Safety in Dermatologic Procedures: How to Prevent, Recognize, and Treat Bleeding Complications in Dermatologic Surgery

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"apellidos" => "Pizarro" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731021002763?idApp=UINPBA000044" "url" => "/00017310/0000011300000001/v2_202202160543/S0001731021002763/v2_202202160543/es/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0001731021002064" "issn" => "00017310" "doi" => "10.1016/j.ad.2021.05.014" "estado" => "S300" "fechaPublicacion" => "2022-01-01" "aid" => "2683" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Actas Dermosifiliogr. 2022;113:67-71" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "DERMATOLOGÍA PRÁCTICA" "titulo" => "Seguridad en procedimientos dermatológicos: hemorragia quirúrgica en cirugía dermatológica. 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Modificada de Cabezas Calderón et al.<a class="elsevierStyleCrossRef" href="#bib0070">2</a>." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.E. Iglesias Zamora, J. Aróstegui Aguilar" "autores" => array:2 [ 0 => array:2 [ "nombre" => "M.E." "apellidos" => "Iglesias Zamora" ] 1 => array:2 [ "nombre" => "J." 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"apellidos" => "Aróstegui Aguilar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Seguridad en procedimientos dermatológicos: hemorragia quirúrgica en cirugía dermatológica. Cómo reconocerla, prevenirla y tratarla" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2220 "Ancho" => 2510 "Tamanyo" => 240891 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Dermatological surgery: management of patients receiving direct oral anticoagulation therapy. *High thromboembolic risk in patients with any of these characteristics: recent venous thromboembolism (<90 days), active malignancy, severe thrombophilia, atrial fibrillation with a CHADS2 score of 5–6 or a CHADS2-VASc score of 7–9, stroke <90 days or mechanical heart valve (mitral or aortic, tipping disc or balloon type, multiple mechanical valves, or recent cerebral ischemia [<6 months]). Abbreviations: DOAC, direct oral anticoagulants. Modified from Cabezas Calderón et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>" ] ] ] "textoCompleto" => "Description of the Complication: How is an At-Risk Patient Identified?While complications in dermatological surgery are infrequent, a considerable proportion are due to major perioperative or postoperative bleeding (i.e. bleeding that does not subside with compression measures). In a study of a large series of patients who underwent Mohs micrographic surgery, complications occurred in approximately 2% of patients, and corresponded to postsurgical bleeding in 40% of cases.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Although this complication does not usually have major implications (a decrease in hematocrit requiring blood transfusion occurred in very few cases), it can occasionally lead to infection of the surgical wound, suture dehiscence, or necrosis of the flap or graft.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Bleeding is defined as a noncircumscribed accumulation of blood that infiltrates tissues after rupture of a blood vessel wall. A hematoma is defined as the localized collection of usually coagulated blood in an organ, space, or tissue due to rupture of a blood vessel wall. Hematoma formation consists of 4 stages: early formation (I), gelatinous (II), organized (III), and liquefaction (IV) stages.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It is important to detect the hematoma as early as possible to avoid the aforementioned complications.It is essential to recognize the possibility of bleeding both during and after the intervention, and to perform a meticulous medical history and physical examination in the consultation before surgery. Indices such as the HAS-BLED2 are useful to assess a patient’s risk of bleeding (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Other factors to take into account are the anatomical location and the surgical technique performed, although some authors have reported no significant differences in bleeding risk between different surgical procedures.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> Larger defect size, administration of perioperative antibiotics, and a history of hidradenitis suppurativa are associated with an increased risk of bleeding.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Three specific regions are associated with a higher risk of bleeding: the frontotemporal region, where the temporal artery is located; the mandibular rim, over which the facial artery runs; and the area adjacent to the nose, where the angular artery runs.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Other regions that in our experience are associated with a greater risk of bleeding include the genital region (especially in interventions involving the scrotum and vulva) and the flexures (armpits and groin). Furthermore, in areas such as the periorbital or cervical regions formation of a hematoma entails significant risk of compression of neighboring structures due to the mass effect (and greater risk of tissue necrosis or surgical wound dehiscence).