Measurement of blood loss during surgical operations

MEASUREMENT

OF BLOOD LOSS DURING

SURGICAL

OPERATIONS* JOHN J. BONICA, M.D. AND COL. CLINTON S. LYTER, M.C. Tacoma, Washington

T

HE maintenance of the fluid balance of before surgery. They commented on the Iarge surgica1 patients is one of the most imIoss of bIood during certain operations, parportant responsibilities of the modern ticuIarIy radical mastectomy in which there surgica1 team, and the proper repIacement of seemingIy was no excessive bleeding at any bIood is perhaps one of the most important time during the procedure. BIain’ in 1929 disphases of this maintenance. This is true not cussing his experience with 3,000 transfusions only because it is an excellent prophyIactic emphasized the fact that the amount of bIood lost during operations is often several times measure against shock but also because it aids in decreasing postoperative morbidity. In order greater than estimated by the surgeon. He to obtain optimal effects, however, the blood urged the preoperative correction of anemia and the immediate repIacement of bIood Ioss during must be replaced at the proper time-.as the patient loses it-and in the proper amount. operation and condemned the procrastination of some surgeons and the deIay in giving bIood AIthough most surgeons and anesthesiologists transfusions unti1 after shock had deveIoped. we11 appreciate this fact, they are often faced with the probIem of accurately estimating GoIIer and Maddocks in 1932 reported their bIood loss in order to avoid under-replacement observations in measuring IIuid Ioss incIuding or over-replacement, both of which are exbIood during eighteen operations and concluded that the amount Iost was greater than they had tremely important in poor risk patients. Purely estimated. In 1937 Pilcher and Sheardg resubjective estimation by the surgical team has ported the average bIood loss in two series of been shown to be often grossly inaccurate and transurethral prostatic resections as compared at times the errors of personal judgment may to a group of forty-nine genera1 surgical cases. reach dangerous levels, particularly in the poor The first series of fifty&e cases had a blood risk patient. In order to solve this problem Ioss of 479 cc. and in the second series studied several methodsle5 have been proposed, but of after aIterations in their technic the blood Ioss these the direct measurement as the operation was reduced to 291 cc. HubIy’O in the same progresses is the onIy practical and reliable year, while investigating the hemostatic propmeans of determining blood loss. It is the purerties of congo red during this type of operapose of this articIe to present a simple and tion, determined the postoperative bIood loss practical method which we have used to accomwas at Ieast two-thirds of that which occurred pIish this in 748 operations and also to present a complete review of the American literature. during operation. White et al.” studied bIood Ioss in thirtyThe measurement of blood Ioss during surgiseven neurosurgical operations and found that cal operations has been reported by several authors and in some clinics it has become a the Ioss during extensive intracrania1 procedures averaged from 500 to 1,200 cc. and even routine procedure, particularly in poor risk patients. Gatch and LittIe6 in 1924 were the up to 2,000 cc., expIaining such reIativeIy Iarge loss as due to extreme vascuIarity of the scalp first to report measurement during some of the and diffrcuIty in controlling the bleeding in more common operations in genera1 surgery. these cases. They aIso determined that the They used the acid hematin method which inreduction of concentration of red bIood cells, voIves washing a11the sponges, linen and instruhemogIobin and hematocrit readings continues ments free of bIood and then adding hydroprogressively and is found to be Iowest during chloric acid to make the washing a 0.1 N the fourth postoperative day. In 1938 Stewart solution prepared from the blood of the patient * From the Departments of Anesthesia and Surgery, Tacoma General HospitaI and Madigan General HospitaI, Tacoma,

Wash.

