[Present status of preparatory measures for massive hemorrhage and emergency blood transfusion in regional hospitals with an accredited department of anesthesiology in 2006].

BACKGROUND: Annual surveys conducted by the Japanese Society of Anesthesiologists repeatedly show that hemorrhage is the leading cause of life-threatening events in the operating room.

METHODS: We performed a questionnaire survey regarding the present status of critical hemorrhage/ blood transfusion occurring in the operating room on an institutional scale and individual blood transfusion management in cases of massive hemorrhage (> or = 5,000 ml) in hospitals with > or = 500 beds and those with an accredited Department of Anesthesiology regarded as regional hospitals.

RESULTS: Of 384 institutions, 247 responded to the questionnaire (response rate: 64%), and 692,241 cases managed by anesthesiologists in 2006 were registered. There were 2,657 cases of massive hemorrhage above the circulating blood volume in the operating room, and 404 of them were critical. Thus, the number of cases of massive hemorrhage was 6.6 times that of cases of critical events due to hemorrhage. In the survey of individual cases of massive hemorrhage (> or = 5,000 ml), 1,257 cases were registered in 2006, of whom 196 cases (15.6%) died within 30 post-operative days and 160 cases (12.7%) had some sequelae. The amount of transfused red blood cell concentrate was 25.2 +/- 24.2 units. The amount of red blood cell concentrates stocked for emergency was 12.7 +/- 10.1 units for blood group A, 9.7 +/- 7.3 units for group B, 11.9 +/- 9.6 group AB, and 11.3 +/- 11.0 for group O. Therefore, for those other than group O cases, 21-46 units of red blood cell concentrates seemed to be available in the hospital. The survey of individual cases showed uncross-matched, same blood group transfusion and compatible, different blood group transfusion were performed in only 8.2% and 4.3%, respectively. The lowest hemoglobin concentration was below 5 g x dl(-1) in 16.7% of the cases, but uncross-matched, same blood group transfusion was performed only in 19.0% and compatible, different blood group red cell concentrate transfusion in 5.2%. Even in cases who required cardiac massage, uncross-matched, same blood group transfusion was performed only in 17.1% and compatible, different blood group red cell concentrate transfusion in 8.5%. Intraoperative blood salvage was performed in only 5.7% in cases who underwent non-cardiac surgery. The "Guidelines for the Management of Critical Hemorrhage" proposed in 2007 or the manuals for in-hospital emergency blood transfusion were insufficiently recognized, even by anesthesiologists, and rarely known by surgeons. There were no such manuals in more than 60% of the institutions.

CONCLUSIONS: Undertransfusion may occur in 16.7-28.3% of cases of massive hemorrhage in the operating room, and the rate of emergency blood transfusion was much lower than this percentage. To avoid operation-associated deaths from hemorrhage, the improvement of hospital systems for emergency blood transfusion, including the active use of intraoperative blood salvage, should be promoted.