Wednesday, December 26, 2007

Postop Hematomas in Plastic Surgery

In the most recent issue of the Aesthetic Surgery Journal (ASJ), there is an interesting article on postoperative hematoma formation in plastic surgery patients. We have long been aware of the correlation of postoperative hematomas and blood pressure. (BP) Most of these studies have been done in face lift patients. In 1973, Straith showed that patients with elevated BP (greater than 150/100 mm Hg) on admission had a 2.6 times greater incidence of postop hematoma formation. Berner suggested that the patient should be medically protected against uncontrolled postop elevated BP's to reduce the incidence of postop hematomas. Postoperative "reactive hypertension" can be caused by coughing, retching or vomiting, postoperative pain, and anxiety. For facial and head/neck procedures, we ask patients to avoid bending over with their head down. We ask them to squat to pick up dropped items or ask someone else to pick them up. Baker used a strict antihypertensive and perioperative blood pressure control regimen of chlorpromazine, valium, and clonidine which reduced his incidence of postop hematomas from 8.7% to 3.97% in his face lift patients.

The ASJ article (see first reference below) was done in patients undergoing body contouring surgery (abdominoplasty, thigh lifts, etc). Many of these patients were placed on antithrombotic therapy, because most of them were massive weight loss patients, the surgery was of increased length, and the current (rightfully so) interest in preventing pulmonary embolus in surgery patients. The incidence of hematoma formation in abdominoplasty surgery ranges from 1%-10%. This study looked at blood pressure and antithrombotic therapy as risk factors in the formation of postop hematomas.

Plastic surgeons have long asked the anesthesiologist to keep the patient's blood pressure low (hypotensive anesthesia) for many of our procedures. This does result in lower pressures within the small vessels and capillaries, which helps keep the surgical field "dry". However, once the patient has returned to their normal blood pressure, these small vessels and capillaries may open (ones that weren't cauterized because they weren't bleeding and therefore missed), and bleeding may ensue. This may lead to a postop hematoma.

So it may be time to give up hypotensive anesthesia, as we begin to use more antithrombotic therapy. Of their 360 patients, 137 received enoxaparin (Lovenox). There were 11 (3.1%) hematomas among the 360 patients. Ten of the 11 (90.9%) occurred in patients receiving Lovenox. These patients were then evaluated for perioperative blood pressures and compared to similar patients without hematoma formation. Mean preoperative MAP's were similar (97.4 mm Hg in the hematoma patients, 95.8 mm Hg in the non-hematoma patients). The mean intraoperative blood pressures (within the last 2 hours of each case) differed significantly. In the hematoma patients, the MAP was 66.7 mm Hg and 82.4 mm Hg in the non-hematoma patients. Postoperative MAP's were 96.3 mm Hg in the hematoma patients and 88.5 mm Hg in the non-hematoma patients.

Though the risk of pulmonary embolus is small (0.1%-0.3%), they can be fatal. So currently, most surgeons feel that the increased risk of hematoma formation from use of antithrombotic prophylaxis is worth it. The things we can do to reduce the risk of hematoma formation are try to keep blood pressure more even between pre-, intra-, and postoperative periods. Then the small capillaries and veins that might get missed by hypotensive anesthesia can be seen and cauterized and the ones that might be missed would be less likely to bleed if the "hyper"tension postoperatively didn't occur.

  • Patients who are taking antihypertensive medication should be well maintained until the time of surgery and reinstated as soon as possible postoperatively.
  • Patients should be informed to stop all medications that can cause bleeding, such as aspirin, St. John’s wort, gingko, nonsteroidal anti-inflammatory drugs, and others. Aspirin and aspirin containing compounds are stopped for 2 weeks before surgery and 1 week postoperatively.
  • Patients should adhere to the restrictions given them postoperatively. It is good to get up and move, but do so in a way as to not raise your blood pressure. No heavy lifting means that. No speed walking or jogging means that. Squat rather than bending over.

REFERENCES

The Effect of Blood Pressure on Hematoma Formation with Perioperative Lovenox in Excisional Body Contouring Surgery; Aesthetic Surgery Journal, Vol 27, No 6, pp 589-593; Jordan P. Farkas, Jeffrey M. Kenkel, Daniel A. Hatef, Gabrielle Davis, Tuan Truong, Rod J. Rohrich, Spencer A. Brown

The Study of Hematomas in 500 Consecutive Face Lifts; Plastic & Reconstructive Surgery. 59(5):694-698, May 1977; Straith, Richard E. M.D.; Raju, D. Raghava M.D.; Hipps, Chauncey J. M.D.

