What is the management for a post-operative adult patient with a history of back pain or spinal instability, 5 days after thoracic pedicle screw placement, now with a screw in a major blood vessel and experiencing a slow decline in hemoglobin levels?

Management of Thoracic Pedicle Screw in Major Blood Vessel with Slow Hemoglobin Decline

This patient requires immediate surgical exploration with vascular surgery consultation for screw removal and vessel repair, combined with activation of a massive hemorrhage protocol and aggressive resuscitation while preparing for urgent intervention. 1

Immediate Resuscitation and Stabilization

Activate Massive Hemorrhage Protocol

• Designate a team leader immediately to coordinate management, appoint a communications lead for laboratory coordination, and secure large-bore intravenous access (8-Fr central line preferred in adults). 1
• Obtain baseline labs: complete blood count, PT/INR, aPTT, fibrinogen (Clauss method, not derived), and cross-match for at least 6 units of packed red blood cells. 1
• Initiate near-patient testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available to guide component therapy. 1

Transfusion Strategy

• Begin transfusion when hemoglobin drops below 7-8 g/dL, or earlier if signs of organ ischemia develop (tachycardia, hypotension, altered mental status, oliguria). 1
• Maintain 1:1 ratio of packed red blood cells to fresh frozen plasma during active hemorrhage to prevent dilutional coagulopathy. 1
• Administer warmed blood products and actively warm the patient to prevent hypothermia-induced coagulopathy. 1
• Target hemoglobin >7 g/dL initially; higher targets (8-10 g/dL) may be needed if patient has cardiovascular disease or ongoing bleeding. 1

Permissive Hypotension Until Hemorrhage Control

• Target systolic blood pressure 80-90 mmHg (permissive hypotension) until definitive surgical control is achieved. 1, 2
• Avoid vasopressors as primary therapy—use only transiently for life-threatening hypotension during active resuscitation, as vasopressors without volume replacement increase mortality in hemorrhagic shock. 2
• Monitor pulse pressure; narrowing to <30-40 mmHg indicates worsening shock and need for more aggressive resuscitation. 2

Urgent Surgical Intervention

Timing and Approach

• Minimize time to operating room—delays in surgical hemorrhage control directly increase mortality in bleeding patients. 1
• Obtain urgent CT angiography if patient is hemodynamically stable enough to tolerate imaging, to define exact vessel involvement and guide surgical planning. 1
• If patient is unstable (systolic BP <90 mmHg despite resuscitation, hemoglobin dropping >2 g/dL/hour), proceed directly to operating room without imaging. 1

Surgical Management

• Coordinate with vascular surgery for screw removal and vessel repair—this is not a routine orthopedic revision. 1
• Major thoracic vessels at risk include aorta, azygos vein, intercostal arteries, and segmental arteries. 3, 4
• Prepare for potential thoracotomy or sternotomy if great vessel injury (aorta, vena cava) is suspected. 1
• Have cell salvage autotransfusion available in operating room. 1

Intraoperative Hemorrhage Control

• Control bleeding with direct pressure, vascular clamps, or temporary balloon occlusion while preparing for definitive repair. 1
• Consider interventional radiology for endovascular balloon occlusion or coil embolization if anatomy permits and patient too unstable for open surgery. 1

Coagulopathy Management

Component Therapy Based on Laboratory Values

• Transfuse platelets if count <50,000/mm³ in actively bleeding patient (target >100,000/mm³ for major hemorrhage). 1
• Administer fresh frozen plasma if PT/INR >1.5 or aPTT >1.5 times normal. 1
• Give cryoprecipitate if fibrinogen <150-200 mg/dL (target >200 mg/dL in active bleeding). 1

Pharmacologic Adjuncts

• Administer tranexamic acid 1 gram IV over 10 minutes, then 1 gram over 8 hours if fibrinolysis suspected or documented. 1
• Consider recombinant activated factor VII (rFVIIa) only as rescue therapy when traditional options exhausted, recognizing increased thromboembolic risk. 1
• Use prothrombin complex concentrate (PCC) if patient on warfarin with elevated INR, combined with 5-10 mg IV vitamin K. 1

Monitoring and Endpoints

Continuous Assessment

• Monitor hemoglobin every 1-2 hours until bleeding controlled, then every 4-6 hours for 24-48 hours post-operatively. 1
• Track coagulation parameters (PT/INR, aPTT, fibrinogen, platelet count) every 2-4 hours during active resuscitation. 1
• Assess for compartment syndrome post-operatively with serial creatine kinase levels, as reperfusion injury can occur after vascular repair. 5

Resuscitation Endpoints

• Pulse pressure restoration to >40 mmHg. 2
• Heart rate <100 bpm, systolic BP >90 mmHg after hemorrhage control. 2
• Lactate clearance and central venous oxygen saturation >70%. 2
• Urine output >0.5 mL/kg/hour, improved mental status, warm extremities. 2

Critical Pitfalls to Avoid

• Do not attempt percutaneous screw revision or removal at bedside—this requires open surgical exploration with vascular control. 1
• Do not delay surgery waiting for hemoglobin to stabilize—ongoing slow bleeding will accelerate without source control. 1
• Do not use crystalloid-only resuscitation in actively bleeding patient—this worsens dilutional coagulopathy. 1
• Do not rely on normal blood pressure to rule out significant hemorrhage—compensatory mechanisms can maintain BP until 30% blood volume lost. 1, 2
• Do not use vasopressors as primary therapy before adequate volume resuscitation—this increases mortality. 2