<a class="elsevierStyleCrossRef" href="#bib0005">1</a>PreventionDifferent measures can be taken before the intervention to prevent both perioperative and postoperative bleeding. Twenty years ago, anticoagulant and antiplatelet treatments were withdrawn to prevent bleeding in most patients undergoing dermatological surgery. Nowadays, the trend is to maintain these therapies, especially in cases of minor outpatient surgery. Given the usually minor implications of surgical bleeding complications and the serious consequences of thromboembolic phenomenon after surgical intervention when anticoagulant therapy is withdrawn (despite the low frequency of these episodes), we recommend making the decision to withdraw treatment on a case-by-case basis.Acetylsalicylic acid does not appear to increase the risk of surgical bleeding, and therefore withdrawal of antiplatelet therapy is not recommended. Patients who take clopidogrel have a higher risk of bleeding than those not receiving anticoagulation or antiplatelet therapy. Nonetheless, given the low severity of bleeding episodes, continuation of this treatment or replacement with acetylsalicylic acid is recommended.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> For patients receiving dual antiplatelet therapy (e.g. acetylsalicylic acid + clopidogrel) there is no clear consensus on the appropriate course of action. In these patients the risk of bleeding appears to be greater than in patients receiving antiplatelet monotherapy, and therefore it is recommended to reduce antiplatelet therapy to a single agent if possible.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>In patients receiving anticoagulant therapy, the international normalized ratio (INR) should first be assessed, when possible, as in the case of acenocoumarol (Sintrom), and postponement of the intervention should be considered if the value exceeds 3.5.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>There is little information on the preoperative management of patients being treated with new direct oral anticoagulants, which are prescribed with increasing frequency. <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows the algorithm for the management of patients undergoing treatment with these drugs.<a class="elsevierStyleCrossRef" href="#bib0010">2</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>As mentioned above, nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to control pain and inflammation. Given the potential risk of bleeding caused by this type of drug, it is recommended to discontinue treatment 1 week before surgery until up to 2 days after the intervention. It is advisable to manage postoperative pain with paracetamol or metamizole.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>Given that blood pressure (BP) is a risk factor for bleeding, it is recommended to perform the intervention provided the patient has a systolic BP ≤ 160 mmHg or a diastolic BP ≤ 100 mmHg (BP monitoring before and during the intervention is advisable). If the patient’s BP exceeds the aforementioned values, the intervention should ideally be postponed until values are brought to within the recommended range.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the points that should be taken into account to prevent intraoperative bleeding.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In our experience, patients who undergo general anesthesia may experience an increase in BP in the recovery room after the intervention, with a consequent increase in the risk of bleeding due to improperly ligated or coagulated vessels. For this reason, we believe it is useful to evaluate the intervened area a few minutes after surgery to rule out the presence of postoperative bleeding.It is also advisable to apply a compression bandage during the first 24 hours in at-risk patients or after risky interventions. After 24 hours the efficacy of this measure likely decreases. It is also important to instruct the patient about correct care of the postoperative wound and any warning signs about which the surgeon should be notified (e.g. bleeding or hematoma, necrosis of the flap or graft, dehiscence, or infection). Ideally the patient should not consume alcohol in the first 7 days after the intervention owing to its vasodilatory effect.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>TreatmentAs mentioned above, bleeding in dermatological surgery does not usually have major implications, and in most cases can be controlled using compression for a maximum of 15 to 20 minutes. In cases of severe bleeding the affected vessel can be compressed. This allows time for platelet adhesion and initiation of the coagulation cascade, as well as application of other techniques to stop the bleeding.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> As indicated in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, other therapeutic options in cases of intraoperative bleeding include ligation or electrocoagulation of the affected vessel.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>A case series of 9154 operated patients found that 7.4% presented some form of postoperative bleeding, which in most cases (87.5%) was controlled by applying pressure or replacing bandages.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Intervention by a dermatologist was required in 12.5% of postoperative bleeding cases; electrocautery was used to stop bleeding in 10% of cases; and bleeding was considered severe in only 2.2% of patients.