A 64 years old man is scheduled for an elective amputation of his right foot. He is a diabetic and had developed a gangrene of his right foot. Preoperatively his sugars were well controlled and he was wheeled into the theatre for surgery. On the table the dorsalis pedis artery was slit and it started bleeding profusely. There was considerable blood loss.  

Question (1)    All the following measures taken preoperatively would prevent the need for blood transfusion on table except?

 (a)    A haemoglobin assay and correcting nutritional deficiencies.

(b)   Injecting human recombinant erythropoietin preoperatively to improve haemoglobin

(c)    Normovolemic hemodilution technique

(d)   Autologous blood donation

 Answer: The answer is (d). Correcting nutritional deficiencies can help to improve the stores of RBCs and Haemoglobin. Human recombinant erythropoietin injections also help to improve the RBC and haemoglobin reserve. Normovolemic hemodilution is a technique carried out for elective surgery where the amount of blood loss intraoperatively can be considerably reduced. In case of autologous blood donation it is useful in that it avoids the use of homologous blood from other donors. But it does not help to avoid blood transfusion.

Question (2)   Intraoperatively it was noticed that his blood pressure fell rapidly. The operative field also became very pale. At this point a decision to transfuse blood is taken. The patient's blood group is O positive. Which of the following statements about his blood transfusion is true?

 (a)    Intraoperative blood transfusion is spared of transfusion reactions

(b)   If there is a transfusion reaction intraoperatively there is no need to stop the transfusion as the patient is under controlled ventilation and circulation.

(c)    If there is a transfusion reaction intraoperatively the transfusion must be stopped. After an injection of hydrocortisone the transfusion may be resumed.

(d)   Transfusion reactions intraoperatively are common and the transfusion needs to be stopped. Volume expanders should be used instead.

Answer: The answer is (d). Transfusion reactions can occur during surgery. In this case the transfusion must be stopped immediately and volume expanders such as starch solutions should be used to manage the hypotension. The transfusion should be considered again post operatively under well-controlled and monitored environment.