What are the recommended pharmacological and non-pharmacological blood conservation techniques for an adult female undergoing total hysterectomy?

Blood Conservation Techniques for Total Hysterectomy

Preoperative Optimization

All women undergoing total hysterectomy should have hemoglobin checked preoperatively, with any patient having Hb <120 g/L requiring investigation and treatment of the underlying cause before elective surgery. 1

• Preoperative anemia occurs in up to one-third of surgical patients and directly correlates with worse postoperative outcomes. 1
• Delay elective surgery if necessary to allow adequate time for anemia correction through established pre-assessment pathways. 1
• Iron supplementation, vitamin B12, or folate replacement should be initiated based on the specific etiology identified. 2

Pharmacological Blood Conservation

Tranexamic Acid

Administer tranexamic acid 1 g intravenously over 10 minutes prior to skin incision for all total hysterectomies where significant blood loss is anticipated. 3

• Both intravenous (1 g) and topical (2 g intra-abdominal application) tranexamic acid significantly reduce intraoperative and postoperative blood loss during abdominal hysterectomy compared to placebo (p = 0.0001). 4
• Tranexamic acid is safe, cheap, and effective when anticipated blood loss is high. 5
• The optimal timing is administration before skin incision, with potential for repeat dosing at the end of surgery. 3

Preemptive Analgesia to Reduce Blood Loss Risk

Use preemptive gabapentin and paracetamol (acetaminophen) before hysterectomy to decrease postoperative narcotic consumption without increasing blood loss, procedure length, or hospital stay. 3

• Preemptive NSAIDs or COX-2 inhibitors reduce total postoperative narcotic consumption and improve patient satisfaction without increasing intraoperative blood loss. 3
• Phenothiazines should be added preemptively in patients at higher risk of nausea and vomiting. 3
• These medications pose no risk of increased blood loss, length of procedure, or duration of hospital stay. 3

Vasopressin (Context-Specific)

• Vasopressin significantly reduces estimated blood loss during hysterectomy (mean difference -119.85 mL, 95% CI [-177.55, -62.14], p <0.001) compared to normal saline, though it does not change clinically significant outcomes like transfusion rates or complications. 6
• This is primarily studied in vaginal and abdominal approaches, with limited evidence for laparoscopic hysterectomy. 6

Non-Pharmacological Blood Conservation

Cell Salvage

Cell salvage equipment should be available and considered in "collect only" mode for any total hysterectomy where blood loss may exceed 500 mL. 3

• Cell salvage reduces the likelihood of allogeneic red cell transfusion and severe postoperative anemia. 3
• The Association of Anaesthetists recommends cell salvage be immediately available 24 hours a day in hospitals performing surgery where blood loss is a recognized complication. 3
• If the patient has known or suspected malignancy, a leucocyte depletion filter must be used during re-infusion to reduce the theoretical risk of tumor cell reinfusion. 1
• Specific consent should be obtained when cell salvage is proposed in cancer surgery, explaining potential risks and benefits. 3

Surgical Technique Optimization

• Meticulous surgical hemostasis and tissue handling minimize blood loss. 2
• Correct patient positioning and maintenance of normothermia are essential anesthetic techniques. 5
• Regional anesthesia techniques may contribute to reduced blood loss when appropriate. 5

Blood Sampling Reduction

• Limit diagnostic phlebotomy volume and frequency during the perioperative period. 3
• Use small-volume blood collection tubes to decrease iatrogenic anemia. 3
• Avoid standing orders for routine blood draws. 3

Transfusion Management

Restrictive Transfusion Strategy

Adopt a restrictive transfusion threshold of 7.0 g/dL hemoglobin for stable patients without active bleeding or cardiovascular disease. 3

• The landmark TRICC trial demonstrated no difference in 30-day mortality between restrictive (Hb 7.0-9.0 g/dL) and liberal (Hb 10.0-12.0 g/dL) transfusion strategies, with significantly fewer units transfused in the restrictive group (2.6 ± 4.1 vs 5.6 ± 5.3 units, p <0.01). 3
• Patient Blood Management represents the current standard of care in reducing allogeneic transfusion. 3, 1

Consent and Documentation

• Obtain informed consent for potential blood transfusion preoperatively and document this discussion in the medical record. 1
• Inform patients before hospital discharge if they received blood or blood components, as they are removed from the donor pool and need to be aware. 1

Postoperative Considerations

• Re-dose prophylactic antibiotics if blood loss exceeds 1,500 mL. 1
• Measure blood loss volumetrically rather than relying on visual estimation, which is notoriously inaccurate. 3
• Monitor hemoglobin postoperatively and treat persistent anemia with oral iron supplementation. 2

Common Pitfalls to Avoid

• Do not delay treatment of preoperative anemia—this is a modifiable risk factor that significantly impacts outcomes. 1
• Do not use liberal transfusion thresholds—restrictive strategies are equally safe and reduce transfusion-related complications. 3
• Do not forget leucocyte filtration with cell salvage in malignancy cases—this is a critical safety measure. 1
• Do not rely on visual estimation of blood loss—use quantitative measurement techniques. 3