Volume 36, No. 2 • June 2021   Issue PDF

Management of Massive Intraoperative Hemorrhage

Taizoon Q. Dhoon, MD; Darren Raphael, MD; Govind RC Rajan, MBBS; Doug Vaughn, MD; Scott Engwall, MD, MBA; Shermeen Vakharia, MD

Hemorrhage is the leading cause of death in the operating room, with one third of hemorrhagic deaths occurring during elective procedures due to unexpected organ or vessel injury. The response to unanticipated hemorrhage can determine the difference between survival and death for these patients. We describe the implementation of Code Hemorrhage, a structured response strategy that has enhanced communication, decision making, and patient care at our institution. Adoption of Code Hemorrhage at other institutions offers the potential to improve patient outcomes.

Hemorrhage is the leading cause of death in the operating room,1 with two thirds of hemorrhagic deaths occurring in the setting of emergent surgery. However, one third of hemorrhagic deaths occur during elective procedures due to unexpected organ or vessel injury.1-5 The response to unanticipated hemorrhage can mean the difference between life and death for these patients.

Crisis management is the process by which one deals with an emergent critical event in the operating room.6 When an unanticipated hemorrhage occurs, the anesthesia professional must mobilize resources, coordinate multidisciplinary care, and treat the patient within minutes. This process is often chaotic and is provider dependent, which can lead to compromised patient care. A recent elective surgical case at our institution was complicated by uncontrolled surgical bleeding and ultimately resulted in a surgical death. A 70-year-old female with hypertension and chronic pain was scheduled for a spinal fusion and artificial disc replacement via an anterior retroperitoneal exposure of the lumbar spine. A vascular surgeon provided surgical exposure to the spine, but the case was complicated by major venous injury when providing exposure. A root cause analysis was performed, which prompted reevaluation of our crisis management protocol. We describe here the development and implementation of a crisis response protocol for intraoperative bleeding called Code Hemorrhage.

Development of the protocol began with a working group of key stakeholders. Anesthesia professionals, surgeons, nursing staff, transfusion specialists, and hospital administrators reviewed existing guidelines, consensus statements, and current practices relating to intraoperative crisis resource management and surgical bleeding. Key factors linked to critical events were identified utilizing the Joint Commission’s methodology and its extranet site Joint Commission Connect™ to create a framework for the root cause analysis and action plan. Components of the root cause analysis and elements pertaining to anesthetic management are depicted in table 1. Using this information, the team developed a comprehensive crisis response protocol for intraoperative hemorrhage whereby an alert summons a multidisciplinary team including anesthesia professionals, a trauma surgeon, nursing staff, support staff, and the blood bank. This protocol was then refined by holding simulations with key personnel and stakeholders.4,6 Code Hemorrhage may be initiated by anesthesia professionals, surgeons, or operating room nurses in response to a bleeding event. A call to the operating room front desk triggers an overhead page of “Code Hemorrhage operating room number.”

Table 1: Key Factors Linked to Critical Events.
Depicts important elements linked to critical adverse events in the perioperative period.


The Anesthesia Team’s Role

The anesthesia team leader mobilizes additional anesthesia professionals and assigns staff to specific roles (figure 1). The secondary anesthesia professionals include anesthesiology attendings, residents, nurse anesthetists, and an anesthesia technician. Assigned roles include medication and infusion management, venous and arterial access, administration of blood products, deployment of a rapid infuser, operation of point of care lab testing, and appropriate documentation. The anesthesia technologist is responsible for setting up the rapid infuser, obtaining a transesophageal echocardiogram (TEE) machine and assisting in placement of central venous or arterial access. The secondary anesthesia professional provides explicit and succinct instruction to the anesthesia team and ensures execution of tasks, permitting the primary anesthesia professional to focus on patient management and communication with the surgical team, which is critical for patient outcomes.⁵ Additionally, the secondary anesthesia professional serves as a sounding board for the primary one, expediting diagnosis and treatment. Our institution has multiple anesthesia professionals in-house during nights and weekends. For institutions with less accessible resources, utilizing intensivists or the hospital’s rapid response team as part of the operative crisis response team could be an option.

Figure 1: Code Hemorrhage Personnel and Responsibilities.
Depicts the responsibilities of each team during a perioperative critical adverse event.

  • Assist primary anesthesia professional
  • Assign staff to specific roles:
    • Check blood products
    • Manage rapid infuser
    • Manage medication and infusions
    • Central venous & arterial access
    • Frequent lab draws
    • Documentation
  • Coordinate multidisciplinary response
  • Optimize communication with surgeon
  • Declare end of response in conjunction with primary anesthesia professional and surgeon
  • Assist primary surgeon
  • Address life-threatening injuries
  • Discuss:
    • Etiology of bleeding
    • Anticipated procedures
    • Length of procedure/repair
    • Temporary packing bimanual vessel compression
    • Damage control surgery
  • Confirm with anesthesia team that packing, vascular compression, and/or aortic cross clamp is maintained until adequate resuscitation has occurred
  • Optimize communication with anesthesia team
  • Setup equipment that is potentially used during hemorrhage:
    • Ultrasound
    • Rapid infuser
    • Transesopheageal
    • echocardiogram
    • Central venous and
    • arterial catheter access
  • Assist anesthesia team as directed
  • Assist primary circulating nurse
  • Communicate with blood bank
  • Coordinate transport of blood to operating room
  • Expedite equipment and supply retrieval
  • Check blood products
  • Prepare for massive transfusion
  • Communicate with operating room staff regarding product availability
  • Provide consultation: Blood product utilization and coagulation optimization

