Editor’s note: This is a two-part series reporting on “Top Tips” Instructional Course Lectures from the AAOS 2019 Annual Meeting. Part two will appear in the June issue and cover tips for handling pelvic and extremity “disasters” in the operating room.
During the AAOS 2019 Annual Meeting Instructional Course Lecture titled “Preparing for Your Worst/Best Moment in the Operating Room,” Kevin A. Raskin, MD, offered tips and pearls for managing hemorrhage. They were gleaned from his experience as an orthopaedic oncology surgeon at Massachusetts General Hospital. He provided technical instruction for handling bleeding events, but his overall message for handling such episodes was: “Slow down. Pack and wait. You can handle this.”
The first step to take when bleeding occurs is to assess the situation. “Recognize the source,” Dr. Raskin said. “If you are plating a femur with a lateral approach, bleeding may be coming from the medial side. In the pelvis during total hip arthroscopy, it may come from a separate compartment after acetabular screw placement. It is important to think: Where am I? What have I done with the things I’ve placed inside this patient’s body that is causing this bleeding?”
When confronted with serious hemorrhage, Dr. Raskin’s first step is to “pack and wait,” he shared. “Pack with whatever you want—lap sponges, thrombin-soaked Gelfoam, Surgicel, combat gauze—whatever the operating room (OR) has, whatever you’re comfortable with.”
Bleeding from a breached artery or vein may be alarming and can trigger a counterproductive response. “What I see all the time is that the first thing surgeons grab is ‘the sucker,’” Dr. Raskin said. “That’s only going to lead to [more] business for the blood bank, because you’re just exsanguinating the patient.”
Instead, he advised, “You may wish to have the suction tip in one hand, while applying pressure on the field and suctioning around the packs, so that ultimately, when you relieve the packs, you can see the bleeding. The suction tip is not your friend. It’s only going to hurt you.”
Assess and stabilize
Upon packing, the next step is to assess the patient, not rush into motion.
“If the patient is unstable, this requires patience,” he said. “It doesn’t require action, oddly enough. An unstable patient with hemorrhage means you pack and wait, so that you stop the bleeding and let your anesthesia team catch up. Correct the anemia [and] restore the heart rate and blood pressure. Correct the pH, because if there is lactic acidosis, the pH is dropping, and the patient is hypotensive and poorly perfusing, they can’t clot. Let the team on the other side of the screen catch up, even if it takes 20 minutes. You will have a whole new patient. When you relieve the packs, and the bleeding starts up again, you are starting from a healthier patient. If the patient is stable, then you have time to think about resolving the problem.”
Hemorrhage may be either frank or subtle, Dr. Raskin said. Arterial bleeding often “is obvious and shoots out of the wound, maybe to the ceiling,” he said. Venous bleeding “may be obvious if you strike a big vein, or subtle with welling up or slow ooze—where you’ve made your way through a case, and it just seems to be wetter than normal.”
Venous bleeding may be less flamboyant but can flummox the surgeon more, he said, noting the words of his friend and colleague Michael Watkins, MD: “It’s the amateurs who fear arterial bleeding and the pros who fear venous bleeding.”
In his practice of oncologic surgery, commonly working in the pelvis and other difficult locations, he said that he has “grown to respect venous bleeding more than arterial in the sense that arteries are easier to see, easier to stop, and easier to sew, whereas veins are often crummy in the best of circumstances. The walls are thin and poor and may be of even poorer quality in circumstances such as irradiated wounds. I have respect for the high-volume, low-pressure system that are veins.”
Knowledge of anatomy combined with an intrepid approach will result in an effective response to bleeding, Dr. Raskin said. In a classic anatomy drawing, the “green stripe” means, “I can go there,” he said. The red stripe may mean an artery. “These [guidelines] are appropriate when getting access to bones, but you have to think differently when getting to blood vessels,” he advised.
“The notion of blood vessels and nerves as ‘tiger country’ is annoying to me. As the surgeon, you are the tiger; the patient is not the tiger—they’re asleep! Go find the vessels. Find what’s bleeding and solve the problem. Peel back the anatomy so that you can get to tiger country. There is nothing to be afraid of if you know the anatomy. Never be surprised by nerves, arteries, and veins. You [should] surprise them. Find them, protect them, [and] repair them,” Dr. Raskin added.
