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Veteran Practices for Bleeding during Sinus Surgery

A panel of expert rhinologists discussed steps to minimize significant bleeding, tool preferences, and postoperative medications during “Maximizing Hemostasis in Sinus Surgery: Practical Tips.”

“Bleeding is a problem because it slows you down,” said John M. DelGaudio, MD, from Emory Clinic, and moderator of the panel. “The question is how do you minimize it so that your field of vision remains clear.” Poor visualization is one of the most important factors that increases the risk of intraoperative complications such as injury to major vessels and nerves.

The primary step, according to the panel, is to obtain a preoperative understanding of medications and anticoagulants patients may be taking and have them stop usage up to three days in advance.

“It is on us to be aware of what patients are taking,” said Raj Sindwani, MD, from the Cleveland Clinic. “Even herbal supplements such as ginseng and Vitamin E count.”

The panel discussed the use of steroids for minimizing bleeding and agreed there is no good evidence that it helps; it is more subjective than objective.

John S. Schneider, MD, Washington University School of Medicine, said he thinks surgeons underestimate blood loss.

“If you see bleeding you are uncomfortable with, trust yourself. Slow down. Keep the lines of communication with the anesthesiologist open,” he said.

Kevin C. Welch, MD, from Northwestern University Feinberg School of Medicine, agreed. “I don’t think there will be significant loss in the few seconds you stop to think about the blood loss.”

“Bleeding is not the issue. Sequalae is what you have to consider,” said Dr. Sindwani.

Soft tissue and bone removal is a common challenge because of the likelihood of bleeding from adenoids, polyps, and tumors. Even small amounts of bleeding during surgery can obscure the surgeon’s view of the small operative field, thereby increasing the risk of complications.

The panel discussed whether it preferred using hand instruments or the microdebrider. The field was evenly split, some preferring the “feel” of hand tools, while others used the microdebrider for cleanup.

The decision is split on whether there is an optimal process for packing or even if any packing is necessary. Once the sinus is packed, the challenge, they said, is that it has to be extracted at some point following surgery. This can be painful for the patient and risk injuring mucosa and rebleeding.

Postoperatively, panelists agreed with Dr. Sindwani who said, “Often, I will put nothing in the sinuses. I am more concerned with patient comfort at that point.”

Speaking of comfort, are medications a concern following surgery?

“I am still reluctant to let patients use NSAIDs after surgery. I don’t know which patient is going to do badly with them. It is all under the umbrella of opioids. I don’t want them to be uncomfortable. I am still developing an algorithm,” said Dr. Schneider.

“It is just not a painful surgery,” he said. “If there is pain, there is something else going on.”

Dr. Welch agreed. “When we give them narcotics, most stop them around day three. It is just not normally postoperatively painful.”