What is the treatment for post-surgical hemorrhage (postoperative bleeding)?

From the Guidelines

The treatment for post-surgical hemorrhage (postoperative bleeding) is primarily surgical, with a focus on achieving hemostasis through mechanical means, such as packing, ligation of damaged vessels, or embolization, and may also involve the administration of tranexamic acid to reduce bleeding.

Treatment Options

• Surgical intervention: Pre-peritoneal pelvic packing (PPP) is a commonly used technique to control bleeding in hemodynamically unstable pelvic fractures, and can be performed along with external fixation 1.
• Angioembolization: May be recommended in selected cases with ongoing hemorrhage and/or transfusion requirements after pelvic packing procedure 1.
• Tranexamic acid administration: Recommended in cases of severe bleeding, as it has been shown to reduce bleeding without increasing the risk of thrombotic events 1.

Management Considerations

• Early surgical management: Implementation of standardized multidisciplinary clinical guidelines that include early surgical management with pelvic external fixation and direct PPP can lead to a significant decrease in transfused blood products and post-injury mortality 1.
• Post-operative care: Flexible postoperative resumption timing of anticoagulant therapy, such as low-molecular-weight heparin (LMWH), may be necessary to balance the risk of bleeding and thrombosis 1.
• Coagulopathy management: Recombinant activated factor VII (rFVIIa) may be considered in cases of uncontrolled bleeding due to coagulopathy, although its use is not well established in post-surgical hemorrhage 1.

From the Research

Treatment Options for Post-Surgical Hemorrhage

• The management of postoperative bleeding involves identifying and correcting potential causes of coagulopathy both pre- and post-operatively 2
• Treatment options for postoperative small bowel or colic anastomotic bleeding include conservative approach, surgery, endoscopic management, and angiographic embolization 3
• Conservative management is often undertaken for patients with postoperative anastomotic bleeding, but other therapeutic options may be necessary if this approach fails 3
• Strategic multimodal management, including the use of tranexamic acid, desmopressin, fibrinogen and prothrombin complex concentrates, may be used to improve management and reduce allogeneic blood product administration 4

Assessment and Management of Post-Operative Hemorrhage

• Improved surgical outcomes have been achieved as a result of preoperative risk assessments and developments in surgical and anaesthetic techniques, but post-operative haemorrhage remains a life-threatening complication requiring swift recognition and management 5
• The ABCDE (airway, breathing, circulation, disability, exposure) approach may be used for the rapid assessment of patients with post-operative haemorrhage 5
• Management interventions used to halt the bleeding and restore intravascular volume include fluid resuscitation, blood transfusion, and surgical intervention 5

Risk Factors for Secondary Hemorrhage

• Secondary hemorrhage after abdominal surgery is mainly associated with subjective human factors, such as duration of the operation, time of the first bleeding incident, and intervention time 6
• A long operative duration (>5 h) and an extended intervention time (>5 h) are independent predictors of risk of secondary hemorrhage 6
• Proper reductions in operation time and implementation of a quick response to bleeding are key factors in tackling bleeding and reducing the rates of postoperative hemorrhage and mortality 6