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Postoperative Hemorrhage

Postoperative bleeding is a particularly significant problem during the acute phase of mechanical circulatory and respiratory support (first 24–48h), occurring at suture lines and cannulation sites, and can be difficult to localize [8].

From: Mechanical Circulatory and Respiratory Support, 2018

Related terms:

Cardiopulmonary Bypass

Tranexamic Acid

Blood Stasis

Anticoagulation

Heart Surgery

Transfusion

Blood Transfusion

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Complications of Surgery for Pineal Region Tumors

Randy S. D'Amico, Jeffrey N. Bruce, in Complications in Neurosurgery, 2019

Hemorrhage

Postoperative hemorrhage into an incompletely resected tumor (Fig. 24.1) is the most serious complication after pineal surgery.1–5 Risk of postoperative hemorrhage is closely associated with the nature of the tumor and its malignant potential, with a higher incidence after subtotal resections of soft, vascular malignant pineal parenchymal tumors.1-5,9 Notably, the risk of postoperative hemorrhage remains over several postoperative days, and careful surveillance with frequent neurologic assessment is critical. Whereas small hemorrhages without significant mass effect can usually be managed conservatively, large hemorrhages may require immediate evacuation and are associated with a greater risk of mortality.4 Importantly, any hemorrhage can result in obstructive hydrocephalus requiring urgent cerebrospinal fluid (CSF) diversion.

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Complications of Nasal Surgery and Epistaxis Management

Alexis H. Jackman, Marvin P. Fried, in Complications in Head and Neck Surgery (Second Edition), 2009

Postoperative Bleeding

Postoperative bleeding is the most common complication of most nasal surgery, including septoplasty and turbinoplasty.48,49 A through preoperative history targeted at identifying patients who are predisposed to bleeding (e.g., from bleeding disorders, as a result of over-the-counter or prescribed medications) is an important step in the prevention of postoperative bleeding. Common iatrogenic sources of bleeding in nasal surgery include trauma to the sphenopalatine artery if the lateral attachment of the middle turbinate is violated; the nasal branch of the sphenopalatine artery, which runs across the face of the sphenoid to supply the posterior aspect of the nasal septum; and the anterior ethmoidal artery when the vessel is pedicled from the skull base, although this vessel is more commonly the source of postoperative bleeding after sinus surgery. In addition, diffuse mucosal bleeding is a common complication of turbinate surgery. It can occur during the immediate or late postoperative period, and it is frequently observed after the removal of nasal packing.48 The management of postoperative bleeding is similar to that of other causes of epistaxis. However, in the case of immediate postoperative bleeding that is uncontrolled by simple nasal packing, a reasonable alternative is promptly returning the patient to the operating room for diagnostic nasal endoscopy and the control of epistaxis under local or general anesthesia.

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Postoperative Hematoma in Cranial and Spinal Surgery

Anil Nanda, Amey R. Savardekar, in Complications in Neurosurgery, 2019

Location of Postoperative Hemorrhage

POH after a cranial surgery can occur at any of the following locations: epidural, subdural, intraparenchymal, remote, or mixed. Many studies have found that the majority of postoperative hematomas were epidural or intraparenchymal.2 Kalfas and Little analyzed a series of 4992 intracranial procedures performed over an 11-year period for the occurrence of POH.5 Forty patients (0.8%) experienced POH, out of which 24 (60%) were intracerebral, 11 (28%) were epidural, 3 (7.5%) were subdural, and 2 (5%) were intrasellar. POH in 33 patients occurred at the operative site, and in 7 it occurred remote from the operative site. Palmer et al., in a review of 6668 operations performed over 5 years, reported 71 surgically evacuated POH, accounting for an incidence of 1.1%.6 POHs were intraparenchymal in 43% of cases, subdural in 5%, extradural in 33%, mixed in 8%, and confined to the superficial wound in 11%. In a study by Gerlach et al., 21 out of 296 patients operated for intracranial meningiomas developed a POH and needed resurgery.7 Out of those 21, 9 patients had extradural hematoma (EDH), 3 patients had intraparenchymal hematoma (IPH), and the remaining 9 patients had mixed [EDH/subdural hematoma(SDH)/IPH] hematomas. In 2305 cranial neurosurgical procedures reviewed by Taylor et al., 50 (2.2%) developed a hematoma.8 The hematomas were extradural in 26 patients (52%), intracerebral in 22 (44%) patients, and subdural in two (4%) patients.

Remote intracerebral hemorrhage is a rare complication of craniotomy with significant morbidity and mortality.3,9 Brisman et al. reviewed 37 cases of remote POH occurring after cranial neurosurgery and concluded that such hemorrhages likely develop at or soon after surgery, tend to occur preferentially in certain locations, and can be related to the craniotomy site, operative positioning, and nonspecific mechanical factors.9 They are not related to hypertension, coagulopathy, cerebrospinal fluid drainage, or underlying pathologic abnormalities.

