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Discussion in 'Anesthesiology' started by Noyac, May 15, 2008.
How do you guesstimate EBL?
Do you care what it is? Why or why not?
Do I care about EBL?
Not really. Unless, of course, I want to get into a haggling session with the surgeon.
I don't transfuse unless the patient is symptomatic. If I'm not sure where I'm at, I send CBC or an ABG to the lab and let them tell me for sure.
look at the suction minus irrigation.
if you're running patients relatively dry you can do a hct and work out the EBL from the max allowable blood loss formula.
i like to transfuse right before the patients become symptomatic by anticipating likely changes. if i have a pt with ischemic CM i will not wait till patient is symptomatic. if i have a kid who is bleeding, i will transfuse before they become symptomatic - because once they're symptomatic they go downhill QUICKLY.
What about the laps, drapes, floor, etc. Suction minus irrigation is not enough, IMHO.
What if you are not running them dry?
So when is "before they become symptomatic"? And why transfuse at all if they are healthy otherwise? I have seen Jehovah's Witness pts who have bled to a Hgb of 3 (Hct 9) who have survived without sequela. We currently have one in our ICU. She got down to 2.7 Hgb if I remember right after a MVA with multiple trauma. Maybe the little "sick" kids go downhill quickly but the healthy ones don't. They can take a hit and not miss a beat. Again, my opinion.
For CV cases, I don't even bother writing a number. Like copro said, if it's a big case with lots of blood loss, I'll just send an ABG and voila I know. Agree with the drapes hiding blood, especially the ones we use in OB for C-sxn's. You can never see it and the things must hold at least +/- 100 gallons (may be a slight overestimation).
I'm not sure about treating asymptomatic patients. If they are not symptomatic, why would you treat them?
One of my peds attendings takes the number of products transfused (PRBC + FPP or whatever) x 2 + 1000 (for big kids and adults). We tend to arrive at the same number.
Heres my EBL (calling out to surgeon):
"Dude, whatcha gonna put down for blood loss?"
It doesnt matter, as long as its reasonable.
If they need blood, transfuse.
The only part about blood loss I care about is when its not ending...
you know, when the room is incessantly filled with the surgical suction making that wet, sucking noise...
FOR A LONG TIME....
"uhhhh, Dude, ya gotta make that stop or we're gonna start having problems..."
Arguing over EBL with the surgeon is dumb. What good does that do?
Just write down what he's gonna document.
Pick your battles, friends.
Pick your battles.
So when they ask me "what's the EBL?"
I say, "not enough to transfuse."
ok, laps, drapes, etc. it's all reasonable. i think most EBL estimates are guesses at best.
if i'm not running them dry it's quite easy to estimate the diluted blood volume.
i give blood if hb is 7 (10 in ischemic CM) AND bleeding is ongoing.
many start transfusion when pts are hypotensive. this is WRONG. PRBCs are not meant to be used for IV volume expansion. theoretically, we should only give PRBCs if lactates go up or MVo2 goes down (CO is WNL).
as an aside, had a surgeon lose 3.5 L (clearly suction - irrigation) on a case. he argued he lost only 1.5 L. this DOES matter. a couple of hundred here and there don't make a difference, but 2L matters. he tried to make the reason for not extubating pt at the end of the case (she was in trend for 10 hours and got lots of volume) as "anesthesia volume overloading the patient." SORRY BUDDY - it's SURGICAL BLEEDING.
Thats why I put "as long as its reasonable."
That isnt reasonable.
"We currently have one in our ICU. She got down to 2.7 Hgb if I remember right after a MVA with multiple trauma."
Out of curiosity, how many days for her Hgb to get above 8?
I remember the first time I had a trauma patient with a Hgb in the 2-3 range. Withdrew on the art line and the blood looked like dilute red kool-aid.
At least 2 weeks
I say - put your number...
Remember.............all bleeding eventually stops! For that mater, so does all brochospasm eventually stop...
But seriously, just having completed the oral boards, It was important to review the ASA guidelines for transfusion...........everyone should look at this at least briefly, good basic guidelines.
I love it when you look in the canister and it says 500mL, you go around and ask the scrub tech how much irrigation they used and they say, "2L" - now where did that other 1.5 go?
Even better, when you ask the scrub tech how much irrigation they have used and they say, "how am I supposed to know - I just took over".
Ive quit arguing with surgeons on EBL. I chart what I think and they can report what they think.