Haemorrhage

Question 1

What procedures can post-op haemorrhage occur after?

Answer 1

Any

Question 2

What are the classifications of post-op haemorrhage?

Answer 2

• Primary bleeding
• Reactive bleeding
• Secondary bleeding

Question 3

What is primary bleeding?

Answer 3

Bleeding that occurs within the intra-operative period

Question 4

How should primary bleeding be managed?

Answer 4

Should be resolving during the operation, with any major haemorrhages recorded in the operative notes and the patient monitored closely post-op

Question 5

What is reactive bleeding?

Answer 5

Bleeding that occurs within 24 hours of the operation

Question 6

What are most cases of reactive bleeding cause by?

Answer 6

A ligature that slips, or a missed vessel

Question 7

Why might a vessel be missed during the operation (causing reactive bleeding)?

Answer 7

Due to intraoperative hypotension and vasoconstriction, meaning only once the blood pressure normalises post-op will this bleeding occur

Question 8

When does secondary bleeding occur?

Answer 8

7-10 days post-op

Question 9

What is secondary bleeding often caused by?

Answer 9

Erosion of a vessel from spreading infection

Question 10

When is secondary haemorrhage most often seen?

Answer 10

When a heavily contaminated wound is closed primarily

Question 11

What are the clinical features of haemorrhagic shock?

Answer 11

• Tachycardia
• Dizziness
• Agitation
• Visible bleeding
• Decreased urine output

Question 12

What is one of the most sensitive signs of haemorrhagic shock?

Answer 12

Raised respiratory rate

Question 13

What should be considered when thinking about hypotension as a sign of haemorrhagic shock?

Answer 13

It is often a late sign, and you should not assume a patient is stable or not bleeding just because their BP is normal

Question 14

What should examination include in suspected haemorrhagic shock?

Answer 14

• Thorough exposure for bleeding
• Systematic palpation of the surgical Rea looking for swelling, discolouration, disproportionate tenderness, and any peritonitis

Question 15

What is important when there is clinical suspicion of post-operative bleeding?

Answer 15

Fast and efficient initial management

Question 16

What are the initial steps in monitoring post-op haemorrhage?

Answer 16

A-E approach, taking particular care to ensure IV access (18G cannula as minimum) and rapid fluid resuscitation

Question 17

What is involved in the management of post-op haemorrhage?

Answer 17

• Direct pressure applied to bleeding site
• Urgent senior surgical review
• Appropriate imaging to ascertain level of bleeding
• Urgent blood transfusion
• Read op notes

Question 18

When should urgent blood transfusion be considered in post-op haemorrhage?

Answer 18

In case of moderate to severe post-op haemorrhage

Question 19

What blood products may be used in post-op haemorrhage?

Answer 19

• RBC
• Platelets
• FFP
  Major haemorrhage protocol activated as necessary

Question 20

What should be looked for in the op notes in post-op haemorrhage?

Answer 20

• Type of surgery

- Location of wounds, drains, or areas of importance

Question 21

What may be required after senior review in post-op haemorrhage?

Answer 21

May be appropriate to re-operate on the patient for further haemostasis

Question 22

After what surgeries might haemorrhage have catastrophic consequences?

Answer 22

Post thyroidectomy or parathyroidectomy

Question 23

What is the result of the potential for bleeding post thyroidectomy or parathyroidectomy having catastrophic consequences?

Answer 23

Surgeon must take great care to ligate any vessels and coagulate any bleeding points

Question 24

What is the primary sign of post-op haemorrhage after thyroidectomy or parathyroidectomy?

Answer 24

Airway obstruction

Question 25

Why is the primary sign of post-op haemorrhage after thyroidectomy or parathyroidectomy likely to be airway obstruction?

Answer 25

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

Question 26

What should be done if there is any evidence of respiratory distress or airway compromise in patients post thyroidectomy or parathyroidectomy?

Answer 26

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

Question 27

What artery is vulnerable to injury from laparoscopic ports?

Answer 27

Inferior epigastric artery

Question 28

Why is the inferior epigastric artery vulnerable to injury from laparoscopic ports?

Answer 28

Because of its course

Question 29

What is the course of the inferior epigastric artery?

Answer 29

Arises from external iliac artery and runs up abdominal wall below recus muscle vertically in approx mid-clavicular line

Question 30

Why might injury to the inferior epigastric artery not be noticed at the time of surgery?

Answer 30

Due to gas insufflation

Question 31

Where is the entry site for angiography?

Answer 31

External iliac artery in groin, above inguinal ligament

Question 32

Where will bleeding from the external iliac artery caused by angiography go?

Answer 32

Any bleeding from this artery will go into the retroperitoneum

Question 33

Why can bleeding from external iliac artery after angiography be difficult to detect?

Answer 33

Because the actual arterial puncture site is hidden by the inguinal ligament

Question 34

Why do patients with bleeding from the external iliac artery after angiography often bleed profusely?

Answer 34

Because tamponading the area is difficult

Question 35

What should be done in any suspected occult retroperitoneal haemorrhage cause by angiography?

Answer 35

Apply pressure to puncture site, resuscitate the patient, ensure blood products are made immediately available, and call for senior support