Bleeding

Surgical bleeding

By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2019-05-23


Surgical bleeding usually occurs after traumatic injury or surgery, and can be divided into minimal, small, moderate, large, very large or massive bleeding. Blood volume in ml is normally 70 times the body weight, calculated in kg. A person weighing 50 kg then has an estimated blood volume of 3500 ml, a 70 kg person has about 4900 ml blood volume and one 100 kg person has about 7000 ml blood volume. Less bleeding than small bleeding can be called minimal bleeding and usually does not require volume substitution at all. Minimal bleeding is primarily treated with local measures such as dressing, compression dressing, tamponade, suturation or diathermy. Small, moderate or larger bleeding should be treated surgically and with intravenous fluid therapy to maintain good tissue perfusion and good microcirculation.

The question of optimal Hgb is controversial, but a Hgb of 9-11 g/dL after trauma or surgery with an EVF of 30-35 is considered optimal for ideal rheology and optimal oxygen delivery in microcirculation. In some American studies, a lower Hgb of 7-9 g/dL has been considered optimal. EVF is the relationship between erythrocyte volume and blood volume (EVF = erythrocyte volume fraction). A hematocrit value of 25% is generally a safe minimum value in patients without the risk of cardiovascular disease. Note that when administered with colloid with dextran, the platelet adhesion decreases and bleeding tendency may increase slightly, especially when more than one liter of Macrodex is supplied.

A rule of thumb recommends the supply of blood and plasma in the 1:1 relationship after a bleeding volume greater than 20% of the blood volume with the addition of platelets following a bleeding corresponding to the patient’s entire blood volume.

Factor concentrate is used when the contents of normal plasma are not sufficient without the volume load becoming too large. Administration is controlled by the clinic and current laboratory values ​​(INR, aPTT, fibrinogen, platelets, TEG). Blood products are supplied in the same volume as it bleeds to maintain the required blood volume, adequate rheology and functional haemostasis.

High blood pressure preoperatively and high venous filling gives greater risk of bleeding than moderate filling, especially from parenchymal organs such as liver and spleen in abdominal surgery. Optimal blood pressure is considered to be a low blood pressure that still provides good tissue perfusion in vital organs, especially heart and brain and with some safety margin against critical hypovolemia. Moderate or severe bleeding should usually be corrected by surgical intervention and fluid replacement. An old key rule is not to wait for surgical intervention in the case of a bleeding requiring replacement with more than 6 units of blood. A good alternative to surgical interventions for major bleeding is interventional radiology (IR) through catheter catheters that can be used to correct bleeding blood vessels endovascularly with “coiling” (mechanical vessel obstruction with different spirals) or different types of tissue strips. Endovascular measure of major bleeding is increasingly becoming a first-hand measure at medical centers where interventional radiology exists. The advantage is, of course, that the method is less invasive than open surgery with less surgical trauma and mild postoperative recovery. The choice of open surgery or catheter-borne radiology in bleeding can be tricky and taken in consultation with the affected anesthesiologist, surgeon and radiologist.

The fluid replacement for bleeding is controlled by the size of bleeding and physiological vital parameters, mainly pulse and blood pressure and blood volume estimates. Peripheral circulation is primarily assessed clinically and by repeated blood gas analyzes (Hgb, pH, lactate). Coagulation can be assessed using laboratory tests and bleeding parameters (Hgb, thrombocyte count, PK, APTT, fibrinogen, antithrombin, etc.) and graphical illustration of the coagulation, for example by thrombus stroke. In case of pronounced coagulation effect, a coagulation expert may be consulted. In the case of fluid therapy of bleeding, intravenous fluid delivery may usually be relatively rough in adult patients but must always be related to the size of the bleeding and the coagulation effect to obtain good hemostasis and avoid over- or undersupply of fluids.

