Intraoperative blood loss is one of the causes of death during surgical procedures [
Patients may be required to donate varying number of units of blood prior to surgery which may or may not be used. The potential blood loss and estimated number of blood products required should therefore be predetermined using many factors [
Much attention has been given to blood loss following general and orthognathic surgeries in the literature, but little work has been done on other maxillofacial procedures [
Ethical approval to carry out the study (UPTH/ADM/90/S.II/VOL.X/371) was provided by the University of Port Harcourt Hospital’s Ethics and Research Committee (Chairperson Professor Anthony Okpani) on January 27, 2014. All cases of maxillofacial surgical procedures done under GA in the MFU theatre, from January 2007 to December 2013, were included in the study. Patients’ demographics and haematological profile retrieved from the case files and theatre records by the house officer and cross-checked by one of the consultants (B. O. A) were documented in a retrospective review chart. Data included the extent, diagnosis of lesion, and medical comorbidities. Pre- and postoperative haematocrit values, number of units of whole blood requested, cross-matched, and used, procedure, amount of blood loss, and duration of surgery were recorded. All cases done under local anaesthesia in the clinic were excluded from the study. The cases were divided into two groups which were diseases or procedures on soft and hard tissues. The total blood loss estimation was done by calculating the amount of blood in the suction bottle and adding this to the estimated value from all the blood soaked gauze.
Data obtained was analyzed with SPSS (SPSS Inc., Chicago, IL) version 16. Means and standard deviation of haematocrit values, estimated blood loss, and duration of surgery for each category of disease were determined and the means within groups and between the two groups were compared with paired sample
A total of 139 patients were analyzed, out of which 75 (54.0%) were males and 64 (46.0%) were females; age range was 2 months to 78 years; mean
Age, gender, hematocrit values, and blood requirements of fifty-six (56) patients with 56 procedures on soft tissues.
Diagnosis | Number of procedures | Age range | Male (%) | Female (%) | Range, |
Number of units requested | Number of units used | Range, mean (SD) |
---|---|---|---|---|---|---|---|---|
Cleft lip | 18 | 2 months–35 years | 9 (6.6) | 9 (6.6) | 21–35, |
1 | 0 | 27–29, |
Cleft palate | 19 | 10 months–28 years | 4 (2.9) | 15 (11.0) | 28–38, |
1 | 0 | 27–30, |
Cleft lip and palate | 4 | 5 months–20 years | 2 (1.5) | 2 (1.5) | 25–35, |
1 | 0 | 24–32, |
Soft tissue tumors | 9 | 4 months–33 years | 6 (4.4) | 3 (2.2) | 33–46, |
2 | 1 | 23–44, |
Malignant soft tissue tumors | 3 | 26–32 years | 2 (1.5) | 1 (0.7) | 25–32, |
3 | 3 | 34–40, |
Palatal salivary gland tumors | 3 | 26–41 years | 3 (2.2) | 0 (0) | 30–35, |
1 | 0 | — |
Total |
|
— |
|
|
— | — | — | — |
Eighty-three cases involved hard tissues. Range and mean haematocrit values of bony lesions are reflected in Table
Age, gender, hematocrit values, and blood requirements of eighty-three (83) patients with 83 procedures on bony tissues.
Diagnosis | Number of procedures | Age range |
Male (%) | Female (%) | Range, |
Number of pints requested | Number of pints used | Range |
---|---|---|---|---|---|---|---|---|
Fractures of the mandible | 17 | 2–65 | 14 (10.1) | 3 (2.2) | 31–38, |
1 | 1 | 38–44, |
Zygomatic fractures | 6 | 8–38 | 4 (2.9) | 2 (1.5) | 21–44, |
1 | 0 | 29–32, |
NOE and Le Fort fractures | 6 | 4–27 | 3 (2.2) | 3 (2.2) | 28–35, |
0 | 0 | — |
Multiple fractures | 3 | 24–35 | 2 (1.5) | 1 (0.8) | 20–31, |
2 | 2 | — |
Mandible tumors | 24 | 10–78 | 11 (8.1) | 13 (9.6) | 25–44 |
3 | 2 | 25–42, |
Maxillary tumors | 16 | 6–60 | 9 (6.5) | 7 (5.0) | 25–36, |
2 | 1 | 32–38, |
Cysts and fibroosseous | 6 | 11–27 | 3 (2.2) | 3 (2.2) | 35–38, |
2 | 1 | 28–42, |
TMJ ankylosis and dislocation | 5 | 11–64 | 3 (2.2) | 2 (1.5) | 25–42, |
1 | 1 | 30–35, |
Total |
|
|
|
— | — | — | — |
Isolated unilateral cleft lip had the lowest mean value of estimated blood loss of 10.4
Estimated blood loss, duration of surgery, and
Diagnosis | Treatment | Estimated blood loss |
Duration of surgery Mean (SD) (mins) |
|
Significance level |
---|---|---|---|---|---|
Unilateral cleft lip | Millard’s repair | 10.4 (10.8) | 58 (76) | 0.191 | 0.464 |
Cleft palate | Palatoplasty | 142 (139) | 127 (48) | 0.081 | 0.749 |
Complete cleft lip and palate | Millard’s repair/palatoplasty | 400 (265) | 263 (58) | 0.327 | 0.788 |
Benign soft tissue tumors | Excision | 360 (164) | 130 (82) | 0.130 | 0.835 |
Malignant soft tissue tumors | Excision | 1950 (778) | 360 (81) | 1.000 | 0.009 |
Palatal salivary gland tumors | Excision | 367 (293) | 83 (40) | 0.985 | 0.109 |
The association between blood loss in benign soft tissue tumours, 360 mls, and duration of surgery, 2 hrs 10 mins, was the least significant,
Estimated blood loss and duration of surgery and
Diagnosis | Treatment | Estimated blood loss Mean (SD) (mls) | Duration Mean (SD) (mins) |
|
Significance level |
---|---|---|---|---|---|
Fractures of the mandible | ORIF and IMF | 352 (351) | 175 (75) | 0.585 | 0.014 |
Zygomatic complex fractures | Zygomatic bone elevation, antral support, and ORIF | 248 (185) | 185 (112) | 0.966 | 0.034 |
NOE and Le Fort fractures | Nasal bone reduction, ORIF, canthopexy, and internal suspension | 370 (421) | 287 (53) | 0.873 | 0.325 |
Multiple fractures | Zygomatic bone elevation, internal suspension, and IMF | 350 (50) | 293 (11) | 1.000 | 0.009 |
Mandible tumors | Resection and reconstruction | 1214 (661) | 328 (95) | −0.061 | 0.843 |
Maxillary tumors | Resection/hemimaxillectomy | 627 (471) | 127 (61) | 0.550 | 0.125 |