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Percutaneous Approach in Renal Lithiasis

Petrişor A. Geavlete, ... Bogdan Geavlete, in Percutaneous Surgery of the Upper Urinary Tract, 2016

3.13.2.1 Postoperative Bleeding

Postoperative bleeding may occur after inserting the nephrostomy tube and is more frequently due to an important venous lesion. Postoperative bleeding can also occur as a result of migration of the nephrostomy tube outside the kidney or secondary to its withdrawal.

When the bleeding occurs secondary to withdrawal of the drainage, it is usually from a venous cause and can be controlled by compressive dressings or sometimes by reinserting the nephrostomy tube and maintaining it for several days, until the urine becomes clear. Staghorn calculi, multiple tracts, diabetes mellitus, and large calculi seem to be associated wih a higher risk of postoperative bleeding (Turna et al., 2007).

Most bleedings are minor, clinically insignificant, but in some cases the blood loss is severe and requires blood transfusions. In a series of 5803 patients with PCNL, de la Rosette et al. (2011) observed significant bleeding in 7.8% of cases, hematological re-equilibration being necessary in 5.7% of patients.

Severe late postoperative bleeding may occur in the first 3–4 weeks after the intervention, in most cases due to the injury of the segmental arteries. These may lead to late bleeding through the development of pseudoaneurysms or arterio-venous fistulas and usually require therapeutic intervention (embolization). In a series of 1854 patients with percutaneous nephrolithotomy, 1.4% of them presented complex hemorrhagic complications that required angiography and/or embolization for controlling the bleeding (Srivastava et al., 2005).

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Coarctation of the Aorta and Interrupted Aortic Arch

Laura A. Hastings MD, David G. Nichols MD, MBA, in Critical Heart Disease in Infants and Children (Second Edition), 2006

Bleeding and the Collateral Circulation

Postoperative bleeding is a common problem following CoA repairs.77 The aortic repair itself, by definition, is a high-pressure suture line that is relatively extensive. Loss of integrity of the suture line results in catastrophic bleeding. In older children with longstanding CoA, collaterals may have formed. The collateral system has an anterior and posterior collateral circulation. The anterior connects the internal mammary arteries and the external iliac arteries via the epigastric system. The posterior connects the thyrocervical arteries and the descending aorta via retrograde flow through dilated intercostal arteries. The intercostals can cause significant bleeding after a CoA repair; it takes time for the collaterals to regress. Heparin is frequently given for CoA repair in older children and is not always antagonized with protamine. This can contribute to postoperative bleeding. The intensive care management of bleeding involves careful blood pressure control and correction of a heparin-induced coagulopathy with protamine or fresh frozen plasma.

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Pharmacogenomics

Vidya Chidambaran, Senthilkumar Sadhasivam, in A Practice of Anesthesia for Infants and Children (Sixth Edition), 2019

Perioperative Bleeding

Postoperative bleeding after cardiac surgery has been associated with SNPs of coagulation proteins and platelet glycoproteins (GPIaIIa-52C>T and 807C>T, GPIb alpha 524C>T, tissue factor -603A>G, prothrombin 20210G>A, tissue factor pathway inhibitor-399C>T, and angiotensin-converting enzyme [ACE] deletion/insertion).352 Plasminogen activator inhibitor 1 (PAI-1) attenuates the conversion of plasminogen to plasmin, and the use of plasminolytic inhibitors may be subject to PAI-1 variants. In a study that evaluated the effectiveness of tranexamic acid (TXA) for reducing postoperative chest tube blood loss in adults undergoing cardiac bypass, patients with plasminogen activator inhibitor-1 5G/5G homozygotes who did not receive TXA showed more postoperative bleeding than those with other PAI-1 genotypes. Those with 5G/5G homozygotes who received TXA showed the greatest blood-sparing benefit.353

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Acute Liver Failure, Liver Transplantation, and Extracorporeal Liver Support

David M. Steinhorn, ... Timothy E. Bunchman, in Pediatric Critical Care (Third Edition), 2006

Bleeding.

Postoperative bleeding occurs because of the profound coagulopathy and thrombocytopenia many patients have going into liver transplantation, as well as the dilutional coagulopathy and thrombocytopenia that can occur intraoperatively. Bleeding should abate as function of the graft returns postoperatively. In addition, patients may return to the PICU on heparin infusions in an attempt to maintain patency of the hepatic artery and portal vein anastomoses. Monitoring drainage devices for trends in the amount and the characteristics of the drainage is critical to detect postoperative bleeding at the surgical site. Additionally, monitoring of the hemoglobin level is important; it is an indirect sign of bleeding and can ensure adequate oxygen-carrying capacity, optimally 9 to 12 g/dl. Platelet count should be followed and maintained in a suitable postoperative range as agreed on by both surgical and medical teams. Attempts to achieve perfect clotting function are generally avoided because of the high potential to promote thrombosis of the vascular anastomoses. Worsening coagulopathy suggests hepatic dysfunction, sepsis with DIC, or unrecognized internal bleeding and requires rapid, aggressive diagnosis with treatment of the underlying cause.