The blood replacement of young children needs to be more natural for natural reasons. Overtransfusion of predominantly plasma can cause problems with  pulmonary edema as a consequence and development of “TRALI” (transfusion related acute lung injury). Monitoring coagulation with thromboelastography has been refined in recent years (Natem, Heptem, Intem, Extem, etc.) and provides the opportunity to get a quick idea of ​​the current coagulation status and what measures should be taken in fluid therapy and blood replacement. In case of severe bleeding, it is extremely important to try to maintain normal body temperature. Hypothermia significantly decreases the coagulation ability.


Fluid Therapy in Case of Bleeding


By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21


Large bleeding should be treated with crystalloid solutions plus colloidal solutions plus blood components. Blood is given in the same amount as current blood loss to achieve optimal Hgb and effective hemostasis (Hgb 8-10 g/dL, EVF 30-35%). HES should be given as little as possible and avoided entirely in pediatric patients or critically ill.

Table 1. Small Adult (50 kg)
Degree of bleedingReplacement amount
Small bleeding1000 ml crystalloid solution, for instance Ringer-Acetat 350-1500 ml
Moderate bleeding1500-2000 ml crystalloid solution and 500 ml of a colloid solution, for example a solution with a hydroxyetyl starch alternatively dextran, gelatin or albumin.
Large bleeding2000-4000 ml crystalloid solution, and 1000 ml of a colloid solution, for example a solution with a hydroxyetyl starch alternatively dextran, gelatin or albumin.
Very large bleeding3000-6000 ml crystalloid solution, and 1000-1500 ml of a colloid solution, for example a solution with a hydroxyetyl starch alt. dextran, gelatin or albumin.
Massive bleeding3000-6000 ml of crystalloid solution, and 1000-1500 ml of a colloidal solution, e.g. a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Table 2. Normal adult (70 kg)
Degree of bleedingReplacement amount
Small bleeding1500 ml crystalloid solution, eg Ringer-Acetate 500-2200 ml
Moderate bleeding1500-3000 ml of crystalloid solution and 500 ml of a colloidal solution, for example a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Large bleeding3000-5000 ml of crystalloid solution, and 1000-1500 ml of a colloidal solution, for example a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Very large bleeding4000-6000 ml of crystalloid solution, and 1500-2000 ml of a colloidal solution, for example a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Massive bleeding4000-6000 ml of crystalloid solution, and 1500-2000 ml of a colloidal solution, for example a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Table 3. Large adult (100 kg)
Degree of bleedingReplacement amount
Small bleeding2000 ml crystalloid solution, e.g. Ringer Acetate 700-3000 ml
Moderate bleeding2000-3500 ml of crystalloid solution and 500-1000 ml of a colloidal solution, for example a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Large bleeding3500-6000 ml of crystalloid solution, and 1500-2000 ml of a colloidal solution, for example a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Very large bleeding5000-7000 ml of crystalloid solution, and 2000-2500 ml of a colloidal solution, e.g. a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.
Massive bleeding5000-7000 ml of crystalloid solution, and 2000-2500 ml of a colloidal solution, e.g. a solution with hydroxyethyl starch alt. dextran, gelatin or albumin.

Small bleeding


By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21


Small bleeding includes 5-15% loss of blood volume. A small bleeding can usually be replaced by only crystalloid solutions, such as Ringer’s Acetate or Sodium Chloride (NaCl). Other solutions usually do not need to be given. Crystalloid solutions should be given in a volume of two to three times the size of the bleeding. Small bleeding means the following approximate blood loss for a small, normal and large person respectively.

  • 200-500 ml bleeding for a small person weighing 50 kg.
  • 250-750 ml bleeding for a normal adult weighing 70 kg.
  • 350-1000 ml bleeding for a large person weighing 100 kg.

This means that a small bleeding can be compensated as follows at 5-15% loss of blood volume. The supply can be approximated in adult patients.

  • A small person should be given about 1000 ml of crystalloid solution, for example Ringer-Acetate (350-1500 ml).
  • A normal sized person should be given approximately 1500 ml of crystalloid solution, e.g. Ringer-Acetate (500-2200 ml).
  • A large person should be given approximately 2000 ml of crystalloid solution, e.g. Ringer-Acetate (700-3000 ml).


