BLOOD TRANSFUSION AND CONSERVATION

DURING SURGERY
Dr. Ekwem C. U
Dr Ajefolakemi J.O
Dept. of Anaesthesia and Intensive Care
OAUTHC
Outline
• Introduction
• Principles of Blood Transfusion
• Types of Blood Transfusion
• Blood Substitute
• Emergency Transfusion
• Massive Transfusion
• Blood Conservation Techniques
• Literature Review
• Conclusion
Introduction

• Blood is a reddish fluid that circulated the body of humans and other
vertebrate animals
• Technically, blood is a transport fluid pumped by the heart to all part of the
body
• It is both a fluid and a tissue, containing aggregate of cells with specialised
functions
• Blood can be divided into the cellular component and the non cellular
components refer to as the plasma
Introduction

• Blood transfusion is the infusion blood or blood conponents into one’s

circulation
• It is one of the commonest life saving medical procedure done worldwide
• About 15 million unit of red cells are transfused annually in the United State
and about 85 million worldwide
• Nigeria is estimated to require about 1.8 million unit of blood annually,
contrary to the 500,000 unit currently being donated
• Blood is classified on WHO list of essential medications
 Historical Background
• 1628 - William Harvey discovered blood circulation
• 1665 - Richard Lower demostrated first recorded blood transfussion in a dog
• 1818 - British obstetrician Bluendell performed first human to human blood transfusion
for treatment of PPH... unfortunately patient died

• 1901 - Karl Landsteiner discovered the ABO blood group

• 1907 - Reuben Ottenberg performed the first transfusion with typed and cross-matched
blood
• 1914 - Adolf Hustin discovered sodium citrate for blood anticoagulation faciltating storage
• 1939-1940 - Karl Landsteiner and colleagues discovered the Rhesus system
Principle of blood transfusion
1. It should be absolutely indicated
2. Benefit must outweighs the risk
3. Transfuse only the needed component
4. It is not a substitutee to blood conservation techniques
Trigers for blood Transfusion
ASA Guildline 2006 ( transfusion Indicator)
a. Hb > 10g/dl: Transfusion rarely indicated
b. Hb < 6g/dl : Transfusion almost always indicated
c. Hb between 6-10g/dl : Transfusion decision should be made based on;
1. Risk for complications of inappropriate oxygenation,
2. Rate and magnitude of ongoing loss, and
3. Patient intravascular volume status
Types of blood transfusion

a) Allogenic/Homologous Blood Transfusion: Transfusion of blood taken from a

donor to another recipient

b) Autogenic/Autologous Blood Transfusion: re-infusion of blood or blood

products taken from same person
Allogenic/Homologous
Blood transfusion
 Allogenic/Homologous Blood transfusion
• Allogenic/Homologous Blood transfusion: Transfusion of blood taken from a
donor to another recipient
• It Involves:

a. Donation of the blood

b. Blood typing
c. Blooding Screening
d. Cross matching
e. Storage of the blood
a. Donation of the blood
• Pre-donation
– Medical hx and examination:
– Donor Eligibility: >18yrs, Hb > 12g/dl, clinically fit, last donation >4months
– Donor Consent: Cargiver if less than 18yrs
– Donor Screening: HCV, HIV, HBV, Syphilis
• During donation
– Donation Procedure
• Post donation
– Rest, advice
– Donor ID card
b. Blood typing/grouping
• This is the classification of blood based on the presence or absence of
antigenic substances on the RBC surface
• The common classification
– The ABO system:
– Rhesus System:

