Perioperative bleeding is a dreaded surgical complication. More often than not you will hear, “It was dry when we closed…” as your surgical colleagues struggle to identify the source. Hospitalists are often involved in managing patients before and after surgery, hence they need a good working knowledge of how to predict, evaluate, and manage perioperative bleeding. This chapter will focus on the preoperative evaluation of bleeding risk, intraoperative risk factors for bleeding, typical presentations of postoperative bleeding, and how a hospitalist needs to evaluate and manage the bleeding.
PREOPERATIVE EVALUATION OF BLEEDING RISK
To identify patients at increased risk of perioperative bleeding complications, inquire about any history of bleeding problems, such as a known bleeding diathesis, excessive bleeding from minor trauma, menorrhagia, gingival bleeding, hemarthoses, excessive bruising, petechiae, liver, or renal disease. Review medications that can affect normal coagulation, such as antiplatelet agents and anticoagulants, and review the risks and benefits of stopping these agents with the surgeon. All patients identified with risk factors for bleeding should have preoperative laboratory evaluations including a complete blood count, liver function tests, chemistry panel, prothrombin time (PT), activated partial prothrombin time (aPTT), and international normalized ratio (INR). The laboratory test results should be interpreted based on the information in Table 43-1.
TABLE 43-1Expected Laboratory Results by Type of Bleeding Disorder ||Download (.pdf) TABLE 43-1 Expected Laboratory Results by Type of Bleeding Disorder
|Bleeding Disorder ||CBC ||Platelet Count ||PT* ||aPTT ||TT ||Reptilase ||Fibrinogen** ||Clotting Time ||Comment |
|Antiplatelet agents ||Normal ||Normal ||Normal ||Normal ||Normal || || ||Prolonged || |
|Renal failure || ||Qualitatively abnormal ||Normal ||Normal ||Normal || || ||Prolonged ||Skin hemorrhage, bleeding at sites of surgery, trauma |
|Myeloproliferative disorders || ||Usually high, qualitatively abnormal ||Normal ||Normal ||Normal || || ||Prolonged ||Bleeding and/or thrombosis |
|Liver failure (+/– vitamin K deficiency, thrombocytopenia, fibrinolysis, DIC) ||+/– MAHA with schistocytes, helmet cells ||Low in liver disease due to splenic sequestration and TPO deficiency ||Prolonged (lack of procoagulant and anticoagulant proteins in unpredictable ratios) ||Prolonged (lack of procoagulant and anticoagulant proteins in unpredictable ratios) ||Prolonged || ||Low due to abnormal fibrinogen, increased fibrinolysis, DIC ||Variable ||Transient correction of prolonged INR with administration of Vit K and FFP |
|DIC ||MAHA with schistocytes, helmet cells ||Low ||Prolonged due to consumption of coagulation factors ||Prolonged due to consumption of coagulation factors ||Prolonged || ||Low due to increased fibrinolysis || ||Oozing from sites of trauma, catheters, or drains & petechiae, ecchymoses |
|Vitamin K deficiency, warfarin therapy, argatroban, oral direct thrombin and factor Xa inhibitors || ||Normal ||Prolonged due to predominant effect on factor VII ||Normal if mild, prolonged if severe || || || || ||Due to poor nutrition, prolonged use of broad spectrum antibiotics and other drugs |
|Deficiency or inhibition of factors VII, X, II (prothrombin), V, or fibrinogen || ||Normal ||Prolonged ||Normal || || || || ||Rarely, acquired prothrombin deficiency in antiphospholipid syndrome |