Anyone have a good system for monitoring EBL?

[propadex]

EBL appears to be so subjective. Anyone have a reliable system they would like to share for monitoring it? Counting lap sponges, looking for blood pooling on the floor, and adding whatever is in the suction canister? What if they are intermittently using irrigation and that ends up in their suction canister? What about using ABG and calculating likely blood loss based on preop and postop Hgb and weight? Any other ideas?

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[MirrorTodd]

Just add 2-300ml to what the surgeon says depending on whatever surgery is going on. There really is no way to estimate. We're better at guestimating what level our epidural is at than guessing how much blood loss there was.

 

[DoctwoB]

Surgeon weighing in. Its a pretty stupid metric. You can usually go roughly by the suction canister -irrigation used which will overcount since there are non blood fluids in there (especially in lap cases where we rarely use sponges) but also undercount since it doesn’t include blood from sponges. Honestly should be categorized as “minimal” (say <100cc), “ Moderate” (say 100-500) “heavy” say (500-1500) and “liver transplant.”

Really though for any significant blood loss you should be treating based on blood counts and hemodynamics, not the quoted EBL.

 

[DoctwoB]

Just add 2-300ml to what the surgeon says depending on whatever surgery is going on. There really is no way to estimate. We're better at guestimating what level our epidural is at than guessing how much blood loss there was.

i know you’re mostly joking, and it is true that we suck at estimating EBL, just keep in mind we may suck in both directions.

 

[drmwvr]

Recording EBL is about as useful as the " restricted to non-flammable anesthetics only" signs that are still around.

 

[chocomorsel]

Unless it’s significant and approaching requirements for transfusion I honestly don’t care. I ask the surgeon and put it down.
I find it to be essentially irrelevant.

 

[dchz]

just keep in mind we may suck in both directions.

It's 2020, no one is judging. Unless you're offering.

 

[MirrorTodd]

i know you’re mostly joking, and it is true that we suck at estimating EBL, just keep in mind we may suck in both directions.

Edit: misread statement. Most def agree with you there. I've wondered if there are any studies identifying whether blood loss is estimated on the higher side or the lower side more often. I'd be the lower side cause lower numbers look better and we're all subjective to pride. That's why I had some ob residents try to claim 500cc blood loss on a twins cesarean.

 

[DoctwoB]

Edit: misread statement. Most def agree with you there. I've wondered if there are any studies identifying whether blood loss is estimated on the higher side or the lower side more often. I'd be the lower side cause lower numbers look better and we're all subjective to pride. That's why I had some ob residents try to claim 500cc blood loss on a twins cesarean.

Agreed our cognitive bias (or conscious decision) is to limit blood loss. Very surgeon dependent though, I definitely worked with some that would always overestimate.

 

[NoodleIncident]

For some cases, we've been weighing sponges, raytex, measuring suction canister volumes and subtracting dry weights and irrigation. The numbers are all over the place and we occasionally get negative EBLs

 

[MirrorTodd]

For some cases, we've been weighing sponges, raytex, measuring suction canister volumes and subtracting dry weights and irrigation. The numbers are all over the place and we occasionally get negative EBLs

negative EBL's!

 

[deleted162650]

negative EBL's!

Every time I ask the scrub tech how much irrigation was used, and the (obviously wrong) amount they tell me results in a negative EBL, I exclaim to the room “Alert the Vatican! It’s a miracle!”

(Catholic Hospital)

 

[kidthor]

If you do give blood and have pre/post HgB, it can help you estimate mentally too.

A unit of blood is 350 ml or so. So if you started with a HgB of 9, they lose some and you give 3 units, and the post HgB is 8.5 - I figure they probably lost about 900ml (350*3 minus a bit). Granted there are other factors in the mix like crystaloid given, UOP, insensibles, how your Lactate/base excess have trended, but at least this way you have a good confirmation of your estimate.