• Others include;
– Lewis, Kidd, Kell, Duffy, Lutheran, Sid, Cartright,YK, and Chido Rodgers. With the
exceptions (Kell, Kidd, Duffy, and Ss), they rarely cause any serious hemolytic
reaction
The ABO system
• Depending on the presence of the
Glycolipid A and B
• Classify Blood group into Group A, B, AB
and O (No A or B Antigen on the RBC)
• Antibodies to antigen A & B occur
naturally in blood group A, B and O, and
absent in blood group AB
The Rhesus System
• Depending on the presence of the Rh Antigen into Rh +ve or Rh -ve
• There are several Rhesus antigen, however D is the most antigenic, and
so often test for
• Rh Antibodies do not occur naturally. It only occur following sensitization
from Rh +ve blood e.g during pregnancy
c. Blood Screening
Antibody Screening
• The purpose of this test is to detect in the serum the presence of the antibodies
that are most commonly associated with non-ABO hemolytic reactions.
• The test is also known as the indirect Coombs test
• It involves mixing the patient’s serum with red cells with known antigenic
composition;
• if specific antibodies are present, they will coat the red cell membrane, and
subsequent agglutinate with the addition of human antiglobulin antibodies
• Can be done on both donor or patient blood
d. Blood Crossmatching
• Crossmatch mimics the transfusion, and it involves mixing the donor red cells
with the recipient serum.
• Crossmatching serves three functions:

1. It confirms ABO and Rh typing

2. It detects antibodies not tested for during antibody screening

3. It detects antibodies in low titers or those that do not agglutinate easily.
• It is often done following a negative antibody screening
• Take about 45min
• Can be done traditionally or Electronically
e. Other blood bank practices

• Infection Screening
– Hepatitis B, Hepatitis C, Syphilis, HIV.

• Seperation into components and storage

– Pack Red Cells
– Platelet concentrate
– Fresh frozen plasma (within 8hrs of collection)
– Cryoprecipitate

• MCS done randomly on stored blood and blood product

Blood Component and Storage
S/N Component Vol Storage Duration Dose Indication

1 Fresh Whole Blood 450ml 2 - 24℃ CPDA - 8hrs 10-15ml/kg 1. Acute Blood Loss
PCV-45% 2. Exchange Blood
(1Unit ↑ Hct by 3% and hb (Within 4hrs) Transfusion
by 1g/dl) 3. Cardiovascular Bypass
Surgery
2 Packed Red Cell 250mls 2- 6℃ CPD - 21days 15ml/kg 1. Symptomatic Anaemia
Sedemented (PCV 60- CPDA -35days
70%) ADSOL-42days
Centrifuged (PCV 70-80%) 20% Glycerol -
10yrs
3 Platelet concentrate 50ml 20-24℃ 3-5days (Single 1unit/10kg 1. Thrombocytopenia
(Preferably ABO Donor) or 2. DIC
compatible) 4hrs (pooled) 10-15ml/kg (1 Unit ↑ PC 5-10,000 x109)
Within 20min
4 Granulocyte Concentrate 20-24℃ 24hrs 1. Severe Neutropenia
(Leukopheresis) unresponsive to
Antibiotics
Blood component and storage cont’d
5 Fresh frozen plasma 200ml -20 - 1 year 10-15ml/kg 1. Reversal of Warfarin toxicity
(FFP) 40℃ 7 years Within 20min 2. DIC
(ABO Compactibility -65℃ 24hrs 3. Coagulopathy 2o Massive
Required) Thawed transfusion
(1-6℃) 4. Single or Multiple Clotting
Factor Deficiency
5. Haemorrhagic disease of
Newborn
6 Cryoprecipitate 20ml -20 - 1 year 1. Factor VIII ,XIII, deficiency
40℃ 2. VWD
3. Fibrinogen deficiency

7 Prothrombin Complex Pooled 1. Emergency Reversal of

Concentrate (PCC)
Rich in Factor II, VII, IX & X
Protein C&S
8 Human Albumin
(5% or 25%)
Plasma Warfarin Therapy
1. Blood volume expansion post
ascitic fluid removal
Changes with stored blood
• Cellular Changes • Others
– Red Cell- ↓ in Hb Conc, Hemolysis, free hb – Hypothermia
– Granulocyte - non-functional after 24hrs but – Coagulation
remain antigenic • Anticoagulation effect of citrate
– Platelet - Function declines to zero after 48hrs • Factor V & VIII activity ↓ to 50%
• Biochemical Changes after 72hrs

