Overview
Definition:
Post-operative hemorrhage refers to bleeding occurring after a surgical procedure, ranging from minor oozing to life-threatening exsanguination
A "return to OR" is indicated when conservative measures fail to control bleeding or when the hemorrhage is significant and potentially life-threatening.
Epidemiology:
The incidence of post-operative hemorrhage varies widely depending on the surgical specialty, complexity of the procedure, and patient factors, but it is a common and serious complication
Estimates range from 1-5% for general surgery to higher rates in complex vascular or oncologic resections
Early hemorrhage (within 24 hours) is often related to technical issues, while later hemorrhage can be due to infection or coagulopathy.
Clinical Significance:
Post-operative hemorrhage is a critical surgical emergency that can lead to hypovolemic shock, organ dysfunction, prolonged hospital stays, increased morbidity, and mortality
Prompt recognition and appropriate management, including a timely return to the operating room, are paramount for patient survival and recovery
Understanding the algorithm ensures systematic evaluation and swift decision-making.
Clinical Presentation
Symptoms:
Sudden onset of increased surgical drain output
Active bleeding from the surgical site or drains
Tachycardia and hypotension (signs of shock)
Decreased urine output
Diaphoresis
Restlessness or altered mental status
Pallor
Abdominal distension or pain (if intra-abdominal).
Signs:
Hypotension (systolic BP < 90 mmHg or a drop of >20 mmHg from baseline)
Tachycardia (>100 bpm)
Tachypnea
Cool, clammy skin
Decreased peripheral pulses
Signs of peritonitis if intra-abdominal bleeding
Expanding hematoma at the surgical site
Oozing from wound edges or drains.
Diagnostic Criteria:
No strict diagnostic criteria exist
diagnosis is primarily clinical, based on the signs and symptoms of active bleeding and hemodynamic instability following surgery
A significant increase in drain output compared to baseline, especially when bloody, is a key indicator
Hemodynamic instability despite fluid resuscitation strongly suggests ongoing significant hemorrhage.
Diagnostic Approach
History Taking:
Review the patient's baseline vital signs and fluid status
Note the type of surgery performed, the operative findings, and any intra-operative complications
Assess the onset and volume of any bleeding or drain output
Inquire about any coagulopathy, medications (anticoagulants, antiplatelets), or recent changes in patient condition.
Physical Examination:
Perform a rapid ABC assessment (Airway, Breathing, Circulation)
Assess vital signs meticulously
Palpate for abdominal distension or tenderness
Examine the surgical wound for active bleeding, hematoma formation, or dehiscence
Check drain output for color, volume, and consistency.
Investigations:
Complete Blood Count (CBC) to assess hemoglobin and hematocrit levels and platelet count
Coagulation profile (PT/INR, aPTT) to rule out or quantify coagulopathy
Blood type and crossmatch for potential transfusion
Basic Metabolic Panel (BMP) to assess electrolyte balance and renal function
Lactate level to assess tissue perfusion
Imaging may include FAST scan (Focused Assessment with Sonography for Trauma) if abdominal bleeding is suspected, CT scan with contrast to identify bleeding sources (if stable enough), or portable X-ray for suspected viscus perforation or retained foreign body.
Differential Diagnosis:
Technical error (e.g., poorly ligated vessel, slipped suture)
Coagulopathy (pre-existing or acquired)
Sepsis-induced coagulopathy
Erosion of a vessel by a drain or suture
Wound dehiscence with associated bleeding
Retained foreign body causing irritation and bleeding
Arteriovenous fistula formation
Bleeding from a previously unrecognised injury.
Management
Initial Management:
Immediate resuscitation is paramount: Establish large-bore IV access (two lines if possible)
Administer crystalloid fluids aggressively
Administer blood products (packed red blood cells, fresh frozen plasma, platelets) based on hemodynamic status and laboratory results (e.g., following ATLS or massive transfusion protocol guidelines)
Correct coagulopathy with appropriate blood products (FFP for INR, platelets for thrombocytopenia)
Administer tranexamic acid if indicated (e.g., in trauma or specific high-risk surgeries).
Medical Management:
While awaiting return to OR, continue aggressive fluid resuscitation and blood product replacement
Ensure adequate oxygenation and ventilation
Monitor urine output closely with an indwelling catheter
Control pain adequately
Monitor vital signs and drain output continuously
Administer vasopressors if hypotension persists despite adequate volume resuscitation (use with caution).
Surgical Management:
The primary surgical management is immediate return to the operating room for exploration and control of hemorrhage
The surgeon must be prepared to identify and ligate bleeding vessels, repair injured structures, evacuate hematomas, and ensure adequate hemostasis
Techniques include direct ligation, use of hemostatic agents (e.g., surgicel, bone wax), cautery, and potentially vascular interventional radiology for embolization of specific bleeding vessels if available and stable.
Supportive Care:
Intensive monitoring in an ICU setting is often required postoperatively
Maintain meticulous fluid balance and electrolyte management
Provide adequate pain control
Monitor for signs of organ hypoperfusion or failure
Initiate early nutritional support as appropriate once hemodynamically stable
Continue vigilant monitoring of drain output and wound status.
Complications
Early Complications:
Hypovolemic shock
Multi-organ dysfunction syndrome (MODS)
Acute kidney injury (AKI)
Respiratory distress
Disseminated intravascular coagulation (DIC)
Anastomotic leak (if related to ischemia from hypoperfusion).
Late Complications:
Incisional hernia
Chronic pain
Adhesions
Infection at the surgical site
Pseudoaneurysm formation
Strictures.
Prevention Strategies:
Meticulous surgical technique with careful attention to hemostasis during the primary procedure
Careful ligation of all vessels
Use of appropriate surgical instruments and energy devices
Thorough irrigation and suction to identify bleeding
Preoperative assessment and correction of coagulopathies
Prophylactic antibiotics
Careful postoperative monitoring of drain output and vital signs
Early identification of patients at risk.
Prognosis
Factors Affecting Prognosis:
The degree of blood loss, the speed of diagnosis and intervention, the patient's underlying comorbidities, the site and nature of the bleeding, and the presence of shock and organ dysfunction are critical prognostic factors
Timely return to OR significantly improves outcomes.
Outcomes:
With prompt and effective management, many patients can recover fully
However, significant morbidity can occur due to hypoperfusion, blood loss, and prolonged ICU stay
Mortality is directly related to the severity of the hemorrhage and the presence of shock and organ failure.
Follow Up:
Postoperative follow-up should focus on wound healing, pain management, and monitoring for any late complications
Patients who experienced significant hemorrhage and shock may require a longer recovery period and multidisciplinary follow-up
Review of operative notes and the management of the hemorrhage event is crucial for future learning and quality improvement.
Key Points
Exam Focus:
The "Return to OR Algorithm" is a critical concept
Key decision points revolve around hemodynamic stability, drain output, and rapid assessment
Recognize that ongoing, significant bleeding requiring resuscitation is a strong indication for re-exploration.
Clinical Pearls:
Never dismiss a sudden increase in drain output, especially if it becomes serosanguinous or bloody
Continuous monitoring of vital signs and trends is more important than single values
Think "bleeding until proven otherwise" in a post-operative patient with hemodynamic instability.
Common Mistakes:
Delaying return to OR due to fear of re-operation or misinterpreting drain output as benign
Inadequate fluid resuscitation or delayed administration of blood products
Failure to correct coagulopathy promptly
Not considering technical errors as the primary cause of bleeding.