Catastrophic Intraoperative HemorrhageSalah Roshdy Professor & Senior Consultant Of Obstetrics&Gynecology Qassim College of Medicine,KSA Sohag University,Egypt
Blood supply to the pelvisovarian arteries .internal iliac (hypogastric) a.Are the main vascular supply to the pelvis . connected in a continuous arcade on the lateral borders of the vagina, uterus, and adnexa.
Blood supply to the pelvis The ovarian arteries : are direct branches of the aorta beneath the renal arteries. They traverse bilaterally and retroperitoneally to enter the infundibulopelvic ligaments.
Blood supply to the pelvis The hypogastric artery: retroperitoneally posterior to the ureter it divides into an anterior and posterior divisions.
The hypogastric artery important collateral to the pelvisPosterior Iliolumbardivision lateral sacral superior gluteal
BleedingHemorrhage, or bleeding, is the escape of blood from arteries, veins, or even capillaries because of a break in their walls.Types of bleeding include:
Arterial Bleeding Arterial bleeding is characterized by blood that is coming from an artery, is bright red, and gushes forth in jets or spurts that are synchronized with the victim’s pulse.
Venous BleedingVenous bleeding is characterized by blood that is coming from a vein, is dark red, and comes in a steady flow.
Capillary Bleeding Capillary bleeding is characterized by blood that is coming from damaged capillaries (smaller veins), is bright red, and oozes from the wound.
Incidence:Overall the incidence of vascular injuries is still relatively low, estimated at 0.9 to 2.3 per 100,000 population, However, this incidence is rising in recent years due to the increasing number of iatrogenic injuries.Currently vascular trauma is responsible for 5% to 75% of all vascular injuries.
5-step action plane STEP ONE 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:
step one PlateletsThe primary laboratory test to evaluatepotential bleeding is the platelet count.In general, 10,000 to 20,000 plateletsare needed for hemostasis. However,50,000 are needed for any surgery orinvasive procedure, such as insertion ofa central line. I recommend plateletevaluation for patients scheduled formajor abdominal surgery.
step oneHistory of bleeding If the patient or her family has a history of bleeding with any surgery, evaluate her for von Willebrand’s disease .
step oneSome 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.
step oneREMEDY USED FOR PERIOPERATIVE RISKSBeta-carotene Vitamin A coagulopathy precursorFeverfew migraine and inhibit coagulation menstrual crampsFish oil cardiovascular inhibit coagulation healthGarlic hypertension and prolonged bleeding high cholesterol time, and impaired platelet aggregation
step oneGinkgo Treatment of platelet-activating- dementia factor antagonist propertiesGinseng stimulant, tonic, hypertension, diuretic, mood cardiovascular elevator, and instability, energy booster coagulopathy, and sedationSt. John’s wort Antidepressant cardiovascular instability, coagulopathy, and sedationVitamin E Antioxidant interfere with coagulation
step oneAspirin 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 .
step onePoor 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.
Step TwoIntraoperative factors such as the 3 “inadequacies” (inadequate incision, retraction, and anesthesia), low core body temperature, severe adhesions 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.
step twoFollow These BasicPrinciples 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.
step twoIf the source of bleeding is unknown, apply pressure on the aorta using a hand, weighted speculum, or Conn aortic compressorSecure individual vessels with finetipped clamps and small-caliber sutures or clips, and minimize the use of clamps.Never place clamps or sutures blindly, and never use electrocautery for large lacerations.
step twoIf you choose to use packs to temporarily control bleeding, insert them carefully to avoid tearing veins, and place pelvic packs (hot or cold) in a stepwise fashion, from sidewall to sidewall.Leave packs in place for at least 15 minutes and remove them sequentially.