<a class="elsevierStyleCrossRef" href="#bib0030">6</a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes the management of patients with postsurgical bleeding, differentiating between hematoma within the first 24 hours and late hematoma.Conflicts of InterestThe authors declare that they have no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1665623" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1479705" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1665622" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1479704" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Description of the Complication: How is an At-Risk Patient Identified?" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Prevention" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Treatment" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-03-17" "fechaAceptado" => "2021-05-23" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1479705" "palabras" => array:3 [ 0 => "Hemorrhage" 1 => "Dermatologic surgery" 2 => "Oral anticoagulants" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1479704" "palabras" => array:3 [ 0 => "Hemorragia" 1 => "Cirugía dermatológica" 2 => "Anticoagulantes orales" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Bleeding complications during dermatologic surgery are uncommon and usually minor, but bleeding occasionally leads to infection, wound dehiscence, or flap/graft necrosis. This review covers the keys to preventing, recognizing, and treating excessive bleeding during and after surgery." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las complicaciones por hemorragia quirúrgica en la cirugía dermatológica son infrecuentes y poco relevantes en la mayoría de los casos. En algunas ocasiones la hemorragia quirúrgica puede conllevar infección de la herida quirúrgica, dehiscencia de sutura o necrosis del colgajo/injerto. En esta revisión se muestran los aspectos más importantes para prevenir, reconocer y tratar este tipo de complicaciones durante el acto quirúrgico y tras él." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Iglesias Zamora ME, Aróstegui Aguilar J. Seguridad en procedimientos dermatológicos: hemorragia quirúrgica en cirugía dermatológica. Cómo reconocerla, prevenirla y tratarla. Actas Dermosifiliogr. 2022;113:67–71." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2220 "Ancho" => 2510 "Tamanyo" => 240891 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Dermatological surgery: management of patients receiving direct oral anticoagulation therapy. *High thromboembolic risk in patients with any of these characteristics: recent venous thromboembolism (<90 days), active malignancy, severe thrombophilia, atrial fibrillation with a CHADS2 score of 5–6 or a CHADS2-VASc score of 7–9, stroke <90 days or mechanical heart valve (mitral or aortic, tipping disc or balloon type, multiple mechanical valves, or recent cerebral ischemia [<6 months]). Abbreviations: DOAC, direct oral anticoagulants. Modified from Cabezas Calderón et al.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: INR, international normalized ratio; HT, hypertension; NSAID, nonsteroidal anti-inflammatory drugs.HAS-BLED evaluates the risk of bleeding complications based on the indicated parameters.Significant risk of intervention-related bleeding if score ≥3." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension >160 mmHg (1 point) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abnormal kidney or liver function (1 point for each) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stroke: clinical history of stroke (1 point) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bleeding: history of bleeding or predisposition to hemorrhage. Alterations in platelet aggregation/adhesion (Von Willebrand disease, Marfan syndrome, etc.), hereditary coagulation disorders (hemophilia A/B), Rendu-Osler-Weber syndrome, Ehlers-Danlos syndrome, etc. (1 point each) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Labile INR >3.5 (1 point) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elderly: age >65 years (1 point) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drugs: antiaggregants or anticoagulants (34% and 7.2% of operated patients, respectively), NSAIDs (6.1% of operated patients), alcohol, herbal products, or vitamin supplements<a class="elsevierStyleCrossRef" href="#bib0005">1</a> (1 point each) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other: anatomical location, size of defect, surgical technique \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2835250.png" ] ] ] ] "descripcion" => array:1 [ "en" => "HAS-BLED Scoring System." ] ] 2 => array:9 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Bunick et al.,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Davila and Garcia-Doval,<a class="elsevierStyleCrossRef" href="#bib0045">9</a> and Zilinsky et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Abbreviations: ASA, acetylsalicylic acid; DOAC, direct oral anticoagulants; INR, international normalized ratio; NSAIDs, non-steroidal anti-inflammatory drugs; TXA, tranexamic acid." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperative prevention \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraoperative/postoperative prevention \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Determine risk of bleeding prior to intervention (see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reverse Trendelenburg position \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ASA 300 mg/clopidogrel 75 mg: do not suspend \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local anesthesia with epinephrine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Acenocoumarol (customize HAS-BLED risk): if INR >3.5, consider substitution or postpone intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tumescent anesthesia<a class="elsevierStyleCrossRef" href="#bib0045">9</a>,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DOAC (adjusted according to renal function)<a class="elsevierStyleCrossRef" href="#bib0010">2</a>: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tranexamic acid<a class="elsevierStyleCrossRef" href="#bib0050">10</a>,<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a>: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Suspend 24 h before intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oral or intravenous (maximum effective dose, 1 g/8 h) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reintroduce 6–12 h after intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subcutaneous (lidocaine 2% + TXA 100 mg/mL, delivered in a volume of 1–6 mL) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Contraindications: severe kidney disease, hypersensitivity, acute arterial/venous thrombosis, history of seizures, disseminated intravascular coagulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NSAIDs: suspend 1 wk before \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Careful surgical technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Blood pressure <160/100 mmHg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apply compression dressing/bandage (first 24 h) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If greater: treatment to decrease value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insert drain in cases of large flaps or detachments with marked bleeding and in patients with very high risk of postsurgical bleeding \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2835248.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Safe technique, which consists of the introduction of a large volume of diluted anesthetic and adrenaline. This ensures sufficient anesthesia with a reduction in bleeding and easier dissection for the surgeon." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Several studies in animals have demonstrated a theoretical risk of decreased graft/flap survival after application of tranexamic acid. However, this has not been demonstrated in studies in human patients, and further studies of this possible complication are required." ] ] ] "descripcion" => array:1 [ "en" => "Preoperative, Intraoperative, and Postoperative Prevention of Surgical Bleeding." ] ] 3 => array:9 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Bunick et al.,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Henley et al.,<a class="elsevierStyleCrossRef" href="#bib0020">4</a> and Zilinsky et al.<a class="elsevierStyleCrossRef" href="#bib0050">10</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraoperative bleeding \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postoperative bleeding<a class="elsevierStyleCrossRefs" href="#bib0005">1,10</a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Compressive measures (15–20 min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Tranexamic acid (oral, intravenous, or subcutaneous) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Electrocoagulation<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a>: limited to the bleeding vessel (avoiding damage of adjacent tissue)<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hematoma, first 24 h: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ligation of vessels >2 mm in diameter<a class="elsevierStyleCrossRef" href="#bib0020">4</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Manual compression, bandage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- No remission: reintervention and electrocoagulation/ligation of site of bleeding \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drain placement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Superficial bleeding: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Late hematoma: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Caustic hemostatic agents<a class="elsevierStyleCrossRef" href="#bib0005">1</a>: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Observation if small \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Aluminum chloride \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Material extraction if larger (reintervene) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Ferric sulfate 20% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="5" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Given the high risk of infection, it is advisable to add antibiotic treatment or to closely monitor the patient</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Silver nitrate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Noncaustic hemostatic agents<a class="elsevierStyleCrossRef" href="#bib0005">1</a>,<a class="elsevierStyleCrossRef" href="#tblfn0025">c</a>: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Gelatin sponges (Gelfoam) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">- Oxidized cellulose (Surgicel) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2835249.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "In the case of patients with a pacemaker or implantable automatic defibrillator, it is recommended to use a bipolar electric scalpel, which has a greater safety profile (the current flows between 2 electrodes placed in the area of application, and does not flow through the patient).<a class="elsevierStyleCrossRef" href="#bib0060">12</a>." ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "In cases of deeper bleeding, diffuse oozing may occur, requiring more extensive and less specific electrocoagulation." ] 2 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "c" "nota" => "Useful in procedures such as punch biopsy, healing by second intention, or interventions in which the wound remains open for extended periods (e.g. margin control surgery, Mohs surgery)." ] ] ] "descripcion" => array:1 [ "en" => "Treatment of Bleeding." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hemorrhagic complications in dermatologic surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C.G. 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Practical Dermatology