– ↓ 2,3 DPG
– Hyperkalemia - may exceed 30mmol/l
– ↓ Ph, Accumulation of lactic acid
Complications of Homologous blood transfusion
Immune Mediated
1. Acute Hemolytic Transfusion reaction
– Characterise by acute intravascular hemolysis usually due to ABO incompatibility,
– The most common cause is clerical error
– Symptoms: chills, fever, nausea, and chest and flank pain in awake patient
– In anesthetized patients, may manifest by ↑ temp, unexplained tachycardia,
hypotension, hemoglobinuria, oozing in the surgical field. DIC, shock, and AKI can
develop rapidly
– Management involves stopping further transfusion and returning blood to blood bank
– Manage complications and close haemodynamic monitoring
Complications of Homologous blood transfusion
2. Delayed Hemolytic Transfusion Reaction
– Characterise with extravascular hemolysis 2o to antibodies to non-D, non ABO
antigens
– Symptoms are generally mild seen about day 2-21, consisting of malaise, jaundice,
and fever.
– The patient’s hematocrit typically fails to rise, or ↑ transiently inspite transfusion
– Mgt is supportives

3. Febrile Transfusion Reaction

– Characterized by an ↑ in temp without evidence of hemolysis
– Usually due to sensitization to donor’s white cells, platelets, or plasma proteins;
Complications of Homologous blood transfusion
4. Urticaria
– Characterized by erythema, hives, and itching without fever. Thought to be due
to sensitization of the patient to transfused plasma proteins.

5. Anaphylactic reaction
– Severe reactions occuring after only a few ml of blood has been given
– Typically 2o IgA antibodies reacting to IgA-containing blood
– Treatment involves adminstration of epinephrine, IV fluids, corticosteroids, and
antihistamine.

6. Others: Transfusion Related Lung injury, Graft vs Host Disease & Post
transfusion papura
Complications of Homologous blood transfusion
Non-Immune Mediated
1. Transmission of Infection
a. Viral: HBV, HCV, HIV, CMV, HTLV 1&2, Parvovirus, west Nile virus
b. Parasite: Malaria, toxoplasmosis, chhhagas dieases
c. Bacteria: Staph aureaus, (Rarely: Yersinia, Syphilis, Brucellosis, Salmonellosis)
a. Platelet has highest risk of bacteria contamination 1 in 2,000
d. Prion dx: Creutzfieldt Jakob disease
2. Electrolyte derangement
a. Hyperkalemia, Hypocalcemia, Acid-base disturbance
3. Hypothermia: Impaired platelet function, risk of VF
4. ↑ risk of postoperative bacterial infection & cancer recurrence,
Autogenic/Autologous
Blood Transfusion:
Autogenic/Autologous blood Transfusion:

Techniques Advantages

1. Pre-operative blood donation • Avoid complications associated with

2. Acute normo-volemic allogenic transfusion

haemodilution • Benefical in patient with rare blood

3. Intra-op/post-op blood salvage group

Pre-operative blood donation
• Can be consider for elective cases with risk of significant blood loss
• Patient donate 4-5 wks to surgery at maximum of 1 unit per week depending
on quantity needed
• Collected blood is specially labelled and stored seperately
• Duration of donation to surgery should be > 72hrs (preferably a week)
• Patient is commenced on Iron supplementation. The use of erythropioetin
administration is not routinely recommended
• Screening, crossmatching and transfusion of pre-donated blood follows same
guildline with allogenic transfusion
Pre-operative blood donation cont’d

Patient selection
1. Elective surgery with significant risk of blood loss and reliable surgery date
e.g Plastic, Orthopedic surgery. POBD have been described in obstetric
patient
2. Clinically fit patient
– Hb greater than 11mg/dl in men and 10mg/dl in women

3. Exclude: Children weight <25kg, Infectious disease: HCV, HIV, HBV, Cardiac
disease: Aortic stenosis, coronary artery disease, epilepsy
Pre-operative blood donation cont’d

