Excessive Intraoperative Bleeding

One of the most disturbing and complicating events during any surgical procedure is excessive bleeding. This can obscure anatomical details and create frustration for the surgeon and the operating team. Additionally, excessive bleeding can cause significantly more edema, ecchymosis, and scarring and subsequently influence the final outcome. Therefore, it is crucial to control intraoperative bleeding to minimize the adverse consequences. However, despite careful preoperative preparation and intraoperative implementation of appropriate measures to reduce bleeding, excessive bleeding may occur and every surgeon must be capable of coping with this condition and prepared to deal with it.

The most common reason for intraoperative bleeding is hypertension. It is therefore prudent to seek information on this from the anesthesiologist immediately when excessive bleeding is encountered. Hypertension is most commonly induced by the sudden systemic absorption of the vasoactive agents contained in the local anesthetic or the nasal packing, both of which are intended to cause vasoconstriction in the nose, septum, and turbinates. The level of anesthesia also plays a significant role in controlling hypertension. Inadequate depth of anesthesia at the beginning of the surgery, during the operation, or at the time of emergence from anesthesia, along with any painful stimulus, can result in a sudden rise of blood pressure and thus excessive bleeding. This type of abnormal bleeding should not occur often and can be readily controlled if the anesthesia is provided by an experienced attendant and certain measures are implemented by the surgical team. Injection of the turbinates, placement of gauze saturated with vasoactive agent in the nose, and subsequent injection of the nasal soft tissues must be done gently and in a systematic manner. Throughout the process, there should be constant communication between the anesthesiologist and the surgeon. The injections should be titrated to prevent a sudden rise in blood pressure. Additionally, the double injection technique described in Chapter 4 minimizes the systemic effect of injected vasoactive agents. Furthermore, the injection must be targeted to cause thorough vasoconstriction in all the surrounding superficial and deeper vessels on the exterior and interior surfaces of the nose. The rate of infusion and the content of the intravenous fluid should also be watched closely. If a patient, especially an older patient, receives too much salt-containing solution, the result will be an uncontrollable rise in blood pressure, which may persist postoperatively. Such excessive fluid administration may also result in dilution of coagulation factors, disturbance of the clotting cascade, and exaggerated postoperative swelling.

Uncontrolled preoperative hypertension can be a major adverse factor intra- and postoperatively. Such patients are extremely sensitive to vasoactive materials and blood pressure will rise significantly immediately upon injection of epinephrine-containing solutions or any type of painful stimulation. It is, therefore, crucial to control hypertension preoperatively in all patients. Those patients who are hypertensive during the surgery may require antihypertension medication intraoperatively, which should be continued during the immediate postoperative period. Younger patients who undergo surgery in the late afternoon have a greater propensity to develop hypertension from the injected vasoactive materials because of an abundance of circulating catecholamines. It is, therefore, essential that intraoperative hypertension is rigorously controlled by the anesthesiologist throughout the surgery.

If excessive bleeding is observed in the absence of hypertension, the most likely possibility is some type of insidious coagulopathy. The majority of patients who bleed without a prior history are likely either to have von Willebrand disease or to have consumed some pharmaceutical or herbal product with a detrimental effect on coagulation. Some patients may form clots, but due to fibrinolysis the clots may not be stable. Additionally, patients who adhere to a vegetarian diet may experience more bleeding than usual due to inadequate absorption of vitamin K. Moreover, patients who have been on antibiotics for a long time may have experienced a change in intestinal flora that alters the absorption of vitamin K. This group of patients should be identified and should receive vitamin K preoperatively and, if necessary, intraoperatively. A prescription of 10 mg of oral or intramuscular vitamin K, commencing the day before surgery, may benefit patients who bleed excessively, especially those who are known to be vegetarians.

Von Willebrand disease type I and type IIa, which are the most common subtypes and represent the majority of patients with this condition, respond favorably to the infusion of DDAVP (desmopressin). The usual dose of DDAVP is 0.3 µg/kg of body weight. This is dissolved in 50–75 ml of saline and infused over a period of 30–45 minutes. DDAVP almost invariably reverses the condition and stabilizes the hemostasis. Although testing for von Willebrand disease during surgery may yield some meaningful information, results are not always reliable because of natural fluctuations in levels of von Willebrand factor, and response to surgery may specifically alter these levels. Moreover, the test results will not be available in time to help with intraoperative treatment decisions. A more reliable time to run this test is at least 1 week after surgery. Nevertheless, if intraoperative serum levels are abnormally low, it would be clearly diagnostic.

Infusion of DDAVP, with or without vitamin K, often effectively stops the bleeding and allows the surgery to be completed. Side effects of administration of DDAVP include slight hypotension, reduction in urine output, and retention of fluid for approximately 24 hours. If the patient starts bleeding after the initial cessation following infusion of DDAVP, the dose of DDAVP can be repeated every 8 hours for an additional two doses. The patient may need one more dose about a week following surgery, but only if another episode of epistaxis is encountered, which is not uncommon in patients with von Willebrand disease.

