Emergency Management of Intraoperative Hemorrhage in a Patient with DNR/DNI Orders

Take patient consent before loss of consciousness (Option B) and proceed with blood transfusion to control the hemorrhage. 1

Critical Distinction: DNR Does Not Equal Refusal of All Treatment

A DNR order specifically addresses cardiopulmonary resuscitation in the event of cardiac arrest—it does not automatically preclude other life-saving interventions such as blood transfusion, vasopressors, or surgical hemorrhage control. 1
The American Heart Association explicitly states that "a DNAR order does not automatically preclude interventions such as administration of parenteral fluids, nutrition, oxygen, analgesia, sedation, antiarrhythmics, or vasopressors, unless these are included in the order." 1
The scope of DNR orders must be reviewed and clarified before surgery by the anesthesiologist, attending surgeon, and patient or surrogate to determine their applicability in the operating suite and during the immediate postoperative recovery period. 1

If the patient is still conscious and has decision-making capacity, obtain direct consent from the patient for blood transfusion and hemorrhage control measures. 1
This respects patient autonomy and ensures informed consent for interventions not explicitly covered by the DNR order. 1

Initiate blood transfusion immediately—DNR orders do not prohibit blood products unless specifically documented. 1
In cases of massive hemorrhage during cesarean section, transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed ratio. 1
Keep the patient warm (body temperature >36°C) as clotting factors function poorly in hypothermia. 1
Avoid acidosis and re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1

Employ rapid surgical techniques including uterine compression, uterine artery ligation, or hysterectomy as indicated for placental bleeding. 1
Consider pelvic packing for severe uncontrolled hemorrhage, which can be highly effective for patient stabilization. 1
Interventional radiology with hypogastric artery embolization may be useful for persistent bleeding without a single identifiable source. 1

Calling a relative delays life-saving treatment when the patient herself is available to consent. 1
Surrogate decision-makers are only necessary when the patient lacks decision-making capacity. 1

Ethics committee consultation is not feasible during an acute life-threatening emergency requiring immediate intervention. 1
This would result in unacceptable delays in hemorrhage control, leading to preventable morbidity and mortality. 1

Some patients choose to accept certain interventions (like blood transfusion and vasopressors) but not intubation and mechanical ventilation—this must be explicitly documented. 1
The limitation-of-treatment order should provide explicit instructions for specific emergency interventions including blood products, vasopressors, mechanical ventilation, and antibiotics. 1
DNR orders carry no implications about other forms of treatment, and other aspects of the treatment plan should be documented separately. 1

Do not assume DNR means "do not treat"—this is a dangerous misinterpretation that leads to withholding appropriate medical care. 1, 2
Do not delay life-saving hemorrhage control to seek surrogate consent when the patient is conscious and capable of providing consent herself. 1
Do not conflate DNR with refusal of all interventions—blood transfusion for surgical hemorrhage is not resuscitation from cardiac arrest. 1, 2
Ensure DNR orders are reviewed preoperatively to clarify which specific interventions are refused versus accepted in the perioperative period. 1