Safety in Dermatologic Procedures: How to Prevent, Recognize, and Treat Bleeding Complications in Dermatologic Surgery

Seguridad en procedimientos dermatológicos: hemorragia quirúrgica en cirugía dermatológica. Cómo reconocerla, prevenirla y tratarla

M.E. Iglesias Zamora

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info@doctoraiglesias.com

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, J. Aróstegui Aguilar

Servicio de Dermatología, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatological surgery&#58; management of patients receiving direct oral anticoagulation therapy&#46; &#42;High thromboembolic risk in patients with any of these characteristics&#58; recent venous thromboembolism &#40;&#60;90 days&#41;&#44; active malignancy&#44; severe thrombophilia&#44; atrial fibrillation with a CHADS2 score of 5&#8211;6 or a CHADS2-VASc score of 7&#8211;9&#44; stroke &#60;90 days or mechanical heart valve &#40;mitral or aortic&#44; tipping disc or balloon type&#44; multiple mechanical valves&#44; or recent cerebral ischemia &#91;&#60;6 months&#93;&#41;&#46; Abbreviations&#58; DOAC&#44; direct oral anticoagulants&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Modified from Cabezas Calder&#243;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Description of the Complication&#58; How is an At-Risk Patient Identified&#63;</span><p id="par0005" class="elsevierStylePara elsevierViewall">While complications in dermatological surgery are infrequent&#44; a considerable proportion are due to major perioperative or postoperative bleeding &#40;i&#46;e&#46; bleeding that does not subside with compression measures&#41;&#46; In a study of a large series of patients who underwent Mohs micrographic surgery&#44; complications occurred in approximately 2&#37; of patients&#44; and corresponded to postsurgical bleeding in 40&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Although this complication does not usually have major implications &#40;a decrease in hematocrit requiring blood transfusion occurred in very few cases&#41;&#44; it can occasionally lead to infection of the surgical wound&#44; suture dehiscence&#44; or necrosis of the flap or graft&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Bleeding is defined as a noncircumscribed accumulation of blood that infiltrates tissues after rupture of a blood vessel wall&#46; A hematoma is defined as the localized collection of usually coagulated blood in an organ&#44; space&#44; or tissue due to rupture of a blood vessel wall&#46; Hematoma formation consists of 4 stages&#58; early formation &#40;I&#41;&#44; gelatinous &#40;II&#41;&#44; organized &#40;III&#41;&#44; and liquefaction &#40;IV&#41; stages&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is important to detect the hematoma as early as possible to avoid the aforementioned complications&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is essential to recognize the possibility of bleeding both during and after the intervention&#44; and to perform a meticulous medical history and physical examination in the consultation before surgery&#46; Indices such as the HAS-BLED2 are useful to assess a patient&#8217;s risk of bleeding &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Other factors to take into account are the anatomical location and the surgical technique performed&#44; although some authors have reported no significant differences in bleeding risk between different surgical procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Larger defect size&#44; administration of perioperative antibiotics&#44; and a history of hidradenitis suppurativa are associated with an increased risk of bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Three specific regions are associated with a higher risk of bleeding&#58; the frontotemporal region&#44; where the temporal artery is located&#59; the mandibular rim&#44; over which the facial artery runs&#59; and the area adjacent to the nose&#44; where the angular artery runs&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Other regions that in our experience are associated with a greater risk of bleeding include the genital region &#40;especially in interventions involving the scrotum and vulva&#41; and the flexures &#40;armpits and groin&#41;&#46; Furthermore&#44; in areas such as the periorbital or cervical regions formation of a hematoma entails significant risk of compression of neighboring structures due to the mass effect &#40;and greater risk of tissue necrosis or surgical wound dehiscence&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Prevention</span><p id="par0030" class="elsevierStylePara elsevierViewall">Different measures can be taken before the intervention to prevent both perioperative and postoperative bleeding&#46; Twenty