Massive perioperative hemorrhage: Considerations in clinical management

Massive perioperative hemorrhage can be a significant challenge that requires immediate multidisciplinary response and communication between clinicians, nurses, paramedics, laboratory testing, and blood banks. Risk factors include major trauma, various surgical procedures like spine and cancer surgery, obstetric complications such as placenta previa, embryotic fluid embolism-induced DIC, and a few congenital or acquired coagulation defects. Patients may develop tachycardia, tachypnea, hypotension, reduced urine output, and altered mental status depending upon the severity of hemorrhage. The diagnostic tests of choice are thromboelastography (TEG) or/and thromboelastometry (ROTEM) as they can be performed at bedside without any delay waiting for laboratory results. Management options include blood transfusion depending upon the hemoglobin levels; volume expanders; antifibrinolytic agents such as ε-aminocaproic acid, tranexamic acid, and aprotinin; and other strategies. Proper patient positioning during massive perioperative hemorrhage could be an effective remedy in bleeding control along with measures like maintaining normothermia and acid-base balance. Prothrombin complex concentrate is an ideal option for the patients already undergoing treatment with anticoagulants as warfarin. FFP is the treatment of choice for dilutional coagulopathy defined as the "loss, consumption, or dilution of coagulation factors that occurs when blood is replaced with fluids that do not contain adequate coagulation factors. " Anesthesiologists should also be suspicious for undiagnosed congenital or acquired coagulation defects which may lead to certain morbidities and mortalities perioperatively. Massive hemorrhage requires replacement by massive transfusion. So, massive transfusion guidelines and components are also briefly discussed in this chapter.