Post-operative Bleeding | Acute Management | ABCDE

Post-operative bleeds can range from minimal to life-threatening. Haemorrhage is a common complication that can happen after any operation, including laparoscopic procedures.
As post-op bleeds can be potentially life-threatening, you need to be able to recognise and manage them in the acute setting. This guide gives an overview of the recognition and immediate management of post-op bleeds using an ABCDE approach. You can check out our overview of the ABCDE approach here.

This guide has been created to assist students in preparing for emergency simulation sessions as part of their training. It is not intended to be relied upon for patient care.

Clinical features of post-op bleeds

Post-op bleeds can be divided into three different categories.

Primary bleeding

• This is bleeding that happens during the surgical procedure.
• The surgical team should deal with this bleeding intraoperatively.
• Look at the surgical notes for a documented record of how much blood they are estimated to have lost.
• Sometimes the operation note might even recommend a post-op transfusion for blood loss.

Reactive bleeding

• This is bleeding within 24 hours of the operation.
• During surgery patients are often hypotensive and relatively vasoconstricted. In the post-operative period when the blood pressure rises and vasodilatation occurs, a damaged blood vessel may start to bleed more.

Secondary bleeding

• This is bleeding 7-10 days after the operation.
• Secondary bleeding is often associated with spreading wound infection.

Clinical signs of a significant post-op bleed

• Tachypnoea
• Tachycardia
• Hypotension (significant hypotension suggest a very large bleed, your patient can lose a lot of blood and still have a normal blood pressure)
• Clamminess
• Cold peripheries
• Dizziness
• Confusion/agitation

On examination you must look for:

• Evidence of external bleeding
• Swelling (which could represent a collection of blood/haematoma)
• Discoloration/bruising
• Tenderness around the surgical site
• Peritonism

Classification of haemorrhagic shock

It is also useful to be aware of how haemorrhagic shock is classified, as it provides a reference point as to the likely volume of the bleed based on your clinical findings. An important thing to note is that blood pressure can appear normal despite a significant loss of circulating volume(30%). A normal blood pressure in isolation should therefore not reassure you that the patient is stable.

Classification of haemorrhagic shock ¹

Tips before you begin

• Treat all problems as you find them
• Re-assess regularly and after every intervention to see if your management is effective
• Make use of the team around you to delegate tasks where appropriate
• All critically unwell patients should have continuous monitoring equipment attached for accurate observations including:
  • Blood pressure
  • 3-lead ECG
  • Oxygen saturations
  • Heart rate
  • Respiratory rate
• Communicate how often you would like these observations to be relayed to you
• Call for help early using an appropriate SBARR handover structure (check out the guide here)
• You need to both request investigations and review results as they become available
• You don’t have to memorise everything off by heart, ask for guidelines and algorithms that are relevant (i.e. major haemorrhage protocols)
• If you would like medications or fluids, these will need to be prescribed
• Don’t forget to document everything you have found and done in the patient notes!

Initial steps

You are likely to be called to see this patient either:

• On the ward after their operation OR
• As a presentation to ED following a day case or shortly after discharge

Inspection

Perform a quick general inspection of the patient to get a sense of how unwell they are:

• If the patient is unconscious, check for a pulse and check that the patient is breathing.

If the patient is unconscious or unresponsive and not breathing start the basic life support (BLS) algorithm as per resuscitation guidelines. Call 2222 for help!

• Perform AVPU and assess their consciousness level
• How do they look?
• What is their breathing like?
• Can you smell anything? (i.e. infected wound)
• Are there any clues from around the bedside? (look for drug charts, medication, IV lines, monitoring equipment etc)

Interaction

• Introduce yourself to the patient even if they appear unconscious as they may still be able to hear you.
• If the patient is able to answer questions- ask them how they are feeling.

Preparation

Ensure you have as much information as possible available to you

• Operation note
  • Clarify exactly what operation they have had and the site.
  • Look for estimated intraoperative blood loss.
  • Also look to see if the surgical team have specified a particular management plan or offered any advice on what to do should the patient become poorly.
• Patient notes
• Drug charts including diabetes charts!
• Observations charts

Catastrophic bleeding

An exception to ABCDE: If there is a visible bleeding site and significant bleeding, direct pressure should be applied ASAP.

If the patient is not exsanguinating then the normal ABCDE approach should be followed.

Airway

Assessment

Assess the patient’s ability to speak, listen to the patient’s breathing for added sounds and inspect the mouth.