Leap- frog technique Withdrawn Unit Unit Unit Left

Time Withdrawn Transfused
• used when 4-5 units of blood Day 0 A None A

are required for POBD Day 7 B, C A B, C

• Schedule starts weeks before

Day 14 D, E B C, D, E
surgery
Day 21 F, G C D, E, F, G

Day 28 H, I D E, F, G, H, I

Total 9 4 5
Pre-operative blood donation cont’d

Challenges
1. Clerical error - leading to mix-up of blood
2. Contamination especially bacteria
3. Re-transfusion of previously donated blood- Thrombocytopenia, Chills,
Hypocalcemia
4. Fainting 2o Hypovolemia
Acute Normo-volemic Haemodilution (ANH)
• This involves removal of blood from patient just before surgery and replacement
with crystalloid or colloid to maintain the circulating volume
– If crystalloid ratio 3:1 and ratio 1:1 for colloid

• Volume collected should not cause max of 30% fall in Haematocrit /derangement
of Clinical parameters (Tachycardia)
– Volume collected = EBV x [Hct(i)-Hct(f)]/Hct(av)

• Upto 4 units (2L can be collected)

• Collected blood should be labelled, stored in room temperature upto 4hrs
(Ideally) or at 1-6℃ for upto 24hrs and should not leave the theatre
Acute Normo-volemic Haemodilution cont’d

• Blood is re-infused starting with the last unit and the first unit given last
• EBL >90% will likely benefit from allogenic transfusion asides ANH
• Suitable in
– Religious/personal contraindication to blood
– Cardiac bypass surgery, Liver, spine, knee replacement, prostatectomy surgery
– Special concern in Obstetric patient for regional anaesthesia

• A multi infusion port can be used for Jehovah witness patient who requires
continous connection and circulation of collected blood
Acute Normo-volemic Haemodilution cont’d
Advantages
• Simple and less expensive technique
• Provide fresh whole blood for transfusion
• No Biochemical changes caused by storage
• No risk of hypothermia as blood is stored in room temperature
• Reduce Red cell loss with surgery
• Reduce/ Eliminate the complications of allogenic blood transfusion
• No need for blood testing
• Can be used in emergency
Acute Normo-volemic Haemodilution cont’d
Contraindication Conplications
• Anaemia Hb < 10g/dl in Female • Myocardia Ischaemia
and 11g/dl in male • Cerbral Hypoxia
• Clotting Disorder • Hypotension
• Significant Pulm Disease • Dilutional Coagulopathy
• Background commorrbid condition
– Renal Insufficiency, CAD, severe
pulm dysfunction
Intra-op/post-op blood salvage

• This involves collection of blood from operative site and re-infusing back into
patient
• Collected blood is first anticoagulated, filtered, seperated then washed with
saline, then pumped into an infusion bag, and re-infused into patient
• Most WBC, platelet and clotting factors are lost along the processing
• Hematocrit of re-infused blood vary from 50-60%
• Applicable to Neurosurgery, CV surgery, Liver surgery, rare blood group,
ruptured ectopic pregnancy, Urology surgery
Cell Salvage Circuit
Intra-op/post-op blood salvage in resource-poor
Setting
• The use of layer of gauze for Blood Salvage have been used especially in
resource-poor settings
• It involves collection of blood from operating site while minimizing contaminant
• Anticoagulant may be added, and blood is then passed through 6 layers of
latex gauze, the blood is recieved in an infusion bag, and re-infuse into patient.
• Modern modification: Hemofuse, Haemobag, Leucocyte depletion filters,
• Suitable for Heamothorax, Haemoperitoniuem, PPH
Intra-op/post-op blood salvage Cont’d

Hemofuse Haemobag
Intra-op/post-op blood salvage cont’d

Advantages
• Simple Technique
• Reduce risk associated with allogenic blood tranfusion
• Minimize risk of hypothermia
• Eliminate clerical error
• Does not require any special preparation - most suitable for unexpected
massive transfusion
Intra-op/post-op blood salvage

Contraindication Complications
• Presence of contaminants • Embolism
– Dirt e.g faeces, pus – Air,fat, bone, amniotic fluid
– Malignant cell embolism
• Lack of skill and equipment • Sepsis
• Patient’s refusal • Coagulopathy
• Tumor dessemination
Blood Substitute
Substances with O2 carry capacity

