Introduction/Background*Significant intraoperative blood loss can be encountered in complex pelvic surgery and impact on post-operative outcomes. There are a number of key anaesthetic techniques that can be used to optimise a patient in preparation for and to mitigate against predicted and unpredicted blood loss.

Methodology We performed a systematic review of the literature to identify the current perioperative anaesthetic strategies for optimisation of the patient and reducing blood loss in complex pelvic surgery.

Result(s)*This article explores the pre-operative and intra-operative techniques to reduce both the volume and physiological impact of blood loss.

Preoperative optimisation aims to identify patients that are at risk. This includes those with significant comorbidities or abnormal clotting disorders. Anticoagulation/antiplatelet therapies may require adjustment. Pre-operative anaemia should also be managed.

Intraoperative techniques are essential for reducing the rate of blood loss. Hypothermia leads to reversible disruption of the coagulation cascade and therefore techniques to maintain normothermia are required. Relative hypotension and avoidance of tachycardia both reduce blood loss but require close monitoring to ensure adequate tissue perfusion. Using regional anaesthesia can further support this. The use of pharmacological agents, such as tranexamic acid, have been demonstrated to reduce blood loss in pelvic surgery. Blood products such as clotting factors can specifically target and correct coagulopathies using point of care testing. Cell salvage allows use of autologous blood and clotting factors, reducing the need for cross-matched blood and the associated risks of transfusion.

Notably, reducing blood loss into the surgical field allows for improved visualisation of the anatomy and performance of surgical instruments used to cauterise bleeding, thus further improving haemorrhage control.

Conclusion*In conclusion, minimising blood loss during surgery requires input from the multidisciplinary team. Preoperative assessments should be held in a timely fashion to implement strategies for patient optimisation. Careful consideration and planning should be given to the intraoperative stage. Application of the strategies mentioned in this review will reduce the risk of significant intraoperative haemorrhage, aiming to improve the morbidity and mortality associated with complex pelvic surgery.