Barry Armstrong
“The wounded surgeon plies the steel That questions the distempered part;
Beneath the bleeding hands we feel The sharp compassion of the healer’s art…”
(East Coker, T.S. Eliot, 1888–1965)
Every stroke of the scalpel opens capillaries or larger vessels, shedding precious blood. Blood – the iconic image of surgery – is a sign of the surgical sacrifice made by the patient through the ministration of the surgeon. This sacrifice has an inverse benefit – the greater the bloodshed, the worse will be the outcome.
The scalpel’s bloody harvest must be limited by the joint action of the surgeon’s technique and the patient’s natural hemostasis. This interplay of patient factors and surgical technique determines the amount of bleeding during and after surgery.
If the patient’s hemostasis is weak, then the surgical control of bleeding must be
“strong” and complete.
Bleeding complications are responsible for at least a tenth of surgical deaths.
They usually occur in trauma patients, but few types of operations escape the occa- sional complication due to a postoperative bleed. The bleeding may have started before the operation or during the operation, or it may have commenced following the procedure.
Whenever natural hemostasis fails, the surgeon eventually learns about the hematoma, a falling blood count, or unexpected shock. Depending upon the size of the bleeding vessel,the quality of the nursing care and the cooperation of the patient, things might deteriorate slightly or seriously, before the surgeon is called. Detecting bleeding and notifying the surgeon is one of the key functions of postoperative nursing care.
Bleeding in the first day or two after surgery is called “reactionary hemor- rhage”.If the hemostasis was good when the wound was closed then this reactionary bleeding is due to a displaced or lysed clot, a failed suture or a slipped clip. But in truth, in many instances it represents continued oozing that started during the operation.
“Secondary hemorrhage”arises more than a week after surgery. This is usually associated with an infection or inflammatory process. An example would be bleed- ing from the pancreatic bed after necrosectomy for infected pancreatic necrosis
(> Chap. 18).
Preventing Hematomas and Postoperative Bleeding
Technical factors: check the wound hemostasis after opening.Major “pumpers”
are controlled as they are encountered. Minor bleeders and ooze should stop spon- taneously. Remember that natural hemostasis of minor bleeders (“bleeding time”) takes about 5–7 minutes. Double-check wound hemostasis in mid-operation and at closing. Don’t let your assistant wipe the wound with a sponge since this may strip away the beneficial platelet plugs. Teach him to gently daub at bleeders, rather than wiping.
Patient factors: you surely do not want us to bore you with yet another lecture on hemostasis.So just remember the 12 Ps – a mnemonic that may help your patient clot and prevent him from bleeding – presented in > Table 50.1.
For details on coagulation testing log on to: http://www.anaesthetist.com/icu/
organs/blood/test.htm
Postoperative Wound Hematomas
The most important clotting factor is the surgeon.
Fallacy 1: “The wound was dry when we closed.”(> Fig. 50.1)
Fact: Careful surgical technique will minimize the risk of post-op bleeding.
A single look, as the abdomen is closed, may miss an important bleeder that is tem- porarily in spasm. Hypotension, surgical retractors and/or a pressurized pneumo- peritoneum can also mask bleeders. The wise surgeon will check for hemostasis a few times over the last 10–15 minutes of the operation. He will relax the pneumo- peritoneum or reposition the retractors and sponges to spot hidden bleeders.
Table 50.1. The 12 Ps of surgical hemostasis: what to do if the patient is still bleeding?
(Developed by Ahmad Assalia)
First Then consider
Apply PRESSURE… Giving PLATELETS,
with PACKS or PADS Fresh frozen PLASMA,
Have PATIENCE PROTAMINE (to reverse heparin), Suture with PROLENE and PACKED CELLS (if still bleeding)
(or whatever) Call PROFESSOR for help…
If he can’t help – PRAY…
…that you will not meet your patient at the POSTMORTEM
If postoperative wound bleeding continues despite local pressure, then the wound should be re-explored. Often this can be done with local anesthetic using sterile technique in a well-lit minor-surgery room, evacuating clots and controlling the bleeding points. Give a dose of intravenous prophylactic antibiotic first, as re-exploration for bleeding boosts the risk of infection. But if you think the wound hematoma arises from a major vessel, a return to the operating room will be best.
For example, a rapidly expanding hematoma at the epigastric trocar site after laparoscopic cholecystectomy typically originates from an injured inferior epigas- tric artery. Awaiting natural hemostasis of the inferior epigastric will usually not kill your patient, but it will result in a large, uncomfortable and ugly hematoma and bruise, which will take weeks to subside.
Postoperative Abdominal Bleeding
The three words most often associated with re-operation for hemorrhage are:
“It will stop.”
Fallacy 2: If the patient is bleeding and hypotensive, then you should start two large-bore IVs, and give Ringer’s lactate quickly, at least 2 l.
