Episode #53 Massive Intraoperative Bleeding and the Code Hemorrhage Response

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show. Did you know that the APSF Newsletter is the official journal of the APSF and it is published 3 times a year. You can subscribe for free at APSF.org/subscribe and I will include a link in the show notes. This way you can get early access by email to our current newsletter issue. Today, we will be checking out the current APSF Newsletter from June 2021 to discuss the leading causes of death in the operating room.

Before we dive into today’s episode, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company- we wouldn’t be able to do all that we do without you!”

We are talking about a big threat to patient safety in the OR today. Our featured article is “Massive intraoperative hemorrhage” by Dhoon and colleagues. To help get us started today, I reached out to one of the authors and I will let him introduce himself now.

[Dhoon] Hi, my name is Taizoon Dhoon and I am an assistant professor of anesthesiology at UC Irvine and the director of quality and patient safety. I want to thank APSF for having me on their podcast.

[Bechtel] To get started, I asked Dhoon why he wrote the article. Let’s keep listening for a behind the scenes peek at what motivated Dhoon and colleagues to write this article.

[Dhoon] The reason this topic is so important to us is because hemorrhage is the leading cause of death in the operating room. Surprisingly, one third of these deaths occur during elective surgeries. Some of the cases we’ve encountered include hepatic and aortic injury related to trocar placement and ICV injury. Before code hemorrhage was created, we had something called the Anesthesia Stat page which asked all available people to come to the operating room which needed help. This resulted in too many people within the room and the response felt ineffective at times and chaotic. We realized we needed the right mix of personnel, resources, and an organized framework. Ion this way, we could respond faster and more effectively. In developing code hemorrhage, we made up a team of the anesthesia professional, anesthesia tech, circulating nurse, blood bank and trauma surgery.  The key step in hemorrhage crisis is source control, so including a trauma surgery in each and every response was unique and helps expedite this goal. The Code hemorrhage response protocol allows for a choreographed response where everyone knows their role.

[Bechtel] Thank you Dhoon for helping to kick off the show. We can’t wait to learn more about the Code Hemorrhage response. To follow along with us online, head over to ASPF.org and click on the Newsletter heading. First one down is the Current Issue. From here, scroll down looking at the list of articles in the left hand column until you come to our featured article today, “Massive Intraoperative Hemorrhage.”

Have you taken care of a patient who developed significant intraoperative hemorrhage? This is such an important topic, since it is one of the leading causes of death in the OR. It can be difficult to predict which patients will develop this complication since one third of hemorrhagic deaths occur during elective surgical procedures following unexpected injury to major vessels or organs. This is the time to act quickly to help save patient lives in the operating room. The authors describe a protocol at their institution for a coordinated response to a massive intraoperative hemorrhage event which focuses on improved communication, decision making, and patient care. The benefits of a code hemorrhage protocol for improving patient outcomes are not unique to the authors’ institution, and this may be something to consider starting at your institution.

What does this threat to patient safety look like? Well, unexpected massive hemorrhage may rapidly lead to hemodynamic instability. Anesthesia professionals must act fast to call for help, lead the multidisciplinary team, communicate with the surgery team, and treat the patient to prevent complete cardiovascular collapse. This is a crisis management event and when it is not organized and efficient, there may be delays in providing vital treatment. The authors provide an example case to highlight this scenario. A 70 year old woman with hypertension and chronic pain presented for an elective spinal fusion and artificial disk replacement through an anterior retroperitoneal exposure approach to the lumbar spine. A vascular surgeon was part of the surgical team to provide exposure to the spine. During the exposure, injury to a major venous vessel occurred leading to massive hemorrhage and intraoperative death. Following this event, a root cause analysis was performed. The Code Hemorrhage response protocol was developed to improve the response time, organization, treatment, and ultimately patient outcomes following unexpected intraoperative hemorrhage events.

Let’s take a look at the process to develop the new protocol now. The first step is to recruit a group of key stakeholders including anesthesia professionals, surgeons, nursing staff, transfusion specialists, and hospital administrators. Next, this group will need to review the current practices as well as existing guidelines and consensus statements related to intraoperative crisis resource management and surgical bleeding. It is helpful to use a framework to be able to go from the root cause analysis to the development of an action plan. One option is to use the Joint Commission’s methodology and the Joint Commission Connect. Check out Table 1 in the article for a list of the key factors related to critical events and we will review it now. The important elements linked to adverse perioperative events include:

• The type of surgery
• Surgical judgement
• Surgical technical complications
• Timing of the call for help
• Communication
• Blood Supply
• And the Anesthetic Management which includes medication, equipment, timing of additional access, role clarity, and follow-up communication.

Once the key factors are identified, the next step is the development of a new and improved response protocol designed for intraoperative hemorrhage. The Code Hemorrhage alert may be initiated by anesthesia professionals, surgeons, or operating room nurses to send a page of Code Hemorrhage followed by the designated operating room in order to summon a designated team that includes additional anesthesia professionals, a trauma surgeon, nursing staff, support staff, and the blood bank. It is vital to get the right people and equipment to the OR quickly to help save the patient.

We are going to take a closer look at Code Hemorrhage right now to see what this specific response protocol looks like. Figure 1 in the article lists all of the team members and their responsibilities during this critical event and I will include the Code hemorrhage in the show notes as well.

Here we go.

First, the anesthesia professionals. The primary anesthesia team leader is responsible for organizing additional secondary anesthesia professionals and assigning designated roles. These secondary anesthesia professionals may include attendings, residents, nurse anesthetists, anesthesia assistants, and anesthesia technicians. Designated roles for these additional team members include medication and infusion management, venous and arterial access, administration of blood products, deployment of a rapid infuser, operation of point of care lab testing, and appropriate documentation.

