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Catastrophic intraoperative hemorrhage: 5-step action plan

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If this emergency cannot be averted with careful preoperative assessment, rely on a reasoned plan, basic tools, a few new tools, and tried-and-true techniques.


 

References

SALLY’S CASE

Placenta accreta leads to hemorrhage

Sally is a 27-year-old gravida with 1 prior cesarean whose ultrasound imaging is suspicious for “placenta adherent to the bladder.” At 38 weeks, she delivers a viable infant by classical cesarean, at which time the ultrasound finding is confirmed: the placenta is densely adherent.

The placenta is left in situ, no methotrexate is given, and Sally is followed with clotting studies and exams.

Eight weeks later, when her fibrinogen level falls and the prothrombin time and partial thromboplastin time become abnormal, the obstetrician attempts to perform dilatation and evacuation, but massive bleeding ensues. The physician then performs a total abdominal hysterectomy, but bleeding continues from the cuff.

What is the best way to manage the hemorrhage?

After identifying its source, the surgeon should apply pressure to abate the bleeding, using packing if necessary, and repair the affected artery or vein. Fortunately, we have many tools at our disposal, from preventive steps like careful preoperative assessment to the use of hemostatic agents, fibrin glues, hypogastric artery ligation, and specialized pelvic packing techniques. With prompt action and a stepwise approach, this bona fide catastrophe can usually be successfully managed. This article details a 5-step action plan.

If massive bleeding occurs during laparoscopic or vaginal surgery, a laparotomy may be indicated, and intraoperative management would follow the same 5 steps.

STEP 1Like the Boy Scouts, Be Prepared

Although surgeons are acutely aware that drugs such as warfarin and heparin can cause intraoperative bleeding, the patient history and predisposing factors sometimes get short shrift.

Besides asking about the patient’s medications, assess the following:

  • Platelets. The primary laboratory test to evaluate potential bleeding is the platelet count. In general, 10,000 to 20,000 platelets are needed for hemostasis. However, 50,000 are needed for any surgery or invasive procedure, such as insertion of a central line.1 I recommend platelet evaluation for patients scheduled for major abdominal surgery.
  • History of bleeding. If the patient or her family has a history of bleeding with any surgery, evaluate her for von Willebrand’s disease.
  • High alcohol intake warrants preoperative liver function and coagulation studies.
  • Some herbal or natural remedies can exacerbate intraoperative hemorrhage through their inhibition of coagulation, especially the agents listed in TABLE 1. They should generally be discontinued 2 to 7 days before surgery.2
  • Aspirin and nonsteroidal anti-inflammatory drugs should be discontinued 7 days before anticipated surgery. However, patients may continue aspirin at a daily dose of 81 mg.
  • Poor nutrition and obesity predispose the patient to wound complications and intraoperative bleeding. Patients who are severely malnourished can take dietary supplements or receive total parenteral nutrition prior to surgery.
  • Intraoperative factors such as the 3 “inadequacies” (inadequate incision, retraction, and anesthesia), low core body temperature, severe adhesions (ie, endometriosis), and large vascular tumors also are sometimes associated with bleeding.
For patients predisposed to bleeding, obtaining exposure is mandatory. Blood components and a cell-saving device also should be available, as described below.

TABLE 1

Alternative remedies that may exacerbate bleeding

  • 32% to 37% of Americans use these remedies, but only 38% of them tell their doctor
  • Stop all alternative remedies 2 to 7 days before surgery
REMEDYUSED FORPERIOPERATIVE RISKS
Beta-caroteneVitamin A precursor; often taken as a nutritional supplementMay cause coagulopathy
FeverfewUsed to prevent or treat migraine and ease menstrual crampsMay inhibit coagulation
Fish oilRich in omega-3 fatty acids, recommended for cardiovascular healthOmega-3s inhibit coagulation
GarlicUsed to reduce hypertension and high cholesterolCase reports of unexpected or increased surgical bleeding, prolonged bleeding time, and impaired platelet aggregation
GinkgoTreatment of dementia, impaired cognition, and memoryVarious ginkgolides have platelet-activating-factor antagonist properties; case reports of spontaneous bleeding
GinsengWidely used as a stimulant, tonic, diuretic, mood elevator, and energy boosterMay cause hypertension, cardiovascular instability, coagulopathy, and sedation
St. John’s wortAntidepressantMay cause cardiovascular instability, coagulopathy, and sedation
Vitamin EAntioxidantMay interfere with coagulation

STEP 2Follow These Basic Principles

Whenever bleeding is encountered in any area of the abdominal cavity, the first step is simple: Apply immediate pressure with a finger or sponge stick. Then obtain exposure and assistance. Exposure usually means extending the incision and using a fixed table retractor.

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