The Nurses’ Role

Code Hemorrhage triggers a nursing staff response as well. The OR charge nurse assigns an additional circulating nurse (a float/break nurse) to assist the primary OR circulating nurse, enhancing OR efficiency. The role of the additional nurse includes bringing a trauma surgical cart to the OR, so equipment is available to treat bleeding. The additional circulating nurse also facilitates communication with the blood bank and the anesthesia team and assists with the independent double check process of blood products in the OR. Our institution has nurses available for breaks, as well as a charge nurse to provide help. For other institutions who have more limited resources, employing post-operative care nurses as part of the operative crisis response team may be an option.

The OR charge nurse also alerts the blood bank that a massive transfusion protocol (MTP) could be imminent. The additional circulating nurse facilitates close communication with the blood bank throughout the case. The transfusion medicine team’s role involves preparing for the massive transfusion protocol. The blood bank physician specialist routinely discusses management of transfusion, coagulation optimization, and blood bank resources with the anesthesia professional by calling into the operating room or an in person discussion.

The Trauma Surgeon’s Role

Unique to Code Hemorrhage is the standardized involvement of an in-house trauma surgeon as a member of the crisis response team. A trauma surgeon offers a set of experienced hands that can address life-threatening injuries and rapidly stabilize the patient’s condition. The most crucial step in a hemorrhagic crisis is to determine and control the source of the bleeding.² Publications on OR hemorrhage management espouse a multidisciplinary approach, massive transfusion protocols, and often focus on obstetric/peripartum bleeding.

One publication discussed the benefits of a multidisciplinary protocol, involving early vascular surgeon involvement when managing patients with a suspected ruptured abdominal aortic aneurysm.⁷ Despite this concept having been described in high-risk surgical procedures, it is likely to be useful in many other causes of hemorrhagic shock. Though numerous massive transfusion protocols exist in the literature, Code Hemorrhage is distinctive in that it always includes participation of a trauma surgeon, who can expeditiously help secure the source of intraoperative hemorrhage and lend a trained hand to the primary surgeon.

When deciding whether or not to call for help in an operative crisis, the primary surgeon may feel a sense of trepidation in inconveniencing a colleague. The primary surgeon may be unduly influenced by ego when making this decision, as well. Therefore, the objective use of a trauma surgeon as compulsory member of the Code Hemorrhage may reduce the risk of delayed inappropriate treatment. Also unique to Code Hemorrhage is the availability of an emergency trauma cart with the instruments needed to perform emergency exploratory laparotomy and thoracic surgery. Finally, Code Hemorrhage is remarkable in its organized approach to resource deployment for all disciplines involved; enhancing communication, decision making, and patient care at our institution.

A trauma surgeon’s expertise offers expedited diagnosis and treatment which may include source control, application of direct pressure, temporary packing, clamping of the aorta, resuscitative endovascular balloon occlusion of the aorta (REBOA), or damage control surgery.1 Intraoperative emergencies are tremendously stressful, and a loss of situational awareness may lead to “tunnel vision” on the part of the primary surgical team. This is further compounded in the academic setting where cases may be more complex, and residents may lack the education and experience to assist in intraoperative crisis management.⁴ The trauma surgeon provides both perspective and expertise for the primary surgical team.


In creating Code Hemorrhage, our goal was to establish a shared mental model to facilitate an organized, systematic, and robust response when managing intraoperative crises.

Implementation of this structured response strategy has enhanced communication, decision making, and patient care at our institution. Since Code Hemorrhage went live approximately one year ago it has been triggered eight times to manage intraoperative hemorrhagic crises that would have possibly resulted in intraoperative death prior to its application. The cases were comprised of four hepatobiliary, two obstetric, and two orthopedic procedures. In addition to hemorrhage, four cases involved suspected concomitant pulmonary embolism based on transesophageal echocardiography findings. All eight patients survived the intraoperative period. Five patients died following their operative course; notably, three patients suffered ischemic brain injury related to hypotension and hemorrhage. Remarkably, three patients were successfully discharged home. Adoption of Code Hemorrhage at other institutions offers the potential to improve patient outcomes.


Taizoon Q. Dhoon, MD, is an assistant professor at the University of California, Irvine.

Darren Raphael, MD, MBA, is an associate professor at the University of California, Irvine.

Govind R.C. Rajan MBBS, FAACD, FASA, is a professor at the University of California, Irvine.

Doug Vaughn, MD, is an associate professor at the University of California, Irvine.

Scott Engwall, MD, MBA, FAACD, is a professor at the University of California, Irvine.

Shermeen Vakharia MD, MBA, is a professor at the University of California, Irvine.

The authors have no conflicts of interest.


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  6. Bracco F, de Tonetti G, Masini M, et. al. Crisis resource management in the delivery room: development of behavioral markers for team performance in emergency simulation. Int J Environ Res Public Health. 2018;15:439.
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