Q&A on bleeding in small animal patients: Triage, transfusions, reactions, and practical considerations

In this Q&A, Gianluca Bini, DVM, MRCVS, DACVAA, answers some questions surrounding bleeding in surgery. He discusses triage steps, von Willebrand disease, common mistakes made when administering blood products, common adverse reactions to transfusions, and a few things hospitals can do to improve how they manage bleeding patients.

Editor’s note: This dvm360 Q&A has been lightly edited and consolidated from a verbal interview to better fit a written format while retaining the substance of the original conversation.

dvm360: Can you introduce yourself and your background?

I'm Dr Gianluca Bini. I'm the cofounder and CEO of Safe Pet Anesthesia. I'm also an assistant professor at Oklahoma State University. I originally got my DVM in Italy. I did a rotating internship and an anesthesia internship in England, and then I did my residency in anesthesia at [North Carolina State University]. Then, I worked as a professor at Ohio State [University] for 3 years. I am now currently at Oklahoma State [University] — I moved here in 2024.

dvm360: What are some of the most common causes of bleeding that veterinarians encounter in small animals?

Bini: Usually, the bleeding we deal with most often is under anesthesia and during surgery, although pets can bleed for many different reasons. For example, rodenticide toxicity—pets may get into products stored in a garage or garden shed. There are also conditions that predispose certain breeds to bleeding. Dobermans and Greyhounds come to mind, but many breeds can have diseases that increase bleeding risk.

That said, what we most commonly encounter is surgical bleeding. Sometimes it’s easy to identify and ligate a vessel beforehand, and sometimes it’s unexpected. In a general practice setting, that can be challenging because you don’t always have access to blood products or more advanced devices for hemostasis to stop the bleeding, so that can be a challenge.

dvm360: When a patient begins bleeding during surgery, what are the first triage steps you recommend?

Bini: Unfortunately, the most common thing that people do [when a patient starts bleeding] is run a [packed cell volume] (PCV) and total solids. PCV looks at the percentage of red blood cells in the blood, and [total solids] looks at...the concentration of proteins in the blood. Unfortunately, those tests may kind of lie to you at the beginning — it takes a few hours for [PCV and total solids values] to actually be affected. A common misconception is that people [should] try to look at PCV first. In reality, total solids is usually affected first—it actually takes a longer time for PCV to be affected.

If there is significant bleeding, you can also see it on your monitor. You’ll see the heart rate spike and the blood pressure come down afterward. Usually those are more telltale signs of lack of volume. And of course, if there is active bleeding, you're going to have less blood volume, so those are the signs we look at the most.

Visualization of the bleeding is, of course, the easiest thing, but sometimes it's hard to quantify. A lot of people doing surgery use suction. You can technically look at your suction canister, but if you've been flushing with saline, it's diluted, so it’s kind of hard to tell how much of that is actual pure blood [versus] how much has been diluted.

There are some tests you can run to figure that out. You can run a PCV/[total protein] on your suction canister [to estimate] how much of it is actual blood. You can look at your sponges that have been soaking up blood, and there are some numbers you can use to estimate how much blood is in them. Ideally, you should weigh your sponges first and then do surgery. In reality nobody does that—it's very time-consuming, and you don’t want to do it for every single surgery. Sometimes it can be hard to quantify [blood loss]. Sometimes it’s very apparent, and sometimes it can be tricky.

dvm360: Can you choose one bleeding disorder and talk about how it’s typically managed?

Bini: In terms of disease itself, probably the most common one people think about is von Willebrand disease, especially in Dobermans. Some [clinicians] will preventively give desmopressin about 20 to 30 minutes before surgery to stimulate release of von Willebrand factor.

Unfortunately, the injectable form of desmopressin is very expensive, so cost can [be a limitation] for owners. [The therapy] can help, but there’s also no guarantee that it actually works. If a patient is truly affected by the disease, you may still see some more bleeding than you would see in a normal patient.

[Testing for these conditions] requires effort and expense, and not every owner can afford it. That makes [management] more challenging in veterinary medicine compared with human medicine, where insurance often covers those diagnostics.

dvm360: When choosing or administering blood products, what are some common mistakes you see?

Bini: One issue is giving blood products too quickly. With blood products, you need to get that blood from a donor, and that can cause some transfusion reactions—giving blood too fast could increase your chance of a reaction. We always try to start at a slow rate to gauge whether the patient is reacting to the product. If you give too much too fast and a reaction occurs, it may already be too late to stop it.

Starting slow allows you to stop the transfusion early if needed. You can increase the rate later, after you’ve checked that the patient did not have a reaction. There are also delayed transfusion reactions that can happen hours later, [which are harder to predict]. Unfortunately, there is no way to [completely eliminate risk of adverse] effects [when giving blood products].

dvm360: Speaking of reactions, when detectable, what are the most common signs clinicians see?

Bini: You might see a spike in temperature, hives, vasodilation, or an increase in heart rate—these are the most common reactions that we would see. Sometimes you need some expertise to detect reactions. Some reactions are obvious, but others are really subtle. While there’s a long list of [possible reactions], those are the most common ones we see.

dvm360: If a hospital wanted to improve how it manages bleeding patients, what’s one impactful change it could make?

Bini: That’s a good question. Unfortunately, there are a lot of pieces to the puzzle and there is no single answer. Bleeding can happen anytime and in any patient. There are hemostatic devices available, like cautery, foams, or gels. Cautery systems can be expensive, while some gels and foams are more affordable and easier to use.

Being able to recognize bleeding, knowing when to administer products, and knowing how to control bleeding is very important.