Haemorrhage Flashcards
What procedures can post-op haemorrhage occur after?
Any
What are the classifications of post-op haemorrhage?
- Primary bleeding
- Reactive bleeding
- Secondary bleeding
What is primary bleeding?
Bleeding that occurs within the intra-operative period
How should primary bleeding be managed?
Should be resolving during the operation, with any major haemorrhages recorded in the operative notes and the patient monitored closely post-op
What is reactive bleeding?
Bleeding that occurs within 24 hours of the operation
What are most cases of reactive bleeding cause by?
A ligature that slips, or a missed vessel
Why might a vessel be missed during the operation (causing reactive bleeding)?
Due to intraoperative hypotension and vasoconstriction, meaning only once the blood pressure normalises post-op will this bleeding occur
When does secondary bleeding occur?
7-10 days post-op
What is secondary bleeding often caused by?
Erosion of a vessel from spreading infection
When is secondary haemorrhage most often seen?
When a heavily contaminated wound is closed primarily
What are the clinical features of haemorrhagic shock?
- Tachycardia
- Dizziness
- Agitation
- Visible bleeding
- Decreased urine output
What is one of the most sensitive signs of haemorrhagic shock?
Raised respiratory rate
What should be considered when thinking about hypotension as a sign of haemorrhagic shock?
It is often a late sign, and you should not assume a patient is stable or not bleeding just because their BP is normal
What should examination include in suspected haemorrhagic shock?
- Thorough exposure for bleeding
- Systematic palpation of the surgical Rea looking for swelling, discolouration, disproportionate tenderness, and any peritonitis
What is important when there is clinical suspicion of post-operative bleeding?
Fast and efficient initial management
What are the initial steps in monitoring post-op haemorrhage?
A-E approach, taking particular care to ensure IV access (18G cannula as minimum) and rapid fluid resuscitation
What is involved in the management of post-op haemorrhage?
- Direct pressure applied to bleeding site
- Urgent senior surgical review
- Appropriate imaging to ascertain level of bleeding
- Urgent blood transfusion
- Read op notes
When should urgent blood transfusion be considered in post-op haemorrhage?
In case of moderate to severe post-op haemorrhage
What blood products may be used in post-op haemorrhage?
- RBC
- Platelets
- FFP
Major haemorrhage protocol activated as necessary
What should be looked for in the op notes in post-op haemorrhage?
- Type of surgery
- Location of wounds, drains, or areas of importance
What may be required after senior review in post-op haemorrhage?
May be appropriate to re-operate on the patient for further haemostasis
After what surgeries might haemorrhage have catastrophic consequences?
Post thyroidectomy or parathyroidectomy
What is the result of the potential for bleeding post thyroidectomy or parathyroidectomy having catastrophic consequences?
Surgeon must take great care to ligate any vessels and coagulate any bleeding points
What is the primary sign of post-op haemorrhage after thyroidectomy or parathyroidectomy?
Airway obstruction
Why is the primary sign of post-op haemorrhage after thyroidectomy or parathyroidectomy likely to be airway obstruction?
Because the paratracheal fascia of the neck will only distend so far, so when bleeding occurs into this space, compression on the venous return results in venous congestion, with subsequent laryngeal oedema leading to eventual asphyxiation
What should be done if there is any evidence of respiratory distress or airway compromise in patients post thyroidectomy or parathyroidectomy?
Emergency protocol for airway rescue, involving removing skin clips and deep layer sutures and suction of haematoma beneath, done at bedside as no time to get patient to theatre
Urgent senior surgical opinion and anaesthetic review should be organised
What artery is vulnerable to injury from laparoscopic ports?
Inferior epigastric artery
Why is the inferior epigastric artery vulnerable to injury from laparoscopic ports?
Because of its course
What is the course of the inferior epigastric artery?
Arises from external iliac artery and runs up abdominal wall below recus muscle vertically in approx mid-clavicular line
Why might injury to the inferior epigastric artery not be noticed at the time of surgery?
Due to gas insufflation
Where is the entry site for angiography?
External iliac artery in groin, above inguinal ligament
Where will bleeding from the external iliac artery caused by angiography go?
Any bleeding from this artery will go into the retroperitoneum
Why can bleeding from external iliac artery after angiography be difficult to detect?
Because the actual arterial puncture site is hidden by the inguinal ligament
Why do patients with bleeding from the external iliac artery after angiography often bleed profusely?
Because tamponading the area is difficult
What should be done in any suspected occult retroperitoneal haemorrhage cause by angiography?
Apply pressure to puncture site, resuscitate the patient, ensure blood products are made immediately available, and call for senior support