Fact: evidence of the truth is mounting – vigorous fluid resuscitation might restore blood pressure and pulse, but mortality and morbidity are increased. In the
Fig. 50.1. “When we closed it was dry…”
presence of uncontrolled bleeding, rapid fluid resuscitation will dilute clotting factors, increase the rate of blood flow from an actively bleeding site and can “pop the clot” (Ken Mattox), opening new bleeders. Animal and human data show the benefits of restricting intravenous fluids when there is uncontrolled bleeding.
Permissive hypotension and small volume intravenous therapy is the best strategy for supporting the patient’s hemostatic mechanisms.
While any bleeding from or into a superficial surgical wound is obvious to the eye, postoperative bleeding into the abdominal cavity is “hidden” and, thus, more difficult to diagnose. Postoperative abdominal bleeding represents an iatrogenic surgical trauma posing diagnostic and therapeutic considerations not dissimilar from those arising in the management of penetrating and blunt abdominal trauma
(> Chaps. 34 and 35).
Is the patient bleeding into the abdomen?Tachycardia, hypotension, confu- sion,sweating,increased pain in the incision or the abdomen,abdominal distension, oliguria, dropping hematocrit, or a positive bedside ultrasound scan are usually diagnostic. Remember, however, that hypotension after surgery is not always due to blood loss. The persisting effects of anesthetics and narcotics may cause the blood pressure to drop. Postoperative epidural pain relief is a common cause of hypo- tension but beware of missing hemorrhage in this situation. Fluid resuscitation during the first operation may have been inadequate to compensate for the fluid losses and “third space” sequestration. The patient may have lost fluids from diar- rhea or vomiting. In the elderly, or those chronically taking steroids, an addisonian crisis may provoke hypotension with a rapid response to corticosteroids.
Should I rush him to the OR?With profound shock and full blown abdominal compartment syndrome caused by the expanding hemoperitoneum you should run to the operating room and open the abdomen. Otherwise, think about the following steps.
Should I image the abdomen?In a stable patient CT scan would confirm the size of the hematoma (e.g. in the gallbladder bed) and help estimate the volume of the hemoperitoneum. As the case with blunt abdominal trauma CT diagnosis and follow-up would allow safe non-operative management. A CT “blush” – extravasat- ing contrast – may mark the source of active bleeding.In specific situations (e.g.after operations for hepatic trauma) angiography could localize and treat the bleeding.
Should I treat the patient non-operatively?Today, with most blunt abdominal trauma patients managed successfully without an operation we tend to apply the lessons learned to the postoperative abdominal bleeders. Patients who continue to exhibit signs of hypovolemia after “gentle” resuscitation should be returned to the operating room.Also, you should avoid the old dogma of treating hemoperitoneum by tamponade, waiting for the intraperitoneal pressure to exceed that of the bleed-
ing source. Such outdated practice will only produce abdominal compartment syndrome necessitating abdominal decompression. Stable patients could be watched under close hemodynamic observation and with serial measurement of their hematocrit. The initial need for blood transfusions is not a contra-indication to conservative approach; we seldom know how much of the hemoglobin was shed during the operation and how much after – and how much of the drop is caused by hemodilution.
Is my conservative approach failing?Continuing blood loss reflected by the need for more blood would indicate that the conservative approach has failed.
Continued transfusion is associated with increased mortality, more infections, and increased length of stay – independent of the severity of shock. In patients who cannot be transfused because of religious objections (Jehovah Witnesses) consider more liberal indications for radiologic or surgical intervention. Also, be quicker to intervene in pregnant patients, since even early and mild maternal shock can cause uteroplacental vasoconstriction and severe fetal shock.
Is it safe to leave a large hematoma or blood clots within the abdomen?Surely it is better to have a perfectly clean abdomen than blood and its products of degra- dations floating around? And of course, blood and its metabolizing hemoglobin offer a perfect breeding ground for abscess-forming bacteria. Moreover, the by- products of old blood have been shown to contribute to the systemic inflammatory response syndrome (SIRS;> Chap. 48). Re-laparotomy, on the other hand, is associ- ated with its own early and late morbidity (and mortality). While it is the perfect tool to stop the hemorrhage from an actively bleeding artery, it may only increase generalized surface oozing associated with coagulopathy. Remember that large residuals clots can be washed and removed by an elective laparoscopy days after the bleeding has stopped.
Is my patient clotting adequately?This should be one of your concerns irre- spective whether you decide to wait or to operate.Severe acquired coagulopathy may develop intra-operatively or in the immediate post-op period. This “disseminated intravascular coagulation” (DIC) syndrome is secondary to a serious insult, such as sepsis, embolism of air, fat or amniotic fluid, shock, blood transfusion mismatch, extensive cancer,or severe trauma.Recovery requires rapid correction of the primary cause and treatment of the coagulopathy that is consuming both the platelets and coagulation factors, and destroying fibrin and fibrinogen through fibrinolysis.
