include the following:
1. Intraoperative Strategies:
- Blood Transfusion: A refractive transfusion threshold is used for individuals with little blood loss, that is, less than 500 milliliter of blood loss. The refractive transfusion threshold is defined as blood transfusion to those with less than 7 grams per deciliter. Blood transfusion should be used to replace lost blood if the patient shows signs of anemia or the hemoglobin threshold is reached. Red blood cell transfusion and fluid therapy are also required if significant bleeding of more than 500 milliliter cannot be contained.
- Fluid Therapy: Fluids are administered until the hemoglobin level goes down the transfusion threshold. Fluid administration is carried out with the help of either a balanced electrolyte crystalloid solution or a colloidal solution to maintain an average blood volume. A large volume of standardized crystalloid solution should be avoided, as it may lead to dilutional anemia and coagulopathy, leading to tissue-related side effects.
- Acute Normovolemic Hemodilution: This is an appropriate blood-saving strategy for individuals with normal preoperative hemoglobin levels who are expected to lose two or more units of blood during surgery. In this strategy, after the administration of anesthesia, some amount of blood is removed, and an average volume is maintained with the help of crystalloid or colloid replacement fluids. This is a safe technique that is used in healthy young adults. This is also a good option if a blood transfusion cannot be given.
- Maintenance of Normal Temperature: Hypothermia or a reduced temperature should be avoided during surgery. A decreased temperature leads to coagulopathy due to hampered platelet aggregation and reduced activity of the enzyme used in coagulation. This impairment leads to reduced clot formation, thus increasing blood loss. It has been found that even a little reduction in the temperature can lead to blood loss. In such instances, a blood warmer should be used for all refrigerated blood products used during transfusion. Apart from this, all intravenous fluids should be warmed with the help of blood-warming devices along with upper and lower body forced-air warming devices and blankets.
2. Surgical Techniques:
- Minimally Invasive Procedures: Procedures like laparoscopic surgeries are minimally invasive. These procedures reduce blood loss and thus the need for transfusion compared to open surgeries.
- Electrocautery: This procedure uses heat from an electric current to control bleeding from the smaller blood vessels and as a suturing technique for the larger blood vessels.
- Blood Recovery: This procedure emphasizes retrieving the blood that is lost. The shed blood is collected and filtered, and returned to the patient's body when transfusion is required. It is a safe procedure with a meager rate of side effects. It is significant in surgeries with heavy blood loss, such as cardiac surgery.
3. Pharmacological Management:
- Topical Hemostatic Agents: In some instances, hemostatic agents, tissue adhesives, fibrin sealants, and platelet gels are used along with the standard procedure and electrocautery to control bleeding.
- Systemic Hemostatic Agents: Systemic hemostatic agents reduce or treat heavy bleeding due to an anticoagulant or other cause of reduced hemostasis.
- Antifibrinolytic Agents: Antifibrinolytic agents are the commonly used intraoperative hemostatic agents. Fibrins are proteins that are formed during clotting. These prevent the destruction of the fibrin by plasmin, an enzyme that thus promotes hemostasis. These are commonly used in cardiac surgery, orthopedic surgery, and other procedures associated with colossal blood loss. The agents include Epsilon aminocaproic acid and Tranexamic acid. Aprotinin, an antifibrinolytic agent, increases morbidity in cardiac surgery patients.
- Desmopressin: Desmopressin is a drug that has been found to increase the levels of factor VIII (a factor involved in the blood clotting mechanism) by triggering their release from the blood platelets and endothelial cells.
- Coagulation Factor Concentrate: Factor concentrates such as fibrinogen concentrates and prothrombin complex concentrates replace allogeneic blood products.
- Protamines: Protamines are nuclear proteins that bind to DNA to provide structural integrity. It significantly reduces blood loss post-cardiac surgery.
- Direct Oral Anticoagulants: Direct oral anticoagulants are a group of anticoagulation factors used in patients with venous thromboembolic disease and stroke prevention.
- Antiplatelet Agents: Antiplatelet agents such as Aspirin are extensively used to prevent peripheral arterial disease, occlusive coronary artery, and cerebrovascular thromboembolism.
Conclusion
The probability of bleeding or blood loss is a significant complication in surgical procedures. Perioperative management of blood loss refers to managing bleeding complications with the help of blood transfusion and adjuvant therapies. Intraoperative administration of blood and components such as allogeneic blood (blood from a donor), red blood cells, platelets, cryoprecipitate, plasma products, fresh frozen plasma, etc., helps control blood loss. Other adjuvant therapies include drugs and strategies to prevent blood loss. Integrating pharmacologic agents, factor concentrates, and allogenic transfusion into a coagulation treatment plan during surgery is an effective strategy for managing bleeding in patients undergoing surgery.
