Risk and crisis management in intraoperative hemorrhage: Human factors in hemorrhagic critical events

Abstract

Hemorrhage is the major cause of cardiac arrest developing in the operating room. Many human factors including surgical procedures, transfusion practices, blood supply, and anesthetic management are involved in the process that leads to hemorrhage developing into a critical situation. It is desirable for hospital transfusion committees to prepare hospital regulations on 'actions to be taken to manage critical hemorrhage', and practice the implementation of these regulations by simulated drills. If intraoperative hemorrhage seems to be critical, a state of emergency should immediately be declared to the operating room staff, the blood transfusion service staff, and blood bank staff in order to organize a systematic approach to the ongoing problem and keep all responsible staff working outside the operating room informed of events developing in the operating room. To rapidly deal with critical hemorrhage, not only cooperation between anesthesiologists and surgeons but also linkage of operating rooms with blood transfusion services and a blood bank are important. When time is short, cross-matching tests are omitted, and ABO-identical red blood cells are used. When supplies of ABO-identical red blood cells are not available, ABO-compatible, non-identical red blood cells are used. Because a systematic, not individual, approach is required to prevent and manage critical hemorrhage, whether a hospital can establish a procedure to deal with it or not depends on the overall capability of critical and crisis management of the hospital.

Keywords: Crisis management; Hemorrhage; Risk management; Transfusion.

Fig. 1

Factors affecting hemorrhagic critical events caused by surgical procedures. Analysis of 1,105 patients who are registered in the surveys conducted by JSA between 2003 and 2005 [2].

Fig. 2

Outcome of 1,257 patients whose intraoperative blood loss exceeded 5,000 ml in terms of the function of blood loss (A) and the minimum intraoperative hemoglobin level (B).

Fig. 3

Urgency code for emergency blood transfusion. RBCs to be permitted differ among hospitals according to the amount of stock, manpower of the blood supply center especially during nights/weekends, and the time required for emergency blood supply from blood banks. Code color for I, II, III is red, yellow, green as in the case of a triage tag. ^*RBC: red blood cell.