Haemorrhage

Question 1

Briefly differentiate between primary, reactive and secondary bleeding

Answer 1

Primary bleeding: bleeding that occurs within the intra-operative period

• This should be resolved during the operation, with any major haemorrhages recorded in the operative notes and the patient monitored closely post-operatively

Reactive bleeding: occurs within 24 hours of operation

• Most cases of reactive haemorrhage are from a ligature that slips or a missed vessel. These vessels are often missed intraoperatively due to intraoperative hypotension and vasoconstriction, meaning only once the blood pressure normalises post-operatively will this bleeding occur

Secondary bleeding: occurs 7-10 days post-operatively

• Secondary haemorrhage is often due to erosion of a vessel from a spreading infection. Secondary haemorrhage is most often seen when a heavily contaminated wound is closed primarily

Question 2

What are the clinical features of haemorrhage?

Answer 2

Clinical features of haemorrhagic shock include tachycardia, dizziness, agitation, visible bleeding, or decreased urine output. One of the most sensitive signs is a raised respiratory rate.

Hypotension is often a late sign- do not assume a patient is ‘stable’ or not bleeding just because their blood pressure is normal.

Question 3

Briefly describe the examation of haemorrhage

Answer 3

Examination of the patient should include a thorough exposure looking for bleeding, systematic palpation of the surgical area looking for swelling, discoloration, disproportionate tenderness, and any peritonism.

Question 4

Briefly differentiate class I-IV for haemorrhagic shock

Answer 4

Question 5

What is the initial management of haemorrhage?

Answer 5

If there is a clinical suspicion of post-operative bleeding, fast and efficient initial management will reduce overall morbidity and mortality. An A to E approach is advised, taking particular care to ensure adequate IV access and rapid fluid resuscitation.

1. Read the operation notes, clarifying the type of surgery and the location of wounds, drains, or areas of importance
2. Direct pressure should be applied to the bleeding site (if visible)
3. Urgent senior surgical review should be sought and appropriate imaging arranged in order to ascertain the level of bleeding
4. Urgent blood transfusion should be considered in the case of moderate to severe post-operative haemorrhage

Upon review with a senior, it may be appropriate to re-operate on the patient for further haemostasis. Conservative management may be indicated in smaller haemorrhages but close monitoring should always be undertaken.

Question 6

Briefly describe the process of transfusion following haemorrhage

Answer 6

If severe bleeding, this should be in the form of red blood cells, platelets and fresh frozen plasma, with a major haemorrhage protocol activated as necessary.

Question 7

Briefly describe the importance of haemorrhage and neck surgery

Answer 7

Post-operative thyroidectomy or parathyroidectomy haemorrhage can have catastrophic consequences and the surgeon must take great care to ligate any vessels and coagulate bleeding points.

The primary sign of post-operative haemorrhage is likely to be airway obstruction. This is because the pretracheal fascia of the neck will only distend so far; when bleeding occurs into this space, compression on the venous return results in venous congestion, with subsequent laryngeal oedema leading to eventual asphyxiation.

Any evidence of respiratory distress or airway compromise in these patients requires an emergency protocol for airway rescue. This involves removing both the skin clips and deep layer sutures and suction of the haematoma beneath, all done at the bedside as there is no time to get the patient to theatre!

Urgent senior surgical opinion should be sought and an anaesthetic review should be organised.

Question 8

Briefly describe the risk of haemorrhage and the inferior epigastric artery

Answer 8

The inferior epigastric artery arises from the external iliac artery and runs up the abdominal wall below the rectus muscle, vertically in approximately the mid-clavicular line. It is therefore vulnerable to injury from laparoscopic ports.

Due to the gas insufflation, this may not be noticed at the time of surgery. Always think of post-operative bleeding and inferior epigastric artery injury in an acutely unwell patient shortly after any surgery, but particularly after laparoscopic surgery or surgery with a Pfannenstiel incision.

Question 9

Briefly describe the risk of haemorrhage and retroperitoneal bleeding post-angiography

Answer 9

Many procedures are now performed using angiography, with an entry site in the groin. The puncture site is often the external iliac artery, above the inguinal ligament. Therefore, any bleeding from this artery will go into the retroperitoneum.

There will likely not be a large haematoma around the skin puncture site, because the actual arterial puncture site is hidden by the inguinal ligament. These patients often also bleed profusely because tamponading the injury is difficult. For any suspected occult retroperitoneal haemorrhage, apply pressure to the puncture site, resuscitate the patient, ensure blood products are made immediately available and call for senior support.