Post-Op Haemorrhage

Question 1

Classifications

Answer 1

Primary bleeding

Reactive bleeding

Secondary bleeding

Question 2

Explain primary bleeding

Answer 2

Bleeding that occurs within the intra-operative period.

This should be resolved during the operation.

Any major haemorrhages should be recorded in the operative notes and the patient monitored closely intra and post-op.

Question 3

Explain reactive bleeding.

Answer 3

Occurs within 24 hours of operation.

Question 4

Most common causes of reactive bleeding

Answer 4

Ligature that slips or a missed vessel.

The vessels are often missed intra-op due to intra-op hypotension and vasoconstriction.

This means they only start bleeding once BP normalises.

Question 5

Explain secondary haemorrhage.

Answer 5

Occurs 7-10 days post-OP

Question 6

Common causes of secondary bleeding.

Answer 6

Erosion of a vessel from a spreading infection.

Most often seen when a heavily contaminated wound is closed primarly.

Question 7

Clinical features

Answer 7

Haemorrhagic shock

Tachycardia

Dizziness

Agitation

Visible bleeding

Decreased urine output

Tachypnoea

Hypotension is often a late sign.

Question 8

Examination

Answer 8

Thorough exposure looking for bleeding

Systematic palpation of surgical area looking for swelling, discoloration, disproprotionate tenderness, and any peritonism.

Question 9

Degrees of shock

Answer 9

Question 10

Management

Answer 10

Fast and efficient initial management with A to E approach.

Adequate IV access with 18G cannula minimum + rapid fluid resus.

Question 11

Specific management

Answer 11

Read operation notes to clarify surgery and the location of wounds, drains, or areas of importance.

Direct pressure should be applied to the bleeding site.

Urgent senior surgical review should be sought and appropriate imaging arranged in order to ascertain the level of bleeding.

Urgent blood transfusion in the case of moderate to severe post-op haemorrhage. (In severe this should be RBCs, platelets and FFP)

Question 12

What neck surgery might lead to catastrophic haemorrhage?

Answer 12

Thyroidectomy or parathyroidectomy.

Question 13

Clinical features of neck surgery haemorrhage.

Answer 13

Airway obstruction is usually the primary sign.

Pretracheal fascia of the neck will only distend so far when bleeding into it, then when bleeding occurs into it there will be compression on the venous return.

This leads to venous congestion with subsequent laryngeal oedema leading to eventual asphyxiation.

Question 14

Management of neck surgery haemorrhage.

Answer 14

Airway rescue by emergency protocol

This involves removing both the skin clips and deep layer sutures and suction of haematoma beneath.

This is all done at the bedside as there is no time to get the patient to the theatre

You should also get urgent senior surgical opinion and anaesthetic review.

Question 15

What artery is vulnerable during laparoscopic ports around RUQ?

Answer 15

Inferior epigastric artery.

Question 16

Why might an inferior epigastric injury not be noticed at time of surgery?

Answer 16

Due to the gas insufflation.

Always be conscious about inferior epigastric artery injury in bleeding especially after laparoscopic surgery or surgery with a Pfannenstiel incision.

Question 17

When is the external iliac artery vulnerable?

Answer 17

During angiography where there is an entry site in the groin.

This is because the puncture sit is often the external iliac artery, just above the inguinal ligament.

Any bleeding from this artery will go into the retroperitoneum

Question 18

Clinical features.

Answer 18

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.

The patients bleed profusely because tamponading the injury is difficult.

Question 19

Management of retroperitoneal bleeding post-angiography.

Answer 19

Apply pressure to the puncture sit

Resus the patient and nesure blood products are available immediately.

Call for senior support.