 

[kidthor]

Every time I ask the scrub tech how much irrigation was used, and the (obviously wrong) amount they tell me results in a negative EBL, I exclaim to the room “Alert the Vatican! It’s a miracle!”

(Catholic Hospital)

Does this put someone in line for sainthood, and if so who?

 

[DrZzZz]

If you do give blood and have pre/post HgB, it can help you estimate mentally too.

A unit of blood is 350 ml or so. So if you started with a HgB of 9, they lose some and you give 3 units, and the post HgB is 8.5 - I figure they probably lost about 900ml (350*3 minus a bit). Granted there are other factors in the mix like crystaloid given, UOP, insensibles, how your Lactate/base excess have trended, but at least this way you have a good confirmation of your estimate.

The hct of a unit of PRBCs is about 60. A cc of PRBC does not equate to a cc of blood in the body / EBL.

 

[Monty Python]

Surgeon weighing in. Its a pretty stupid metric. You can usually go roughly by the suction canister -irrigation used which will overcount since there are non blood fluids in there (especially in lap cases where we rarely use sponges) but also undercount since it doesn’t include blood from sponges. Honestly should be categorized as “minimal” (say <100cc), “ Moderate” (say 100-500) “heavy” say (500-1500) and “liver transplant.”

Really though for any significant blood loss you should be treating based on blood counts and hemodynamics, not the quoted EBL.

Agreed, and did that for years, until someone in authority (Joint Commission, bylaws, Medicare, someone) said we must put a numerical digit, not a descriptive term. So now on essentially bloodless cases we’re charting ridiculous things like “2 ml.”

Added to the fun is how my hospital switched from suction canisters changed between each case to a device resembling R2D2. I think “Neptune“ is the brand name. It stays in the OR all day, not emptied between cases, had a multiliter capacity, and is only docked to the central suction system at the end of the day for emptying. I don’t like it.

How Do You Handle Fluid Waste? > Outpatient Surgery Magazine > November, 2013

Handling fluid waste and managing runoff after the Neptune recall.

www.outpatientsurgery.net

 

[ethilo]

Every time I ask the scrub tech how much irrigation was used, and the (obviously wrong) amount they tell me results in a negative EBL, I exclaim to the room “Alert the Vatican! It’s a miracle!”

(Catholic Hospital)

I used to ask the scrub tech but had too many surgeons that would chime in with some defensive statement. I stopped asking, also stopped arguing with their proposed EBL numbers at the end of the case unless it was a matter of patient safety. Rapport and social capital with my surgeons is more beneficial to everyone than getting accurate numbers 99.9% of the time.

 

[secretasianman]

I never understood this. Is this like a badge of honor to have low ebl?

Surgeon: what’s the ebl?
Me: I dunno, 100?
S: nah it wasn’t that much, maybe 25.
M: okay sure whatever i don’t really care.

I used to ask the scrub tech but had too many surgeons that would chime in with some defensive statement. I stopped asking, also stopped arguing with their proposed EBL numbers at the end of the case unless it was a matter of patient safety. Rapport and social capital with my surgeons is more beneficial to everyone than getting accurate numbers 99.9% of the time.

 

[coffeebythelake]

I never understood this. Is this like a badge of honor to have low ebl?

Surgeon: what’s the ebl?
Me: I dunno, 100?
S: nah it wasn’t that much, maybe 25.
M: okay sure whatever i don’t really care.

Yepp

 

[OTCAwesome]

I never understood this. Is this like a badge of honor to have low ebl?

Surgeon: what’s the ebl?
Me: I dunno, 100?
S: nah it wasn’t that much, maybe 25.
M: okay sure whatever i don’t really care.

Hahaha, This.. This is pretty much how every EBL conversation goes around the world

 

[kidthor]

The hct of a unit of PRBCs is about 60. A cc of PRBC does not equate to a cc of blood in the body / EBL.

I'm giving a way to estimate not equate - and your thinking is wrong, resident.