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of Surgery

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Loss

and Kourke3 studied hematocrit changes induced by blood loss and trauma and found that with the loss of blood there is usually a dcrreasc in blood volume without physical or chemical changes of the bIood, thus demonstrating the fallacy of assuming quantitive relationship between changes in the concentration of hemoglobin and plasma protein and changes in plasma volume. They were also the first to show that the decrease in total blood volume is greater than can be accounted for by a loss of blood at the site of the wound during the operation, indicating that there is an additional loss into the tissues. In 1939 Nadal12 presented a series of sixteen orthopedic operations in which he investigated not only the blood loss but aIso the percentage ,of the volume of blood lost and its reIationship to shock. He found that patients who Iost between 15 and 20 per cent or over of the total blood volume frequently went into peripheral circulatory failure. Nesbitt and Conger13 in 1941 measured blood loss during the operative and postoperative period of IOO transurethral prostatectomies and found that it averaged I 69 cc. during operation and at Ieast two-thirds of that amount during the postoperative period, confirming the work of Hubly. In 1942 Wangensteen14 described for the first time the simple gravimetric method of determining blood loss with which he determined that the average loss in gastric resections was from 300 to qoo cc. In the same year Buxton and White15 measured blood loss in 109 patients undergoing surgery of the chest and determined that the loss was about 700 cc. for each stage thoracoplasty and about 1,600 cc. for both Iobectomy and pneumonectomy. They strongly advocated Iarge transfusions during these operations. 0ppenheim16 in 1944 measured the amount of blood loss in abdominal operations and concluded that aIthough the loss \vas not excessive, a transfusion of 500 to 600 cc. during the operation is of great benefit to the patient operated upon for cancer of the gastrointestinal tract. CoIIer and associates4r5 wrote two articIes in 1944 in which they reported the investigation of bIood loss and the relationship between the amounts of blood lost and the changes in the hematocrit, hemoglobin and plasma protein concentrations before and after operations. They concluded from their findings that no correlation exists among the amounts of blood ,\fuy,

I()$I

in Surgical

Operations

497

lost and changes in these values. Therefore, these determinations cannot be used to estimate the riced for blood volume rcplaccmcnt. They contended that the patient benefits most when the blood loss is replaced by blood given as the loss occurs and believed that even minimal losses retard convalescence, that any loss over 300 cc. in healthy adults should be replaced and that a11 loss during operations in aged, undernourished, seriously ill or bedfast patients should be replaced with equa1 quantities of blood. In 1946 Baronofskyl’ compared the colorimetric and gravimetric method in twenty-one patients and found that there was a cIose relationship between the two methods and, therefore, advocated the simpler gravimetric technic. Two years later Lenahan et al.lx published their findings in 270 patients who had undergone various surgical procedures and concIuded that the effect of blood loss depends upon a relationship of the amount lost to the total blood volume, the rapidity of the loss and the preoperative status of the patient. Lyon et aL2 recently measured blood loss during various surgical procedures by the standard calorimetric and gravimetric methods and compared the results with those obtained with the red cell volume method. They found that the operative blood loss measured by the latter method was higher than that obtained by either colorimetric or gravimetric procedure. They explained this discrepancy by pointing out that in addition to the blood removed from the wound there is some Ioss in the surgical specimen, some infiltrated into the wound and surrounding tissue spaces and therefore not absorbed by sponges, and some immobiIized in vessels proximal to the ligatures. The present authors have compiled the findings of these different investigators in an effort to compute an “average bIood loss” for different operations. These are shown in Table I. PRESENT

INVESTIGATION

Method of Study. For most of this study we have used the gravimetric technic which is based on the use of sponges, packs, towels or other linen employed for colIecting blood during the operation and weighing them after use. A weighing scale accurate to 0.1 gm. is used. Dry sponges and packs do not have to be weighed before each operation because they are remarkably uniform in weight and come

Bonica,

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BLOOD LOSS DURING

Lyter-BIood

SURGICAL

Loss in SurgicaI

TABLE I OPERATIONS-REVIEW

-

Operations

OF THE AMERICAN

No. of Cases

Operations

T

BIood Loss in cc.

