What is the prognosis and survivability of a patient with an intraabdominal (in the abdominal cavity) bleed post-operatively in shock?

Prognosis and Survivability of Post-Operative Intra-Abdominal Bleeding with Shock

Patients with post-operative intra-abdominal bleeding in shock have a poor prognosis with mortality rates of 30-35% unless immediate surgical control of bleeding is achieved.

Initial Assessment and Classification

The severity of hemorrhagic shock should be assessed using the American College of Surgeons classification system 1:

Class	Blood Loss	Pulse Rate	Blood Pressure	Mental Status
I	<750 ml	<100	Normal	Slightly anxious
II	750-1500 ml	>100	Normal	Mildly anxious
III	1500-2000 ml	>120	Decreased	Anxious, confused
IV	>2000 ml	>140	Decreased	Lethargic

Prognostic Factors

Several factors significantly impact mortality in patients with post-operative intra-abdominal bleeding in shock:

Negative Prognostic Indicators:

• Prolonged time between onset of bleeding and surgical intervention 1, 2
• Development of the "lethal triad" (acidosis, hypothermia, coagulopathy) 1
• Multiple vessel injuries (mortality approaches 100% with four or more injured vessels) 2
• Multiple associated non-vascular injuries 2
• Hypovolemic shock on presentation 2
• Hypothermia below 34°C (strongest independent predictor of mortality) 3
• Age (mortality increases significantly in patients over 70 years) 1

Management Algorithm and Survival Impact

1. Immediate Surgical Intervention

   • Minimizing time between bleeding onset and operation is critical 1
   • Prolonged diagnostic evaluation in the emergency department worsens outcomes 2
   • Mortality increases significantly with delays in surgical control of bleeding

2. Damage Control Surgery Approach

   • Indicated for patients with deep hemorrhagic shock, ongoing bleeding, coagulopathy, hypothermia, acidosis 1
   • Three-phase approach:
     • Initial abbreviated surgery for bleeding control
     • ICU resuscitation focusing on correcting coagulopathy, acidosis, hypothermia
     • Definitive repair once stabilized
   • Improves survival compared to prolonged definitive surgery in unstable patients 1

3. Angioembolization

   • May be considered as adjunct to surgery for persistent arterial bleeding 1
   • Can be used as first-line for delayed hemorrhage without severe hemodynamic compromise 1

Survival Statistics

• Overall mortality rate: 30-35% for major intra-abdominal vascular injuries 2
• Early mortality (70% of deaths) occurs due to massive blood loss at operation or early postoperative period 2
• Emergency surgery mortality: approximately 10% for lower GI bleeding despite improved localization methods 1
• Damage control surgery mortality: 27-33% for total abdominal colectomy 1
• Blind segmental resection mortality: 30-57% 1

Critical Pitfalls to Avoid

1. Delayed Intervention

   • Avoid prolonged diagnostic workup in unstable patients
   • Recognize that each hour of delay increases mortality

2. Inadequate Resuscitation

   • Target systolic blood pressure of 80-100 mmHg until bleeding is controlled 1
   • Avoid hyperventilation and excessive PEEP in hypovolemic patients 1

3. Attempting Definitive Repair in Unstable Patients

   • Major hepatic resections should be avoided initially 1
   • Use damage control principles for severely unstable patients

4. Failure to Monitor for Ongoing Bleeding

   • Serial clinical evaluations and laboratory testing are essential 1
   • Single hematocrit measurements are unreliable indicators of bleeding 1
   • Serum lactate and base deficit should be used to monitor shock severity 1

In conclusion, the prognosis for patients with post-operative intra-abdominal bleeding in shock is poor without prompt intervention. Immediate surgical control of bleeding using damage control principles, correction of coagulopathy, and prevention of hypothermia are essential to improve survival outcomes.