Haemorrhage

Question 1

Classification of post op bleeding

Answer 1

• Primary bleeding - within intraoperative period, resolved during operation
• Reactive bleeding - occurs within 24hrs of operation
• Secondary bleeding - 7-10 days post op

Question 2

What usually causes reactive bleeding?

Answer 2

• Ligature that slips or missed vessel
• Vessels can be missed during op due to intraoperative hypotension and vasoconstriction
• Only when BP normalises post op will bleeding occur

Question 3

Cause of secondary bleeding

Answer 3

• Erosion of vessel from spreading infection
• eg when heavily contaminated wound is closed

Question 4

Physiological response to bleeding

Answer 4

• Localised and splanchnic vasoconstriction
• Activation of RAAS - to maintain BP
• But if ongoing bleeding and hypovolaemia this system cannot maintain BP unless bleeding is stopped and volume is replaced

Question 5

Features of haemorrhagic shock

Answer 5

• Tachycardia
• Dizziness
• Agitation
• Raised RR
• Decreased urine output
• Hypotension - often very LATE sign

Question 6

Examination signs of haemorrhage

Answer 6

• Seeing external bleeding from wound/drain
• Swelling
• Discolouration
• Disproportionate tenderness
• Peritonism (if abdo)

Question 7

Management post op bleeding

Answer 7

• A-E approach
• IV access - fluids
• Read operation notes
• Direct pressure on bleeding site
• Urgent senior review
• Urgent blood transfusion if moderate/severe haemorrhage

Question 8

What should be part of transfusion if severe bleeding?

Answer 8

• RBC
• Platelets
• FFP
• Major haemorrhage protocol may need to be activated

Question 9

What might happen after senior review in post op bleeding cases?

Answer 9

• May need to re-operate
• Can be conservative for smaller haemorrhages
• Close monitoring should always be done

Question 10

Sign of post op haemorrhage after thyroidectomy/parathyroidectomy

Answer 10

• Airway obstruction - if vessels are not ligated or bleeding points not coagulated

Question 11

Why do you get airway obstruction in post neck op bleed?

Answer 11

• Pre-tracheal fascia will only distend so far
• So then you get compression of venous return = venous congestion and then laryngeal oedema
• –> asphyxiation

Question 12

Management of airway distress for post neck op bleed

Answer 12

Airway rescue:
* Removing both skin clips and deep layer sutures
* Suction of haematoma beneath
* ALL at bedside - no time to get to theatre
* Urgent senior surgical opinion, anaesthetic review, often need to return to theatre

Question 13

How can inferior epigastric artery be damaged?

Answer 13

• Arises from external iliac artery, then runs up abdominal wall below rectus muscle at mid clavicular line
• Vulnerable to injury from laparoscopic ports

Question 14

Presentation of inferior epigastric artery injury

Answer 14

• May not be noticed during surgery due to gas insufflation
• Acutely unwell post surgery - esp laparoscopic or Pfannensteil incision

Question 15

How can retroperitoneal bleeding occur post angiograph?

Answer 15

• Entry site into groin - external iliac artery punctered
• Bleeding from this artery can track into retroperitoneum

Question 16

Clinical signs of retroperitoneal bleeding post angio

Answer 16

• Unlikely to have large haematoma as arterial puncture is hidden by inguinal ligament
• BUT they often bleed profusely because tamponading is difficult

Question 17

Management of retroperitoneal haemorrhage post angio

Answer 17

• Apply pressure to puncture site
• Resuscitate patient
• Blood products
• Cross sectional imaging to confirm