Maximum

I. NeurosurgicaI Brain........................... Exploratory craniotomy.. . SpinaIcord...................... ThoracoIumbar sympathectomy. . Lumbar sympathectomy.. Others. .. . . 2. Neck Surgery Thyroidectomies. . RadicaI neck dissections. ... Others.. . . . 3. Breast Surgery Simple mastectomies.. . Radical mastectomies.. 4. Thoracic Sureerv * ....................... ThoracopIasties. ............ Thoracotomies (expIoratory). Lobectomies. ...................... ..................... Pneumonectomies. 5. Gastric Surgery Gastric resection. ...................... Vagotomy ............ .................... Others (enterostomies, etc.). 6. BiIiary System Surgery .................... Cholecystectomies. BiIe ducts operations. ................... 7. Splenectomies............................ 8. IntestinaI Surgery SmaII intestine (resections and others). Large intestine ”

19

2,150

12

1,100

12

1,264 950 309 950

6 4 7

Minimum

574 542 255 105 I53 86

4verage

I ,287 803 655 325 215 65

16

4oo I74

4oo 174

249 4oo 174

220

190 I96

205 690

24 17

2,565 2,375 3,050 2,983

97 424 475 691

705 1,158 1,558 1,558

99

’ ,432

IO

690 305

150 165 ‘5

441 423 120

357 1,455 160

51 75 58

171 460 109

II

1,425

50

7o4

32

2,420 450 62

183 13 4

619 133 IO

3z

629 579 1,257

40 ‘4 93

358 ‘53 536

4o 4

263 306

6 48

58 146

12

20

845 1,254 1,235 650 ‘50

208 4 265 4oo 20

484 296 551 525 55

28 5

2,790 176

103 -&o

795 95

I 3 27

1,272

I

102 I2

: :

VentraI ............................... UroIogic ........................ Nephrectomies. Transurethral prostatic resection ......... Suprapubic. ........................... 14. Perineal ................................. ..................... 15. Hemorrhoidectomies. 16. Orthopedic ....... Major (bone grafts, amputations). Minor .................................

‘3 26 20 2

...

IO. PeIvic Surgery ......................... Hysterectomies. Others (saIpingectomies, oophorectomies) Intra-abdominat ............. II. Miscellaneous Herniorrhaphies 12. InguinaI ...............................

27 110

33

‘3.

.

T

888

43 I

Abdominoperineat.................... Other resections. ..................... ......................... 9. Appendectomies.

TotaI .

LITERATURE

237 IO 2

1,081

American

Journal of Surgery

Bonica, Lyter-Blood

Loss in Surgical Operations

from the autoclave at a constant level of dryness. Immediately after use the sponges arc weighed by the circulating nurse so that evaporation from them does not become an item of importance. In intra-abdominal and intrathoracic operations serous fluid is absorbed which is accounted for along with the blood. The complete gain in weight of sponges is treated as blood loss, each gram being considered as I cc. with no correction being attempted for the slight difference of the specific gravity of the blood from unity. In the first 132 operations we used dry sponges as advocated by Wangensteen,14 but many surgeons commented that it was a decided disadvantage not to use saline sponges in certain operations. We, therefore, undertook to modify the technic so that the wet sponges could be used whenever necessary. This is aIso a simpIe procedure and as accurate in the determination of bIood loss as using dry sponges. The sponges are, of course, moistened with saline which is measured by a scrub nurse. Whenever saline is needed, the circuIating nurse under aseptic conditions pours it into a steriIe graduated 1,000 cc. cylinder and records the amount of sahne on the especially prepared blood Ioss chart. The scrub nurse then transfers the measured amount of saline to the sponge basin. Whenever necessary she moistens the sponges in the saline and then squeezes as much of the excess saline as possible so that none is spilled out of the basin or while the sponge is being given to the surgeon. At any point during the operation that the blood toss is to be determined, the amount of saline used is calculated by measuring the amount remaining. The amount used is added to the weight of dry sponges employed and this is subtracted from the total weight of the used sponges. If suction is employed, the amount of blood in the suction bottle is included. The amount of blood lost on the drapes, surgeons’ gowns and gloves is not usually measured because it is not practical to weigh these. However, measurement by the calorimetric method in several cases indicated that this often does not exceed $0 cc. The amount of blood spilled on the drapes is minimized by sewing toweIs to the skin immediately after the skin incision is made. The towels, of course, are weighed and the amount of blood on them is calculated. With only a simple explanation of the procedure and some emphasis on the importance ILfay,

