What is the management of surgical site bleeding?

Management of Surgical Site Bleeding

Immediately control surgical site bleeding through direct surgical intervention, local hemostatic measures, and correction of coagulopathy, with the time to bleeding control being the most critical determinant of survival. 1

Immediate Assessment and Hemorrhage Classification

• Classify bleeding severity using the ATLS grading system based on vital signs, estimated blood loss, and hemodynamic stability to guide resuscitation intensity 1
• Patients with hemodynamic instability (hypotension, tachycardia) or ongoing blood loss requiring >2 units of packed red blood cells require immediate surgical bleeding control unless initial resuscitation is successful 1
• Obtain baseline laboratory studies including complete blood count, coagulation parameters (PT/INR, aPTT), and serum lactate or base deficit to identify coagulopathy and guide transfusion 1

Immediate Surgical Bleeding Control

Patients presenting with hemorrhagic shock and an identified source of bleeding should undergo immediate surgical bleeding control procedure unless initial resuscitation measures are successful (Grade 1B). 1

• Minimize time between injury/bleeding onset and operative intervention, as delays directly increase mortality 1
• Apply a damage control surgical approach in severely bleeding patients, prioritizing hemorrhage control over definitive repair 1
• For pelvic fractures with bleeding, close and stabilize pelvic ring disruptions followed by angiographic embolization or surgical packing 1

Local Hemostatic Measures

Use topical hemostatic agents in combination with other surgical measures or packing for venous or moderate arterial bleeding associated with parenchymal injuries (Grade 1B). 1

• Apply collagen-based, gelatin-based, or fibrin-based hemostatic agents directly to bleeding sites, particularly when surgical access is challenging 1
• Consider oxidized cellulose, poly-N-acetyl-glucosamine, or mineral-based agents (kaolin, zeolite) for additional hemostatic effect 1
• Combine topical agents with manual compression and surgical packing rather than relying on agents alone 1

Correction of Coagulopathy

Antifibrinolytic Therapy

Administer tranexamic acid (TXA) 1 g IV over 10 minutes followed by 1 g over 8 hours as soon as possible and within 3 hours of bleeding onset (Grade 1A). 1

• Do not delay TXA administration while awaiting viscoelastic assessment results 1
• TXA reduces bleeding deaths by one-third and overall mortality by 1.5% in trauma patients 1

Reversal of Anticoagulation

For patients on anticoagulants with surgical site bleeding:

• Stop oral anticoagulation immediately for all major bleeding (hemodynamic instability, hemoglobin drop ≥2 g/dL, or critical site bleeding) 1, 2
• For vitamin K antagonists (warfarin): Administer 5-10 mg IV vitamin K plus prothrombin complex concentrate (PCC) for immediate reversal 1, 3
• For direct oral anticoagulants (DOACs): Administer specific reversal agents—idarucizumab for dabigatran or andexanet alfa for apixaban/rivaroxaban 1, 2
• Stop concomitant antiplatelet agents in major bleeding scenarios 1

Blood Product Transfusion

• Transfuse packed red blood cells to maintain hemoglobin ≥7 g/dL (≥8 g/dL if coronary artery disease present) 2, 4
• Transfuse platelets to maintain count >50,000/μL in active surgical bleeding 4
• Consider fresh frozen plasma and cryoprecipitate for ongoing coagulopathic bleeding after initial measures 5
• Higher-dose prothrombin complex concentrate (>15 IU/kg based on factor IX) without FFP may be effective for significant coagulopathic surgical field bleeding 5

Management of Specific Bleeding Scenarios

Cardiac Surgery Bleeding

• Surgical sites account for 65.7% of bleeding requiring re-exploration, with graft body (20.2%), sternum (17.0%), and vascular sutures (12.5%) being most common 6
• Surgical site bleeding has lower mortality compared to diffuse coagulopathic bleeding 6
• Meticulous intraoperative checking of potential bleeding sites reduces re-exploration risk 6

Abdominal/Pelvic Bleeding

• For unstable pelvic fractures with ongoing bleeding after external stabilization, use preperitoneal packing combined with angioembolization 1
• Consider intraoperative angioembolization with C-arm digital subtraction angiography when available 1
• REBOA (resuscitative endovascular balloon occlusion of the aorta) may serve as temporary bridge to definitive control but lacks quality evidence for routine use 1

Supportive Care and Monitoring

• Provide volume resuscitation with isotonic crystalloid (2000 mL in adults; 20 mL/kg bolus in children) 1
• Correct hypothermia (maintain temperature >36°C) and acidosis, as these worsen coagulopathy 1, 4, 7
• Assess and manage comorbidities contributing to bleeding (thrombocytopenia, uremia, liver disease) 1, 4
• Monitor serial hemoglobin, platelet counts, and coagulation parameters to guide ongoing transfusion 4

Common Pitfalls

• Approximately 75-90% of intraoperative and early postoperative bleeding is due to technical surgical factors, not coagulopathy—prioritize surgical control first 7
• Avoid blind segmental resection for gastrointestinal bleeding without preoperative localization, as this carries 30-57% mortality and 33% rebleeding rates 1
• Do not confuse heparin vial concentrations—fatal hemorrhages have occurred from using 10,000 units/mL vials instead of catheter lock flush products 8
• Uncontrolled bleeding creates a vicious cycle of hemodilution, hypothermia, consumption of clotting factors, and acidosis that perpetuates bleeding 7