Multiple component blood therapy will be needed, and possibly specialized treat- ment such as recombinant activated factor VII. Platelet transfusions may be useful when the absolute platelet count is <50,000 and the patient is bleeding. Alert the blood bank immediately and consider hematology consultation, if there is DIC.
Consider the specific index operation.You did the first operation so you are the one to know best what went – or could go – wrong. Factor it into your decision- making.
Life-Threatening Abdominal Bleeding
“Bleeding started in the rectal area and continued all the way to Los Angeles.”
(A patient chart, reproduced in Details in Professional Liability, January 27, 1999)
When a patient is compensating for blood loss his blood pressure may be a third below normal but central organs remain perfused. He is awake and coopera- tive, making 0.5 ml/kg urine each hour and has palpable pulses in the wrists and ankles. However, ongoing hemorrhage or sudden severe bleeding can overwhelm such a steady state. The history (e.g. soaked bed sheets or bandages, a “bloody”
primary operation) combined with physical findings will tell you that you must intervene urgently.
Medical hemostasis through rapid correction of coagulation abnormalities is useful, but mechanical hemostasis is critical in this urgent situation.Re-inter- vention for mechanical hemostasis usually means a re-laparotomy but could selecti- vely (in a stable patient) be accomplished laparoscopically, through gastrointestinal endoscopy or by the interventional radiologist.
Re-laparotomy for Hemorrhage
In the operating room, you will want as many “aces” in your hand as possible.
These multiple options will increase your confidence as you answer the question,
“What practice will stop the hemorrhage?”
Until now you restricted volume resuscitation and allowed permissive hypo- tension. Now, immediately before induction of anesthesia hypovolemia must be ag- gressively corrected to avoid cardiovascular collapse.Such a collapse is often caused by sudden decrease in peripheral resistance – a result of muscle paralyzing agents and sudden decompression of high intra-abdominal pressure – leading to peri- pheral pooling and decreased venous return.
You will want an adequate blood bank,a capable anesthetist,the means to keep the patient warm during surgery, good assistants (including a senior colleague), adequate lighting (consider extra lamps or headlights), good retraction and visual- ization (possibly magnification or video-laparoscopy) to allow for rapid exposure of the bleeding site, plus dissection of any major bleeding vessel with proximal and distal control.
Prepare your equipment. Mechanical hemostasis at re-operation might mean the surgeon’s pinching finger, sutures, staples, clips, electrocautery (bipolar or monopolar with or without autologous muscle fragment “welding” for retroperi- toneal venous oozing), ultrasonic energy, laser, argon-beam, heat-gun, proximal vessel ligation, injection sclerotherapy, or the application of topical hemostatic
agents (gauze packs, sponge balls, gelatin foam, cellulose pads, collagen fleece, topical thrombin, or fibrin sealants). Omentoplasty has been used to cover diffusely oozing surfaces, but topical energy or hemostatic agents can be effective.
If the bleeding has been heavy, you should consider harvesting the shed blood for autologous autotransfusion.
Often, the emergency nature of the procedure and the serious state of the patient will have you and the team on edge. The wise surgeon will tell a little humor- ous personal story or a non-offensive joke to relax the team. This breaks the emo- tional ice and will often increase the effectiveness of your team’s performance.
Patienceis required in order not to damage adjacent structures and also to arrest the hemorrhage. We were educated on the story of a famous British surgeon who was called to operate on a patient who bled after cholecystectomy. At surgery a large “pumper” – probably the stump of the cystic artery – was visualized in the depths of the triangle of Calot. The surgeon did not rush to apply clamps endangering the nearby bile duct. Instead he calmly placed a large gauze pack into the gallbladder bed and said: “Chaps, I am leaving for a cup of tea. Call me in 30 minutes.”When he returned everything was dry. [The Editors]
Most probably the source of blood will be what you expected it to be – some- thing at the site of your previous butchery. If this is not the case, search elsewhere;
pulling on the omentum during colectomy may have torn the spleen, retracting on the liver to expose the duodenum may have damaged it, eviscerating edematous small bowel may tear its mesentery and so forth. It is not unusual, though somewhat disconcerting, to find at exploration only blood clots with no evidence of the actual source of bleeding – by now contracted and thrombosed.
Most sources of bleeding will be controlled by the basic Ps (see Table 50.1).
If not, try one of the hemostatic gimmicks available to you. Make yourself familiar with “speciality maneuvers”(e.g.,use of thumb tacks to control pre-sacral bleeding).
And do not forget the principles of “damage control” you learned in trauma
(> Chap. 35): do not hesitate to pack stubborn surface ooze or venous bleeding and
come back another day (or after a cup of tea!).
“The only weapon with which the unconscious patient can immediately retaliate upon the incompetent surgeon is hemorrhage.” (William Stewart Halsted, 1852–1922)