If the patient initially forms clots appropriately but the clots are unstable, which will result in bleeding off and on, an antifibrinolytic agent such as aminocaproic acid is effective. The usual dose is 4–5 g, which is dissolved in 250 ml of physiological saline and infused slowly. If bleeding is encountered postoperatively while the patient is awake, 1 g of aminocaproic acid is administered orally every hour for 8 hours. If a hematology consultation is feasible and the blood sample can be tested for fibrinolysis, this should be done before starting the treatment.

As a last resort, fresh frozen plasma can be infused. However, this may require transferring the patient to a facility where blood products can be infused. This has never become necessary in my 31 years of experience.

At one time the most common reason for intraoperative bleeding was the preoperative consumption of aspirin and aspirin-type nonsteroidal anti-inflammatory drugs (NSAIDs). With rigorous patient education, the incidence of bleeding related to the consumption of these pharmaceutical agents has greatly diminished, but has not been eliminated completely. Excessive bleeding related to the use of aspirin or NSAIDs commonly also responds favorably to infusion of DDAVP.

Factor 11 and 13 deficiency, which is rare, can also cause excessive intraoperative bleeding. With either of these conditions, if the bleeding does not stop, use of fresh frozen plasma would be indicated.

Loss of Dorsal Support

This complication can occur for one of two reasons. The less common cause of dorsal collapse is loss of dorsal support due to cocaine abuse or infection. More commonly, this complication occurs as a consequence of zealous and imprudent septoplasty, leaving insufficient support for the dorsum. Although most experts recommend leaving at least 10 mm of dorsal L-shaped frame, in my experience this is not adequate and can result in sinking of the dorsal frame postoperatively. This causes an unstable dorsal frame and formation of a hump that was not present intraoperatively, which may not become apparent until several months after surgery. More importantly, and pertinent to this discussion, since the dorsal bar is not strong enough it can fracture easily and the nose may rotate cephalically and posteriorly while the osteotomy is being completed. It is therefore essential to leave at least 15 mm of cartilage for the dorsal support, although caudally cartilage 10 mm wide might be sufficient. It is also for this reason that frequent examination of dorsal stability after septoplasty and nasal osteotomy is crucial to ensure that the patient and surgeon will not be surprised postoperatively by unanticipated changes. Should dorsal instability be encountered, the nasal bones must be checked first. If they are stable, since the upper lateral cartilages often have adequate attachment to the nasal bones, they can be effectively used to stabilize the septum. After spreader grafts are placed in position and sutured to the septum, the septum is lifted to a proper position and sutured to the upper lateral cartilages. This very commonly stabilizes the unstable septum. In the extremely rare situation where the nasal bones are unstable, it may be necessary to pass two K wires through them while the anterior border of the septum is aligned with the rest of the dorsum in an optimal position. The K wires are passed through both nasal bones and the septum and brought out through the skin on the opposite side. They are kept in place for 3 weeks. The patient is maintained on antibiotics throughout this period. Alternatively, one can use a 5-0 nylon stitch through the burr holes in the nasal bones to suspend the septal cartilage without K wires, depending on the condition and stability of the nasal frame.

Unstable Nasal Bones

This condition can occur, especially in older patients who have brittle nasal bones and who are unlikely to have a greenstick fracture. The bones may sink into the nasal cavity or shift too far medially. Commonly, they can be repositioned and an interposition absorbable packing such as Surgicel™ is inserted between the septum and nasal bone to avoid medial transposition, after insertion of spreader grafts and approximation of the upper lateral cartilages to the spreader grafts. Essentially, the septum and the spreader grafts are used to stabilize the unstable nasal bones. However, if the instability is significant, one can use either trans-septal sutures to suspend the nasal bones or K wires to stabilize them.

Septal Perforation

Perforation of the septum during septoplasty is exceedingly common, especially when a sharp spur or an extreme deflection of the septum is present. Dissection of the mucoperichondrium around a sharp angle of the spur sometimes becomes very difficult and, on occasions, impossible. It is essential to start elevation of the mucoperichondrium on the concave side of the septum so the lining on at least one side of the septum is kept intact. If a unilateral septal perforation occurs, as long as the opposite mucoperichondrium is intact, no other measures will be necessary. Usually, the septum heals uneventfully without any attempt at repair of the unilateral perforation. If the perforations occur bilaterally but are not apposing, they are not repaired and the surgeon may consider placing back a straight septal cartilage or a piece of PDS foil. However, this is not absolutely necessary, and the surgeon only repairs the incision, ignoring the non-apposing perforations in the septum. Chronic perforations almost invariably ensue if apposing tears in the mucosa are not dealt with properly. In this scenario, a straight piece of the septal cartilage, a perpendicular plate of the ethmoid bone, or a piece of PDS foil is placed between the two mucoperichondrial layers to prevent free flow of air through the perforations. This is followed by repair of the original incision in the septum, if one has been made, without any attempt to repair the perforations. Next, a simple stent (SupraMed) is tailored to a size long and wide enough to span across the perforation, applied on either side of the septum, and then fixed in position using 4-0 polypropylene through-and-through sutures. Alternatively, Doyle stents can be placed and kept in position for at least 2 and preferably 3 weeks, depending on the size of the perforation, similar to repair of perforation as discussed in Chapter 19 . A chronic perforation may be avoided in the majority of patients by adhering to these principles.