Surgical Haemostasis - VMS 3010 2024 PDF

SURGICAL H A E M O S TA S I S ALISON LIVESEY  L E A R N I N G OBJECTIVES Be able to: recognise the signs, importance and significance of surgical blood loss describe means of measuring surgical blood loss describe methods and strategies for limiting intraoperative haemorrha...

SURGICAL H A E M O S TA S I S ALISON LIVESEY  L E A R N I N G OBJECTIVES Be able to: recognise the signs, importance and significance of surgical blood loss describe means of measuring surgical blood loss describe methods and strategies for limiting intraoperative haemorrhage discuss the benefits and drawbacks of materials to promote clotting describe the means of limiting blood loss by the application of dressings Presentation Name | Date | Version 0.0 2  H A E M O R R H A G E A N D HAEMOSTASIS Haemostasis Allows good visualisation Decreases surgical time Prevents SSI Blood on drapes, instruments is medium for bacterial growth – increased SSI Contributes to good post op healing Haematoma/seroma Prevents good apposition of tissues Physical obstruction to macrophages Physical obstruction to invading blood vessels Poor oxygen delivery, favours bacterial growth Haemoglobin inhibits phagocytic cells Haematoma provides nutrient source for bacteria Prevents haemorrhage Complications, Shock... Death Presentation Name | Date | Version 0.0 3  INTRA-O P E R A T I V E HAEMOSTASIS Proper surgical technique – Meticulous Surgical Haemostasis Gentle tissue handling Use of appropriate instruments Excellent knowledge of relevant anatomy Knowledge of procedure Understand normal haemostatic mechanisms Be aware of diseases that affect haemostasis Presentation Name | Date | Version 0.0 4  I N T R A - O P E R AT I V E B LO O D LO S S Blood loss is a normal part of surgery Extent of haemorrhage is often inversely proportional to technical and anticipatory skills of surgeon Preventative haemostasis Planning, ligation/coagulation prior to transecting vessels Gently and accurate dissection Significant haemorrhage can occur unexpectedly During surgery or post operatively Must maintain IV access for volume resuscitation Monitor BP Monitor patient Presentation Name | Date | Version 0.0 5  SHOCK Reduced tissue perfusion Reduced O 2 delivery Clinical signs Sinus tachycardia or bradycardia Hypotension, poor pulse quality Cold extremities (hypothermia) Pallor Biochemistry changes (renal, lactate?) Death if untreated Presentation Name | Date | Version 0.0 6  A P P R O A C H TO I N T R A - O P E R AT I V E H A E M O R R H A G E Recognise and address blood loss Rule out, identify source of bleeding Suture malfunction/deficiency Occult haemorrhage (unknown/unexplored/distant to surgical field) Accidental damage or collateral damage during surgery Damage after surgery (post operative haemorrhage) Restore haemostasis Reverse hypothermia, shock and other complications Monitor Stability of coagulation New or ongoing blood loss Complications Presentation Name | Date | Version 0.0 7  QUANTIFYING BLOOD LOSS Blood losses should be estimated or measured during surgery Swabs contain standard amounts of fluid dependent upon size (6, 8 or 10 mls) Weigh swabs Compare dry swab with saturated swab Blood essentially water; 1g=1ml Loss onto floor, drapes should be estimated Suctioned blood should be measured and recorded Record volume of flush used and remaining and calculate blood loss Presentation Name | Date | Version 0.0 8  A V O I D I N G S U R G I C A L BLEEDS Know your anatomy and be prepared for procedures Good surgical prep and planning WIDE CLIP LARGE INCISION Appropriate kit Good lighting Assistance if possible Dissect tissue appropriately to know where you are Avoid blind, sharp cutting Use finger and blunt dissection where possible/appropriate Presentation Name | Date | Version 0.0 9  PREVENTION OF SURGICAL BLEEDS Be aware of bleeding disorders Lungworm-Angiotest R Greyhound fibrinolytic syndrome-pretreat tranexamic acid Doberman Pinscher –von Willebrand’s disease XL Bully? Platelet disorders Liver disease Coagulopathy Presentation Name | Date | Version 0.0 10  SURGICAL BLEED Don’t panic and remain calm Go back to first principles Find the source of the bleed Increase exposure Easy if wide clip and drape/cuttable drape Difficult/risky if small clip and drape Ask for help – assistant Utilise retractors, swabs, suction to clear field and locate bleed Deal with bleed Presentation Name | Date | Version 0.0 11  S U R G I C A L M E T H O D S O F HAEMOSTASIS Pressure (tamponade) Haemostatic forceps Ligation techniques Vascular clips Electrosurgery Radiosurgery Vessel sealing devices Adrenaline Topical haemostatic agents Antifibrinolytic Tourniquet/Esmarch Presentation Name | Date | Version 0.0 12 D I R E C T P R E S S U R E (TAMPONADE) Useful for minor bleeds/small vessels/initial temporary control of larger bleeds NOT for major bleeds Won’t work for coagulopathic patients Compression