What are the key things to watch out for in post-operative care, especially in patients with a history of clotting disorders or those who have undergone major surgery?

Post-Operative Monitoring Priorities

Monitor for bleeding complications and thromboembolic events as your two primary concerns, with bleeding risk assessment driving your anticoagulation strategy and surveillance intensity.

Critical Bleeding Surveillance

Immediate Assessment Parameters

• Check dressings every 4-6 hours initially - saturated dressings requiring more frequent changes signal abnormal bleeding 1
• Monitor for bright red bleeding persisting beyond 24-48 hours - normal drainage should transition from serosanguinous to serous within this timeframe 1
• Watch for expanding hematomas with increasing pain at the surgical site, which indicates active bleeding 1
• Track hemodynamic stability - tachycardia or hypotension suggests significant blood loss requiring immediate intervention 1

High-Risk Bleeding Scenarios

Patients undergoing cardiac, intracranial, spinal, urologic surgeries, or procedures lasting >45 minutes have 2-4% risk of major bleeding in the first 48 hours 2, 1. For these patients:

• Document drainage amount, color, and consistency at each assessment 1
• Monitor hemoglobin levels serially if significant blood loss is suspected 1
• Check coagulation parameters (PT, aPTT, fibrinogen) if abnormal bleeding develops 2, 1

Anticoagulation-Related Bleeding

Patients on therapeutic anticoagulation face 8% overall bleeding complication rates (10% in arthroplasty, 6% in trauma) 3. For these patients:

• Maintain INR monitoring 2-3 times weekly initially if on warfarin, then weekly once stable 4
• Consider platelet transfusion only if count <50 × 10^9/L with active excessive bleeding 1
• Avoid needle aspiration of hematomas due to infection risk 1

Venous Thromboembolism Prevention and Detection

Standard VTE Prophylaxis

All patients undergoing major surgery (>30 minutes) require pharmacologic thromboprophylaxis with low-dose UFH or LMWH unless active bleeding contraindicates it 2:

• Commence prophylaxis preoperatively or immediately postoperatively 2
• Continue for minimum 7-10 days postoperatively 2
• Extend prophylaxis to 4 weeks for major abdominal/pelvic cancer surgery, obese patients, or those with prior VTE history (reduces VTE from 12% to 4.8%) 2

Mechanical Prophylaxis

• Add 30-40 mmHg graduated compression stockings immediately to reduce post-thrombotic syndrome risk 4
• Use intermittent pneumatic compression during immobility periods to enhance venous return 4
• Never use mechanical methods as monotherapy unless pharmacologic prophylaxis is contraindicated by active bleeding 2

High-Risk VTE Patients

Patients with prosthetic heart valves, atrial fibrillation with prior stroke, or known clotting disorders require bridging anticoagulation:

• Maintain ACT 200-350 seconds during procedures depending on thrombotic risk 2
• Continue heparin infusion 24 hours postoperatively (aPTT 1.5-2.3 times control) for highest-risk patients 2
• Monitor closely in intensive care environment for early recognition of complications 2

Early Mobilization Protocol

Aggressive early mobilization is safe and essential - excessive immobilization worsens venous stasis and increases post-thrombotic syndrome risk 4:

• Begin supervised physical therapy immediately with graduated weight-bearing exercises 4
• Focus on calf muscle pump activation and range of motion exercises 4
• Assess mobility, swelling, and pain weekly for the first month 4

Infection Surveillance

Monitor for signs of surgical site infection, particularly in patients on therapeutic anticoagulation who face 5% overall infection rates (9% in arthroplasty) 3:

• Check for fever, increasing pain, erythema, or purulent drainage 5
• Patients should seek immediate attention for severe abdominal pain not relieved by medication or signs of infection 6

Common Pitfalls to Avoid

• Do not withhold mobilization due to VTE fear - immobilization actually increases thrombotic risk 4
• Do not rely on derived fibrinogen levels - use Clauss fibrinogen for accurate assessment 2
• Do not evacuate hematomas unless skin tension increases - premature intervention risks infection 1
• Do not use vasopressors before achieving hemostasis - restore perfusion only after bleeding control 2

Procedure-Specific Considerations

For endovascular procedures with thrombotic complications, maintain arterial access for 12-24 hours in high-risk patients to enable rapid intra-arterial thrombolysis if needed 2. Recombinant t-PA or urokinase (mean dose 975,000 IU) achieves complete recanalization in approximately 50% of cases 2.