Haemorrhage in the surgical patient can be classified into 3 main categories:

• Primary bleeding – bleeding that occurs within the intra-operative period. This should be resolved during the operation, with any major haemorrhages recorded in the operative notes and the patient monitored closely post-operatively

• Reactive bleeding – occurs within 24 hours of operation. Most cases of reactive haemorrhage are from a ligature that slips or a missed vessel. These vessels are often missed intraoperatively due to intraoperative hypotension and vasoconstriction, meaning only once the blood pressure normalises post-operatively will this bleeding occur

• Secondary bleeding – occurs 7-10 days post-operatively. Secondary haemorrhage is often due to erosion of a vessel from a spreading infection. Secondary haemorrhage is most often seen when a heavily contaminated wound is closed primarily.

Clinical Features and Assessment

Clinical features of haemorrhagic shock include tachycardia, dizziness, agitation, visible bleeding, or decreased urine output. One of the most sensitive signs is a raised respiratory rate.

Hypotension is often a late sign – do not assume a patient is ‘stable’ or not bleeding just because their blood pressure is normal.

Examination of the patient should include a thorough exposure looking for bleeding, systematic palpation of the surgical area looking for swelling, discoloration, disproportionate tenderness, and any peritonism.

Management

If there is a clinical suspicion of post-operative bleeding, fast and efficient initial management will reduce overall morbidity and mortality. An A to E approach is advised, taking particular care to ensure adequate IV access (an 18G cannula as an absolute minimum, ideally larger) and rapid fluid resuscitation.

• Read the operation notes, clarifying the type of surgery and the location of wounds, drains, or areas of importance
• Direct pressure should be applied to the bleeding site (if visible)
• Urgent senior surgical review should be sought and appropriate imaging arranged in order to ascertain the level of bleeding
• Urgent blood transfusion should be considered in the case of moderate to severe post-operative haemorrhage. If severe bleeding, this should be in the form of red blood cells, platelets, and fresh frozen plasma, with a major haemorrhage protocol activated as necessary

Journal of Surgery and Anesthesia is a peer reviewed, open access journal dedicated to publishing research on all aspects of surgery and anaesthesia. This journal aims to keep anaesthesiologists, anaesthetic practitioners, surgeons and surgical researchers up to date by publishing clinical & evidence based research.

Journal of Surgery and Anesthesia addresses all aspects of surgery & anesthesia practice, including anesthetic administration, pharmacokinetics, preoperative and postoperative considerations, coexisting disease and other complicating factors, General Surgery, Robotic Surgery, Orthopedic Surgery, GI Surgery, Neurosurgery, Plastic Surgery, Cardiothoracic Surgery, Vascular Surgery, Urology, Surgical Oncology, Radiology, Ophthalmology, Pediatric Surgery, Trauma Services, Minimal Access Surgery, Endocrine Surgery, Colorectal Surgery, Laparoscopic and Endoscopic Techniques and Procedures. Submit manuscripts at https://www.longdom.org/submissions/surgery-anesthesia.html

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Kate Williams

Editorial Assistant

Journal of Surgery and Anesthesia.

Email: surgery@emedicalsci.com