Akademik Veri Yönetim Sistemi
ANESTEZI DERGISI, cilt.31, sa.1, ss.162-165, 2023 (Scopus)
Background: Myomectomy remains the most popular methods for those who have myomas and desire further childbearing. Substantial perioperative blood loss has been associated with myomectomy and sometimes comprehensive management needs to be performed to control bleeding which results in increased morbidity and mortality. In this case, we aimed to share the management of massive perioperative bleeding in abdominal myomectomy. Case: A 24-year-old ASA 1 patient was scheduled for myomectomy under general anesthesia. Anesthesia was induced with intravenous (IV) propofol, lidocaine, and rocuronium, followed by sevoflurane and remifentanil while ECG, SpO2, and noninvasive arterial blood pressure were monitored. Intraoperatively, due to increased bleeding, invasive arterial monitoring was performed and another vascular access was established. Thoughout the procedure there was a total of 2000 mL of bleeding. Intraoperatively, 3 units of packed red blood cell (RBC) and 3 units of fresh frozen plasma (FFP) were administered to the patient, whose hemoglobin value dropped to 2.8 g/dL. One gram (g) of tranexamic acid was given intravenously. The patient was transferred to the post-anesthesia care unit (PACU) after extubation. Postoperatively 1 g of IV tranexamic acid was repeated, IV infusion of 20 IU oxytocin in 1 L Ringer's lactate solution, and intramuscular 0.2 mg methylergonovine were administered. After the hemoglobin level reached 5.3 g dL-1, 2 units of RBC were administered, and ROTEM analysis was performed. The patient was given 5 g of IV fibrinogen since FIBTEM A5 was 3 mm and EXTEM A5 was 15 mm. Since the drain was oozing 850 mL of blood and the patient was hypotensive and tachycardic, she was transported to interventional radiology unit, where uterine artery embolization was performed under monitored anesthesia care anesthesia. Following the surgery, the patient was taken to the PACU. Discussion: Myomectomy is often associated with intraoperative bleeding, leading to significant blood loss and consequently resulting in anemia, hypovolemia, and coagulation abnormalities, necessitating blood transfusions thus lengthening hospital stay. Treatment options for hemorrhage due to uterine atony include administration of pharmacologic agents, tamponade of the uterus, surgical techniques or endovascular embolization. Conclusion: Since ROTEM-guided bleeding management has an important role in improved patients' outcomes including perioperative morbidity and mortality, effective coagulopathy management by using ROTEM together with interventional radiologic techniques if available would be the best practice in bleeding abdominal myomectomy patients.