Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper

WSES/AAST · 2024 · international

Source and licence

Authors: Federico Coccolini, Aryeh Shander, Marco Ceresoli et al.
Title: Strategies to prevent blood loss and reduce transfusion in emergency general surgery, WSES-AAST consensus paper
Journal: World Journal of Emergency Surgery : WJES, 2024
DOI: 10.1186/s13017-024-00554-7
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC11251377

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Identification and treatment of anaemia

11.0 g/dl for children 0 – ≤ 5 years old.
11.5 g/dl for children 5 – ≤ 12 years old.
12.0 g/dl for children 12 – ≤ 15 years old, and non-pregnant women ≥ 15 years old.
13.0 g/dl for men ≥ 15.0 years old.

Desmopressin (DDAVP; 1‐deamino‐8‐D‐arginine‐vasopressin)

Opportunity for preadmission autologous blood donation
Damage control resuscitation Damage control resuscitation is a strategy that should be applied both in the prehospital and in the in-hospital setting [72, 73]. It aims at first to increase survival by reducing the physio-metabolic impact of extensive bleedings and as a positive collateral outcome it may reduce the total amount of blood products transfused. In fact, it is demonstrated that the decrease in blood products usage is associated to reduced mortality [74]. At present the cornerstones of this strategy focus on temporary hemorrhage-control devices and early use of whole blood or balanced blood product-based transfusions. This brings a reduction in crystalloid use through also the application of hypotensive resuscitation protocols aiming to promote hemostasis and decrease coagulopathy. All these procedures in general help in correcting physio-metabolic impairment and allow a rapid and definitive hemorrhage control. Damage control resuscitation is part of to the more general damage control management strategy that must be structurally applied and must be multidisciplinary; in order to obtain the best results, it should be participated by all the actors of the emergency and trauma patient management [75–77]. However, for many years, a discussion on the benefit of ratios for damage control resuscitation has become the center of attention. Controversies about the true benefits of this approach have been addressed in several research. Since the publication of The Pragmatic, Randomized Optimal Platelet and Plasma Ratios trial, a balance of 1:1:1 ratio of red blood cells, plasma, and platelets has become the standard of care despite a lack of differences in the trial’s primary outcome.Like this study, other retrospective data have supported these findings over the last decade, adding to the body of evidence on the importance of balancing blood product administration for acutely bleeding trauma patients. The PROPPR study only showed a benefit on survival at 6 h with no benefit in the first analysis for a 30-day survival rate; a secondary analysis found a possible benefit in the 30-day survival rate [78]. Several studies have found a dose-dependent relationship between blood transfusion and mortality. Schneider et al. found that the mortality was significantly higher in the Massive Blood Transfusion (MBT defined as patients that received at least 10 PRBC in the first 4 h of admission group (39.4% versus 14.5%; P < 0.001), and for each additional PRBC unit transfused in the OR increased by 1.08 (95% confidence interval 1.08–1.09, P < 0.001) for mortality. In patients receiving 6 to 10 units of red blood cells, red blood cell: platelet ratios were not associated with 4-h mortality, and only red blood cell:fresh frozen plasma ≥ 4:1 were associated with significantly higher odds of 4-h mortality compared to 1:1. For patients receiving > 10 red blood cell units, increasing red blood cell:platelet and red blood cell:fresh frozen plasma ratios were consistently associated with increased odds of 4-h mortality. For example, in red blood cell volumes of 11 to 15, 16 to 20, and > 20 units, risk-adjusted 4-h mortality odds ratios for red blood cell:platelet ≥ 4:1 were 2.27 (1.47–3.51), 3.32 (2.26–4.90), and 3.01 (2.33–3.88), respectively [79]. For this reason resuscitation measures should be continued using a goal-directed strategy, guided by standard laboratory coagulation values and/or VEM [80]. For non-trauma related bleeding In the early treatment phase of uncontrolled massive elective surgery bleeding, they suggest massive transfusion [6 to 10 units] with a high ratio (1: 1) of plasma to RBCs; however, it is also recommended switching to a goal-directed transfusion strategy (based on Hb and/or physiological RBC transfusion triggers, coagulation factor substitution and platelet transfusion triggers) as soon as possible, to reduce risk of massive transfusion.

