How to manage intraoperative bleeding from bone during surgery?

Management of Intraoperative Bleeding from Bone During Surgery

For intraoperative bone bleeding, apply direct pressure with a gauze and use bone wax as the primary hemostatic agent when conventional methods like electrocautery are ineffective. 1

Assessment of Bone Bleeding

When encountering bone bleeding during surgery, it's important to:

• Assess the extent and severity of bleeding using an established clinical grading system 1
• Determine if the bleeding is from cancellous bone (more common) or a specific vessel within the bone
• Consider whether the bleeding is from an identifiable vessel such as the intraosseous alveolar antral artery, which may require specific management 1

First-Line Management Techniques

1. Direct Pressure:

   • Apply direct pressure with gauze as the initial intervention 1
   • Maintain pressure for at least 3-5 minutes to allow natural hemostasis

2. Bone Wax:

   • Apply bone wax directly to bleeding bone surfaces when pressure is insufficient 1
   • Most effective for cancellous bone bleeding
   • Technique: Apply with firm pressure using the tip of a surgical instrument or finger

Advanced Hemostatic Options

If first-line measures fail, consider:

Topical Hemostatic Agents:

1. Oxidized Cellulose (e.g., Surgicel):

   • Effective for moderate bone bleeding
   • Apply directly to bleeding site
   • Caution: Use minimal amounts as excessive use may promote infection (45% infection rate with 20mg) 2

2. Gelatin-Based Products (e.g., FloSeal, Gelfoam):

   • FloSeal (gelatin matrix with thrombin) has demonstrated superior hemostasis compared to other agents 3
   • Apply to bleeding site and hold with gentle pressure

3. Microfibrillar Collagen:

   • Use with caution as it has higher infection rates (90%) compared to oxidized cellulose (45%) 2

4. Tranexamic Acid:

   • For significant bone bleeding, consider topical application
   • Mechanism: Inhibits fibrinolysis by preventing binding of plasminogen to fibrin 4
   • Dosing: Can be applied directly to bleeding site

Pharmacological Interventions:

For severe bleeding, consider systemic antifibrinolytic agents:

• Tranexamic acid: 10-15 mg/kg IV followed by infusion of 1-5 mg/kg/h 1
• Reduce dosage in patients with renal impairment 4

Special Considerations

Vascular Bone Bleeding:

If bleeding is from an identifiable vessel within bone:

• Consider vessel ligation if accessible 1
• For large-diameter vessels (e.g., alveolar antral artery >1mm), consider isolation or double window approach 1
• Piezoelectric surgery can be used to preserve vessel integrity while accessing surrounding bone 1

Fluid Management:

• Maintain adequate intravascular volume with crystalloid fluids 1, 5
• Target systolic blood pressure of 80-90 mmHg until major bleeding is controlled (unless contraindicated by head injury) 1
• Aim for 1-2L positive fluid balance by the end of surgery 5

Monitoring During Management

• Monitor hemoglobin/hematocrit to detect ongoing bleeding 1
• Use point-of-care hemoglobin analyzers to guide blood transfusion decisions 1
• Monitor serum lactate and base deficit to assess the extent of bleeding and tissue hypoperfusion 1

Pitfalls and Caveats

1. Avoid excessive use of bone wax:

   • May impair bone healing and osteogenesis
   • Can serve as a nidus for infection

2. Hemostatic agent retention:

   • Remove excess hemostatic materials when possible to prevent foreign body reactions 6
   • Oxidized cellulose can be left in situ but may cause complications in up to 38 reported cases 6

3. Thermal necrosis:

   • Avoid excessive use of electrocautery on bone as it can cause thermal necrosis

4. Anticoagulation considerations:

   • For patients on anticoagulants, consult with the prescribing physician regarding temporary discontinuation
   • Resume anticoagulation as soon as hemostasis is achieved 1

By following this algorithmic approach to bone bleeding management, surgical teams can effectively control hemorrhage while minimizing complications and optimizing patient outcomes.