Moderate bleeding


By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21


Moderate bleeding includes 15-50% loss of blood volume. This means the following blood loss for a small, normal and large person respectively.

  • 500-1750 ml bleeding for a small person weighing 50 kg.
  • 750-2500 ml bleeding for a normal adult weighing 70 kg.
  • 1000-3500 ml bleeding for a large person weighing 100 kg.

This means that moderate bleeding can be compensated as follows at 15-50% loss of blood volume. The supply can be approximated in adult patients.

  • A small person should be given 1500-2000 ml of crystalloid solution and 500 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin.
  • A normal-sized person should be given 1500-3000 ml of crystalloid solution and 500 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin.
  • A large person should be given 2000-3500 ml of crystalloid solution and 500-1000 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin. Alternatively to 500 ml of hydroxyl starch colloid, 100 ml of 20% Albumin or 500 ml of Macrodex can be given.

Moderate bleeding should be replaced with crystalloid solutions plus colloidal solutions plus blood products on bleeding in the upper range of moderate bleeding. Blood is usually given in the form of transfusion units such as erythrocyte concentrate (SAG) for optimal Hgb and for best rheology and best microcirculation. Usually, blood is given to a small person in acute bleeding over 500 ml, to a normal person in bleeding over 800 ml and to a large person in bleeding over 1 liter, but this can be adjusted individually according to the patient’s general condition and current Hgb. Moderate bleeding usually does not require replacement with plasma, platelets or special pharmacy to get good haemostasis. HES should be given as small as possible and avoided entirely in pediatric patients.


Large Bleeding


By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21


Large bleeding includes 50-100% loss of blood volume. This means the following blood loss for a small, normal and large person respectively.

  • 1750-3500 ml bleeding for a small person weighing 50 kg.
  • 2500-5000 ml bleeding for a normal adult weighing 70 kg.
  • 3500-5000 ml bleeding for a large person weighing 100 kg.

This means that a major bleeding can initially be treated as follows at 50-100% loss of blood volume. The supply can be approximated in adult patients. Large bleeding usually requires blood transfusions.

  • A small person should be given 2000-4000 ml of crystalloid solution, and 1000 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin, HES) alt. dextran, gelatin or albumin.
  • A normal-sized person should be given 3000-5000 ml of crystalloid solution, and 1000-1500 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin.
  • A large person should be given 3500-6000 ml of crystalloid solution, and 1500-2000 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin.

Large bleeding should be replaced with crystalloid solutions plus colloidal solutions plus blood components. Blood is initially given as in moderate bleeding where replacement for ongoing losses, usually with the same amount as bleeding to get optimal Hb and good hemostasis. In case of pronounced dilution of the blood (hemodilution), hemostasis is usually impaired at Hb below 80 g / l.

After replacement with 4 units of blood concentrate, equal parts of plasma should be added. After delivery of 8 units of blood (and 4 units of plasma) 2 units of platelets should be given. Next, 2 units of platelets should be given after every fourth unit of blood. Ionized calcium should be kept normally, this drops easily in blood transfusions, and calcium must often be added as blood transfusions occur. HES should be given as small as possible and avoided entirely in pediatric patients.

In case of severe bleeding you should give:

  • Fibrinogen 2 g
  • Tranexamic acid (TXA) 1 g x 2
  • Calcium (Calcium-Sandoz) 9 mg/ml 10 ml intravenously multiple (after ionized calcium in blood gas)

Check levels of fibrinogen in plasma.


Very Large Bleeding


By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21


Very large bleeding includes 100-200% loss of blood volume. Treatment of this blood loss requires good access to the bloodstream (venous access) through multiple coarse peripheral needles, usually 3 of which at least two should have a diameter greater than 1.7 mm. Very large bleeding means:

  • 3500-7000 ml bleeding for a small person weighing 50 kg.
  • 5000-10000 ml bleeding for a normal adult who weighs 70 kg.
  • 7000-14 000 ml bleeding for a large person weighing 100 kg.

