A patient suffered a 3000ml haemorrhage during elective gynaecology surgery undertaken during a weekend waiting list initiative. The list was overbooked. None of the patients attended pre-assessment. The patient’s haemorrhage was predictable: Surgery involved open laparotomy and resection of a large vascular fibroid in a young patient with high BMI (over 35) and poor venous access.

Commentary

Major haemorrhage was the commonest cause of perioperative cardiac arrest in NAP 7, accounting for 20% of reported cases.¹ 

Patients at increased risk of intraoperative bleeding require careful pre-operative planning involving a multi-disciplinary team including input from other surgical specialties (such as vascular surgeons who in this case may have been able to perform intra-operative balloon tamponade of the uterine arteries) or interventional radiology.  Had this patient been seen pre-operatively, the patient might have been offered medical treatment to reduce the size of the fibroid prior to surgery such as gonadotrophin-releasing hormone agonists. 

Poor peripheral venous access may necessitate the use of central access.  Invasive blood pressure measurement may also be required.  Such high-risk elective cases should be carried out during working hours at a location where all necessary specialties are available for consultation when required.

1. Soar, J; Kane, A et al. Chapter 4: NAP7 headlines and summary of key findings. At the Heart of the Matter: Report and findings of the 7^th National Audit Project of the Royal College of Anaesthetists examining perioperative cardiac arrest. Royal College of Anaesthetists, Nov. 2023