1. Perflucarbon Emulsions-
– e.g Flusol DA 20, Oxygent, Peftorom
– Halogenated substituted carbon non-polar oil
with enhanced binding ability for O2, N2, Co2
& NO.
– Life span 42hrs
2. Hb Based O2 Carrier e.g Polyheme, Hemopure
– Polymerize recombinant bovine haemoglobin
– Life span : 1day
Blood Substitute cont’d

Advantages Limitations

1. Can be use by all blood group 1. Low Conc 2,3DPG ; Shift o2

delivery curve to the left
2. Emergency use
2. Nitric oxide scavenger- cause
3. Longer shelf life
vasoconstriction
4. Suitable in people with religious
3. Increase Pulm HTN/ risk of Mi
bias
4. Activate platelet and are pro
5. Antibacteria and antiviral
inflammatory
properties
5. Methemoglobinemia
Emergency Transfusion

• Transfusion in emergency situations where the blood type of patient is

unknown or pending crossmatchhing
a. Unknown blood group
1. Transfuse with O Rh neg Blood

2. After blood group is done - Switch to type specific blood.

(Note: After 2nd unit of O neg, continue with O neg blood because of risk of Immune
cross reaction)

b. Known blood group

1. Transfuse with type specific blood
Massive Transfusion
• Massive transfusion is defined as transfusing patients entire blood volume or
10units in 24hr. Half the entire blood volume in 3hrs, more than 3 units in one
hour and >150ml/min
• Challenges
1. Electrolyte Derangement: Hyperkalemia, Hypokalemia, acid-base disturbance
2. Dilutional Coagulopathy- Thrombocytopenia, DIC
3. Citrate Toxity- Hypocalcemia
4. Volume overload
Blood Conservation
Techniques
Blood Conservation Techniques

• This refers to strategies to reduce need for transfusion and facilitate

appropriate transfusion
• It involves a multidisciplinary approach
• Why blood conservation
– Global shortage of blood and blood product
– The inherent risk with blood transfusion
– Provide alternative to blood
– Religious bia as regard blood transfusion
– Cost effective option
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Blood Conservation Strategies
a. Pre-Operative
– Ensure Optimal BP control e.g Use antihypertensives
– Discontinue drug that can ↑ bleeding tendency e.g Aspirin, Heparin, NSAID,
warfarin
– Identify causes of anaemia and treat e.g Taeniasis, bleeding PUD
– Correct anaemia e.g Fe supplementation, erythropietin therapy
– Schedule surgery appropriately e.g when patient is not menstrating, take as
elective if possible
– Regional technique preferred
– Pre-operative blood donation (POBD)
Blood Conservation Strategies Cont’d
b. Intra-Operatively
a. Environment: - Avoid hyperthermia -Risk of clotting dysfunction
b. Positioning: Prone position ↑ risk,
c. Induction: Smooth induction
d. Use of delibrate hypotensive technique (MAP 30% below baseline)
e. Surgical techniques
1. Mosk skilled personnel
2. Possibility of staging surgery
3. Minimal incision
4. Local infiltration e.g Ldocain + Adrenaline
Blood Conservation Strategies Cont’d
b. Intra-Operatively cont’d
f. Surgical techniques
• Use of Surgical devices e.g ; Touniquet, Ligasure, Diathermy, Pressure packing,
bone wax, Fibrin glue, Bioglue
g. Haemodilution technique
• Hypervolemic Hemodilution
h. Autologous transfusion
• Acute Normovolemic Hemodilution (ANH)
• Intra operative Cell Salvage
i. Pharmacologic agent
• Antifibrinolytic: Tranexemic acid, Aprotinin
Blood Conservation Strategies Cont’d
c. Post-Operative
a. Smooth extubation
b. Gentle airway suctioning and manipulation ↓ risk of suture displacement
c. Post Op Blood Salvage from drains
d. Post op BP and pain control
e. Reduce number of blood sample collection
f. Hematinics
Literature Review
Efficacy of Tranexamic Acid with Hypotensive Anesthesia
versus Hypotensive Anesthesia Alone on Intraoperative
Blood Loss in Orthognathic Surgeries
- A Comparative Study
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