I95 I

499

of certain details, we have trained our surgical nurses so well that the amount of saline that is spilled and thus unaccountable is minimal. This has been confirmed by many preliminary experiments with a measured amount of saline. The coIorimetric method was used for the determination of the blood Ioss in fourteen transurethral prostatic resections, and the red cell voIume method was employed in two cases undergoing intracranial surgery. Results. The amount of blood loss as determined by the aforementioned methods during 748 operations is shown in Table II. These operations were performed by fifty-six different surgeons who represent a cross section of surgical skill in two general hospitals. The cases have been grouped in fifteen main categories and the maximum, minimum and average blood loss has been shown. It is of interest to mention that our figures were consistent with those figures found in the American literature, as shown in Table I, in which the average values obtained by all the other investigators are presented with our averages. It is important to note that many operations entail a loss of more than 500 cc. of blood, particularly radical neck dissections, radicaI mastectomies, intrathoracic procedures, removal of brain tumors, perineal repairs and orthopedic operations. Many of the patients who undergo these operations are usually in the old age group or in poor condition or both and cannot tolerate the loss of even small amounts of blood and invariably develop shock if it is not promptly replaced. The patient wh o lost 3,944 cc. during a nephrectomy presented a very severe problem because for several hours after one of the major anomalous vessels was inadvertently torn by the surgeon, the patient was in grave condition in spite of immediate replacement. We are convinced that under-replacement would have prevented recovery whereas over-replacement may have been just as deleterious to a heart which had been weakened by the episode. COMMENTS The importance of proper replacement of blood loss during and after operation has been recently re-emphasized by several clinical investigator+ who have demonstrated that although there is a compensatory increase in plasma volume and circulating plasma proteins following uncompensated bIood loss in the well hydrated patient, there is no such compensa-

Bonica,

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BLOOD

Lyter-BIood

Loss in Surgical Operations TABLE II OPERATIONS

loss DURINGSUR~ICAI_

(AUTHOR’s

-

No.

Operation

oi

Cases

Maximun (cc.)

\Iinimun (cc.)

SERIES) 1

Average (cc.)

Literature 4verage Loss (cc.)

1,159 741 674 992 655 314 667

I ,287 803 532 655 325 215 65 249 4.00

_I. NeurosurgicaI Operations Brain operations. .......................... SpinaIcord ................................ Thoracolumbar sympathectomy .............. Lumbarsympathectomy .................... Others. ................................... 2. Neck Thyroidectomy ............................ Radical neck dissection ...................... Thyroglossai cyst. .......................... Others. .................................... 3. Breast Sim Ie mastectomy. ........................ Ra d?caI mastectomy ......................... 4. Thoracic Operations Exploratorythoracotomy .................... Lobectomy .................................

1,096 521 4.02 798 285 365 440

I5 8 4

739 I.154 511

528 363

320 759 470

II 53

394 1,608

62 202

151 647

205 690

16

I97 1,056 238 870

705

‘5 4

1,246 I.905 1,810 1,688

I ,482 ’ ,455

1,148

1,158 1,558 1,558

36 9

648 801

39 102

228 416

171 460

30 3 4

1,650 206 797

131 115 97

576 I59 376

441 423 109

27 18

829 252

108 75

511 183

,.

1,132 I*337 570 349

432 187 86 19

790 5x1 206 76

.

61 19

I ,798

69 51

48 24

861 1,354

21

3,944 973 918 I ,006

IO

II

Pneumonectomy............................

Transthoracic diaphragmatic hernia ........... Thoracoplasties. ............................ 5. BiIiary Operations Cholecystectomy ............................ Bile ducts operation. ....................... 6. Gastric Operatrons SubtotaI gastric resection. ................... Vagotomy .................................. 7. Splenectomy................................. 8. SmaII IntestinaI Operations Resections. ................................ 9. Large Intestinal Operations Abdominoperineai ........................... Other resections. ........................... Others ..................................... IO. Ap endectomies. ............................. 1I. Pe Ip. vrc Operations Hysterectomies. ............................ Adnexa operations .......................... I 2. Miscellaneous Intra-abdominal ................. 13. Herniorrhaphies InguinaI ................................... Ventral .................................... I *_ UroIogic Operations Nephrectomies. ............................. Cystectomies ............................... Perineal prostatectomies. .................... Transurethral prostatic resections .............