• The presence of stridor (a high pitched inspiratory noise) indicates upper airway obstruction. In post-op bleeding, this might indicate that your patient’s consciousness level is impaired enough to compromise airway patency (the brain is being hypoperfused).

Head and neck surgery: Swelling or bleeding post-op can cause airway compromise and asphyxiation. You need senior surgical help ASAP.

Intervention

If you think your patient has a compromised airway you need help. Put out a crash call immediately as you require urgent anaesthetic input to secure the airway. You can perform some simple airway manoeuvers in the meantime.

Maintaining the airway whilst awaiting senior support

1.  Perform a head tilt, chin lift manoeuvre.

2.  If noisy breathing persists, try a jaw thrust.

3.  If this is still not enough to open up the airway you can consider the use of an airway adjunct:

• If your patient is still semi-conscious then consider using a nasopharyngeal (NP) airway.
• If your patient is able to tolerate an oropharyngeal (OP, or Guedel) airway then you can use one of these. However, this indicates that your patient is seriously unwell as they no longer have a gag reflex.

Re-assess after any intervention

If your patient starts to improve throughout your assessment, they may no longer be able to tolerate the OP airway and you should remove it as soon as possible to prevent gagging/aspiration.

Breathing

Assessment

Oxygen saturation: aim for 94-98%.

Respiratory rate:

• Tachypnoea is a very sensitive marker of post-op bleeding. As there is less haemoglobin available to carry oxygen around the body your patient will try to compromise for this by breathing faster.
• Impaired consciousness may lead to a reduced respiratory rate (bradypnoea).

Examination

Auscultate both lungs:

• Reduced air entry bilaterally suggests significant airway compromise and the need for critical care input.
• Unilaterally reduced air entry might represent a haemothorax. Palpate and percuss to assess chest expansion and resonance/dullness.

Intrathoracic surgery: Each side of the thorax can hold up to 1.5L of fluid. A significant haemothorax can accumulate before your patient complains of feeling unwell.

Investigations

Arterial blood gas

An arterial blood gas may be useful to quantify the degree of hypoxia if your patient has very low oxygen saturations, however, it should not delay volume replacement.

A blood gas can also give you a quick blood glucose level. You should always try to get a more accurate reading to confirm the blood gas result.

Chest x-ray

If you are concerned about an intra-thoracic collection order a CXR to assess what you are dealing with i.e. a large haemothorax.

A chest x-ray is not immediately indicated if all your examination findings are normal.

Intervention

Oxygen

• Administer oxygen as soon as possible to maximise saturation levels.
  • High-flow oxygen (15 litres) should be administered through a non-rebreathe mask.
• If the patient is conscious, sit them upright.
• Maintain oxygen saturations between 94-98%

Assisted ventilation

• If your patient is unconscious and their respiratory rate is inadequate (too slow or irregular with big pauses), you can provide assisted ventilation through a bag-valve-mask (BVM).
• Ventilate at a rate of 12-15 breaths per minute (roughly one every 4 seconds).

Re-assess after any intervention

Circulation

Assessment

Pulse

• Your patient will likely be tachycardic due to hypovolaemia
• Check several pulses (i.e. brachial, femoral, pedal)

Blood pressure

• Hypotension will eventually occur as a result of fluid depletion, however, your patient might be able to maintain their blood pressure so don’t be falsely reassured by a normal BP (remember the classifications of haemorrhage above).

Surgical drains

• Check any drains/catheters in situ for blood and try to quantify the amount

Examination

• Look for any visible bleeding/bruising – apply direct pressure if possible
• Your patient may appear clammy/pale
• Capillary refill time may be normal or sluggish due to hypovolaemia
• Pulse: Tachycardic
• Blood pressure: Normal or hypotensive

Intervention

Secure intravenous access

• The gold standard is to insert 2 large bore cannulas for acutely unwell patients.
• If your patient is going to need a blood transfusion they need minimum 18G cannulas so that the blood can run through quickly and without clotting.

Urgent blood transfusion

• In moderate to severe post-op bleeds your patient might require blood replacement
• Ask for the major haemorrhage guidelines and speak to a senior
• Severe bleeding will require more than Packed Red Blood Cell replacement and your protocol will guide Platelet and Fresh Frozen Plasma replacement
• See our guide to prescribing a blood transfusion

Auto-transfusion

• Positioning your patients with their legs up is a useful initial step whilst waiting for blood/fluids to be set up. This uses gravity to redistribute your patient’s own blood to their central organs and brain.

