Postoperative bleeding, reactionary and secondary haemorrhage

When you have closed an operation wound it may start bleeding: (1) During the first 48 hours (reactionary haemorrhage) because a clot in a vessel has been displaced, or a ligature has slipped. Or, (2) 8 to 14 days later (secondary haemorrhage) when the wound has become infected and eroded a vessel, usually quite a small one, sometimes a larger one. One of the purposes of monitoring a patient immediatelay after an operation is to watch for reactionary haemorrhage, so make sure your staff observe him carefully, and take his pulse and blood pressure regularly.

POSTOPERATIVE BLEEDING See also particular operations, particularly Caesarean section (18.10) and prostatectomy (23.19).

If a patient's WOUND BLEEDS, try firm local pressure and packing. If it bleeds briskly, you may have injured an artery, such as his inferior epigastric. Minor bleeding is probably coming from his subcutaneous tissues, and is unlikely to be serious. If local pressure fails to control bleeding, take him back to the theatre and open his wound. You can usually do this under local anaesthesia. Remove the sutures and tie or coagulate his bleeding vessels. Make sure he is on antibiotics (2.7).

If his BLOOD PRESSURE FALLS POSTOPERATIVELY, he may be hypovolaemic because: (1) The blood he lost at the operation has not been replaced, especially if he was hypovolaemic before it began. (2) The fluid which he lost into his sequestrated gut has not been replaced. (3) He was anaesthetised too deeply and his respiration is still depressed, leading to hypoxaemia and hypotension. (4) He has been given large doses of opioids, such as morphine or pethidine. (5) He has had a high subarachnoid (spinal) anaesthesic (A 7.4). (6) He may be septicaemic. (7) His gut may have been roughly handled. (8) He has been roughly handled on a trolley. If necessary, restore his blood volume, and nurse him with his legs raised. See also A 4.6.

If he goes into SHOCK with a fast pulse, pallor, perhaps with abdominal distension, or bright red blood from a drain incision, he has probably bled into his peritoneum. If two units of blood do not restore his blood pressure, consider reopening his wound to control the bleeding.

If, after a stomach operation, you ASPIRATE QUANTITIES OF FRESH BLOOD from his nasogastric tube he has probably bled from the anastomosis in his stomach. If his blood pressure is only a little depressed, perform gastric lavage every half hour with iced water containing 8 mg of noradrenalin 200 ml. If he has required more than 3 units of blood to maintain his blood pressure above 100 mm, and you are still aspirating fresh blood an hour later, re-explore him and revise his anastomosis. He is unlikely to stop bleeding spontaneously. A complete mucosal layer may have missed getting sutured. See also Section 11.3

If he BLEEDS FROM HIS GUT some days after the operation, the blood may be coming from a stress ulcer, or from a pre- existing duodenal ulcer. It may threaten his life. Monitor his pulse, his blood pressure, and his urine output. Keep a good drip going, and measure his haematocrit 3-hourly. Have at least two units of blood cross-matched for him. Irrigate his stomach with iced saline or tap water containing noradrenalin 8 mg in 200 ml every half hour. See also Section 11.3.