134. Takeo Three: Blood

Last year I posted on the difficulty I had in Guatemala because the anesthesiologists were reluctant to do hysterectomies without a blood bank immediately available. I've heard  this debate in conferences. For elective (non-life threatening) surgery, why take the risk of a dying because of blood loss?  But "elective" is a relative term; a day to day functional disability may not be life threatening but still makes a reasonable candidate for surgery.

Haun is a 51 year old who presented with uterine prolapse: the uterus has pushed down into the vagina, turning the latter inside out.  So part (or rarely all) of the uterus is hanging outside the vagina.  Uncomfortable as tendons stretch and the vaginal skin--not made for such exposure--is raw and susceptible to bleeding and superficial infection.  A vaginal hysterectomy for prolapse is not difficult and rarely presents with bleeding complications.  

But this hysterectomy was problematic from the beginning.  It was difficult to separate the uterus from adjacent tissues, I had inadequate lighting at the end of the case, when it's most important.
An hour postop I was called to see the patient in recovery for bleeding.  Light bleeding is okay after this type of surgery, but this exceeded normal expectations, so I placed some packing in side the vagina.  Apply pressure to stop bleeding, right?

Well, not in this case; bleeding continued and we returned to the OR, reopened the vaginal incision and immediately found a small artery bleeding.  Not much, but like a leaking faucet, builds up overtime.  A single suture easily stopped the bleeding, the vagina was reclosed.
We had checked her blood level before returning her to the OR; it was low so she received a unit of blood.  The next morning there was no further bleeding but a recheck of the blood level suggested another unit would help her recovery and so received a second unit of blood.

Lessons?
1.  Blood bank or not; always proceed with extra caution; the first time bleeding was noticed, she might have been returned to the OR
2.  Check blood level before surgery; she may have been low at the beginning and therefore not a good candidate for surgery
3.  No surgery without an immediately available blood bank?  Not so sure about this but certainly this case is an argument for this conclusion.  However, some remote areas will never have available blood.  Does that mean those areas can never receive gyn surgical teams? "First do no harm" says no surgery in these areas. Reality says, think about it.