Documenting Significant Blood Loss

Classification and Documentation

The American College of Cardiology recommends using the VARC-3/BARC bleeding classification, which provides objective criteria for classifying bleeding into four types: Type 1 (Minor), Type 2 (Major), Type 3 (Life-threatening), and Type 4 (Fatal) 1, 2
Type 1 (Minor) bleeding is defined as overt bleeding requiring medical intervention, hospitalization, or increased level of care, or requiring transfusion of 1 unit of packed red blood cells 1, 2
Type 2 (Major) bleeding is defined as overt bleeding requiring transfusion of 2-4 units of packed red blood cells, or hemoglobin drop >3 g/dL but <5 g/dL 1, 2
Type 3 (Life-threatening) bleeding is defined as bleeding in critical organs, bleeding causing hypovolemic shock or severe hypotension, or bleeding requiring reoperation or surgical intervention for control 1, 2
The American College of Cardiology recommends documenting exact transfusion requirements, including the number of units of packed red blood cells transfused within 48 hours of the index procedure, during the total duration of index hospitalization, and during any subsequent hospitalizations 1
The estimated blood volume lost should be defined as a percentage of total blood volume, approximately 7% of ideal body weight in adults and 8-9% in children 3

The American College of Cardiology recommends including physiological parameters such as vital signs, signs of hypovolemia, and interventions required in the documentation of bleeding 1
The timing of bleeding relative to any procedure or intervention should be documented, including the duration of bleeding episode and whether bleeding was immediate, delayed, or recurrent 1, 4
The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting signs of hypovolemia, such as tachycardia, syncope, and orthostatic hypotension 4

The Praxis Medical Insights guideline defines massive hemorrhage as loss of one blood volume within 24 hours, 50% blood volume loss within 3 hours, blood loss rate of 150 mL/min, replacement of >10 units of blood in 24 hours, or blood loss >40% of blood volume 3