Great vessel injuries step two The aorta, vena cava, and common iliac vessels are sometimes injured . Again, the first step in managing great vessel injuries is applying pressure. Then obtain blood components, and, consult with a vascular surgeon
step twoIn general, once the patient is hemodynamically stable, the affected vessel should be compressed proximally and distally. Use Allis or vascular clamps on the torn edges to elevate the lacerated area.The preference is to close these injuries with a running 5-0 or 6-0 nylon or monofilament polypropylene (MFPP) suture on a cardiovascular needle.
step twoReplacing blood and its components Be aware of the following replacement guidelines for catastrophic intraoperative hemorrhage: • For every 8 U of red blood cells replaced, give 2 U of fresh frozen plasma. • If more than 10 U of red blood cells are replaced, give 10 U of platelets, preferably at the end of the procedure. • With prolonged PTT, give fresh frozen plasma. • If fibrinogen is low, give 2 U of cryoprecipitate
Step 3Try A Topical Hemostatic AgentIf hemorrhage contiues after arterial bleeders are secured, consider a topical hemostatic agent .All such agents require pressure to be applied for 3 to 5 minutes.
step 3Topical intraperitoneal hemostaticagentsAGENT WHAT IT IS HOW IT IS APPLIEDAvitene Absorbable collagen powderUltrafoam hemostatFibrin glue Equal amounts of Spray cryoprecipitate and thrombinGelfoam Absorbable gelatin Cut in strips of sponge appropriate size and apply to areaSurgicel Oxidized regenerated cellulose
Step 4Hypogastric Artery LigationIf pelvic oozing persists after application of a topical hemostatic agent, consider hypogastric artery ligation, which controls pelvic hemorrhage in as many as 50% of patients.
Step 5“ Pack And Go ”When All Else Fails If intraoperative bleeding persists despite hypogastric artery ligation and the other measures, the life-saving modality of choice is a pelvic pack left in place 2 to 3 days . A 2- to 4-inch Kerlix gauze is tightly packed over a fibrin glue bed from side to side in the pelvis. Only the skin is closed using towel clips or a running suture.
step 5The patient is immediately transferred to intensive care, where acidosis, coagulopathy, and hypothermia are corrected. In 48 to 72 hours, the packs are gently removed with saline drip assistance. If hemostasis still has not been achieved, repacking is an option.
step 5Autogenous tissue (OAT) patch OAT patch was used successfully to control severe bleeding from a large vein, the pelvic side wall and the paravaginal venous plexus. The use of an overlay autogenous tissue (OAT) patch using a free tissue graft to cover the vascular defect, ensured control of the bleeding and allowed completion of the planned operation .
step 5Possible mechanisms of action may be • (1) the laminar flow within the damaged vessel creates suction on the overlying patch—the Venturi effect, • (2) the resistance to flow between the large patch and the vessel wall beyond the defect may be sufficient impedance to stop flow completely and • (3) the patch provides a framework for the deposition of fibrin and platelets .
Special cases, special tools Presacral venous bleeding : Two helpful methods to quell presacral venous bleeding are: • inserting stainless steel thumbtacks • indirect coagulation through a muscle fragment
The thumbtack method The presacral veins are sometimes injured during operation. This bleeding can be controlled by inserting stainless steel thumbtacks, with direct pressure from the surgeon’s hand, directly into the sacrum. These work by compressing veins adjacent to the bone, and are left in place permanently. No complications have been reported.
Pelvic hemorrhage Arterial embolization: Angiographic insertion of Gelfoam pledgets or Silastic coils may effectively control pelvic hemorrhage in up to 90% of postpartum and postoperative patients. Hypogastric artery embolization can also be done intraoperatively.
Arterial embolization • However, this technique should be used with caution, as it may require 1 to 2 hours to perform and is inappropriate for patients with hypovolemic shock. • Complications are rare, but can occur in up to 6% to 7% of patients. They include postoperative fever, pelvic abscess formation, reflux of embolic material, nontarget embolization, foot and buttocks ischemia, bladder and rectal wall necrosis, and late rebleeding. • Arterial embolization does not appear to affect subsequent pregnancies.
Summary: Venous injuries during elective abdominal operations represent a potentially catastrophic complication with significant morbidity, mortality, and cost. Most often, venous injuries are simple lacerations that can be repaired with venorrhaphy, patch angioplasty, or reanastomosis. Complex injuries with segmental loss require interposition grafting.