Do we visually estimate intra-operative blood loss better with white or green sponges and is the deviation from the real blood loss clinically acceptable? Results from a simulated scenario study

PLoS One. 2020 Oct 21;15(10):e0240808. doi: 10.1371/journal.pone.0240808. eCollection 2020.


Background: The intraoperative blood loss is estimated daily in the operating room and is mainly done by visual techniques. Due to local standards, the surgical sponge colours can vary (e.g. white in US, green in Germany). The influence of sponge colour on accuracy of estimation has not been in the focus of research yet.

Material and methods: A blood loss simulation study containing four "bleeding" scenarios each per sponge colour were created by using expired whole blood donation samples. The blood donations were applied to white and green surgical sponges after dilution with full electrolyte solution. Study participants had to estimate the absorbed blood loss in sponges in all scenarios. The difference to the reference blood loss was analysed. Multivariate linear regression analysis was performed to investigate other influence factors such as staff experience and sponge colour.

Results: A total of 53 anaesthesists participated in the study. Visual estimation correlated moderately with reference blood loss in white (Spearman's rho: 0.521; p = 3.748*10-16) and green sponges (Spearman's rho: 0.452; p = 4.683*10-12). The median visually estimated blood loss was higher in white sponges (250ml IRQ 150-412.5ml) than in green sponges (150ml IQR 100-300ml), compared to reference blood loss (103ml IQR 86-162.8). For both colour types of sponges, major under- and overestimation was observed. The multivariate statistics demonstrates that fabric colours have a significant influence on estimation (p = 3.04*10-10), as well as clinician's qualification level (p = 2.20*10-10, p = 1.54*10-08) and amount of RBL to be estimated (p < 2*10-16).

Conclusion: The deviation of correct blood loss estimation was smaller with white surgical sponges compared to green sponges. In general, deviations were so severe for both types of sponges, that it appears to be advisable to refrain from visually estimating blood loss whenever possible and instead to use other techniques such as e.g. colorimetric estimation.

MeSH terms

  • Adult
  • Biometry / methods
  • Blood Loss, Surgical / statistics & numerical data*
  • Color
  • Computer Simulation
  • Data Accuracy
  • Female
  • Germany
  • Humans
  • Male
  • Middle Aged
  • Monitoring, Intraoperative / methods*
  • Operating Rooms
  • Statistics as Topic / methods
  • Surgical Sponges / trends
  • Visual Perception

Grants and funding

The authors received no specific funding for this work.