Operative considerations

• Surgeon Consultant

Positioning of patient—to prevent venous congestion

Tourniquets if possible

Speed

Meticulous haemostasis

• Anaesthetist Consultant

Regional blocks Hypotensive anaesthesia Hypothermia

660 Isovolaemic haemodilution-permitted as long as blood remains linked to circulation Hypervolaemic haemodilution Intraoperative blood scavenging e.g. cellsavers Blood substitutes (fluorocarbons) Pharmacological methods to improve clotting e.g. DDAVP, tranexamic acid, aprotinin

• Post-operative Observation for re-bleed—HDU, senior surgeon considerations review

Optimise Hb—nutrition enteral or parenteral feeding, B12, folate, Fe, erythropoietin Severe anaemia-IPPV to reduce oxygen demand Reduce phlebotomy and use paediatric vials Acid suppression to reduce GIT bleeding.

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