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The control of bleeding volume in bone plate fixation surgery is one of the key factors for the success of the surgery. Excessive bleeding not only increases the surgical risk but may also affect the postoperative recovery of patients. The following introduces the key points of bleeding volume control from the three stages of preoperative, intraoperative and postoperative:
Preoperative preparation
Evaluate the patient’s coagulation function: Thoroughly understand the patient’s history of coagulation, such as whether there are any diseases prone to bleeding (hemophilia, thrombocytopenia, etc.) and whether they have been taking anticoagulant drugs for a long time (aspirin, warfarin, etc.). The coagulation status of the patient was evaluated through coagulation function tests (prothrombin time, activated partial thromboplastin time, platelet count, etc.). If the coagulation function is abnormal, corresponding treatments should be carried out before the operation, such as discontinuing anticoagulant drugs, supplementing coagulation factors or platelets, etc., to reduce the risk of intraoperative bleeding.
Correcting anemia: Patients with anemia have poor tolerance to intraoperative bleeding and are prone to serious complications such as hemorrhagic shock. Before the operation, the patient’s hemoglobin level should be understood through a blood routine test. If the hemoglobin level is lower than the normal range, corresponding treatment measures can be taken according to the type and degree of anemia, such as iron supplementation, folic acid, and vitamin B₁₂ to treat iron deficiency anemia or megaloblastic anemia. If necessary, concentrated red blood cells should be transfused to quickly correct anemia.
Optimize the patient’s overall condition: Keep the patient’s blood pressure, blood sugar and other indicators within an appropriate range. Intraoperative blood pressure fluctuations in patients with hypertension may lead to increased bleeding. Before the operation, blood pressure should be controlled at a reasonable level through medication. High blood sugar in diabetic patients can affect wound healing and blood coagulation function. Before the operation, the hypoglycemic plan needs to be adjusted to stabilize blood sugar. Meanwhile, patients are encouraged to quit smoking, improve their cardiopulmonary function and enhance their tolerance to the surgery.
Intraoperative measures
Precision operation reduces tissue damage: Surgeons should possess proficient surgical skills. When cutting through the skin, subcutaneous tissue and muscles, their movements should be gentle and accurate, avoiding excessive pulling and rough separation to minimize damage to blood vessels. For instance, when exposing the fracture site, blunt separation should be carried out along the direction of the muscle fibers, and larger blood vessels and nerves should be avoided as much as possible.
Rational use of hemostatic instruments and drugs:
Hemostatic equipment: Advanced hemostatic equipment such as bipolar electrocoagulation and ultrasonic scalpel are used to precisely stop bleeding and reduce thermal damage to surrounding tissues. Bipolar electrocoagulation causes local tissue coagulation and hemostasis through high-frequency current, and is suitable for smaller vascular bleeding. The ultrasonic scalpel utilizes the mechanical vibration and thermal effect of ultrasonic waves to vaporize the water within the tissue, break the hydrogen bonds of proteins, and cause cell disintegration, thereby achieving the purpose of hemostasis and cutting, and causing less damage to the surrounding tissues.
Hemostatic drugs: During the operation, hemostatic drugs such as gelatin sponges and hemostatic gauze can be used locally according to the bleeding situation. Gelatin sponge has excellent water absorption and plasticity. It can absorb blood and promote platelet aggregation and prothrombin activation to achieve hemostasis. Hemostatic gauze can stop bleeding by physical pressure and activating the coagulation mechanism. In addition, hemostatic drugs such as tranacetic acid can also be administered intravenously. It can inhibit plasminogen activator and reduce the dissolution of fibrin, thereby reducing intraoperative blood loss.
Controlled hypotension: For surgeries with a large expected amount of bleeding, such as pelvic fracture plate fixation surgery, controlled hypotension techniques can be adopted. Through the regulation of anesthetic drugs and vasoactive drugs, the patient’s blood pressure was reduced to a certain level (generally systolic blood pressure was reduced to 80-90 MMHG) to reduce intraoperative bleeding. However, for controlled hypotension, the indications and contraindications need to be strictly mastered. The vital signs of patients should be closely monitored to avoid insufficient perfusion of vital organs caused by excessively low blood pressure.
Properly handle bleeding at the fracture site: The fracture site is one of the main sources of intraoperative bleeding. After exposing the fracture ends, the hematoma and accumulated blood at the fracture ends should be removed first with gauze or an aspirator, and then the fracture ends should be reduced and fixed. During the fixation process, bone wax can be applied to the broken ends of the bone to seal the bleeding in the bone marrow cavity. For larger blood vessel bleeding, ligation or suture should be carried out promptly to stop the bleeding.
Postoperative management
Observe the drainage situation: After the operation, a drainage tube is often placed at the wound site to drain the accumulated blood and exudate within the wound. Medical staff should closely monitor the color, nature and volume of the drainage fluid. If the volume of the drainage fluid is excessive (such as exceeding 200ml per hour and lasting for several hours) or the color is bright red, it indicates that there may be active bleeding and the doctor should be informed promptly for treatment.
Maintain effective circulating blood volume: Based on the patient’s bleeding condition and vital signs, replenish blood volume in a timely manner to maintain effective circulating blood volume. Blood volume can be expanded by intravenous infusion of crystal solutions (such as normal saline, Ringer’s solution) and colloid solutions (such as hydroxyethyl starch, albumin). Concentrated red blood cells or whole blood can be infused when necessary. Meanwhile, closely monitor the patient’s blood pressure, heart rate, central venous pressure and other indicators, and adjust the infusion speed and type.
Prevention of infection: Postoperative infection can lead to complications such as delayed wound healing and increased bleeding. Therefore, the principle of aseptic operation should be strictly followed and antibiotics should be used rationally to prevent infection. Keep the wound clean and dry, change the dressing regularly, and observe whether there are any signs of infection such as redness, swelling or exudation in the wound.
Early activities and rehabilitation: Encourage patients to engage in appropriate functional exercises in the early postoperative period, such as isometric muscle contractions and passive joint movements, to promote blood circulation, prevent deep vein thrombosis, and also help reduce swelling and bleeding around the wound. However, activities should be carried out under the guidance of a doctor to avoid excessive activity that may cause the wound to split open or bleed.