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Acute Liver Failure, Liver Transplantation, and Extracorporeal Liver Support

David M. Steinhorn, ... Timothy E. Bunchman, in Pediatric Critical Care (Fourth Edition), 2011

Bleeding

Postoperative bleeding occurs due to the profound coagulopathy and thrombocytopenia that many patients have going into liver transplantation as well as the dilutional coagulopathy and thrombocytopenia that can occur intraoperatively. Bleeding should abate as the function of the graft returns postoperatively. In addition, patients may return to the pediatric intensive care unit on heparin infusions in an attempt to maintain patency of the hepatic artery and portal vein anastomoses. Monitoring drainage devices for trends in the amount and the characteristics of the drainage is critical to detect postoperative bleeding at the surgical site. Additionally, monitoring of the hemoglobin is important as an indirect sign of bleeding and to assure adequate oxygen carrying capacity, optimally 8 to 10 g/dL. Platelet count should be followed and maintained in a suitable postoperative range as agreed on by both surgical and medical teams. Attempts to achieve perfect clotting function are generally avoided due to the high potential to promote thrombosis of the vascular anastomoses. Worsening coagulopathy suggests hepatic dysfunction, sepsis with DIC, or unrecognized internal bleeding and requires rapid, aggressive diagnosis with treatment of the underlying cause.

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Postoperative complications requiring intervention, diagnosis, and management

James J. Mezhir, ... Peter J. Allen, in Blumgart's Surgery of the Liver, Pancreas and Biliary Tract (Fifth Edition), 2012

Hemorrhage

Postoperative hemorrhage is a potentially lethal complication after pancreatectomy, and it can occur in the immediate postoperative period (<7 days) or in a delayed fashion (>14 days). Management is often guided first by the patient's hemodynamic stability. Any unstable patient should be transfused and taken for reexploration. Patients who can be easily stabilized may be candidates for endoscopic or interventional radiologic management. Intraluminal bleeding is most commonly from the gastrojejunal anastomosis and can often be managed with endoscopic therapy. Extraluminal bleeding from arterial pseudoaneurysm (Fig. 25.3) or vascular erosion from a pancreatic fistula typically occur later, following operation, and these can be approached via angiographic embolization in stable patients. A high index of suspicion is critical, as mortality from late postoperative hemorrhage is significant (Brodsky & Turnbull, 1991).

Yekebas and others (2007) analyzed the treatment and outcome of 87 patients who had postoperative hemorrhage in a series of 1669 pancreatic resections in 1524 patients (overall hemorrhage rate, 6%). Hemorrhage was classified as mild in 36 patients (41%) and severe in 51 patients (59%); 29 patients (33%) had a sentinel bleed. The bleeding site was extraluminal in 51 (59%) and intraluminal in 36 (41%); 17 patients had what appeared to be extraluminal hemorrhage, but further evaluation confirmed bleeding from the transected pancreas or resection cavity; and 34 patients (39%) had pancreatic fistula that preceded hemorrhage.

Treatment included endoscopy, angiography with coil embolization, and reoperation. Endoscopic treatment was successful in three (20%) of 15 patients with intraluminal hemorrhage. Any patient with true extraluminal hemorrhage required reoperation, and 17 patients had bleeding from the pancreatic anastomosis and had a secondary anastomotic leak. Among 25 patients treated with coil embolization by angiography, coiling was successful in 20 (80%). Reoperation was performed in 60 patients; in 33, surgery was the first-line treatment of hemorrhage, and the remaining 27 were for failure of nonoperative measures. This included patients with pancreatic fistula (13 patients) and/or vascular abnormalities such as pseudoaneurysm and erosions (12 patients). Fourteen patients died from hemorrhage, for a mortality rate of 16%. All of the mortalities were in the group with delayed hemorrhage, which occurred after postoperative day 5.

This and other studies have demonstrated that significant morbidity and mortality are associated with postoperative hemorrhage, especially when delayed beyond postoperative day 5 (Choi et al, 2004). These patients often require reoperation or interventional radiology procedures to halt life-threatening hemorrhage. Furthermore, patients who experience a postoperative hemorrhage often have underlying complications that require treatment, such as pancreatic fistula. If angiographic embolization successfully treats hemorrhage, cross-sectional imaging should be performed to assess for the presence of leak, fistula, or abscess that would require drainage.

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Coagulation Disorders in Congenital Heart Disease

Scott R. Schulman MD, ... William R. Greeley MD, MBA, in Critical Heart Disease in Infants and Children (Second Edition), 2006

SUMMARY

Postoperative bleeding continues to be a problem, despite two generations of progress in pediatric surgery, anesthesiology, and hematology. In this era of transfusion-acquired disease, cardiac surgery constitutes a major recipient of blood bank services. This chapter has addressed normal coagulation from a developmental perspective, highlighted pre-existing coagulation abnormalities in CHD, examined the relationship of those abnormalities to the hematologic derangement of cardiopulmonary bypass, and explored strategies for blood conservation during pediatric open-heart surgery. Newborn infant heart surgery has created a novel set of hematologic considerations that will provide new challenges and opportunities for future clinical investigation.

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