AIM
• To evaluate the efficacy of tranexamic acid with and
without hypotensive anaesthesia on intraoperative blood
loss in orthognathic surgeries
• To assess the amount of blood loss and need for any
blood transfusion, quality of surgical field, duration of
surgery and Pre-operative and post-operative Hb
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• Blood transfusion can be a life-saving intervention, however,

like all treatments, it may result in acute or delayed
complications and carries the risk of transfusion transmissible
infections, including human immunodeficiency virus, hepatitis
viruses, syphilis, and malaria and Chagas disease
In order to reduce blood loss and improve visibility in the
operative field, hypotensive anaesthesia, acute
normovolaemic haemodilution, preoperative autologous blood
donation and various pharmacological agents have been used
during orthognathic surgery.
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• Tranexamic acid, a synthetic amino acid of lysine

inhibits fibrinolysis, has been shown to reduce blood loss
and need for blood transfusion in cardiac surgery, knee
arthroplasty surgery, spine surgery and orthopaedic
surgery
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

2. OBJECTIVES ARE TO ASSESS

1. The amount of blood loss and need for any
blood transfusion
2. The quality of surgical field
3. The duration of surgery
4. Pre-operative and post-operative Hb(g/dl)
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• METHODS AND METHODOLOGY

• This comparative study was done on patients reporting
to Department of Oral and Maxillofacial Surgery and
Department of Orthodontics and Dentofacial
Orthopaedics, Faculty of Dental Sciences, Ramaiah
University of Applied Sciences, with skeletal
malocclusion, requiring corrective surgeries like anterior
maxillary osteotomy, LeFort 1 osteotomy, bilateral sagittal
split osteotomy and genioplasty, between November 2016
to October 2018
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• INCLUSION CRITERIA
• All ASA-1 patients with age ranging between 17 to 30
years having skeletal malocclusion requiring
orthognathic surgical procedures like LeFort 1
osteotomy, anterior maxillary osteotomy (AMO),
bilateral sagittal split osteotomy (BSSO) and genioplasty
(GP)
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• EXCLUSION CRITERIA
• Patients with cardiovascular, respiratory, renal and hepatic diseases
which would alter the blood loss and hemodynamic status of the
patients.
• Patients allergic to tranexamic acid.
• Patients suffering from bleeding disorders.
• Patients who are on medications like fibrinogen, tretinoin, oestradiol
valerate which would cause interaction with tranexamic acid.
• Pregnant and lactating mothers.
• Patients who are on birth control pills or oral contraceptive pills.
• Patients associated with cleft lip and palate
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

1) Study group -patients receiving tranexamic acid along

with hypotensive anaesthesia
2) Control group - patients receiving hypotensive
anaesthesia alone.
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• METHODOLOGY
• Anaesthesia was induced by intravenous Thiopentone
sodium and Succinyl choline.
• Patients were intubated by nasoendotracheal intubation.
Anaesthesia was maintained with 2-2.5 minimum alveolar
concentration (MAC) of sevoflurane and with incremental
doses of Midazolam, Vecuronium bromide, Fentanyl.
• All patients in both the groups were given hypotensive
anaesthesia, mean blood pressure, around 70-75 mm Hg
was maintained till osteotomy fragments were fixed
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• In study group tranexamic acid was administered

intravenously as an initial bolus dosage of 10 mg/kg
body weight before starting the skin incision over a
period of 20 minutes and then followed by 1mg/kg was
administered everyone hour till the end of the surgery
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• Blood pressure was monitored by non-invasive

method (Oscillometry).
• Systolic, diastolic & mean arterial blood pressure,
oxygen saturation and heart rate were recorded every
5 minutes.
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• Pre-operatively Hb(g/dl) was assessed one day prior to

the surgery and postoperatively Hb(g/dl) was assessed
on postoperative day one.
• Blood loss was measured by reducing the amount of
saline used, from the volume of fluid in suction unit, and
weight of the dry gauze including throat pack was
deducted from the weight of blood-soaked gauze and
throat pack. 1gm of weight was considered 1ml of blood.
The need for transfusion of blood perioperatively was
decided by anesthesiologist.
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• The protocol for management of blood loss during

surgery is as follows: Blood loss up to allowable
blood loss is replaced with crystalloid solutions (1:3
ratios).
• When blood loss is more than the allowable blood
loss, it is replaced by blood transfusion.
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• Estimation of Estimated Blood Volume (EBV) and

