What is the management of bleeding during neck dissection?

Management of Bleeding During Neck Dissection

Patients with bleeding during neck dissection should undergo immediate surgical bleeding control with direct pressure, vessel ligation, or packing, followed by appropriate hemostatic interventions based on the bleeding source and severity. 1, 2

Initial Assessment and Management

• Immediate bleeding control measures:

  • Apply direct pressure with gauze for 3-5 minutes as first-line intervention 2
  • Identify the source of bleeding (arterial, venous, or bone) and assess severity using an established grading system 1, 2
  • For active bleeding with hemodynamic instability, prioritize rapid surgical control 1

• Vessel-specific management:

  • For identifiable vessels: isolate and ligate the bleeding vessel 2
  • For carotid artery injuries ("carotid blowout"): consider reconstructive or deconstructive therapy 3
  • For external carotid artery branches: perform selective branch embolization 3

Surgical Techniques for Bleeding Control

• For arterial bleeding:

  • Identify and isolate the bleeding vessel
  • Apply vascular clamps proximal and distal to the injury
  • Ligate or repair the vessel depending on its importance and the patient's condition
  • Consider double window approach for large-diameter vessels 2

• For venous bleeding:

  • Apply direct pressure
  • Use hemostatic agents (e.g., absorbable gelatin sponge, oxidized cellulose)
  • Ligate or repair larger veins as needed

• For diffuse bleeding:

  • Apply topical hemostatic agents
  • Consider systemic antifibrinolytic agents: tranexamic acid 10-15 mg/kg IV followed by infusion of 1-5 mg/kg/h 1, 2
  • Use surgical packing if other measures fail 1

Advanced Interventions for Persistent Bleeding

• Endovascular management:

  • Consider angiography and embolization for persistent or recurrent bleeding 3
  • Balloon occlusion may help control active bleeding during surgical exploration 4
  • For carotid injuries, endovascular stenting may be an option 3

• Surgical approach for deep neck/base bleeding:

  • For zone I neck injuries (below cricoid cartilage) with active bleeding, consider urgent midline sternotomy combined with cervicotomy 5
  • Use blunt digital dissection to avoid instrumental dissection into hematomas 5

Fluid Management and Monitoring

• Resuscitation targets:

  • Maintain systolic blood pressure of 80-100 mmHg until major bleeding is controlled (unless contraindicated by head injury) 1, 2
  • Use crystalloids initially, with colloids as needed within prescribed limits 1
  • Monitor serum lactate and base deficit to assess extent of bleeding and shock 1

• Blood product administration:

  • For significant bleeding, consider early administration of blood products
  • Monitor hemoglobin/hematocrit to guide transfusion decisions 2

Prevention of Complications

• Minimize time between injury identification and bleeding control 1
• Avoid excessive use of hemostatic materials that may impair healing 2
• For patients on anticoagulants, consult with the prescribing physician regarding temporary discontinuation 2
• Consider damage control approach for severe, ongoing bleeding with coagulopathy, hypothermia, or acidosis 1

Special Considerations

• For small bleeding points that are difficult to visualize, applying pressure to surrounding tissues may help identify the source 6
• Combined endovascular and surgical management may be beneficial for complex cases with active bleeding 4, 3
• Avoid hyperventilation in severely hypovolemic patients as it may decrease cardiac output 1

Following these systematic approaches to bleeding management during neck dissection can significantly reduce morbidity and mortality associated with this potentially life-threatening complication.