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Catastrophic intraoperative hemorrhage: 5-step action plan

OBG Manag. 2005 June;17(6):54-61

References

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7. Clark SL, Phelan JP, Yeh Z-Y, Bruce SR, Paul RH. Hypogastric artery ligation for obstetric hemorrhage. Obstet Gynecol. 1985;66:353-356.

8. Thavarash AS, Sivalingam N, Almohdzar SA. Internal iliac and ovarian artery ligation in the control of pelvic hemorrhage. Aust N Z J Obstet Gynecol. 1989;29:22-25.

9. Burchell RC. Internal iliac ligation. Haemodynamics. Obstet Gynecol. 1964;5:53-59.

10. Finan MA, Fiorica JV, Hoffman MS, et al. Massive pelvic hemorrhage during gynecologic cancer surgery: “pack and go back.” Gynecol Oncol. 1996;62:390-395.

11. Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin N Am. 1997;77:761-777.

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18. Xu J, Lin J. Control of presacral hemorrhage with electrocautery through a muscle fragment pressed on the bleeding vein. J Am Coll Surg. 1994;179:351-354.

19. Miklos JR, Kohli N, Sze EH. Control of presacral hemorrhage using indirect coagulation through a muscle fragment. J Pelvic Surg. 1996;2:268-270.

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STEP 5When All Else Fails: “Pack And Go”

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. I prefer a fast, simple method: “pack and go” or damage-control technique.^10-12

A 2- to 4-inch Kerlix gauze (Kendall Health Care Products, Mansfield, Mass) 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. 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.

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 presacral neurectomy, sacrocolpopexy, or posterior exenteration. This bleeding can be controlled by inserting stainless steel thumbtacks, with direct pressure from the surgeon’s hand, directly into the sacrum.^15-17 These work by compressing veins adjacent to the bone, and are left in place permanently. No complications have been reported.

Indirect coagulation

Another method of controlling presacral venous bleeding is indirect coagulation through a muscle fragment. This is done by harvesting a 2 x 1 cm piece of muscle from the rectus abdominus and pressing it against the bleeding veins. Then set a Bovie (Valley Lab, Boulder, Colo) at 40 W of pure cutting current and apply it to the muscle fragment for 1 to 2 minutes. This method has been successful in 12 of 12 reported cases.^18,19

Other methods of controlling presacral venous bleeding include bipolar cautery, use of bone wax, and suturing in “sandwiches” of Avitene alternated with Gelfoam, but these strategies have met with limited success.

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.^20,21 Hypogastric artery embolization can also be done intraoperatively.²²

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.²¹ 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.²³

Military antishock trousers The MAST or aviation “G” suit is sometimes used as an intermediate step to laparotomy in patients with ectopic pregnancy or postoperative or postpartum hemorrhage.²⁴ Its major use is to stabilize patients for surgery by compressing peripheral circulation, thereby diverting blood to the core circulation.

Inflate the legs first, then the abdomen; leave the MAST suit in place for 2 to 48 hours; and deflate in reverse order.

Contraindications include pulmonary edema, cardiogenic shock, rupture of the diaphragm, and pregnancy.

For the Logothetopolous or “parachute” pack,^13,14 about 6 yards of 4-inch gauze is packed in the center of a 24-inch square laparotomy tape or a sterile bowel isolation bag, tied, and pulled through the vagina. Pressure is maintained with a weight tied to the end that is brought out through the vagina. One problem with the parachute pack is that further bleeding or injury to the bowel upon removal may not be recognized early.

SALLY’S CASE

Hemorrhage abates

A “pack and go” technique is used to control bleeding. The fascia is left open, and the skin is closed with towel clips over the tight pelvic pack. Sally is sent to the ICU, where clotting parameters are corrected.

She undergoes reoperation 36 hours later, at which time no bleeding is encountered.

The left ureter is reimplanted into the bladder, and she makes a full recovery.

The author has served on the speakers bureau for Wyeth.