8. MASSIVE HEMORRHAGE

Massive hemorrhage is a common problem that a cardiac surgeon has to face or is called to assist/solve.

Some principles of managing massive hemorrhage is

1. Pack and call for blood,assistance and instrumentation

If the chest is already open

If the chest is open put a finger on the leak (occasionally more than one finger)with just enough pressure to stop the flood. If not yet on bypass give heparin & cannulate while finger pressure is maintained; this means very often that one surgeon has only one hand to work with so an assistant/co surgeon must do the cannulations. Question at this stage: will repair now be possible? If not, then a decision to cool and reduce flow must be made. In general most leaks can be controlled by one finger or a finger and thumb or sometimes, if the site from which the leak is coming is too small for a finger, a peanut on a clamp. '''DO NOT APPLY CLAMPS BLINDLY. DO NOT PLACE LARGE SUTURES BLINDLY. BE GENTLE; THERE IS NO HURRY ONCE YOU ARE ON BYPASS AND RECIRCULATING THE LEAKING (HEPARINISED) BLOOD VIA THE MACHINE. FORCE YOURSELF TO THINK WHAT ANATOMY IS RELATED TO THE BLEED.''' What will happen often is that one surgeon controls the bleeding while other dissects around the staunched site until there is enough exposure to do an accurate repair without creating extra damage. This is especially the case with redo ops. Sometimes it is essential to control the bleeding digitally while complete freeing of all adhesions is done before a tension free suture can be placed. Remember cranking the sternum open before all adhesions have been freed can tear the heart apart Specific situations are bleeds while dissecting SVC, IVC, AO, Left or Right ventricle (epicardial veins and arteries), right or left atria. Precise answers are different in each case. Place sutures so as not to narrow tubes.

If the chest is not fully opened

If bleeding occurs while dividing the sternum, place a pack in the retrosternal space as you call for heparin and cannulate peripherally and start cooling.

2. Reduce pressure by either pharmacological means for eg Sodium nitroprusside, clamping above and below the bleeder or going on CPB. In the worse case scenario circulatory arrest may be employed either with CPB and cooling or elective fibrillation using a fibrillator.(Remember you have to have a defibrillator if you fibrillate !!)

3. Make the large bleeder small and then try to achieve better hemostasis. Sometimes large buttressed sutures work but if it doesn't, it means that there is excessive tension on tissues and the tissues may be friable and that means smaller sutures are to be used, a patch may have to be placed or the bleeder may actually be originating elsewhere and has dissected to the external point so Intra-luminal closure may be required.

4. Glues may be used to protect a friable bleeding area but will not really substitute mechanical hemostasis.

5. Local tamponade by suturing a piece of pericardium or any flat prosthetic sheet may control the bleeder.

6. Sometimes packing with a long vaginal pack gauze for 24 - 48 hrs with slow withdrawal (Brought out through a seperate stab wound) may be life saving.

7. A Foley's catheter placed via the rent or a Shrock shunt (especially for retrohepatic IVC tears)and endotracheal tubes (cuffed) can be used to control hemorrhage temporarily.

Massive Bleeding in ICU.

Sudden bleeding in ICU after a period of relative stability often means means a large hole. ICU (and the ward) should have a chest re-opening tray at hand. Worth making sure that this is available and has a reasonable set of instruments. Main things are gloves, a bottle of betadine that can be poured on the wound, a disposable drape, a knife, wire cutter and a spreader that is assembled. Access to suction and light need to have been looked at also.

Use the principles above. If possible, control with digital pressure. Do not clamp blindly. Then resuscitate the patient, get help, light, suction etc. See the section on Bleeding and Cardiac Tamponade In the chapter 7._COMPLICATIONS_IN_THE_POST_OP_ICU for more details.