Brit. J. Anaesth.

(1962), 34, 653

THE MEASUREMENT OF BLOOD LOSS AT OPERATION

BY
A. J. S. GARDINER AND H. A. F. DUDLEY
Department of Surgery, University of Aberdeen, and The Royal Infirmary,
Aberdeen, Scotland

Large amounts of blood may be lost from the Therefore, precisely to adjust transfusion in the
circulation without changes in such indices as face of continuing loss requires an accuracy of

Downloaded from https://academic.oup.com/bja/article/34/9/653/239024 by guest on 15 May 2022

blood pressure, pulse rate and skin blanching determination which is well inside this figure and
reflexes. This is true not only in the conscious should be within about 2 per cent of blood volume.
subject (Barcroft et al., 1944) but also and to a For an adult this will represent between 100 and
greater extent when the patient is anaesthetized. 150 ml, but a similar loss in a neonate corresponds
If physiological trespass in the form of hypoten- to only 6-8 ml. The inability to make estimates of
sive techniques, hypothermia or extracorporeal this degree of accuracy should not, of course, deter
circulation is added, the complexity of the problem the anaesthetist from attempting some objective
of indirect assessment of blood loss by reference to measure, because anything is better than guess-
vital signs may defy analysis. It is this difficulty work. However, firm conclusions about the magni-
that has long concerned surgeons and anaesthe- tude of loss should not be drawn without reference
tists interested in the direct measurement of opera- to the precision of the technique involved.
tive blood loss. As the population grows older and
operative surgery becomes more involved the need Methods.
for accurate assessment becomes more clamant. Four methods which have been modified in a
In addition, economy in the use of blood number of ways are available. These, with their
is essential if the growing need is to be met. advantages and disadvantages, are listed in table I.
Finally, accurate measurement and replacement of Subjective estimation. Visual assessment is diffi-
blood is one key to the understanding of other dis- cult and unreliable, and most authorities claim that
orders of the circulation occurring in the intra- the surgeon always underestimates the blood loss.
operative and postoperative period which have Our experience suggests that in the lower loss
been hidden because of concern for hypovolaemia groups, surgeons and anaesthetists can be quite
and pre-occupation with the transfusion bottle. reliable and they they become more so when some
objective measure is also available in the operating
A distinction should be drawn between retro- theatre. However, as the magnitude of loss in-
spective and continuous measurements of blood creases the estimate becomes increasingly unreli-
loss. The former gives information, at a single in- able and may err quite wildly on either side of the
stant, of events that have taken place over a pre- actual figure.
vious period, whereas the latter provides an up-to-
date index. In most situations the degree of elasti- Blood volume. Much has been written on blood
city of the body's compensatory mechanisms volume determination in assessing loss after
renders the determination of summated loss at the trauma or operation (Keith, 1919; Chute, Cleg-
end of a procedure adequate, but continuous mea- horn and Lathe, 1945; Grant and Reeve, 1951;
surement, and its corollary continuous replace- Prentice et al., 1954; Clarke, Topley and Flear,
ment, is of great value, particularly when large 1955; Clarke et al., 1961). One considerable advan-
losses are taking place. tage of this technique is that bleeding which occurs
after the incision has been closed may be detected.
Standards of accuracy. The accuracy of the method varies according to the
A 5 per cent change in blood volume is usually tracer used and 51
is slightly better with red cell
well borne, but one of 10 per cent requires con- labels such as Cr than with plasma labels such
siderable adjustment and if superimposed on pre- as T-1824 or radio-iodinated human serum albu-
existing disease may be of great consequence. men. The cost of the tracers themselves is not
653
 TABLE 1
Group Actual method Advantages Disadvantages
I. Visual assessment

Downloaded from https://academic.oup.com/bja/article/34/9/653/239024 by guest on 15 May 2022

