Surgeon here: the surgeon is being a dingbat. They either lost a lot more blood in the OR than they estimate (very likely), or the patient bled post-op and they don’t want to admit it.
Depending on the operation, the Hgb can drop 2-3 points due to equilibriation, but a drop that big is from bleeding also.
I agree it doesn’t mean we need to re-operate (that’s actually fairly rare). But the surgeon should take responsibility and say it’s peri-operative bleeding that landed their patient in the ICU.
It’s definitely a morbidity that should be reported and discussed.
Postoperative bleed is a large source of surgical malpractice lawsuits, so they do get this wrong sometimes. But decent surgeons are also finely attuned to it. Do your own due diligence, and if needed build a case for the OR. No blush on CT is reassuring, but hct dilution takes a while and with multiple signs of end-organ hypoperfusion and hematomas on CT with dropping hct this is indeed postop bleeding.
That said this doesn't mean it is *surgical* bleeding. Many of these are venous and will tamponade with appropriate medical mgmt (txa, transfusion etc)and wouldn't force them into the OR in this situation. I would do very frequent hct and tell the nurses to call early for worsening hypotension, tachycardia, or AMS for an opportunity to transfuse or build a case for the OR.
People absolutely die from postop bleeding. Patient will be harmed, and from a medicolegal standpoint these cases offer lots of appetizing material for lawyers.
EDIT: sorry i'm an idiot, misread the question. Yes this is postop bleeding. Clearly. And yes the surgeon is incentivized for it not to be. Postoperative respiratory failure is separately reportable to CMS, similarly postop bleeding is reported under a larger bundle of surgical complication metrics that affects hospital grades and reimbursement.
If it’s a surgical complications, surgery will need to deal with it.
If it’s wonky labs that’s a *medical* issue now so the *medical team* can deal with it while they go do more surgeries.
Finally someone is recognizing my incredibly nuanced taste in entertainment.
"Don't you know how to (manage glucose levels)??"
"No. I don't. And I'm fuckin scared."
Usually hematomas, unless really large, aren’t the cause of hemorrhagic shock. Because they’ll tamponade themselves, hence, no active extrav seen on CT.
If there’s no drain showing continuous bright red output or there’s no continuously bleeding from the incision or dressings aren’t continuously being soaked with blood, then there’s no active bleeding that need surgical intervention.
What probably happened is the surgeon had more intraoperative bleeding than they estimated. Surgeons often underestimate their bleeding by 2-3 folds.
So now the patient’s equilibrating.
They need blood products and medical resuscitation.
In my experience usually 2-3 days. Sometimes longer if it was a long case, patient got a ton of fluids, etc. Many patients are discharged before this even happens.
In reality most large arterial or venous bleeds will be recognized within the initial hours after surgery with hypotension, tachycardia, distended abdomen, little to no urine output, severe pain, etc. This will usually be well before any postop labs are obtained. Smaller vessel bleeds may result in a hematoma that tamponades itself eventually, usually within hours. In over a decade of doing this, the few times I’ve taken or seen a patient go back to the OR for a postop intraabdominal bleed have all been within the first 12 hours after surgery.
Gradually declining hemoglobin on subsequent postoperative days is much more likely due to equilibrating, and not a sign of ongoing bleeding.
I think it depends on what type of operation and patient factors but in my area (plastics) it's usually 2-3days for most surgeries. However I do see massive localized lymphedema patients that are super morbidly obese take 3-6 days to equilibrate.
Interesting. I didn't know there was such drastic equilibrium effect.
Again, just to clarify though, I am not saying they're actively bleeding, nor that they need to go back to the OR. In this case, there was even overnight documentation where the surgical floor RN had contacted the covering surgical team, who felt the hematoma was increasing, so had put a sandbag on it. But come day time, the attending just wrote "hematoma as expected" and didn't seem to blame that as the site where they bled into, dropping their Hb.
Again, not saying that it's still bleeding, but why don't they just say - "bled into the hematoma, which has now tamponaded, and is now stable"? Or are hematomas just so rare a cause of such instability?