Good luck with that mindset.

 

[linkin06]

how bout the OB QBL? Sometimes it seems reasonable, but sometimes, I hear the nurse sounding like "carry the one...minus this, plus this...wait negative?"

 

[MirrorTodd]

I'm giving a way to estimate not equate - and your thinking is wrong, resident.

Good luck with that mindset.

Lol Jesus Christ, take it down a notch.

 

[BobLoblaw78]

hissing suction most of the csection = 400 mL EBL
slurping suction most of the c-section = 650 mL EBL
silent suction most of the c-section = 900 mL EBL (I don't do over a liter. Who's got time for that paperwork!)

 

[DrZzZz]

I'm giving a way to estimate not equate - and your thinking is wrong, resident.

Good luck with that mindset.

I may be "greener" than you, but not a resident. And also not the one who seemingly suggested that PRBC volume is roughly equivalent to blood lost in a case. Maybe you misworded it, but that's how it read to me. Not trying to start a feud here, just figured I'd correct what seemed to me like a "resident" type of misguided thought process on your part. Like others said above, I don't really care what the EBL is unless it has a clinical effect on my patient (ie. I'm considering giving blood based off it).

 

[banister]

I may be "greener" than you, but not a resident. And also not the one who seemingly suggested that PRBC volume is roughly equivalent to blood lost in a case. Maybe you misworded it, but that's how it read to me. Not trying to start a feud here, just figured I'd correct what seemed to me like a "resident" type of misguided thought process on your part. Like others said above, I don't really care what the EBL is unless it has a clinical effect on my patient (ie. I'm considering giving blood based off it).

I think he's referring to your "Status" tag under your username, which says "Resident" still, not assuming you are one based on your comment.

 

[fakin' the funk]

There are only three values of EBL
1) don't care
2) hmm might need a CBC this evening
3) MTP / Belmont

97% of all cases are #1, but the surgeon still says "What do you think for EBL, about 6.3ml?"

 

[fakin' the funk]

Every time I ask the scrub tech how much irrigation was used, and the (obviously wrong) amount they tell me results in a negative EBL, I exclaim to the room “Alert the Vatican! It’s a miracle!”

Someone back me up on this, or don't, if you think it's crazy.

In any "real" blood loss case (> 2-3L) don't you all find that you end up giving almost exactly, or sometimes a bit over, in blood product volume as the apparent EBL? To actually achieve a euvolemic, hemostatic, hgb > 7 patient? It's as if the preop "normal" state is just obliterated at that point (and maybe that's the point for a 5L blood volume patient)

 

[DrZzZz]

I think he's referring to your "Status" tag under your username, which says "Resident" still, not assuming you are one based on your comment.

Really? All I see is "ASA Member" and "5+ Year Member." I don't see anything saying I'm still a resident on my post or on my profile page. I'd update that if I could even see it.

Edit: Nevermind. Found what you're talking about. Fixed.

 

[Planktonmd]

I just write whatever the surgeon says!

 

[jwk]

I like giving bizarre answers when the surgeon asks. "EBL was 214.7 doc." I get the look of course - and I just say "hey, it's an estimate".

 

[secretasianman]

And then there’s csection estimates. Historically I have two very common numbers I put down and nothing else..

 

[WholeLottaGame7]

I like giving bizarre answers when the surgeon asks. "EBL was 214.7 doc." I get the look of course - and I just say "hey, it's an estimate".

Same. "What do you want to call EBL?" "I dunno, 33?"

The only time I care is if we start at a Hgb of 13, give 4u of PRBC, and end up at 7.5, and the surgeon is like, "Couldn't have been more than like 400 of EBL." Sure, buddy, whatever.

I think it's meaningless. If someone really cares, anyone can look at the chart, see what the starting Hgb is, how much fluid/blood the patient received, and the ending Hgb, and figure out roughly what the EBL really was.

We never write down EBL for cardiac cases, and the world doesn't implode.