12

31 6 36

.

3

2 21

Suprapubic .................................

1,054

13

310

54

831

18

623 589 1,232 1,657 923 1.784

.

: 18 12

15

..

- -__ 3

..................................

-

..

... ‘94

.

.

174

. .

705

704

I”

358 153 536

35 459

58 146

64 562 382 130

708 810 650 365

484

133

209

114

483

48:

401 321 607 148 275 565

. ‘298

.

.

783 I.153 570 616 630 2,070 357 1.308

799 521 496 1,076

. .

155

748 -

American

551

525 55

:%i

2

.

619 I33

..

..

.

Others ..................................... 1f . PerineaI Operations Vaginal repairs, hysterectomies, cystoceIe. ..... I 6. Hemorrhoidectomies. .......................... 17. Ortho edit Operations Art Krodesis of shoulder. ..................... Open reduction upper extremities. ............ Bone grafts upper extremities. ................ Hip-nailing or arthroplasty. .................. Open reduction lower extremities .............. Bone grafts lower extremities ................. Amputations. .............................. Others..............................: ......

III

....

...

Entero-enterostomy.........................

TotaICases

4

1,434 905 1,004 1,204 I ,083 850 871

4 6 15 3 II

Craniotomy ............................... Spinal column .............................

Journal of Surgery

Bonica,

Lyter-BIood

Loss

tory increase in the red bIood cells. In such cases in which bIood loss is not replaced the depleted red cell volume does not return to normal until several weeks after the loss occurs. In other words the body is abIe to compensate for Ioss of plasma but its abiIity to restore depleted red ceIIs is very limited. In addition, these investigators have shown by bIood volume studies that there is not only loss of bIood from the wound where it is apparent, but there is also a loss into the tissues, in the surgical specimen and in the vessels proximal to the ligatures (where it is immobiIized and therefore lost to the circulating blood) which is not apparent. These studies have also reveaIed that there is usually a postoperative loss which may be significant and at times may be as Iarge or larger in amount than the operative loss. Because such losses are usually insidious the clinical signs customarily observed following acute blood loss may be absent. This decrease in oxygen-carrying red blood cells causes varying degrees of hypoxia which increase the postoperative morbidity, and if the patient’s condition is such, may lead to severe disturbances of the cardiocirculatory mechanism and possibly end up in circulatory faiIure. It is mandatory, therefore, that the surgical team replace the blood loss during the operation as the patient loses it for it is much simpIer to prevent shock than to treat it after it has occurred. Although most surgeons and anesthesiologists well appreciate the problem, there are those who hesitate and even object to giving blood during the operation because they are convinced that their surgical technic precludes large blood losses and often blame the anesthesia if shock does occur. It may be appropriate, therefore, to point out at this time that a review of the literature is impressive by the fact that all of the investigators concluded that (I) the blood loss is always greater than they had anticipated or estimated, (2) procrastination on the part of the surgeon in replacing blood loss during and after operations should be condemned, (3) accurate measurements and replacement not only affords the patient optimal prophyIaxis and therapeusis but also leads to a better appreciation of the problem by the surgical team. SUMMARY AND

CONCLLSION

The repIacement of bIood lost during surgical operations is a very essential part of the operMay,

1931

in SurgicaI

Operations

$0 I

ative procedure because it not only prevents shock but it aIso decreases the postoperative morbidity. In order to have optimal effects the blood must be administered as it is being lost and in proper amounts. The gravimetric method affords the surgical team a simple and practical means of accurately measuring the amount of blood lost from the surgical wound. As there is usually additional blood Iost into the tissue and in vessels iust proxima1 to Iigatures, the amount determined by the gravimetric method is the minimal amount to be replaced. The blood loss has been determined by the authors in 748 surgical procedures which are presented herein. The average bIood loss as found by seventeen other investigators is also presented. Acknowledgment: We would like to express our sincere thanks and appreciation to Captain Virginia Daniels, A.N.c., Mrs. Lucille McDonald and their staffs for the assistance given the authors in this investigation. REFERENCES