This means that a very large bleeding can initially be compensated as follows at 100-200% loss of blood volume. The supply can be approximated in adult patients.

  • A small person should be given 3000-6000 ml of crystalloid solution, and 1000-1500 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) or dextran, gelatin or albumin.
  • A normal-sized person should be given 4000-6000 ml of crystalloid solution, and 1500-2000 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin.
  • A large person should be given 5000-7000 ml of crystalloid solution, and 2000-2500 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran, gelatin or albumin.

Blood is given in the same amount as it bleeds to obtain optimal Hgb and good hemostasis (Hgb 8-10 g/dL). After replacement with 4 units of blood concentrate, equal parts of plasma should be added. After delivery of 8 units of blood (and 4 units of plasma) 2 units of platelets should be given. Next, 2 units of platelets should be given after every fourth unit of blood. Ionized calcium should be kept normally, these drops easily in blood transfusions, and calcium must often be added as blood transfusions occur. A simple recipe is to repeatedly give 4 blood, 4 plasma and 2 units of platelets. When this amount is given, 2 g of fibrinogen and 1 g of cyclocapron should also be given and the coagulation is checked by thrombus stray. HES should be given as small as possible and avoided entirely in pediatric patients.

In very large bleeding you should give:

  • Fibrinogen 2 g can be repeated
  • Tranexamic acid (TXA) 1 g x 2
  • Calcium (Calcium-Sandoz) 9 mg/ml 10 ml intravenously multiple (after ionized calcium in blood gas)

Check the levels of fibrinogen in plasma repeatedly.


Massive Bleeding


By Kai Knudsen, Senior Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.
Updated 2018-12-21


Extraordinary major bleeding which may also be called massive bleeding involves more than 200% loss of blood volume. Replacement of major blood loss is usually done in parallel with ongoing surgery and involves rapid transfusion usually by so-called “set for high transfusion” or “rapid transfusion set” with thick-borne catheters. Rapid transfusion is given at 100-300 ml/min. In the case of massive bleeding, you always have a coagulation defect which must be treated in parallel with blood replacement and the body temperature must be kept up. Treatment of this blood loss requires proper access to the bloodstream (venous access) through multiple coarse peripheral needles and large central catheters, such as a central dialysis catheter.

Massive bleeding means:

  • More than 7000 ml for a small person weighing 50 kg.
  • More than 10,000 ml for a normal sized person weighing 70 kg.
  • More than 14,000 ml of bleeding for a large person weighing 100 kg.

This means that a massive bleeding can initially be compensated as follows in more than 200% loss of blood volume. The supply can be approximated in adult patients.

  • A small person should be given 4000-7000 ml of crystalloid solution, and 1500 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) all. dextran or albumin.
  • A normal-sized person should be given 5000-7000 ml of crystalloid solution and 2000 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) alt. dextran or albumin.
  • A large person should be given 6000-8000 ml of crystalloid solution and 3000 ml of a colloidal solution, for example a solution of hydroxyethyl starch (Voluven, Venofundin) all. dextran or albumin.

Blood is given in the same amount as it bleeds to get optimal Hb and good hemostasis. After replacement with 4 units of blood concentrate, equal parts of plasma should be added. After delivery of 8 units of blood (and 4 units of plasma) 2 units of platelets should be given. Next, 2 units of platelets should be given after every fourth unit of blood. Ionized calcium should be kept normally, this drops easily in blood transfusions, and calcium must often be added as blood transfusions occur. HES should be given as little as possible and avoided entirely in pediatric patients.

A simple recipe is to repeatedly give 4 blood, 4 plasma and 2 units of platelets.

In case of massive bleeding you should always give:

  • Fibrinogen 2 g can be repeated
  • Tranexamic acid (TXA) 1 g x 2
  • Calcium (Calcium-Sandoz) 9 mg/ml 10 ml intravenously multiple (after ionized calcium in blood gas)

Check levels of fibrinogen in plasma. The coagulation should be repeatedly monitored with thrombelastograms and relevant laboratory tests. Strive for normothermia.