Cysts and fibroosseous lesions | Enucleation/excision | 530 (327) | 103 (28) | 0.804 | 0.103 |
TMJ ankylosis/dislocation | Interposition arthroplasty | 550 (303) | 210 (82) | 0.715 | 0.285 |
In mandibular tumours, blood loss was 1214 mLs and duration was 5 hrs 30 min. There was no relationship between both parameters. In maxillary tumours treated by hemimaxillectomy, mean blood loss was 627 mLs and duration was approximately 2 hrs; the relationship was not significant with
When the mean blood loss in the two groups was compared, there was significant difference,
Intraoperative blood loss can be predicted by preoperative thromboelastography which measures the interaction between coagulation factors, platelets, and fibrinolytic agents. Parameters measured included the clot formation time, maximal clot firmness, fibrinolytic resistance of clot, and α angle. Madsen et al. [
Eipe and Ponniah [
In the operating room, considering the controversy surrounding the use of a discrete concentration of haemoglobin as a transfusion trigger for managing acute blood loss, the anaesthetists mainly depend on the clinical estimation of blood loss which includes checking for pallor and the trends of the patient’s oxygen saturation, capillary perfusion, blood pressure, and heart rate patterns. Therefore, each patient was assessed individually and blood transfusion was patient-specific.
In this study, the higher blood loss as well as the longer duration of surgery recorded during operations on hard tissues when compared with soft tissues was likely due to the significant amount of blood loss while dissecting the soft tissue overlying bone before resecting the affected bone itself.
Although our result showed that operations for the excision of malignant soft tissue tumours recorded the highest amount of blood loss and the longest duration of surgery on the whole, this was mainly due to the large dimensions and extent of the tumours involved. Revascularization of abnormally proliferating cells and local spread of the lesion also contributed to increasing bleeding episode seen in our patients.
It is not surprising that, in the hard tissue category, the amount of blood loss and duration of surgery were particularly highest for mandibular tumours undergoing resection and reconstruction of the jaw. The association between these primary and secondary outcome variables was quite significant for mandibular and zygomatic complex fractures but not for tumours of the jaws. Treatment of these fractures involves the dissection and detachment of soft tissues and reflection of the mucoperiosteum overlying the bones and these result in appreciable bleeding. Open reduction and internal fixation of these bone segments are actually major surgeries especially when multiple sites are involved and the number of fracture sites will determine the duration of surgery and amount of blood loss. Our findings will serve as baseline studies for comparison with future studies on intraoperative blood loss from surgical management of facial fractures.
Bell et al. [
We always use infiltration of adrenaline 1 : 200,000 for up to 15 min prior to the wound incision in addition to hypotensive anaesthesia for major surgeries and these contribute to reduction in blood loss. The meta-analysis of Hardwicked et al. has proven that adrenaline infiltration can reduce bleeding during reduction mammoplasties [
The American College of Physicians [
The lowest preoperative packed cell volume taken for elective surgery in our study was 21%. The benefits of performing operations on patients with low PCV or haematocrit values should be weighed against the risks while blood must be made available in case intraoperative transfusion is required. Notwithstanding, the decision to operate despite a low preoperative haematocrit value as in this case was guided by the favourable anticipated amount of blood loss and duration of surgery.
Apart from maintaining haemostasis, care must be taken to prevent excessive blood losses by avoiding major blood vessels. The approach of lesions via avascular planes, as well as subperiosteal dissections for noninvasive lesions, and safety margin sacrifice of tissues in infiltrative lesions are excellent techniques for preventing intraoperative bleeding. Considering that blood transfusion has potential complications [
In maxillofacial patients, allogenic transfusion can be minimized by intraoperative isovolaemic haemodilution [
To provide flexibility, as well as avoid the complications and cost of transfusion, the authors prefer the group and save policy rather than the type and cross-match protocol for lesions with expected blood loss of 500 mLs or less. This blood can then be made available and cross-matched for use in case of unexpected high loss [
In conclusion, in this study, there was significant relationship between estimated blood loss and duration of surgery for mandibular and zygomatic complex fractures. The number of units of whole blood requested for was a little higher than the blood loss estimates except for malignant soft tissue tumours, multiple fractures, mandible fractures, and TMJ disorders. The decision was based on precaution, considering the fact that blood may not be available if needed. Multiple factors may be responsible for blood loss during maxillofacial operations, but much still has to do with the physiological status and normal clotting mechanisms of the patients, nature of the lesions, and the use of anaesthetic and surgical control measures.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Babatunde O. Akinbami and Bisola Onajin-Obembe contributed equally to this work.
The authors hereby acknowledge Dr. Rahul Mongia, House Officer in the Department of Oral and Maxillofacial Surgery, for his effort in the collation of the required data.