Tools for the job
In making repairs, Dr. Raskin favors the use of the Judd-Allis vascular clamp. “It’s not in most orthopaedic instrument sets, so ask for two or three. It is a very fine clamp that lets you take very small bites of an avulsed artery or vein, stop the bleeding nicely, and tie with nylon sutures in between and around the clamps. When you take the clamps off, the hole is patched.”
For manipulating vessels, Dr. Raskin said he likes to use
DeBakey forceps, which “for some reason are foreign to the orthopaedic operating theater.” Invented by Michael DeBakey, MD, specifically to handle blood vessels, the instruments “are relatively aggressive, with small teeth. You can grab vessels with them. They are firm but fair—like raising a child.” He said he prefers them to the tonsil clamp (“the Schnidt” at his organization). “I am much more dexterous with ‘tweezers.’”
Dr. Raskin emphasized the importance of ample exposure. “Prep widely,” he advised. “Oftentimes, trainees fear that if you prep widely you are going to ‘go widely.’ Not necessarily. I am prepping widely in case I have to go wide, so I can put my hand on the groin and stop bleeding if I need to. I don’t want to be boxed out. Prep wider than you think to set yourself up for success, especially in revision surgeries or other procedures where there might be trouble.”
In total joint arthroplasty, “prepping widely is great for exposure, bleeding, and alignment,” Dr. Raskin said. “You can see the limb. You will be so happy and comfortable with a wide exposure. For total hip arthroplasty, prep to the buttock and the umbilicus. For total shoulder, prep to the nipple and the vertebral border of the scapula.”
The goal of gaining exposure and visualization may require disruption to muscle. “Work around your packs and take structures down if you need to,” Dr. Raskin instructed. “If you are in a situation where there is bleeding and [think], ‘I don’t want to take down the sartorius muscle’—the sports surgeons take it down for extra ligaments all the time. I would take it down in one second; I would take anything down if it meant I was going to get to a blood vessel. You can always fix it, and, for the most part, the patient can probably live without it. Exposure begets confidence and vice versa. Once things are in view, you feel in total control.”
Dr. Raskin addressed hemorrhage in the ambulatory care center setting, such as in anterior cruciate ligament surgery when perforation of the popliteal artery occurs. He noted that what often happens is that “immediately a tourniquet is placed, and the patient is transported to the hospital with the tourniquet in place.” He advised a different approach. “The clock is ticking. Especially in the popliteal space, there is fat and the space is controlled. With pressure alone you can control arterial and venous bleeding nicely without the threat or ticking-clock phenomenon of a tourniquet. Try to avoid tourniquets for long periods of time, because you don’t know when the patient will get to the main institution.”
Dr. Raskin offered guidance on managing bone bleeding, which may be encountered especially in oncologic cases. “For instance, if you are broaching a femur for an implant in a myeloma patient, that bone will bleed a lot,” he said. “But usually, once you place the implant, it will tamponade and stop. Cement will also tamponade bleeding, and oftentimes, reducing the fracture helps.” He offered “tricks” to use that include use of methacrylate and hydrogen peroxide—“especially peroxide-soaked lap sponges that gum up bleeding very nicely”—as well as “cigars” of Gelfoam wrapped in Surgicel as “a way of jamming fiber” into the wound and packing it.
Addressing the prospect of the “intraoperative code”—cardiac arrest—Dr. Raskin advised: “Be prepared; it shouldn’t be a surprise.” With at-risk patients, such as the older patient undergoing joint arthroplasty, Dr. Raskin said he would take care to have an iodine-impregnated incision drape (Ioban) at the ready in the OR, so that if a code event occurs, immediately the procedure is halted, the wound is packed, the patient is draped, and cardiopulmonary resuscitation is undertaken. “The wound is the wound, the implant is the implant,” Dr. Raskin said. “You can solve that [implant] problem in the future.”
Terry Stanton is the senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org.