Management of the patient with potential for massive perioperative blood loss

This narrative vignette explores the perioperative management of a 65-year-old man scheduled for extended hindquarter amputation due to pelvic chondrosarcoma, with anticipated massive blood loss of 5-7 liters. Despite being otherwise fit, his preoperative hemoglobin of 125 g/L and low iron stores pose risks, prompting the clinical question: How should this patient be managed perioperatively to mitigate massive hemorrhage? Preoperative evaluation emphasises thorough assessment, including transfusion history, coagulopathy screening, and optimisation of pre-existing anemia via erythropoietin or intravenous iron, even in urgent oncological cases. Discontinuation of antiplatelets and anticoagulants requires balancing bleeding and thrombotic risks. Informed consent includes discussing morbidity such as organ failure and mortality. Intraoperatively, strategies include large-bore access, invasive monitoring, thromboelastography-guided transfusions, tranexamic acid to reduce fibrinolysis, and cell salvage where feasible. A multidisciplinary approach ensures communication between surgical teams, anaesthetic teams, nursinf staff and laboratories. Allogeneic transfusions should commence early to maintain stability, with vigilant monitoring for complications like hypothermia, hyperkalemia, and transfusion reactions. Postoperatively, ongoing surveillance in high-dependency care allows for assessement of further bleeding, and appropriate thromboprophylaxis.