Postoperative Hypertension as an Etiological Factor in Hematoma after Rhytidectomy; Plastic & Reconstructive Surgery, 57(3):314-319, March 1976; Berner, Robert E. M.D.; Morian, William D. M.D.; Noe, Joel M. M.

Reducing the Incidence of Hematoma requiring Surgical Evacuation following Male Rhytidectomy: a 30-year Review of 985 Cases; Plastic & Reconstructive Surgery. 116(7):1973-1985, December 2005; Baker, Daniel C. M.D.; Stefani, William A. M.D.; Chiu, Ernest S. M.D.

Aggressive pharmacologic protocols may be associated with TJR complications: To guide orthopedists in selecting prophylaxes, AAOS has issued new recommendations. By Susan M. Rapp ORTHOPEDICS TODAY 2007; 27:18

11 comments:

Terry at Counting Sheep said...

Interesting post. As an anesthesia provider, I am glad to see that hypotensive anesthesia is being revisited in plastic surgery. Although it can and is delivered safely and effectively, I often wondered what happens to the poorly controlled hypertensive patient after the hypotensive anesthesia is over. This sounds like a much more inclusive purview of BP management.

rlbates said...

Thanks Terry for your comment. I think it is important to review the way we do things. Sometimes small (or large) changes can make a difference in outcome. I love it when we all work together.

Sid Schwab said...

Because there were a couple of anesthesia guys who liked it, I did a couple of mastectomies under controlled hypotension. I never really liked it, for the reasons you mentioned: mainly, I worried that after awakening things would be more likely to bleed, for having been unnoticed during surgery. I never spilled much blood anyway during mastectomy -- never even ordered type and screen -- so I discouraged it after a couple of cases, even though there were no problems.

rlbates said...

Happy to have your input Dr Sid.

smalltowndoc said...

Nice post. It is so interesting when one logical action leads to an unexpected result, which again has a logical explanation. Hypotensive anesthesia- increased bleed due to capillaries opening up after closing the wound because of bp normalizing. Weird. Just n idea. What will happen if we maintain the bp upto just closing up in hypotension and just before closing, normalize the bp and catch-up the bleeders? Do you think that it is stupid or do anesthetist use long-acting anti-hypertensives? -smalltowndoc@wordpress.com

rlbates said...

Thanks Small Town Doc for your comment. SmTD, I don't think it's stupid, but not sure how practical. The "speed" of reversal will depend on which drugs are being used. The anesthesia folk I work with vary the mix depending on the procedure length, the procedure itself, and the patient (history of HBP, allergies, past side effects like nausea and vomiting, etc). It's just important for use to continue watch and learn.

carol a said...

i am an rn who had an s lift 2 wks ago. i was given an antihypertensive med pre op.i have a goose egg type swelling on the r side of my face. my doc said its not a hematoma because its not expanding. however its not shrinking. any comments? thanks carol a

rlbates said...

Carol A, I can't really diagnosis you without seeing or touching. That said, maybe you should go back in and have him/her recheck it to be sure it isn't a localized hematoma. If not, then what?

m schwartz said...

I came accross this article while researching "post surgry hematoma." My mother had a double mastectomy followed by an immediate reconstruction (DIEP flap. Her abdominal wound suddenly began to open and is now open 13 cm and pretty deep. The doctor told us it is a hematoma. I found this article and it was very helpful since my mother's blood pressure became volatile at the onset of the surgery. The surgery was 18 hours (the last six of which were the result of trying to stablizie the BP) so the information here makes total sense to me. My mother is 5 weeks post-surgery and has a very aggressive cancer which needs intense chemo. I feel like we are racing against the clock since the oncologist does not want to start chemo with a wound that is getting progressively worse. This is very frustrating but atleast this has been very insightful. Incidentally, my mother has NEVER had a history of BP problems- always normal. A cardiologist speculated it might have been "thyroid storm" a whole other topic. Thank you!

Maria said...

just following up on my contact info

Sarah said...

Thank you! Been searching internet for answer. Much appreciated. Recovering from some plastic surgery, can't wait to go back and read your archives!