As you can see there is a lot of work that needs to be done and it needs to be performed quickly and safely. The anesthesia technologist is assigned the tasks of setting up the rapid infuser, obtaining a transesophageal echocardiogram probe and machine and assisting with placement of central venous or arterial access. At the same time, the secondary anesthesia professional provides quick and clear instructions to the rest of the anesthesia team to make sure that the tasks are being completed. This allows the primary anesthesia professional to be able to focus on managing the patient and communicated with the surgery team. Remember, it is the primary anesthesia professional who knows the patient, the surgery team, and the surgical procedure best at this point in the event. When the primary anesthesia professional can focus on their role, this can improve patient outcomes. Another important consideration is that the primary and secondary anesthesia professional can work together to develop a working diagnosis and treatment plan. This team approach can be helpful to develop a plan safely and quickly without missing important steps. Are you at a hospital with multiple anesthesia professionals available in case of an emergency? If not, another option is to include intensivists or a rapid response team to the intraoperative hemorrhage response team. Another important part of the Code Hemorrhage response is the anesthesia professional need to be able to coordinate with the multidisciplinary team and communicate with the surgical team. The final step involves declaration of the end of the code hemorrhage response, and this vital step should involve the primary anesthesia team member as well as the primary surgeon.

And speaking of the surgeon…let’s take a look at the next key team member for the code hemorrhage response. There will be a primary surgeon involved in the surgery, but one of the responders for Code Hemorrhage is an in-house trauma surgeon. This is one of the ways that this code team is unique. The trauma surgeon’s role involves helping to determine the source of bleeding and to help control bleeding and to do so quickly to improve the patient’s condition. This is an important component of Code Hemorrhage and while it is vital to also have the knowledge of massive transfusion protocols and a multidisciplinary team to help, the addition of the trauma surgeon early to help assist the primary surgeon is vital. The trauma surgeon has additional training for emergency procedures related to hemorrhage including source control, application of direct pressure, temporary packing, clamping of the aorta, resuscitative endovascular balloon occlusion of the aorta (REBOA), or damage control surgery.

It is also a big step towards improved patient safety because it minimizes the delay for surgical treatment of the hemorrhage. Instead of the primary surgeon having to make the call about needing help with the surgery, the trauma surgeon is part of the team and will be able to provide assistance whenever the Code Hemorrhage is called. In addition, the trauma surgeon will be familiar with the emergency trauma cart (that will be brought to the room for all Code Hemorrhage alerts) and be able to perform emergency exploratory laparotomy and thoracotomy if needed. This means that the Code Hemorrhage response allows the necessary people with the necessary equipment to get to the OR quickly. Remember, when an unexpected intraoperative hemorrhage occurs this is a very stressful situation and one in which the trauma surgeon is used to operating in given their training, perspective, and expertise.

The nursing staff in the OR are important team members during an intraoperative hemorrhage event. There are additional nurses who respond to the Code Hemorrhage including an additional circulating nurse to bring the trauma cart, enhance the communication between the blood bank and the anesthesia team, and help to check blood and blood products prior to the anesthesia team administering to the patient. Another important task is to coordinate transport of blood and products from the blood bank to the OR. The responding nurse may be a nurse assigned to give breaks or the change nurse, but depending on the resources at your institution the post-operative care nurses may need to be included as part of the Code Hemorrhage response. The blood bank team will be working hard to prepare blood and products for the massive transfusion and the blood bank physician in charge will play an important role in consulting about transfusion management, coagulation testing and optimal ratio of blood and the different products and availability of resources. This communication is imperative and may happen over the phone or in person in the OR.

Code Hemorrhage was created by the authors as a protocol that would allow for an organized, systematic, and robust response to the specific intraoperative crisis event of a massive hemorrhage. The authors discovered that this response model resulted in improved communication, decision-making, and patient care at their institution in the 8 events that triggered Code Hemorrhage over a one year time period. The events involved four hepatobiliary cases, two obstetric cases, and two orthopedic surgeries and 4 of these cases involved the combination of hemorrhage and pulmonary embolism, which was discovered during emergent rescue transesophageal echocardiography. These 8 patients were successfully resuscitated in the operating room and then transferred to the ICU. Five patients died postoperatively with three patients developing ischemic brain injury due to hypotension and hemorrhage from the intraoperative events. The good news is that three of these patients survived and were discharged home. This Code Hemorrhage protocol offers a clear model to help establish clear roles, responsibility, and communication to help improve patient outcomes after the devastating complication of intraoperative hemorrhage. Be sure to check out Figure 1 from the article which I will include in the show notes as well.

Now, before we end today, we are going to hear from Taizoon Dhoon one more time. I asked him, “what do you hope to see going forward?” Let’s take a listen now.

[Dhoon] “Similar in concept to a code blue or a code stroke, Code Hemorrhage is a structured response strategy. Using it we have seen encouraging results with enhanced patient outcomes. Going forward, we look forward to the possibility of single or multi-institutional research in the future. We also hope that Code Hemorrhage will provide the framework for our fellow anesthesia providers to develop and or refine their own current response protocols at their home institutions.”

Thank you so much to Taizoon Dhoon for contributing these excellent behind the scenes and looking forward to the future clips to the show today. And we want to hear from you…do you have a Code Hemorrhage at your institution or are you considering implementing a similar framework after reading the article and listening to the show today. Use the hashtag, #APSFpodcast to let us know.

If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. For more great patient safety content, we hope that you will connect with us on Twitter, Instagram, Facebook, or LinkedIn.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2021, The Anesthesia Patient Safety Foundation