with swab or fingers Excessive pressure may prevent platelets from migrates Gentle pressure For long enough time Sufficient for coagulation Lift swab – do not wipe away formed clot Presentation Name | Date | Version 0.0 13  H A E M O S T A T I C FORCEPS Crush tissue Ratchet allows to be left in position Temporarily arrest haemorrhage Damage vascular wall to activate clotting mechanism Leads to clotting/sealing Small vessels only Must leave for appropriate time Require normal coagulation factors Ligation for larger vessels Reduces post operative bruising and maintains visible surgical field Presentation Name | Date | Version 0.0 14  U S I N G H A E M O S T A T I C FORCEPS Use smallest forceps necessary for the size of the vessel Grasp as little of surrounding tissues as possible Curved forceps improve visibility Use wide-based tripod grip Use atraumatic for manipulating tissue surrounding source of bleeding You can palm multiple forceps For small vessels Use tip of haemostat to grasp smallest amount of tissue Apply parallel to vessel For larger or deeper vessels/vascular pedicles Use jaw rather than tip of haemostat Apply perpendicular to vessels Presentation Name | Date | Version 0.0 15 U S I N G H A E M O S T A T I C FORCEPS Presentation Name | Date | Version 0.0 16  L I G AT I O N Traditional and most secure method of haemostasis Not dependent upon clot not being dislodged For larger vessels Reduces post operative bruising Maintains visible surgical field Different techniques and knots Two-hand tie vs One-hand tie vs Instrument tie Surgeon’s knot vs Square knot Simple vs Transfixing Presentation Name | Date | Version 0.0 17  L I G AT I N G A N D T E M P O R A R I LY O C C L U D I N G V E S S E L S Pringle manoeuvre Temporary occlusion with Satinsky clamp, bulldog clamp or rumel tourniquet Can fashion with red tubing or penrose drain. Presentation Name | Date | Version 0.0 18 L I G AT I O N Different techniques and knots Two-hand tie Produces good square knots Time consuming Difficult for deep ligature One-hand tie Quicker for making square knots Easier for deep ligatures Knots are more susceptible to loosening of first throw and producing half hitch Instrument tie Less tactile feel Uses less suture material Best suited to deep ligature placement Presentation Name | Date | Version 0.0 19  KNOTS Square knot Two opposing mirror-image simple knots Reversing direction of each knot Even tension on both strands, parallel to the knot Surgeon’s knot Double loop on first throw (friction) Improved security Useful for elastic tissue/under tension Bulky vascular pedicles Reduces risk of first throw unwrapping before second is placed Bulkier knot Presentation Name | Date | Version 0.0 20  Miller’s knot Loop pedicle twice with second loop overlapping first » Free end of suture passed under the bottom loop and over the first loop Pull free ends in opposite directions Finish with square knots Modified Miller’s knot (strangle) Loop pedicle twice without overlapping loops Free end is passed over and under both loops Pull free ends in opposite directions Finish with square knots Presentation Name | Date | Version 0.0 21  LIGATURE TECHNIQUES » Halsted Transfixing » Simple encircling » Modified transfixing #universityofsurrey 23  LIGATURE TECHNIQUES » Figure of eight » Stick Ties » Three clamp technique » Divide and Conquer #universityofsurrey 23 LIGATURE TECHNIQUES » Figure of eight Third clamp Cut Second clamp First clamp – crush tissue and release clamp Tie ligature here » Stick Ties » Three clamp technique » Divide and Conquer #universityofsurrey 24 L I G AT U R E T E C H N I Q U E S Ligature in tissues Presentation Name | Date | Version 0.0 25  VASCULAR CLIPS Metal clips (Hemoclips) Clips and applicator Tissue should be dissected free from vessel Diameter of blood vessel should measure no more than1/3 and no less than 2/3 length of clip Should be applied several millimetres from the cut end Clip arteries and veins separately Presentation Name | Date | Version 0.0 26 ELECTROSURGERY Does not = electrocautery Grounding plate Electrocautery – heat applied to tissue (disbudding) Electrosurgery/electrocoagulation – electrical current passes from the metal tip to the blood vessel Heat produced in tissue itself and converted into thermal energy to seal vessel Can use for incision but care with thermal necrosis delaying healing Works best for vessels 2mm or less monopolar bipolar #universityofsurrey 28  E L E C T R O S U R G E R Y (DIATHERMY) Monopolar Ground plate lies contact and beneath the patient. Current flows through electrode (handpiece) through patient to ground plate If contact not good can cause burns Cut and coagulate possible Requires dry surgical field Bipolar more precise Presentation Name | Date | Version 0.0 28  RADIOSURGERY Similar to electrosurgery Cut and coagulation Uses high-frequency radio waves Patient is not part of the circuit Plate is not grounding