Guesswork
Clinical impression Mental computation
II. Blood volume (a) Subtractive—subtracting postopera-
analysis tive from pre-operative values
Tracer T-1824, 51Cr,
12
• P radio-iodinated human serum
albumen
(/)) Repeated—using a radio-isotope
tracer, the blood volume being
calculated by a scintillation-counter
computer machine
III. Gravimetric Swab-weighing
Weighing of patient.
IV. Extraction-dilution (1) Simple method of washing
analysis swabs by hand and then
measuring the acid haematin
found on addition of HC1
(2) Washing machine extraction,
and use of Wheatstone Bridge
principle to measure change
in electrical conductivity
(3) Washing machine extraction
and use of flow-through
colorimeter to measure haemo-
globin loss continuously
(i) Inexpensive In differentiating between a 500 and 1500 ml loss, i.e.
(ii) Rapid 1 to 3 pints, observers are extremely inaccurate
(iii) Continuous
Accurate to 5-6% (1) A postoperative result
(2) Unreliable in certain conditions, e.g. cardio-
pulmonary failure, or peripheral circulatory failure
(3) Time-consuming
(4) Haematocrit dependent
(5) Expensive
(1) Fairly rapid (1) Involves servicing and operation of a complex
(2) Reproducible electronic instrument
(3) Accurate 3-5% (2) Haematocrit dependent
(3) Extremely expensive
Inexpensive (1) Inaccurate because
Continuous (a) Loss of weight by evaporation
(b) Susceptibility to mathematical errors in
addition/subtraction of very many small
quantities
(c) Fluids other than blood present
(d) Loss in drapes not measured
(2) Inconvenient because
(a) Swabs, gauzes must be standardized
(b) Time-consuming
Inexpensive (1) Postoperative result
(2) Inconvenient because
(a) Allowance for dressings, drip-sets and such-
like must be made
(b) Excessive patient handling
(3) Inaccurate because the subtractive result includes
(a) Loss of water by respiration
(b) Loss of water by perspiration
(c) Loss of water by evaporation from wound
Inexpensive (i) A postoperative result
(ii) Incomplete extraction of blood
(iii) Acid haematin undergoes change on standing
(iv) Standard haemoglobin solutions and curves
necessary.
Accurate (i) Use of electrolyte containing fluids will invalidate
Rapid these results
Direct reading (ii) Requires servicing of complex electrical equip-
Continuous ment
(iii) Extremely expensive
Accurate
Rapid (i) Bath must be changed at 500 ml
Continuous (ii) Not direct reading
Inexpensive
THE MEASUREMENT OF BLOOD LOSS AT OPERATION
great, but the apparatus is expensive and compli-
cated, particularly if a semi-automatic method
which allows repeated determinations is used (Wil-
liams and Fine, 1901). On the whole the methods
are not suitable for routine application nor do they
give a degree of discrimination consistent with
the effort expended. Furthermore, they are all
haematocrit dependent—that is, conversion from
red cell volume or plasma volume to whole blood
volume requires knowledge of the ratio between
cells and plasma. Inaccuracy of measurement of
this and the variations in its value from place to
place in the vascular system introduce a random
error.
Gravimetric. All weighing methods introduce
considerable inaccuracies, although they have the
great virtue of cheapness and simplicity. They
have the additional advantage of giving a contin-
uous record, marred only by the difficulties of
arithmetic, which frequently creep in when a busy
nurse is charged with the task. Our own experi-
ments suggest that there are large inherent errors,
particularly loss from evaporation which may reach
10 per cent in 15 minutes in a hot theatre. Forsee
and Schmidt (1952) indicate that reliance on swab-
weighing results in under-replacement of up to
45 per cent. Weighing the patient is equally un-
reliable (Ausman et al., 1961) and includes in the
error insensible losses and the difficult calculations
of the weight of excised viscera and dressings.
Extraction-dilution analysis. The fourth group,
that of extraction-dilution analysis, needs some
definition. Blood can be extracted by various
means from the absorptive materials and suction
effluent and any constant chemical or physiochemi-
cal property used as a yardstick for measurement
of its concentration in the resulting solution. The
early results (Gatch and Little, 1924; Pilcher and
Sheard, 1937; White et al., 1938; White and Bux-
ton, 1942; Coller, Crook and lob, 1944) which
were obtained by measuring some derivative of
haemoglobin such as acid haematin were not very
accurate because of incomplete recovery, but this
method has proved popular until very recently
(Dmitriyev, Krinitskiy and Sagaydak, 1960) and
may be more extensively used than is usually
appreciated. An alternative technique is to exploit
the fact that the electrical conductivity of blood is
a constant (LeVeen and Rubricius, 1958; Klop-
stock, LeVeen and Levitan, 1959). Addition of
655