MOON, V. H. Shock, Its Dynamics, Occurrence and Management. PhiladeIphia, 1942. Lea and Febig&. 2. LYON, R. P., STAKTON, J. R., ZEIS, E. D. and SMITHWICK, R. H. BIood and “available fluid” (thiocynate) volume studies in surgical patients. Surg., Gynec. cf Obst., 89: g-19, r81-Igo, rgbg. I. STEWART. J. D. and ROURKE. G. M. Changes in blood and interstitia1 Auid resulting from su;gicaI operations and ether anesthesia. J. C/in. Ina&tigation, 17: 413, 1938. L. COLLER. F. A.. CROOK. C. E. and IOB. V. BIood loss d&ing &gicaI operations. J. A. hf. A., 126: I.

'9 1944. 5. CROOK, C. E., IOB, V. and COLLER, F. A. Correction of bIood Ioss during surgical operations. Surg., Gynec. ti Obst., 82: 417, 1946. 6. GATCH, W. D. and LITTLE, W. D.: Amount of blood Iost during some of the more common operations. J. A. M. A., 83: 1075, 1924. 7. BLAIN, A. Impressions resulting from 3,000 transfusions of unmodified bIood. Ann. Sure., 89: 189. 1929. 8. COLLER, F. A. and MADDOCK, W. G. Dehydration attendant on surgicat operations. J. A. ,Vf. A., 99:

875,

1932.

PILCHER. F. and SHEARD. C. IMeasurements on the loss of: blood during tiansurethral prostatic resection and other surgical procedures, determined by spectrophotometric and photeIemetric methods. Proc. Staff Meet., Ma,yo Clin., 12: 213, 1937. LO. I~UBLY, J. W. Hemostatic effect of congo red in transurethral resection. Proc. Stafl Meet., Ma,vo Clin., 12: 213, 1937. I I. WHITE, J. C., WHITLAW, G. P., SWEET, W. H. and o.

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12. 13.

14.

15.

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Loss in SurgicaI

HURWITT, E. S. Blood Ioss during neurosurgical operations. Ann. Surg., 107: 297, 1938. NADAL, J. W. BIood loss in orthopedic operations. Unirr. Hosp. Bull., Ann Arhor, 5: 74, 1939. NESBIT, R. M. and CONGER, K. B. Studies of blood Ioss during transurethral prostatic resection. J. &ok, 46: 713, 1941. WANGENSTEEN, 0. H. The controIIed administration of fluid to surgica1 patients. Minnesota Med., 25: 783, 1942. WHITE, M. L. and BUXTON, R. W. Blood loss in thoracic operations. J. Tboracic Surg., 12: 198, 1942.

Operations

16. OPPENHEIM, A., PACK, G. T., ABELS, J. C. and RHOADES, C. P. Estimation and significance of blood Ioss during gastrointestina1 surgery. Ann. Surg., I Ig: 865, 1944. r7. BARONOFSKY, I. D., TRELOAR, A. E. and WANGENSTEEN, 0. H. Blood loss in operations: a statistica comparison of losses as determined by the gravimetric and coIorimetric methods. Surgery, 20: 761, 1946. 18. LENAHAN, N. E., SPITZ, T. A. and METCALF, D. BIood determination and estimation of bIood loss during surgical operations. Arch. Surg., 57: 3, 435-442~ 1948.

ADENOMAS of the parathyroid can cause kidney complications because the secretion of these benign growths increase serum calcium and lower serum phosphorus IeveIs. In either case an increase occurs in the amount of these mineraIs in the urine. It is for this reason that many prominent uroIogists suggest that a11patients with renaI calculi be checked for possibIe parathyroidism first. If present, their parathyroid tumor shouId be removed prior to treating the patient for his kidney stones, unIess an acute obstruction to renaI secretions is present, caused by said caIcuIi. (Richard A. Leonardo, M.D.)

American

Journal

of Surgery