Safe, effective hemostasis mandates

New Orleans - Careful preoperative assessment to identify risk factors for increased perioperative bleeding, meticulous surgical technique to gain control of vessels and appropriate use of surgical adjuncts form the foundation for safe and effective hemostasis in dermatologic surgery, says David E. Kent, M.D., at the 63rd Annual Meeting of the American Academy of Dermatology.

"Control of bleeding is fundamental to excisional surgery because in its absence it would not be possible to operate. With the growth of the older population along with increasing clinical use of blood thinners, dermatologists can expect to face more and more patients who pose a challenge for achieving hemostasis," says Dr. Kent, clinical instructor of dermatology, Medical College of Georgia, Augusta.

In assessing the risk of excessive bleeding, the history-taking should query patients about prior excessive bleeding during surgery, dental procedures or childbirth, as well as determine the presence of systemic diseases associated with coagulation problems. In addition, a medication history should be taken to identify use of prescription and OTC drugs and nutritional supplements that interfere with platelet function.

"We don't stop blood thinners because the risks associated with a thrombotic event exceed the risks of excessive bleeding and hematoma," Dr. Kent says.

Defibrillator precautions Patients with implantable defibrillators also present a special situation where there is a need to take special precautions. Working with cardiology and electrophysiology colleagues, Dr. Kent has established protocols for managing those patients when they are undergoing surgery using an electrocautery device for achieving hemostasis.

Appropriate cardiac monitoring is an integral component for all such patients, but other measures vary depending on the specific device implanted.

For example, one specific brand of defibrillator can be temporarily inactivated by placing a circular magnet over it. If the cardiac monitor shows an arrhythmia, the magnet is removed and the defibrillator regains function within five seconds.

"Other defibrillators work differently. Therefore, it is important to develop procedures for each device. Some older defibrillators may need to be shut off and the patient taken to the operating room for surgery, while with some newer defibrillators, surgery can be performed safely in the office using heat cautery for hemostasis," Dr. Kent notes.

Surgical techniques and tools Key points of surgical technique relate to a thorough knowledge of anatomy, some common sense measures and careful selection and use of instruments.

"Knowing where major vessels lie is a must so that you can identify and control them on your own terms. It is better to dissect down to an artery and control it than to inadvertently dissect it with your scalpel blade," Dr. Kent says.

Other simple measures to optimize safety include keeping the skin taut when operating, using good lighting and irrigation to enable visualization, and always spreading scissors parallel to vessels rather than perpendicularly.

Specific situations call for additional strategies. For example, when operating on highly vascular tumors, electrosurgical dissection using a Teflon-coated tip spatula or Colorado needle is an excellent option for allowing bloodless dissection. When removing nonvascular tumors in patients on blood thinners, elevating the flap with electrosurgical needles can be helpful to decrease intraoperative bleeding.

Irrigating with liquid thrombin is another useful adjunct for controlling oozing wounds.

"This agent is available in packages containing 5,000 units and in higher doses, but 5,000 units is usually adequate for the typical dermatologic surgical procedure," Dr. Kent notes.

When oozing does not stop, Dr. Kent advises placing a closed system drain that he constructs simply by connecting a butterfly infusion set and Vacutainer tube. The end of the butterfly set that fits into the IV is placed into the wound after first cutting off the hub and fenestrating it, and the needle tip is inserted into the Vacutainer tube, which helps to drain the wound by providing negative pressure.