Catastrophic i.o prof.salah
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Transcript of Catastrophic i.o prof.salah
Catastrophic Intraoperative
Hemorrhage
Salah Roshdy Professor & Senior Consultant
Of Obstetrics&Gynecology
Qassim College of Medicine,KSA
Sohag University,Egypt
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.
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
Anterior
division 3 parietal branches
5 visceral branches
Obturator
inferior gluteal
internal pudendal
Uterine
superior vesical
middle hemorrhoidal
inferior hemorrhoidal
vaginal
The hypogastric artery
Posterior
division
important collateral to the pelvis
Iliolumbar
lateral sacral
superior gluteal
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:
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 Bleeding
Venous 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:
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
step 4
“ 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
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
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
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 .
step 5
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
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.