ANESTESI PADA

PERDARAHAN

M. Arief kurniawan
Intraoperative hemorrhage is generally defined
as blood loss exceeding 1000 mL or
requiring a blood transfusion.
Massive hemorrhage refers to acute blood loss
of more than 25 percent of a patient's blood
volume or bleeding that requires emergency
intervention to save the patient's life

SURGICAL BLEEDING
 Strategies to minimize intraoperative blood loss during
major surgery

British Journal of Surgery, Volume: 107, Issue: 2, Pages: e26-e38, First published: 05 January 2020, DOI: (10.1002/bjs.11393)
• Oxygen is carried in arterial blood dissolved in solution (<2%
when breathing air) and combined with haemoglobin (>98% in
air).

• Tissue hypoxia is a deficiency of oxygen at the tissue level; it may

be caused by increased demand, decreased supply or abnormal
cellular utilisation.

• The main physiological responses to acute normovolaemic anaemia

are increased cardiac output and increased oxygen extraction ratio.

• The ‘critical’ haemoglobin concentration is that below which tissue

hypoxia occurs; it is ∼50 g litre−1 in healthy humans.
 OXYGEN DELIVERY AND
HAEMOGLOBIN
DO2 = CO x CaO2
 The relative influence of anaemia on oxygen delivery

Parameter Normal Anae Anaemic +

mic oxygen therapy
Inspired oxygen (%) 21 21 100

PaO2 (kPa) 12 12 85

SaO2 (%) 98 98 98

Hb concentration (g litre−1) 150 75 75

Dissolved oxygen (ml litre−1) 3 3 19

Hb-bound oxygen (ml litre−1) 197 98 98

Total CaO2 (ml litre−1) 200 101 117

Cardiac Output 1000 505 585

Algorithm for the Management of
Oxygen Delivery
 FLUID SHIFTS IN
HAEMORRHAGE

■ Immediate Changes

■ Delayed compensatory mechanism

■ Later physiological adaptations

INTRAVASCULAR VOLUME
DEFICIT
■ If the loss is small or gradual, the body is able to
cope with the loss (e.g Slow GI Bleeding)

■ In Acute and Severe Loss, compensatory

mechanisms may not be able to cope and the
body suffers the consequence of hypovolemia
 HOW TO CALCULATE
BLOOD LOSS?
1. Clinical estimation : Inaccurate
2. Weigh a dry swab.
3. Weigh blood soaked swabs as soon as they are
discarded and subtract their dry weight (1ml of
blood weighs approximately 1gm).
4. Subtract the weight of empty suction bottles
from the filled ones.
• Estimate blood loss into surgical drapes,
together with the pooled blood beneath the
patient and onto the floor.

• Note the volume of irrigation fluids, subtract

this volume from the measured blood loss to
estimate the final blood loss
• Maximum capacity of
• Swab Small (10x10cm):
60ml
• Medium (30x30 cm): 140ml
• Large (45x45 cm): 350ml
• Floor spill
• 50 cm diameter: 500ml
• 75 cm diameter: 1000ml
• 100 cm diameter: 1500ml
 THE ACTUAL BLOOD LOSS
(MODIFICATION OF GROSS FORMULA)

MABL = EBV [Hct i - Hct f]

Hct m

• EBV = Estimated Blood Volume = BW (kg) x 70cc/kgbb

• Hct i, f m = initial, final, mean hematocrits
 DECISION TO TRANFUSE
BLOOD
• Percentage Methods
• Health : 30% blood loss
• Average : 20% blood loss
• Poor : < 10% blood loss
• Hemodilution methods
• Health : Hct 21 - 24%
• Average : Hct 24 - 27%
• Poor (Children) : Hct 30%
• The decision to transfuse will depend on the
clinical condition of the patient and their
ability to compensate for a reduction in
oxygen supply.

• Further blood loss should be anticipated,

particularly postoperatively.

• Whenever possible, transfuse blood when

surgical bleeding is controlled.
■ What if haemoglobin falls from 14 g% to 7g%?

■ What if Blood Pressure falls from 120 mmHg to

60 mmHg systolic?
EMERGENCY TRANSFUSION
• The utility of early blood product transfusion in the
treatment of severely injured patients

• Addressing volume requirements and tissue

oxygenation

• Prevent acidosis, dilution and coagulopathy

• ATLS : transition to RBC immediately after failure to

achieve hemodynamic stability with 2L of crystaloid
• Emergent transfusions are typically needed before
identifying a patient’s specific blood type,
UNCROSSMATCHED RBC are commonly used

• some trauma centres maintain dedicated blood refrigerators

within the emergency department (ED)

• the extensive logistics and cost of an offsite refrigerator,

• patients can be exposed to the risk of unnecessary URBC

products
• Blood component transfusion is an important and lifesaving
procedure. It is not risk-free and need careful consideration

• Risks of transfusion include

• haemolysis, transfusion-associated lung injury, infection,

immunosuppression, hyperkalemia, systemic
inflammatory response syndrome and death.
MASSIVE TRANSFUSION
PROTOCOLS
 THERAPEUTIC GOALS
• Maintenance of tissue perfusion and oxygenation
by restoration of blood volume and haemoglobin

• Arrest of bleeding by treating any traumatic,

surgical or obstetric source

• Judicious use of blood componenet therapy to

correct coagulopathy
MASSIVE TRANSFUSION
PROTOCOL
 Rapid
Infusion
 a combination of immediate surgical
intervention and rapid transfusion is crucial
for survival of massive haemorrhage
 CONCLUSION
• Interventions can begin early in the preoperative phase through identification of
patients at high risk of bleeding.
• Directly acting anticoagulants can be stopped 48 h before most surgery in the
presence of normal renal function. Aspirin can be continued for most procedures.
• Intraoperative cell salvage is recommended when anticipated blood loss is greater
than 500 ml and this can be continued after surgery in certain situations.
• Tranexamic acid is safe, cheap and effective, and routine administration is
recommended when anticipated blood loss is high. However, the optimal dose,
timing and route of administration remain unclear.
• The use of topical agents, tourniquet and drains remains at the discretion of the
surgeon.
• Anaesthetic techniques include correct patient positioning, avoidance of
hypothermia and regional anaesthesia. Permissive hypotension may be beneficial
in selected patients.
• Promising haemostatic strategies include use of pharmacological agents such as
desmopressin, prothrombin complex concentrate and fibrinogen concentrate,
and use of viscoelastic haemostatic assays