Recommendation 5: precise and meticulous surgical technique including the use of surgical adjuncts, may help in minimising surgical bleeding. (Grade of recommendation: 1C)

Diathermy Monopolar and bipolar radiofrequency, gas-mediated or other electrosurgical tools are key for achieving haemostasis during surgery. There is however limited evidence that they alone may reduce blood loss and factors such as surgical technique are likely to be more important [70].
Topical agents Topical agents including fibrin sealants (fibrinogen and thrombin), gelatine–thrombin matrices and oxidized cellulose may be applied to bleeding tissues during surgery as a hemostatic strategy. However, these agents are expensive and for this reason not everywhere available. Despite numerous studies across different surgical specialties, there is only weak evidence to suggest that they offer a clinically important reduction in blood loss especially in emergency surgery settings [71, 81]. Accurate technique and hemostasis remain the cornerstone.
Use of laparoscopic and robotic surgery platforms Mini-invasive approaches have been developed and brought several positive outcomes. However, they seem of limited help in substantially reduce blood loss especially in emergency surgery [68, 69, 99]. To increase at best the bleeding during mini-invasive approaches an accurate and anatomical surgical technique is needed.
Cell salvage Cell salvage is a method of recovering blood from the surgical field during the intraoperative or immediate postoperative phase that is then reinfused to the patient. Several indications and guidelines [47] recommend the use of cell salvage for procedures when a very high volume of blood loss is anticipated. Recent indications consider high volume a quantity of blood loss greater than 500 ml [28, 29]. The key principle is to use cell salvage in combination with other blood conservation strategies in trying to prevent or at least to reduce the likelihood of allogeneic blood transfusion and/or severe postoperative anemia [29]. Cell salvage reduces the risk of exposure to allogeneic blood by 54% across all surgical specialties including emergency surgery [30, 31]. Emergency surgical procedures with significant variation in volume of blood loss make difficult to anticipate whether sufficient blood will be collected to permit reinfusion. In this setting, cell salvage can be used in collect-only mode and eventually process it for reinfusion only if in presence of more than 500 ml. There remain controversies regarding which patients benefit from cell salvage, and it is not currently recommended for routine use during all emergency surgical procedures [29, 32, 33]. Moreover, in those situations in facing potential infectious contamination or in high risk of cancer cells spread blood collection and reinfusion is not universally feasible. In fact, infection and malignancy were traditionally contraindications to blood cell salvage, but there is increasing evidence to support its use in these settings. With the use of a leucocyte depletion filter (40 μm), there is a 99% reduction in bacterial contamination in blood resuspended in 0⋅9% saline [34]. The potentially increased risks of bacterial contamination must be weighed against the increased risk of infection through immunomodulation secondary to allogeneic blood transfusion [35].
Tourniquet Tourniquets are used widely during limb surgery, and emergency surgeons may need to use these devices in emergency and trauma situations. However, although tourniquets reduce intraoperative blood loss, meta-analyses of studies suggest that there is no difference in overall blood loss [100, 101]. The release of inflammatory mediators because of limb ischaemia may paradoxically increase blood loss [102]. Interpretation of studies is often limited by the heterogenous data regarding tourniquet application techniques in terms of inflating timing and pressures. Currently, the decision to use a tourniquet is dictated by several factors associated to the blood management, such as visibility of the surgical field. Disadvantages of tourniquet use include increased postoperative pain, impaired muscles function and increased risk of thrombotic events [100, 103, 104].
Drains Surgical-site drains are often used with the aim of reducing hematomas and hypothetically reduce surgical-site infection that may potentially increase post-operative bleeding risks. A limited number of robust studies have investigated the effectiveness of drains in preventing postoperative complications, and many did not demonstrate any benefit of drain insertion over no drain [38, 39, 105, 106]. Conversely, drains may increase infection rates. Some studies have investigated the possibility to deploy autologous reinfusion drains for post-operative cell salvage [107, 108].
Damage control surgery Damage control surgery (DCS) as part of damage control strategy is generally performed together with damage control resuscitation in severely bleeding patients [109–112]. DCS should be implemented as soon as its necessity is recognized [113–116]. It basically reduces the surgical time and procedures only to those fundamental maneuvers aiming to control bleeding and potential contamination [117]. The patients are then transferred to intensive care unit to allow them to recover from the physiological derangements and to be able to face further reconstructive surgical phases. It is demonstrated that DCS helps in increasing overall survival of patients, reduces the risk of developing trauma coagulopathy and can potentially reduce the total amount of blood product usage [109, 110]. DCS strategies may be also applied to non-traumatic emergency surgical patients. Lastly it may fit also to those patients experiencing unexpected severe bleeding during other surgical procedure not amenable of definitive care due to the suddenly deteriorated physio-metabolic conditions.
Endovascular control of bleeding Advances in interventional radiology techniques, employed by vascular and trauma surgeons as well, offer hyper-selective alternatives to surgery [118–120]. In fact, much of the bleeding once considered for open surgical control at present can be safely and definitively stopped with endovascular management [121–123]. This strategy, impact less on the physiology of the patient and allow for less invasive approaches. This in definitive reduces the relative and absolute bleeding. Moreover, endovascular approaches can be also applied to diagnose and prevent bleedings. In those situations where the bleeding is suspected but no source is evident the early application of angiography may help in diagnosis and subsequent treatment [124–128]. Lastly, early radiographic evaluation and eventual prophylactic angioembolization should be considered for injuries that may not currently be bleeding but with potential for deterioration or delayed hemorrhage [129–132]. Access to endovascular approaches should be developed and readily available for all complex procedures with risk of major bleeding.

