Who should manage a post-hip surgery patient with bleeding from the drain site, when the original surgeon doesn't have privileges at the current hospital?

Who Should Manage Post-Hip Surgery Bleeding from Drain Site

The most senior doctor at the receiving hospital should immediately assume the role of team leader and coordinate management of this post-surgical bleeding complication, regardless of the original surgeon's privileges. 1

Immediate Management Structure

Team Leadership and Responsibility

• The consultant or most senior doctor at the scene declares the massive haemorrhage situation and directs patient management. 1 This is the person physically present at the receiving hospital, not the original surgeon.

• The team leader's role is to coordinate all aspects of care including clinical management, laboratory responses, and organization of emergency interventions to stop bleeding (surgical or radiological). 1

• A communications lead should be appointed immediately whose sole role is to communicate with laboratories, other departments, and importantly, the original surgeon for consultation on the surgical specifics. 1

Why the Receiving Hospital Team Must Lead

The guideline framework is clear that massive haemorrhage management requires immediate, coordinated action by those physically present. 1 Waiting for a surgeon without privileges would delay critical interventions and increase mortality risk. The receiving hospital team must:

• Control obvious bleeding points immediately (pressure, haemostatic dressings) 1
• Establish large-bore IV access (ideally 8-Fr central access) 1
• Initiate the hospital's major haemorrhage protocol 1
• Obtain baseline coagulation studies (FBC, PT, aPTT, Clauss fibrinogen, cross-match) 1

Surgical Consultation Strategy

While the receiving hospital team leads resuscitation, the original surgeon should be contacted immediately for consultation regarding:

• Surgical anatomy and approach used
• Potential bleeding sources specific to the procedure
• Whether the patient can be safely transferred once stabilized
• Whether the original surgeon can provide telephone guidance to a local orthopedic surgeon

If definitive surgical control is needed, the receiving hospital's orthopedic surgeon with privileges must perform the intervention. 1 Patient safety and immediate access to operating rooms supersedes continuity with the original surgeon.

Resuscitation Priorities During Coordination

• Resuscitate with warmed blood products, not crystalloids 1, 2
• Blood availability hierarchy: Group O (fastest) → group-specific → cross-matched 2, 3
• Administer tranexamic acid 1g IV over 10 minutes immediately if significant bleeding 2, 3
• Actively warm the patient and all transfused fluids 1
• Target fibrinogen >1.5 g/L; give fibrinogen concentrate 3-4g or cryoprecipitate if <1 g/L 2, 3

Common Pitfall to Avoid

Do not delay resuscitation or bleeding control waiting for the original surgeon to arrive or obtain temporary privileges. 1 Post-operative bleeding one week after hip surgery can represent massive haemorrhage requiring immediate intervention. The receiving hospital must activate its major haemorrhage protocol and manage the patient with available resources. 1

Definitive Management Options

Once stabilized, consider:

• Super-selective angiographic embolization (achieves hemostasis in 40-100% of cases, requires bleeding >0.5 mL/min) 2
• Surgical exploration by the receiving hospital's orthopedic team if embolization unavailable or unsuccessful 1
• Transfer to the original surgeon's hospital only if patient is stable and transfer time is short 4

Post-Resuscitation Care

• Admit to critical care unit for continued monitoring 2, 3
• Monitor coagulation parameters, hemoglobin, and assess for rebleeding 2, 3
• Initiate venous thromboprophylaxis as soon as bleeding controlled (patients rapidly develop prothrombotic state after massive haemorrhage) 2, 3