years ago&#44; anticoagulant and antiplatelet treatments were withdrawn to prevent bleeding in most patients undergoing dermatological surgery&#46; Nowadays&#44; the trend is to maintain these therapies&#44; especially in cases of minor outpatient surgery&#46; Given the usually minor implications of surgical bleeding complications and the serious consequences of thromboembolic phenomenon after surgical intervention when anticoagulant therapy is withdrawn &#40;despite the low frequency of these episodes&#41;&#44; we recommend making the decision to withdraw treatment on a case-by-case basis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Acetylsalicylic acid does not appear to increase the risk of surgical bleeding&#44; and therefore withdrawal of antiplatelet therapy is not recommended&#46; Patients who take clopidogrel have a higher risk of bleeding than those not receiving anticoagulation or antiplatelet therapy&#46; Nonetheless&#44; given the low severity of bleeding episodes&#44; continuation of this treatment or replacement with acetylsalicylic acid is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> For patients receiving dual antiplatelet therapy &#40;e&#46;g&#46; acetylsalicylic acid&#8239;&#43;&#8239;clopidogrel&#41; there is no clear consensus on the appropriate course of action&#46; In these patients the risk of bleeding appears to be greater than in patients receiving antiplatelet monotherapy&#44; and therefore it is recommended to reduce antiplatelet therapy to a single agent if possible&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In patients receiving anticoagulant therapy&#44; the international normalized ratio &#40;INR&#41; should first be assessed&#44; when possible&#44; as in the case of acenocoumarol &#40;Sintrom&#41;&#44; and postponement of the intervention should be considered if the value exceeds 3&#46;5&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">There is little information on the preoperative management of patients being treated with new direct oral anticoagulants&#44; which are prescribed with increasing frequency&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a> shows the algorithm for the management of patients undergoing treatment with these drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">As mentioned above&#44; nonsteroidal anti-inflammatory drugs &#40;NSAIDs&#41; are widely used to control pain and inflammation&#46; Given the potential risk of bleeding caused by this type of drug&#44; it is recommended to discontinue treatment 1 week before surgery until up to 2 days after the intervention&#46; It is advisable to manage postoperative pain with paracetamol or metamizole&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Given that blood pressure &#40;BP&#41; is a risk factor for bleeding&#44; it is recommended to perform the intervention provided the patient has a systolic BP&#8239;&#8804;&#8239;160&#8239;mmHg or a diastolic BP&#8239;&#8804;&#8239;100&#8239;mmHg &#40;BP monitoring before and during the intervention is advisable&#41;&#46; If the patient&#8217;s BP exceeds the aforementioned values&#44; the intervention should ideally be postponed until values are brought to within the recommended range&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the points that should be taken into account to prevent intraoperative bleeding&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In our experience&#44; patients who undergo general anesthesia may experience an increase in BP in the recovery room after the intervention&#44; with a consequent increase in the risk of bleeding due to improperly ligated or coagulated vessels&#46; For this reason&#44; we believe it is useful to evaluate the intervened area a few minutes after surgery to rule out the presence of postoperative bleeding&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is also advisable to apply a compression bandage during the first 24&#8239;hours in at-risk patients or after risky interventions&#46; After 24&#8239;hours the efficacy of this measure likely decreases&#46; It is also important to instruct the patient about correct care of the postoperative wound and any warning signs about which the surgeon should be notified &#40;e&#46;g&#46; bleeding or hematoma&#44; necrosis of the flap or graft&#44; dehiscence&#44; or infection&#41;&#46; Ideally the patient should not consume alcohol in the first 7 days after the intervention owing to its vasodilatory effect&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Treatment</span><p id="par0075" class="elsevierStylePara elsevierViewall">As mentioned above&#44; bleeding in dermatological surgery does not usually have major implications&#44; and in most cases can be controlled using compression for a maximum of 15 to 20&#8239;minutes&#46; In cases of severe bleeding the affected vessel can be compressed&#46; This allows time for platelet adhesion and initiation of the coagulation cascade&#44; as well as application of other techniques to stop the bleeding&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> As indicated in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; other therapeutic options in cases of intraoperative bleeding include ligation or electrocoagulation of the affected vessel&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">A case series of 9154 operated patients found that 7&#46;4&#37; presented some form of postoperative bleeding&#44; which in most cases &#40;87&#46;5&#37;&#41; was controlled by applying