and doesn’t need to be in contact with skin Presentation Name | Date | Version 0.0 29  B I P LO A R D I AT H E R M I C S E A L I N G D E V I C E S Ligasure, Vetseal, Enseal Seals vessels up to 7mm using heat energy Seals then gives a “beep” and then cuts No risks of sutures/ligatures slipping No foreign material left in the site Shorter surgical times Costly Presentation Name | Date | Version 0.0 30  HOTBLADE Plugs into normal diathermy unit Bipolar vessel sealer No automatic adjustment or cutting Adequacy of coagulation determined visually Surgeon activates knife ‘Individual use’ but can be sterilised by ethylene oxide Cheaper than the others Presentation Name | Date | Version 0.0 31  OTHERS Harmonic Scalpel Ultrasonic energy Clamps tissues Vibration shakes cells, resulting in heat coagulation and vessel sealing Cuts and seals at the same time Safer £££ Lasers ££££ Health and safety Suited to a few specific things Impractical in most GPs Presentation Name | Date | Version 0.0 32  ADRENALINE Adrenaline Small superficial wounds Vasoconstriction may reduce blood flow to allow clot formation 1:1000 to 1: 10000 Diffuse bleed – intranasal/intraoral Can have systemic effects Local ischaemia Presentation Name | Date | Version 0.0 33  TO P I C A L H A E M O S TAT I C A G E N T S Mechanical effect – provide pressure or tamponade Scaffold – to allow for clot formation Can cause granuloma formation Should be removed before closure Presentation Name | Date | Version 0.0 34  TO P I C A L H A E M O S TAT I C A G E N T S Gelfoam-Spongostan (absorbable haemostatic gelatin) Lyostypt (collagen sponge) Surgicell –surgicell fibrillar (oxidised regenerated cellulose) Surgiflo (haemostatic gelatin matrix)-reconstituted with saline Bone wax Biocompatible materials absorbed by the body in 3 weeks Lyostypt Presentation Name | Date | Version 0.0 35 T O P I C A L H A E M O S T A T I C AGENTS Bone wax-used in neuro surgery-blocks the blood vessels Presentation Name | Date | Version 0.0 36  A C T I V E T O P I C A L H A E M O S T A T I C AGENTS Autogenous muscle tissue Tamponade, scaffold and adds tissue factor to trigger coagulation Thrombin –gelatin/thrombin Topical fibrin haemostatic sealant – Evicel, Tisseel Polyethylene glycol - Coseal Presentation Name | Date | Version 0.0 37  A N T I F I B R I N O LY T I C Tranexamic acid (TXA) Synthetic analogue of lysine Binds plasminogen and stops conversion to plasmin and fibrin breakdown Duration of thrombus/clot is prolonged Use in greyhounds Presentation Name | Date | Version 0.0 38  Coagulation pathway reminder Fibrinolysis Plasminogen activator Plasminogen Plasmin Delayed haemorrhage Fibrin if fibrin clot Fribrin degradation breaks down products too quickly #universityofsurrey 39  Coagulation pathway reminder Fibrinolysis Plasminogen activator TXA Plasminogen Plasmin Delayed haemorrhage Fibrin if fibrin clot Fibrin degradation breaks down products too quickly #universityofsurrey 40 OTHER Desmopressin Increases expression of von Willebrand’s factor and factor VIII Reduces BMBT in vWD- affected Dobermanns Does not work in type III vWD Dilute and give 30 minutes before surgery Presentation Name | Date | Version 0.0 41 TOURNIQUET Reduce the amount of arterial blood reaching the distal limb Causes ischaemic and anaerobic respiration of tissues lactic acid accumulation can result in pain In dogs tourniquets applied for > 5 hours can result in sufficient potassium accumulation to cause cardiac abnormalities For procedures ~ 1 hour or less, tourniquet to an exsanguinated limb results in good reperfusion quickly after release Blood vessels if not sealed may begin to bleed following release Limb swelling can occur Bandages may be applied For most purposes the tourniquet should be applied for less than 2 hours. Presentation Name | Date | Version 0.0 42  ESMARCH BANDAGE For lower limb surgery Exsanguination of the limb Useful technique for digital amputation in several species as well as lower limb surgery in the horse. A rubber (Esmarch) bandage is tightly applied to the limb working from the distal towards the proximal limb and blood prevented from reperfusing the limb by application of a tourniquet Presentation Name | Date | Version 0.0 43  P O S T O P E R A T I V E H A E M O R R H A G E ( D E L A Y E D HAEMORRHAGE) Often result of ineffective haemostasis Physiological or surgical Slipped ligatures, necrosis, suppuration of ligated or cauterised vessels Hypotension during surgery may prevent detection of vascular injury or ineffective haemostasis resulting in delayed haemorrhage upon restoration of normal BP post op Poor secondary haemostatic plug formation common with coagulation deficiencies Presentation Name | Date | Version 0.0 44  PRESSURE Abdominal wraps/pressure bandage Temporary use in haemoabdomen Care with impeding ventilation Reduce perfusion to abdominal organs Limit/restrict movement Presentation Name | Date | Version 0.0 45