The document discusses various techniques for controlling catastrophic hemorrhage during surgery, including: 1) securing individual vessels with clamps and sutures, 2) applying topical hemostatic agents if bleeding continues, 3) considering hypogastric artery ligation if oozing persists, and 4) using pelvic packing as a last resort to allow bleeding vessels to clot over 2-3 days. Special challenges like presacral venous bleeding can be addressed using thumbtacks or coagulation through muscle fragments.

1. Catastrophic
Intraoperative
Hemorrhage
Salah Roshdy
Professor & Senior Consultant
Of Obstetrics&Gynecology
Qassim College of Medicine,KSA
Sohag University,Egypt

2. Blood supply to the pelvis
ovarian 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.

3. 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.

4. Blood supply to the pelvis
The hypogastric artery:
retroperitoneally posterior
to the ureter it divides into
an anterior and posterior
divisions.

5. The hypogastric artery
5 visceral branches
 Uterine
 superior vesical
 middle hemorrhoidal
 inferior hemorrhoidal
Anterior
division  vaginal
3 parietal branches
 Obturator
 inferior gluteal
 internal pudendal

6. The hypogastric artery
 important collateral to the pelvis
Posterior  Iliolumbar
division  lateral sacral
 superior gluteal

8. Bleeding
Hemorrhage, or bleeding, is the
escape of blood from arteries,
veins, or even capillaries
because of a break in their
walls.
Types of bleeding include:

9. 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.

10. Venous Bleeding
Venous bleeding is characterized
by blood that is coming from a
vein, is dark red, and comes in
a steady flow.

11. Capillary Bleeding
Capillary bleeding is characterized
by blood that is coming from
damaged capillaries (smaller
veins), is bright red, and oozes
from the wound.

12. 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.

13. 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:

14. step one
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. I recommend platelet
evaluation for patients scheduled for
major abdominal surgery.

15. step one
History of bleeding
If the patient or her family
has a history of bleeding
with any surgery, evaluate
her for von Willebrand’s
disease .

16. step one
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.

17. step one
REMEDY USED FOR PERIOPERATIVE
RISKS
Beta-carotene Vitamin A coagulopathy
precursor
Feverfew migraine and inhibit coagulation
menstrual cramps
Fish oil cardiovascular inhibit coagulation
health
Garlic hypertension and prolonged bleeding
high cholesterol time, and impaired
platelet
aggregation

18. step one
Ginkgo Treatment of platelet-activating-
dementia factor antagonist
properties
Ginseng stimulant, tonic, hypertension,
diuretic, mood cardiovascular
elevator, and instability,
energy booster coagulopathy, and
sedation
St. John’s wort Antidepressant cardiovascular
instability,
coagulopathy, and
sedation
Vitamin E Antioxidant interfere with
coagulation

19. step one
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 .

20. step one
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.

21. Step Two
Intraoperative 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.

22. step two
Follow 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.

23. step two
If the source of bleeding is unknown, apply
pressure on the aorta using a hand, weighted
speculum, or Conn aortic compressor
Secure 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.

24. step two
If 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.

25. 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

26. step two
In 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.

27. step two
Replacing 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

28. Step 3
Try A Topical Hemostatic Agent
If 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.

29. step 3
Topical intraperitoneal hemostatic
agents
AGENT WHAT IT IS HOW IT IS
APPLIED
Avitene Absorbable collagen powder
Ultrafoam hemostat
Fibrin glue Equal amounts of Spray
cryoprecipitate and
thrombin
Gelfoam Absorbable gelatin Cut in strips of
sponge appropriate size and
apply to area
Surgicel Oxidized regenerated
cellulose

30. Step 4
Hypogastric Artery Ligation
If 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.

31. step 4

32. 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.

33. step 5
The 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.

34. step 5
Autogenous 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 .

35. step 5

36. step 5
Possible 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 .

37. 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

38. 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.

41. 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.

42. 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.

43. 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.