Allowable Blood Loss (ABL)
• Estimated Blood Volume (EBV):
• Neonates: 85 –90 ml/kg body weight, Children: 80ml/kg
body weight, Adult: 70ml/kg body weight.
• ABL = EBV x (Preoperative Hb - Lowest acceptable
Hb)
(Average of preoperative and lowest acceptable Hb)
• CLINICAL PARAMETERS
• I.Blood loss: Normal saline was used for irrigation, gauze of standard
size was used, volume of saline, weight of the gauze, throat pack and
mop were determined prior to surgery
• The volume of saline used was recorded and volume of fluid (saline
+ blood) in suction was noted
• Weight of blood-soaked gauze, throat pack and mop were recorded
Blood loss = A + B
A = Volume of fluid in suction unit – Volume of saline used B=
Weight of blood-soaked gauze, throat pack and mop – Weight of dry
gauze, throat pack and mop
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

• Quality of surgical field by using fromme’s ordinal scale (Duraiswamy

et al 2012)
5-Massive bleeding; cannot carry out dissection.
4-Severe bleeding; significantly compromises dissection.
3-Moderate bleeding slightly compromises dissection.
2-Mild bleeding, a nuisance but does not
compromises dissection.
1-Minimal bleeding; not a surgical nuisance.
0-No bleeding; virtually bloodless field
Surgical field was rated every 15 minutes by using fromme’s ordinal
scale.
• Duration of surgery was measured in minutes
• Preoperative and postoperative haemoglobin was
assessed
• Blood transfusion if required was recorded
• Comparison of Mean Blood Loss (Ml) In the Study and
the Control Groups Mean estimated blood loss in the
study and the control groups were 109 ± 39.1 ml and
207.4 ± 75.13 ml respectively.
• The estimated blood loss in study group was
significantly less when compared to control group and
the value was statistically significant (p=0.005)
Sasikanth Challari, k Ranganath, Sudha Patil, Kavitha Prasad, KM Sejal, Parimala Sagar
journal of Dental and Orofacial Research 15(2), 21-30,2019

The mean pre-op Hb (g/dl) in control group and

study group were 14.10±1.71 g/dl and 4.36±1.25 g/dl respectively.
Similarly, the mean post-op Hb (g/dl) in control group and study
group were
12.07±1.46 g/dl and 12.95±1.58 g/dl
respectively.
By analyzing the data, it was noted
that the reduction in the post-op Hb (g/dl) was
statically significant in both the groups
ACCURACY OF VISUAL INTRAOPERATIVE
ESTIMATED BLOOD LOSS DURING CAESAREAN
SECTION PERFORMED UNDER SUBARACHNOID
BLOCK
P.A OYEBODE, A.T ADENEKAN, S.A OLATEJU, A.O ADETOYE .
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• Aim: This study was conducted to assess the accuracy of

estimated blood loss during Ceasarean Section performed under
SAB in a Nigerian tertiary institution .
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

MATERIALS AND METHODS

• Ethical approval was obtained from the Ethics and
Research Board of the hospital. The study was carried out
over a 4-month period in 2018
• A total of 56 patients were recruited for the study, but only 52
who completed the study were included in the final analysis.
Three patients who had EBL necessitating blood transfusion
before skin closure were dropped out of the study and
transfused appropriately while 1 patient with block height
below T6 dermatome was excluded and had the block
augmented with intravenous anaesthetics.
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• Inclusion criteria were all women consenting ASA

physical status class II aged 18 to 45years scheduled
for elective CS under SAB
• The exclusion criteria were morbid obesity (BMI ≥ 40
Kg/m2),antepartum haemorrhage, sudden and/or
massive blood loss and any contraindication to SAB.
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

