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Postoperative Bleeding


Bleeding in the postoperative period is a concern for the on-call physician. You must decide whether the bleeding has a surgical cause (major vessel bleeding) or a medical cause (abnormal coagulation status). Some patients will require a return to the operating room (OR) for control of bleeding. Other patients may require bedside care, reversal of coagulopathy, and/or transfusion of blood products. Guidelines for evaluation of bleeding patients and for management of postoperative bleeding problems are discussed in this chapter.

Phone Call

  • 1.

    What are the patient’s vital signs?

    • Rapid postoperative bleeding is occasionally associated with hypotension and tachycardia.

  • 2.

    How severe is the bleeding?

    • Ask the RN to describe the bleeding site. Is the dressing or the wound slowly oozing blood, or is there a large amount of blood on the dressing or on the patient’s bed? If there is a drain present, what is the character of the fluid? Are there large amounts of fresh blood? Also ask the RN if the surgical site appears markedly swollen or bruised (hematoma).

  • 3.

    What surgery did the patient have, and when was the procedure performed?

    • Knowing the surgical site is critical when managing bleeding patients. For example, a bleeding patient who has undergone abdominal, chest, or pelvic surgery can easily bleed into the potential spaces of these anatomic areas.

  • 4.

    Does the patient have known bleeding problems? Is the patient taking anticoagulant medication?

    • Ask the RN if the patient has a history of bleeding diathesis (e.g., alcoholic liver disease). Determine whether the patient is taking, or has recently taken, aspirin, warfarin, or other medication that interferes with normal blood clotting.

  • 5.

    Does the patient have recent blood count and coagulation studies? Is there blood available for this patient in the blood bank?

    • If a postoperative patient is already anemic from a surgical procedure, significant postoperative bleeding is likely to lead to decompensation. Recent coagulation studies are important to help you rule out coagulopathy as a cause of bleeding. Make sure that blood is available for any patient with significant postoperative bleeding.

Orders

  • 1.

    Order intravenous (IV) line access.

    • For patients with significant bleeding, ask the RN to establish an IV if a functional IV is not present.

    • For patients with significant bleeding, one or two large-bore (14- to 16-gauge) antecubital IVs are necessary.

    • Large antecubital IVs are generally better than central lines for fluid resuscitation. Although, if a central line is present, use your judgement.

  • 2.

    Give IV fluids.

    • Order a 500- to 1000-mL fluid bolus (normal saline [NS] or lactated Ringer’s [LR]) if the patient has hemodynamic compromise associated with active bleeding.

  • 3.

    Order hematocrit immediately.

    • Ask the RN to draw a hematocrit immediately if possible. The RN should be sure to draw blood from a site distal to the IV or from the opposite upper extremity. If the patient has bleeding associated with hemodynamic compromise, blood should be drawn only after IV access and fluid resuscitation have been initiated.

  • 4.

    Order platelet count and coagulation studies (prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (PTT)) immediately. Some hospitals monitor heparin with anti-X a levels.

  • 5.

    Order a blood bank laboratory test.

If there is mild bleeding, a type and cross is sufficient. If there is severe bleeding, the institution-specific massive transfusion protocol should be activated.

Informing the RN

Tell the RN you will be at the bedside in XX minutes.

Postoperative bleeding requires immediate bedside evaluation. The amount of bleeding may be underestimated by the RN.

Surgical Chart Biopsy

  • Vital sign trends are of utmost importance. What has the patient’s heart rate (HR) trend been? Tachycardia is an initial sign of hypovolemia and bleeding.

  • What has the patient’s hemoglobin/hematocrit trend been?

  • Is a type and screen available?

Elevator Thoughts

What are the causes of postoperative bleeding?

Surgical Causes

Technical Surgical Errors

  • 1.

    Ties coming off vessels

  • 2.

    Inadequate coagulation of vessels

  • 3.

    Unrecognized vessel injury (traumatic or iatrogenic)

  • 4.

    Transected vessels not bleeding at the time of surgery (vasospasm)

  • 5.

    Anastomotic bleeding

Bleeding From Surgical Sites

  • 1.

    Bleeding associated with coughing or hypertension

  • 2.

    Bleeding from vessel anastomoses (vascular surgery)

Medical Causes

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