Administer IV fluids

• Titrate your fluids to their haemodynamic stability. However, be aware that patients with large bleeds should be resuscitated with blood rather than salty water.
• A maximum of 1-2 litres of fluid should be administered. If your patient is transiently responsive but then becomes hypotensive again then they likely have an ongoing bleed and require blood products, not just fluids.
• Your patient needs fluids to:
  • Restore circulatory volume
  • Correct electrolyte imbalances.
  • Perfuse their kidneys!
• Use NaCl 0.9% or Hartmann’s solution for initial fluid resuscitation
• See our guide to prescribing intravenous fluids in adults

Investigations

Take blood samples

• Try if possible to collect blood samples during cannulation
• Group and Save/Cross Match –  blood type and matching blood products
• Full Blood Count – haemoglobin, platelet, evidence of infection
• CRP – infection/inflammation
• Urea and Electrolytes – to assess renal function (hypoperfusion of the kidneys leading to acute kidney injury)
• Liver Function Tests
• Clotting
• Serum Glucose
• Blood cultures – if considering infection

Record an ECG

• This should not delay your treatment of the bleeding. However, an ECG should be performed at some point. Significant bleeds can cause secondary myocardial ischaemia.

Consider imaging

• You may require an ultrasound scan or a CT scan to assess the source and severity of the bleed.

Re-assess after any intervention

Disability

Assessment

Blood glucose level

Assess pupils

• What size are they?
• Are they equal?
• Are they reactive to light?

Assess level of consciousness – AVPU/GCS

• The above Airway, Breathing and Circulation problems can all alter the patient’s neurological status because of decreased cerebral perfusion, causing the patient to be confused or drowsy.
• A formal record of your patient’s consciousness level will be really useful for tracking progress and changes throughout treatment.

Re-assess after any intervention

Exposure

Assessment

Inspection

• We routinely expose all unwell patients to make sure that we aren’t missing anything.
• Thoroughly inspect your patient for sources of bleeding. This might require a rectal (PR) examination if upper or lower gastrointestinal bleeding is suspected.

Urinary output

• Urine output will likely be reduced secondary to renal hypoperfusion. If possible ask the patient when they last passed urine, what it looked like (e.g. dark, haematuria) and how much they passed (approx). If the patient is already catheterised, inspect the catheter bag and review the fluid balance chart.

Temperature

• Patients with large bleeds are at risk of becoming hypothermic.

Intervention

Catheterise

• If necessary, catheterise your patient so you can keep an eye on urine output and use this to guide fluid replacement.
• Perform a urine dip.

Reverse hypothermia

• Use blankets to re-warm patients who are mild to moderately hypothermic.
• Consider active re-warming techniques in patients with severe hypothermia.

Wound swabs

• If you are considering a post-op wound infection, take swabs where possible.
• Re-assess after any intervention.

Reassess ABCDE

It is essential to continually reassess ABCDE and treat issues as you encounter them. This allows continual reassessment of the response to treatment and early recognition of deterioration.

Next steps

Well done! Your patient’s blood pressure is stable/rising, their pulse is within normal limits and you have fluid resuscitated them. They are starting to feel much better. But you aren’t done just yet…

Take a history

Now your patient might be able to give you a detailed history of what has happened and how they are feeling. If your patient is still confused you might be able to get a collateral history from staff or family members as appropriate. Check out our history taking guides for more information.

Review

• Patient notes
• Observation charts
• Fluid charts
• Investigation findings

Additionally, make sure to check the medications you have just prescribed and what they are normally taking. It might be that their current regime is inappropriate for them i.e. hold off any anti-hypertensives!

Is this a secondary bleed as the result of a spreading infection? Treat any suspected infection post-cultures or swabs being taken. You may need to consult the on-call microbiologist for advice on what antimicrobials to administer.

Document

It is really important that you document your initial ABCDE findings, any interventions you made and the response the patient had to those interventions. Write down important information you have elicited from the history taking.

Discuss

You need to talk to the surgical team about their patient. You need senior input as the patient might require further surgery to stem any ongoing bleeding.

As a junior doctor it would be appropriate to give an SBARR handover outlining your assessment and actions, and to discuss the following:

• Does the patient further surgery for haemostasis?
• Are there any further assessments, investigations or interventions required?
• Does the patient need a referral to HDU/ICU?
• Should they be referred for a review by a specialist doctor (i.e. anaesthetist/surgeon)?
• Should any changes be made to the management of their underlying conditions?

References