Strategies to Reduce Blood Loss During Surgery

Minimizing blood loss during surgery procedures is an important aspect of patient care that can help reduce over-reliance on blood transfusions and improve postoperative recovery. A comprehensive approach to reduce blood loss begins well before surgery and extends throughout the perioperative period, integrating a multitude of strategies and techniques to ensure the best possible outcomes.

In the preoperative phase, optimization of the patient’s health status when possible is ideal. A thorough evaluation of the patient’s medical history that focuses on any underlying conditions that may increase the risk of bleeding, such as coagulopathies or the use of anticoagulants, informs preoperative strategies to reduce blood loss during surgery. When possible, adjusting relevant medications and correcting any coagulation abnormalities are important steps in preparation for surgery. Additionally, preoperative anemia (if present) should be addressed, as it is associated with increased transfusion requirements and adverse outcomes. Iron supplementation and erythropoiesis-stimulating agents should be considered to optimize the patient’s hemoglobin levels prior to surgery (1). Tranexamic acid (TXA), a synthetic derivative of the amino acid lysine, is commonly administered in the preoperative phase for patients undergoing procedures with a high risk of bleeding. TXA reduces fibrinolysis by inhibiting the activation of plasminogen to plasmin, thereby stabilizing blood clots and reducing blood loss. Numerous studies have supported the use of tranexamic acid across various surgical disciplines, demonstrating its efficacy in reducing the need for blood transfusions and improving patient outcomes (2).

As the patient enters the intraoperative phase, strategies to reduce blood loss center on surgery technique and anesthetic management. The advent of minimally invasive surgical techniques has significantly reduced blood loss by offering enhanced precision and minimizing tissue trauma compared to traditional open procedures. Techniques such as laparoscopic and robotic-assisted surgeries are associated with smaller incisions, less postoperative pain, and quicker recovery times, alongside the benefit of reduced blood loss. Intraoperative blood loss can also be effectively managed through careful surgical technique and the cautious use of hemostatic agents. For instance, electrocautery, ultrasonic devices, and advanced suturing techniques contribute to effective hemostasis. Topical hemostatic agents, such as fibrin sealants and absorbable hemostats, are used to control bleeding from capillary, venous, and small arterial sources, particularly in areas where traditional sutures are impractical. Moreover, controlled hypotension, a technique where blood pressure is intentionally reduced during surgery, has been employed in certain surgeries to decrease bleeding and improve surgical field visibility. This technique requires careful monitoring and is contraindicated in patients with certain cardiovascular conditions (1). Intraoperative cell salvage is another strategy that has gained traction. This technique involves collecting the patient’s blood lost during surgery, processing it, then reinfusing it, thus reducing dependency on allogeneic blood transfusions. Cell salvage is especially useful in surgeries that are expected to result in significant blood loss, such as cardiothoracic and major orthopedic surgeries (3). Additionally, maintaining normothermia is a critical component of intraoperative management, as hypothermia can impair coagulation and enhance bleeding. Active warming measures, including forced-air warming blankets and warmed intravenous fluids, can be employed to maintain the patient’s body temperature within the normal range (4).

Strategies to reduce blood loss during surgery encompass preoperative optimization and intraoperative management strategies. From the use of pharmacologic agents like TXA to the employment of advanced surgical techniques and intraoperative blood conservation methods, each step is integral to reducing blood loss, minimizing transfusion requirements, and ensuring optimal patient outcomes.

References

1. Spahn DR, Goodnough LT. “Alternatives to blood transfusion.” The Lancet. 2013;381(9880):1855-1865. doi:10.1016/S0140-6736(13)60146-8.
2. Ker K, Edwards P, Perel P, Shakur H, Roberts I. “Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis.” BMJ. 2014;348:g2212. doi:10.1136/bmj.g2212.
3. Carless PA, Henry DA, Moxey AJ, O’Connell DL, Brown T, Fergusson DA. “Cell salvage for minimising perioperative allogeneic blood transfusion.” Cochrane Database Syst Rev. 2010;(4):CD001888. doi:10.1002/14651858.CD001888.pub3.
4. Rajagopalan S, Mascha E, Na J, Sessler DI. “The effects of mild perioperative hypothermia on blood loss and transfusion requirement.” Anesthesiology. 2008;108(1):71-77. doi:10.1097/01.anes.0000296719.73450.52.