pressure or replacing bandages&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Intervention by a dermatologist was required in 12&#46;5&#37; of postoperative bleeding cases&#59; electrocautery was used to stop bleeding in 10&#37; of cases&#59; and bleeding was considered severe in only 2&#46;2&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes the management of patients with postsurgical bleeding&#44; differentiating between hematoma within the first 24&#8239;hours and late hematoma&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0030">Please cite this article as&#58; Iglesias Zamora ME&#44; Ar&#243;stegui Aguilar J&#46; Seguridad en procedimientos dermatol&#243;gicos&#58; hemorragia quir&#250;rgica en cirug&#237;a dermatol&#243;gica&#46; C&#243;mo reconocerla&#44; prevenirla y tratarla&#46; Actas Dermosifiliogr&#46; 2022&#59;113&#58;67&#8211;71&#46;</p>"
      ]
    ]
    "multimedia" => array:4 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2220
            "Ancho" => 2510
            "Tamanyo" => 240891
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Figure "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Dermatological surgery&#58; management of patients receiving direct oral anticoagulation therapy&#46; &#42;High thromboembolic risk in patients with any of these characteristics&#58; recent venous thromboembolism &#40;&#60;90 days&#41;&#44; active malignancy&#44; severe thrombophilia&#44; atrial fibrillation with a CHADS2 score of 5&#8211;6 or a CHADS2-VASc score of 7&#8211;9&#44; stroke &#60;90 days or mechanical heart valve &#40;mitral or aortic&#44; tipping disc or balloon type&#44; multiple mechanical valves&#44; or recent cerebral ischemia &#91;&#60;6 months&#93;&#41;&#46; Abbreviations&#58; DOAC&#44; direct oral anticoagulants&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Modified from Cabezas Calder&#243;n et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; INR&#44; international normalized ratio&#59; HT&#44; hypertension&#59; NSAID&#44; nonsteroidal anti-inflammatory drugs&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">HAS-BLED evaluates the risk of bleeding complications based on the indicated parameters&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Significant risk of intervention-related bleeding if score &#8805;3&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Hypertension</span> &#62;160&#8239;mmHg &#40;1 point&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Abnormal kidney or liver function &#40;1 point for each&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">S</span>troke&#58; clinical history of stroke &#40;1 point&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">B</span>leeding&#58; history of bleeding or predisposition to hemorrhage&#46; Alterations in platelet aggregation&#47;adhesion &#40;Von Willebrand disease&#44; Marfan syndrome&#44; etc&#46;&#41;&#44; hereditary coagulation disorders &#40;hemophilia A&#47;B&#41;&#44; Rendu-Osler-Weber syndrome&#44; Ehlers-Danlos syndrome&#44; etc&#46; &#40;1 point each&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">L</span>abile INR&#8239;&#62;3&#46;5 &#40;1 point&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">E</span>lderly&#58; age &#62;65 years &#40;1 point&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">D</span>rugs&#58; antiaggregants or anticoagulants &#40;34&#37; and 7&#46;2&#37; of operated patients&#44; respectively&#41;&#44; NSAIDs &#40;6&#46;1&#37; of operated patients&#41;&#44; alcohol&#44; herbal products&#44; or vitamin supplements<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> &#40;1 point each&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other&#58; anatomical location&#44; size of defect&#44; surgical technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2835250.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">HAS-BLED Scoring System&#46;</p>"
        ]
      ]
      2 => array:9 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Source&#58; Bunick et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Davila and Garcia-Doval&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and Zilinsky et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>"
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; ASA&#44; acetylsalicylic acid&#59; DOAC&#44; direct oral anticoagulants&#59; INR&#44; international normalized ratio&#59; NSAIDs&#44; non-steroidal anti-inflammatory drugs&#59; TXA&#44; tranexamic acid&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperative prevention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraoperative&#47;postoperative prevention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Determine risk of bleeding prior to intervention &#40;see <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reverse Trendelenburg position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASA 300&#8239;mg&#47;clopidogrel 75 mg&#58; do not suspend&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Local anesthesia with epinephrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Acenocoumarol &#40;customize HAS-BLED risk&#41;&#58; if INR&#8239;&#62;3&#46;5&#44; consider substitution or postpone intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tumescent anesthesia<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DOAC &#40;adjusted according to renal function&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tranexamic acid<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Suspend 24&#8239;h before intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Oral or intravenous &#40;maximum effective dose&#44; 1&#8239;g&#47;8&#8239;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Reintroduce 6&#8211;12&#8239;h after intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Subcutaneous &#40;lidocaine 2&#37;&#8239;&#43;&#8239;TXA 100&#8239;mg&#47;mL&#44; delivered in a volume of 1&#8211;6&#8239;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contraindications&#58; severe kidney disease&#44; hypersensitivity&#44; acute arterial&#47;venous thrombosis&#44; history of seizures&#44; disseminated intravascular coagulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NSAIDs&#58; suspend 1 wk before&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Careful surgical technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Blood pressure &#60;160&#47;100&#8239;mmHg&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Apply compression dressing&#47;bandage &#40;first 24&#8239;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">If greater&#58; treatment to decrease value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Insert drain in cases of large flaps or detachments with marked bleeding and in patients with very high risk of postsurgical bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2835248.png"
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          "notaPie" => array:2 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Safe technique&#44; which consists of the introduction of a large volume of diluted anesthetic and adrenaline&#46; This ensures sufficient anesthesia with a reduction in bleeding and easier dissection for the surgeon&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Several studies in animals have demonstrated a theoretical risk of decreased graft&#47;flap survival after application of tranexamic acid&#46; However&#44; this has not been demonstrated in studies in human patients&#44; and further studies of this possible complication are required&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Preoperative&#44; Intraoperative&#44; and Postoperative Prevention of Surgical Bleeding&#46;</p>"
        ]
      ]
      3 => array:9 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "Source&#58; Bunick et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Henley et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and Zilinsky et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>"
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intraoperative bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Postoperative bleeding<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Compressive measures &#40;15&#8211;20&#8239;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tranexamic acid &#40;oral&#44; intravenous&#44; or subcutaneous&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Electrocoagulation<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a>&#58; limited to the bleeding vessel &#40;avoiding damage of adjacent tissue&#41;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hematoma&#44; first 24&#8239;h&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ligation of vessels &#62;2&#8239;mm in diameter<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Manual compression&#44; bandage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">- No remission&#58; reintervention and electrocoagulation&#47;ligation of site of bleeding&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Drain placement&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Superficial bleeding&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Late hematoma&#58;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Caustic hemostatic agents<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Observation if small&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Aluminum chloride&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">- Material extraction if larger &#40;reintervene&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Ferric sulfate 20&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="5" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Given the high risk of infection&#44; it is advisable to add antibiotic treatment or to closely monitor the patient</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Silver nitrate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#8226; Noncaustic hemostatic agents<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a>&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Gelatin sponges &#40;Gelfoam&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>- Oxidized cellulose &#40;Surgicel&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 00017310
Original language: English

DOI:10.1016/j.ad.2021.05.024

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2024 May	90	54	144
2024 April	82	36	118
2024 March	83	45	128
2024 February	77	33	110
2024 January	79	30	109
2023 December	69	16	85
2023 November	86	43	129
2023 October	111	36	147
2023 September	92	38	130
2023 August	74	17	91
2023 July	75	40	115
2023 June	84	26	110
2023 May	55	30	85
2023 April	48	18	66
2023 March	80	27	107
2023 February	63	38	101
2023 January	79	76	155
2022 December	86	43	129
2022 November	64	52	116
2022 October	52	63	115
2022 September	46	50	96
2022 August	54	62	116
2022 July	50	72	122
2022 June	42	33	75
2022 May	63	62	125
2022 April	78	52	130
2022 March	128	90	218
2022 February	84	60	144

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