The study procedure was

explained to each patient on the ward and
informed consent was obtained.
In the operating room, the baseline
haemodynamic parameters including pulse
rate (PR), non-invasive blood pressure
(NIBP), mean arterial pressure (MAP),
respiratory rate (RR), and peripheral arterial
oxygen saturation (SpO2) were measured
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• Each patient’s initial haematocrit was checked by the principal

investigator using MissionHb Haemoglobin Testing System (ACON
Laboratories, Inc. 10125 Mesa Rim Road, San Diego, CA 92121,
USA) which processes the haematocrit result within 15seconds.
• The attending physician anaesthetist administered the spinal
anaesthesia in accordance with the standard protocol for CS.
Surgery was allowed to proceed after achieving a block height of
thoracic dermatome of T6 while patient monitoring continued
intraoperatively.
• Hypotension (MAP < 60 mmHg or a SBP of 25% < the patient’s
baseline value) was treated with intravenous 0.9% saline and
ephedrine boluses (3 – 6 mg) titrated to effect.
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• The EBL from skin incision to rupture of the membrane

was estimated by the attending physician anaesthetist
by estimating the volume of blood on the used
gauze, in the suction canister, on the drapes and on
the floor.
• The amount of liquor after rupturing the membrane
was also noted by deducting the previous volume in the
suction canister from the volume after drainage of liquor.
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• The EBL from the delivery of baby to skin closure was equally
estimated by the attending physician anaesthetist and recorded.
• At skin closure, patient’s final haematocrit was measured by the
principal investigator using Mission Hb Haemoglobin Testing System.
The ABL was then calculated by the Principal investigator using the
modified Gross formula
• ABL = BV [Hct (i) - Hct (f)]/ Hct (m) where BV is the blood volume
calculated from the body weight (BV = Body Weight in Kg x 85
ml/kg)17Hct (i), Hct (f) and Hct (m) are the initial, final and mean
haematocrits respectively. For each patient, the difference in blood loss
(DIFF –BL) was calculated from the ABL and EBL. The EBL was
also compared to the ABL.
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• The type of skin incision (Pfannenstiel or midline) made

by the surgeon and the duration of surgery from the time
of skin incision to the last stitch on the skin were noted
and recorded.
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• the mean (± SD) EBL of 522ml (±146ml) was

significantly lower compared to the mean (± SD) ABL of
821ml (± 615ml); p= 0.001.
• The mean difference between ABL and EBL (DIFF- BL)
was 299ml (± 571 ml); range = - 413ml to 2,454 ml (The
negative to positive values indicates over- and under-
estimation of blood loss respectively).
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• Within 20% error margin, blood loss was correctly

estimated in 7 (13.5%) of the patients, under-estimated in
30(57.7%) and over-estimated in 15 (28.8%).
• (57%) of the correct estimation of the EBL were recorded
when the ABL was ≤ 500 ml, the remaining 3 (43%) were
noted when the ABL was within 501 and 1000 ml. The
percentages of patients whose EBL were under-estimated
or overestimated with ABL range within 20% error margin
are also shown on Table 4. The differences were found to
be statistically significant (χ2= 31.852, p - 0.001)
P.A Oyebode, A.T Adenekan, S.O Olateju, A.O Adetoye East African medical Journal 99(2), 4585-4592, 2022

• Both the ABL and the EBL had no correlation with duration
of surgery.
• Majority of the patients (80.8%) had Pfannenstiel
incision; others (19.2%) had midline incision.
• The differences of mean ABL and mean EBL of those who
had Pfannenstiel and midline incisions were comparable
(p= 0.664 and 0.834 respectively).
• Hypotension which was observed and managed
appropriately in 19 patients (36.5%), was the only
complication noted during the study.
Conclusion

• Blood transfusion safety has improved significantly over the years

• Physicians must weigh benefit against risk when taking decision to transfuse
any patient
• It is very important for physicians to be familiar with alternatives available and
deploy such interventions when needed
Thank You