Blood Loss During Abdominal Surgeries - Management and Prevention

Introduction

Each year, 313 million surgical procedures are performed worldwide. According to recent estimates, at least 42 million individuals each year pass away within 30 days of surgery, which accounts for 7.7 % of all mortalities worldwide. Even higher estimates of postoperative morbidity and complications exist. Perioperative bleeding is still a significant danger before, during, and after surgery and is linked to a high mortality rate, complications, and use of healthcare resources. Pre-operative anemia (a condition in which blood is not enough to meet the oxygen requirement of the tissue) and perioperative red blood cell transfusion have a big impact on surgical results. Developing patient-centered clinical pathways is intended to support and promote effective transfusion techniques, often known as the "three pillars of patient blood management" (PBM). They emphasize the prompt and effective therapy of anemia, blood loss prevention, and restricted transfusion when necessary. Lowering surgical blood loss enhances patient outcomes and lowers medical expenses. This article review current surgical, anesthetic, and hemostatic intraoperative blood conservation procedures to control blood loss.

What Are Blood Loss Management in Abdomen Surgeries?

Patient blood management (PMB), a widely accepted and World Health Organization (WHO) endorsed concept, seeks to control the problems of pre-operative anemia and blood transfusion. PBM implementation strategies have considerable advantages in proper transfusion practice, lower costs, and shorter hospital stays.

The following are the ways to manage blood loss in abdomen surgeries:

• Tourniquet - Tourniquets are widely used for blood loss management. They help to reduce intraoperative blood loss.

1. Nowadays, considerations other than blood management, such as the visibility of the operating field, determine whether to apply a tourniquet.
2. Using a tourniquet has drawbacks, such as greater postoperative (after-surgery) discomfort, decreased organ function, and a higher risk of thrombotic events.

• Antifibrinolytics - Antifibrinolytics, such as Tranexamic acid, are synthetic lysine analogs that inhibit plasminogen (a protein that dissolve blood clot) activation and provide clot stabilization.

1. In the UK, Tranexamic acid is recommended for all surgery where blood loss is expected to exceed 500 ml.
2. Tranexamic acid has been shown to reduce blood loss by approximately one-third in all surgical procedures.
3. It has been shown specifically to reduce blood loss.
4. The most important area of ambiguity is the best way to administer Tranexamic acid and when to do so. The administration of Tranexamic acid can be done orally, intravenously, intra-articularly, or in combination.
5. Weight-adjustable doses are typically between 4.53 and 9.07 mg/lb are possible.
6. During the intraoperative and postoperative periods, the administration may be repeated. Tranexamic acid can be given in repeat doses to maintain blood levels. It may play a greater role in prolonged surgery where a large blood volume is lost.
7. The disadvantage of Tranexamic acid is its high cost. It should be considered for all surgical procedures with anticipated moderate blood loss.

• Cell Salvage - Cell salvage is the method of recovering blood from the surgical field during the intraoperative or immediate postoperative phase that is then reinfused to the patient to cope with blood loss.

1. The current Association of Anaesthetists guidance recommends this procedures where a very high volume of blood loss is anticipated to be greater than 500 ml to warrant the use of cell salvage, as advised by the National Institute for Health and Care Excellence (NICE).
2. The principle is to use cell salvage in combination with other blood conservation strategies, when it is expected to reduce the likelihood of blood transfusion or severe postoperative anemia.
3. The procedure of cell salvage includes the collection of blood loss during surgery through a suction system, whereas postoperative blood collection is through surgical drains.
4. The collected blood is infused after being anticoagulated and filtered. Blood collected during surgery is typically washed and resuspended in normal saline. After selective suctioning, the blood is reinfused to the patient in order to prevent the collection of contaminated blood.

• Drains - Hematomas and surgical site infections are frequently reduced with the use of surgical site drains. Drains are effective in preventing postoperative complications.

• Surgical Technique - Multiple outcomes drive surgical advancements, such as the advent of laparoscopic and robotic surgery, but they may also lessen blood loss.

  1. According to a study in major abdominal surgeries, less blood was lost during surgery when doing laparoscopic as opposed to open procedures and robotic as opposed to laparoscopic procedures.

• Diathermy - Diathermy is a key instrument for attaining hemostasis during surgery, including monopolar and bipolar radiofrequency electrosurgery.

  1. There are several new products on the market, frequently in the form of bipolar sealing systems, that are said to do less harm to nearby healthy tissue.

• Topical Agents - Topical agents, including fibrin sealants (fibrinogen and thrombin), gelatine–thrombin matrices, and oxidized cellulose, may be applied to bleeding tissues during surgery to minimize blood loss.

How to Prevent Blood Loss During Abdominal Surgeries?

Preventing blood loss during abdominal surgeries is critical to ensure patient safety and positive surgical outcomes.

Here are some common techniques used to prevent blood loss during abdominal surgeries:

• Preoperative History - Detailed history of the patients, such as the history of bleeding before surgery, challenges faced during previous surgeries, family history, and response to the use of antiplatelet and anticoagulant therapy, is advised by guidelines. Routine coagulation testing is not advised in the presence of a negative history since it has a low predictive value for bleeding. A more detailed description of the symptoms and a referral to a hematologist interested in hemostasis should be requested for patients with a positive history of bleeding.

• Identification of High-Risk Patients - The scoring system of abdomen surgeries helps to identify high-risk patients. Consideration should be given to the type of surgery being undertaken.

• Anti-Coagulant Therapies - In order to lower the risk of serious cardiovascular and blood loss events, more patients are extending their antiplatelet (Aspirin, Clopidogrel, etc.) and anticoagulant (Warfarin) therapy into the perioperative stage. These concerns must be weighed against the bleeding risks associated with the procedure for each patient, which may include talks with the patient, surgeon, hematologist, and anesthetist.

Conclusion:

Substantial intraoperative blood loss is still a serious concern for surgeons. Early in the preoperative stage, strategies to mitigate this can be implemented, such as identifying and caring for high-risk patients. Precision in surgical technique and local hemostasis are essential components in managing bleeding during surgery. Cell salvage is helpful in managing blood loss. Although Tranexamic acid decreases blood loss, the best method, dosage, and timing of administration are still unknown. Blood loss can also be minimized with the use of additional anesthetic methods such as regional anesthesia.