Guyuron Bahman, Cakmakoglu Cagri, Avasarala Vardhan
From the Zeeba Clinic.
Department of Plastic Surgery, Cleveland Clinic.
Plast Reconstr Surg. 2025 Jan 1;155(1):35e-43e. doi: 10.1097/PRS.0000000000011462. Epub 2024 Apr 9.
Persistent intraoperative bleeding, excessive postoperative ecchymosis, epistaxis, and blood collection in the supratip area increase the complexity of rhinoplasty, causing suboptimal outcomes. The authors present an intraoperative bleeding management algorithm, developed by the senior author (B.G.) based on 43 years of experience, and assess its efficacy in achieving hemostatic control through 103 consecutive cases.
A retrospective chart review was conducted on 103 consecutive patients who had undergone septorhinoplasty performed by a single surgeon. The authors reviewed patient demographics; coagulopathies; medications; diet; intraoperative use of tranexamic acid (TXA), deamino-8- d -arginine vasopressin (DDAVP), and vitamin K; and postoperative complications.
Twenty-six patients (25.2%) did not receive intraoperative hemostatic agents. Twenty-six patients (25.2%) required TXA only, 3 patients (2.91%) were given DDAVP only, 1 patient (0.97%) received vitamin K only, and 46 patients (44.7%) required both TXA and DDAVP. One patient (0.97%) needed TXA, DDAVP, and vitamin K. Intraoperative bleeding was controlled in all patients. One patient with known factor 11 deficiency received both TXA and DDAVP intraoperatively but did not require fresh frozen plasma. Intraoperative bleeding was controlled by first administering 10 mg/kg of TXA intravenously, followed by DDAVP with a maximum dose of 0.3 µg if needed, and 10 mg of vitamin K if bleeding persisted. Patients with known type I or IIa von Willebrand disease received DDAVP preoperatively. No patient experienced postoperative epistaxis, thromboembolism, or other associated complications.
The algorithm of TXA, DDAVP, and vitamin K is effective in controlling excessive intraoperative bleeding, postoperative ecchymosis, and epistaxis.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
术中持续出血、术后瘀斑过多、鼻出血以及鼻尖区积血增加了鼻整形手术的复杂性，导致效果欠佳。作者介绍了一种由资深作者（B.G.）基于43年经验制定的术中出血管理算法，并通过连续103例病例评估其实现止血控制的效果。
对由单一外科医生进行鼻中隔鼻整形术的连续103例患者进行回顾性病历审查。作者审查了患者的人口统计学资料、凝血障碍、药物、饮食、术中氨甲环酸（TXA）、去氨-8-D-精氨酸加压素（DDAVP）和维生素K的使用情况以及术后并发症。
26例患者（25.2%）未接受术中止血剂。26例患者（25.2%）仅需要TXA，3例患者（2.91%）仅给予DDAVP，1例患者（0.97%）仅接受维生素K，46例患者（44.7%）需要TXA和DDAVP两者。1例患者（0.97%）需要TXA、DDAVP和维生素K。所有患者的术中出血均得到控制。1例已知因子11缺乏的患者术中接受了TXA和DDAVP，但不需要新鲜冰冻血浆。术中出血通过先静脉注射10 mg/kg的TXA进行控制，随后根据需要给予最大剂量为0.3 μg的DDAVP，若出血持续则给予10 mg维生素K。已知患有I型或IIa型血管性血友病的患者术前接受DDAVP。没有患者出现术后鼻出血、血栓栓塞或其他相关并发症。
TXA、DDAVP和维生素K的算法在控制术中过度出血、术后瘀斑和鼻出血方面有效。
临床问题/证据水平：治疗性，IV级。