Special considerations are required for patients who decline transfusion (e.g. Jehovah’s Witness). (Grade of recommendation: 1C)

Recommendation 15physicians must respect local laws and accept that competent patients have the right to decline blood transfusion. Physicians maintain the right and duty to decide whether they can perform a specific procedure without blood transfusion. If they cannot perform a procedure without blood transfusion, they should consider other therapeutic options.

Abstract

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient’s values and target the best outcome possible given the patient’s desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes.

Contents of the original publication

The section headings of the original.

Introduction
Methods
Recommendations
Preoperative interventions
Intraoperative surgical factors
Recommendation 5: precise and meticulous surgical technique including the use of surgical adjuncts, may help in minimising surgical bleeding. (Grade of recommendation: 1C)
Intraoperative anaesthetic factors
Recommendation 6: maintaining permissive hypotension can help minimise bleeding in the absence of moderate-severe brain trauma. (Grade of recommendation: 1C)
Recommendation 7: central neuraxial anaesthesia to help minimise bleeding. (Grade of recommendation: 1C)
Recommendation 8: in the operating room, patient positioning is important to reduce bleeding; comorbidities and the eventual associated lesions must be taken into consideration. (Grade of recommendation: 1C)
Recommendation 9: it is important to avoid hypothermia to help minimise bleeding. (Grade of recommendation: 1B).
Recommendation 10: ventilation strategies are important to minimise bleeding. (Grade of recommendation: 1C)
Recommendation 11: procoagulant factors are useful to help minimise bleeding. (Grade of recommendation: 1C)
Recommendation 12: viscoelastic haemostatic assays help to identify the risk of bleeding or to minimise transfusion. (Grade of recommendation: 1C)
Recommendation 13: maintain acute normovolemic haemodilution to help minimise bleeding and transfusion. (Grade of recommendation: 1C)
Recommendation 14: constantly monitoring of patient physiology is essential and, if the patient consents, transfuse according to well-founded clinical indications only.
Special considerations are required for patients who decline transfusion (e.g. Jehovah’s Witness). (Grade of recommendation: 1C)
Specific consideration must be reserved to unemancipated minors and patients unable to understand and want. (Grade of recommendation: 1C)
Patient care when blood transfusion is not an option
Conclusion

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