[HSF] Reclacitrant sternal bleeding

[Nasser F. Abou'Seada]

Sorry for your loss Prasanna ..... no way to blame yourself ... the decision
for doing a sternectomy was not an easy straight one indeed. 
I've met some similar cases ... thought not as severe as you've described.
bleeding inside the pericardial sac would result in initiation of
consumption coagulopathy with a vicious cycle. 
One thing I used to do -amid all the dilemma of not knowing what is exactly
going on- was to load the patient as soon as he is out of theatre with 4
units -arbitrary number- of FFP, Plat Conc, AHG, ultra-Hot Fresh same group
blood, all given simultaneously, within a short time, with Diuretics, and
cautious Calcium, plus Vasodilating the patient. the rationale was to allow
for a critical level of coagulation factors to build up SIMULTANEOUSLY to
effect a secure coagulation. Vasodiators were used to allow infusing all the
stuff at the same time, diuretics were very helpful. 
may be there is little rationale behind this way ... yet it worked in all
the cases that I've experienced. Ultra-hot fresh blood was a crucial factor
... 

NFA

> From: > bounces at lists.hsforum.com] On Behalf Of prasannasimha
> Lost the battle - this fortnight has been bad. Patient fibrillated as I
> was proceeding to the Hospital. CPR was pretty unsuccessful - basically
> was receiving lots of blood products etc at the time of fibrillation.
> I had used the surgicel trick but it also hadn't worked. (Hence the
> surgicel gauze + gause roll and used the sternal spreader for
> compression.  I wish I had knocked off the sternum in the morning
> itself. I was thinking what if I had taken a large fold of pericardium
> and sutured it above and below the upper and lower tables to locally
> tamponade the bleeding area ? I always used to say that sternal bleeding
> is managed best by compressing the two ends together but  that just
> didn't work for him.
> Prasanna
> 
> Ben Bidstrup wrote:
> >> Urgent suggestions - pt underwent surgery yesterday - bleeding from
> >> sternum - doesn't seem to stop with wax + cautery + blood products -
> >> chest open packed - no cardiotomy site bleeding - continuing to bleed
> >> (This fortnight has ruined by blood conservation record :-) ) -
> >> Now open packed with gauzes after layering with surgicel  and gauze
> >> and compressed it with the sternal spreader but still oozing - tried
> >> to close twice hoping that it may compresss the sternal edges and
> >> stop the bleeding but hasn't worked. Just bleeds from multiple sites
> >> along the sternal (both edges , marrow and small fractures). Thinking
> >> of doing a sternectomy if a further round of platelets Cryo and fresh
> >> blood doesn't work as I am getting low on blood resources. Any
> >> suggestions - I do not have access to Novo seven /TEGetc. patient had
> >> received Aprotinin through surgery and surgical sites are dry.
> >> Plan is to do sternectomy soon if this round of products is not
> >> controlling the hemorrhage. Any tricks etc are appreciated. This has
> >> been a pretty "interesting"  fortnight for me.
> >> Prasanna
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> > I have use Surgicel in one of its forms folded longitudinally and
> > placed along the cut and bleeding edges. I then close the sternum
> > using this to compress/tamponade the bleeding. If you have a
> > centrifuge  like a cell saver, you can add platelet gel to it.
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