blood to water will produce changes in the electri-
cal conductivity of the mixture which may be
measured using a Wheatstone Bridge. Provided
other electrolytes are not present this is an
extremely accurate method and has the virtue of
giving a continuous reading. Unfortunately, the
commercial equipment is expensive, and home-
made apparatus does not necessarily perform
reliably.
The advent of powerful domestic washing
Downloaded from https://academic.oup.com/bja/article/34/9/653/239024 by guest on 15 May 2022
machines has made simple the complete extraction
of blood from gauzes and by a simple adaptation
(Roe, Gardiner and Dudley, 1962) the concentra-
tion of blood in the resulting solution can be con-
tinously determined by optical densitometry. This
method can give a 1 per cent accuracy, using
simple circuitry only, and at minimal expense.
Both conductometric and optical techniques have
the disadvantage that as the volume of blood added
to the system increases, it itself alters the volume
of the solvent and thus influences the final con-
centration. Allowance can be made for this in
computation or, alternatively, an arbitrary limit is
set, after which the instrument is emptied and a
fresh solution added.
POSTOPERATIVE BLOOD LOSS
Repeated blood volume determination is the only
method so far available of gaining some measure
of postoperative blood loss. This is the case only
in closed injuries and operations. Fortunately the
increasing use of drainage from operation sites has
made some direct measurements possible thus
allowing both surgeon and anaesthetist a better
assessment of continued bleeding. As with intra-
operative determinations this makes for a more
accurate analysis of postoperative circulatory dis-
turbances.
In conclusion, as Moore (1959) has said, this is
"a well-ploughed field full of pitfalls". Estimates
of blood loss can improve operative management
and should become much more widespread. Not
only do they make for accuracy in surgical care
but also they promote a healthy attitude on the
part of surgeons to blood loss and conservation.
REFERENCES
Ausman, R. K., Gemmil, S. J., Lillehei, C. W., and
Aust, J. B. (1961). Blood volume determinations
in open-heart surgery. Trans. Amer. Soc. for Art.
Int. Org.. 7, 216.
656
Barcroft, M., Edholm, O. G., McMichael, J., and
Sharpey-Schafer, E. P. (1944). Post-haemorrhagic
fainting: study by cardiac output and forearm
flow. Lancet, 1, 94.
Chute, A. L., Cleghorn, R. A., and Lathe, G. M.
(1945). Proceedings of 80th Meeting of Committee
on Army Medical Research, Vol. II, Reports of
No. 1 Research Unit, Ottawa.
Clarke, R., Topley, E., and Flear, C. T. (1955). Assess-
ment of blood loss in civilian trauma. Lancet, 1,
629.
Fisher, M. R., Topley, E., and Davies, J. W. L.
(1961). Extent and time of blood loss after civilian
injury. Lancet, 2, 381.
Coller, F. A., Crook, C. E., and lob, V. (1944). Blood
loss in surgical operations. J. Amer. med. Ass.,
126, 1.
Dmitriyev, B. A., Krinitskiy, A. F., and Sagaydak, I. I.
(1960). Simple method of determining the quan-
tity of blood losses and shock during operation.
Voyenno-Meditsinskiy Zhurnal, No. 3.
Forsee, H., and Schmidt, J. (1952). Blood volume
studies in thoracic surgical operations. Arch.
Surg., 65, 88.
Gatch, W. D., and Little, W. D. (1924). Amount of
blood lost during some of the more common
operations. /. Amer. med. Ass., 83, 1075.
Grant, R. T., and Reeve, E. B. (1951). Spec. Rep. Ser.,
Med. Res. Comm., London, No. 277.
BRITISH JOURNAL OF ANAESTHESIA
Keith, A. (1919). Spec. Rep. Ser., Med. Res. Comm.,
London, No. 27.
Klopstock, R., LeVeen, M. M., and Levitan, P. I.
(1959). Instantaneous blood loss determination
during thoracic surgery. J. thorac. Surg., 38, 746.
LeVeen, M. M., and Rubricius, J. L. (1958). Con-
tinuous automatic electric determinations of
operative blood loss. Surg. Gynec. Obstet., 106,
368.
Moore, F. D. (1959). Metabolic Care of the Surgical
Patient. Saunders: Philadelphia and London.
Pilcher, F., and Sheard, C. (1937). Blood loss in pros-
tate surgery. Proc. Mayo Clinic, 12, 209.
Prentice, T. C , Olney, J. M. jr., Artz, C. P., and
Downloaded from https://academic.oup.com/bja/article/34/9/653/239024 by guest on 15 May 2022
Howard, J. M. (1954). Studies of blood volume
and transfusion therapy in Korean battle casualty.
Surg. Gynec. Obstet., 99, 542.
Roe, C. F., Gardiner, A. J. S., and Dudley, H. A. F.
(1962). A simple instrument for the continuous
accurate measurement of operative blood loss.
Lancet, 1, 672.
White, J. C , Whitelaw, G. P., Sweet, W. H., and
Hurwitt, E. S. (1938). Blood loss in neurosuxgical
operations. Ann. Surg., 107, 287.
White, M. L., and Buxton, R. W. (1942). Blood loss in
thoracic operations. J. thorac. Surg., 12, 198.
Williams, J. A., and Fine, J. (1961). Measurement of
blood volume with a new apparatus. New Engl.
J. Med., 264, 842.