What is the management of a hematoma in a postoperative quadriceps surgical site?

From the Guidelines

A hematoma in the quadriceps following surgery should be managed with prompt medical attention, focusing on reducing bleeding and swelling through rest, ice, compression, and elevation (RICE) as the initial step. The management of a hematoma in the quadriceps after surgery is crucial to prevent further complications such as infection, compartment syndrome, or permanent muscle damage.

Initial Management

• Apply ice for 20 minutes every 2-3 hours for the first 48-72 hours to reduce swelling and pain.
• Use compression with an elastic bandage wrapped firmly but not tightly around the thigh to help reduce swelling.
• Elevate the leg above heart level when possible to decrease blood flow to the area and reduce swelling.
• Pain management can include acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) if not contraindicated, as noted in general medical practice 1.
• Avoid aspirin as it may increase bleeding.

Prevention of Infection and Further Complications

• Prevention of hematoma during the procedure is desirable, and several interventions have been used, including meticulous cautery of bleeding sites and consideration of packing the pocket with antibiotic-soaked sponges to provide tamponade while leads are being placed 1.
• The application of topical thrombin may be helpful, particularly in anticoagulated patients, to prevent hematoma formation.
• Irrigation of the pocket is useful to remove debris and may reveal persistent bleeding that could lead to a pocket hematoma.
• Use of monofilament suture for closure of the subcuticular layer may avoid superficial postoperative cellulitis.
• A pressure dressing applied for 12 to 24 hours after skin closure and dressing may further decrease the risk of hematoma formation.

Follow-Up and Potential Surgical Intervention

• Routine ambulatory care follow-up after surgery to detect early complications has been performed in many centers, but recent data suggest that patients should be instructed to call their surgeon for development of fever or incision findings of inflammation 1.
• Large or expanding hematomas may require surgical evacuation to prevent severe complications.
• Physical therapy should begin once cleared by the surgeon, usually within 1-2 weeks, to prevent muscle atrophy and restore function.

Key Considerations

• Hematomas occur when blood vessels damaged during surgery leak into the surrounding tissue, creating a collection of blood.
• Most small to moderate hematomas resolve within 2-4 weeks with conservative management, but severe cases can lead to significant morbidity if not properly treated.
• The management strategy should prioritize reducing the risk of infection and promoting healing, as indicated by the most recent and highest quality evidence available 1.

From the Research

Hematoma in Quad Surgical

• Hematoma in the soft tissue is a swelling caused by bleeding, which can occur after trauma or operative procedures 2.
• Hematomas of the extremities can be seen in as many as 33 per 10,000 individuals annually, and prompt recognition and operative evacuation are necessary to avoid complications such as necrosis of the overlying skin and tissue ischemia 2.
• Post-operative haemorrhage is a life-threatening complication that requires swift recognition and management, and improved surgical outcomes have been achieved through preoperative risk assessments and developments in surgical and anaesthetic techniques 3.
• The management of post-operative haemorrhage involves rapid assessment of patients using the ABCDE approach and interventions to halt the bleeding and restore intravascular volume 3.

Risk of Infection and Antibiotic Prophylaxis

• Trauma, hemorrhage, and transfusion can impair the immune response, resulting in an increased incidence of infection 4.
• The current guidelines for antibiotic prophylaxis in bleeding trauma patients recommend re-dosing prophylactic antibiotic agents for every 10 units of blood products administered, but the evidence supporting these guidelines is limited 4.
• Studies have shown that blood loss and blood resuscitation can alter tissue antibiotic concentrations, but the clinical relevance of these changes is unclear 4.

Perioperative Considerations in Traumatic Injury

• Early management of trauma patients is dictated by the presence or absence of significant bleeding, and standard definitive surgical procedures can be conducted in hemodynamically stable patients 5.
• Damage control resuscitation (DCR) principles are used to manage patients in hemorrhagic shock, combining limited surgical techniques and balanced transfusion resuscitation strategies to mitigate trauma-induced coagulopathy (TIC) 5.
• Coagulation and anticoagulation in the intraoperative setting are critical, and optimal surgical hemostasis and a satisfactory function of the coagulation system are complementary 6.