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

Catastrophic i.o prof.salah

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Page 1: Catastrophic i.o prof.salah

Catastrophic Intraoperative

Hemorrhage

Salah Roshdy Professor & Senior Consultant

Of Obstetrics&Gynecology

Qassim College of Medicine,KSA

Sohag University,Egypt

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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.

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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.

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Blood supply to the pelvis

The hypogastric artery:

retroperitoneally posterior

to the ureter it divides into

an anterior and posterior

divisions.

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The hypogastric artery

Anterior

division 3 parietal branches

5 visceral branches

Obturator

inferior gluteal

internal pudendal

Uterine

superior vesical

middle hemorrhoidal

inferior hemorrhoidal

vaginal

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The hypogastric artery

Posterior

division

important collateral to the pelvis

Iliolumbar

lateral sacral

superior gluteal

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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:

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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.

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Venous Bleeding

Venous bleeding is characterized by blood that is coming from a vein, is dark red, and comes in

a steady flow.

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Capillary Bleeding

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

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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.

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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:

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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.

step one

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History of bleeding

If the patient or her family has a history of bleeding with any surgery, evaluate her for von Willebrand’s

disease .

step one

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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.

step one

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PERIOPERATIVE RISKS

USED FOR REMEDY

coagulopathy Vitamin A precursor

Beta-carotene

inhibit coagulation migraine and

menstrual cramps

Feverfew

inhibit coagulation cardiovascular health

Fish oil

prolonged bleeding time, and impaired platelet aggregation

hypertension and high cholesterol

Garlic

step one

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platelet-activating-factor antagonist properties

Treatment of dementia

Ginkgo

hypertension, cardiovascular instability, coagulopathy, and sedation

stimulant, tonic, diuretic, mood elevator, and energy booster

Ginseng

cardiovascular instability, coagulopathy, and sedation

Antidepressant St. John’s wort

interfere with coagulation

Antioxidant Vitamin E

step one

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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 .

step one

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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.

step one

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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.

Step Two

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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.

Follow These Basic Principles

step two

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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.

step two

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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.

step two

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Great vessel injuries

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 two

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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.

step two

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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

step two

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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.

Step 3

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Topical intraperitoneal hemostatic agents

HOW IT IS APPLIED

WHAT IT IS AGENT

powder Absorbable collagen hemostat

Avitene Ultrafoam

Spray Equal amounts of cryoprecipitate and thrombin

Fibrin glue

Cut in strips of appropriate size and apply to area

Absorbable gelatin sponge

Gelfoam

Oxidized regenerated cellulose

Surgicel

step 3

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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.

Step 4

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step 4

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“ 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 5

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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.

step 5

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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 .

step 5

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step 5

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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 .

step 5

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Presacral venous bleeding :

Two helpful methods to quell presacral venous bleeding are:

• inserting stainless steel thumbtacks

• indirect coagulation through a muscle fragment

Special cases, special tools

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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.

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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.

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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.

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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.

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