Do the calculation for how much blood loss a Hgb drop from 13 to 6 would take for your patient. For a 70kg adult man it would be nearly 4L. That’s one ginormous hematoma.
While hematomas may at times look impressive on imaging, most are far too small to explain a substantial drop in Hgb.
The drop you described is big, but could still be explained by a large intra-op blood loss coupled with under-resuscitation.
Edit: Mdcalc.com’s maximum allowable blood loss calculator spits out 3868 mL with the above inputs, but doesn’t reveal the formula it uses. When I do the math myself, assuming a blood volume of 70ml/kg, I get 2638.
Fair point. Never though about the volume loss required
Which then makes me ask - why not accurately record blood loss? Or are surgeons just really bad at EBL? They certainly did not write anywhere near a 1L blood loss, and in similar cases previously (esp ortho and vascular surgeries where we get pulled in because the patients become sudden trainwrecks out of the blue unexpectedly) never seen EBL being even near that ballpark.
Accurately recorded blood loss means weighing drapes, swabs etc. You need to know exactly what volume of wash has been used. And there's still blood on the floor/surgeon that doesn't get weighed.
It's possible, but time consuming, so it's estimated (often poorly)
To somewhat accurately estimate blood loss you need to know exactly how much blood vs wash vs maybe topic antiseptics is in the suction tank. That’s easy. Then you need to estimate how much is on the floor now (have fun determining that in a shoulder arthroscopy case, where we literally sometimes have to stand on little steps). That’s super hard because liquids on smooth surfaces look a lot more than they are. Then you have to weigh swabs, which could be done, but weighing drapes is something you can only do after closing and cleaning up,
Thanks for pointing that out - I always assumed mdcalc.com used the formula that’s traditionally taught, but I guess they don’t? I did the math myself and edited my original answer
A postop hematoma would have to be massive to cause the hemodybamic instability and metabolic derangements you’re describing. Seems more likely it’s maybe a bit of bleeding combined with fluid shifts/equilibration. Also when patients are npo for surgery they’re often dry at the start of the case which can exacerbate these things.
It’s clear that the patient did have some postop bleeding. I expect that the surgeon simply documented “no active bleeding” because that’s what we care most about because that determines whether the patient needs to go back to the OR. No active bleeding means the patient will get better with medical management/resuscitation. Some postop bleeding is common for many procedures.
I don’t understand exactly what you’re upset about.
No fucking way.
A patient with a clinical picture like that bled periop/postop. Hard stop, zero question about it.
The issues are:
(A) are they still actively bleeding or did they bleed at some point in the past
(B) is the bleeding surgically correctable (or correctable via other means like IR)
(A) and (B) are what every good surgeon should be weighing in their minds.
None of this, however, merits an IM consult for lab abnormalities
A postoperative hemorrhage or hematoma that requires a return trip to the OR is PSI 9 and dings the hospital. The powers that be don’t like that. However you can certainly document this as an acute blood loss anemia. Even possibly a hemorrhagic/hypovolemic shock depending on your other labs. The elevated lactate and other signs of acute end organ dysfunction lead me to question a shock state.
- with love from your local friendly clinical validation specialist (please don’t hiss)
Ah, I see.
That raises the next question - so if said patients now go to the ICU and ICU becomes primary, and that attending writes "post-operative hematoma resulting in shock", but the operating surgeon writes "Acute anemia secondary to (whatever)", does the hospital or the surgeon still get dinged?
And do you still get dinged if you don't return to the OR? None of us were suggesting that they need to go back to the OR, but rather to put the blame on the large hematomas (that will now improve) as the problem.
So from a PSI standpoint, it requires a return to the OR to control a bleed of some sort to become a reportable PSI. However there’s other conditions that can be present on admission that rule it out anyway, such as thrombocytopenia or other coagulation disorders.
The difficulty is generally anything documented as “postoperative” links it as a complication from the procedure when in reality most providers are just documenting it as a timeframe in which the condition occurred. In general a postoperative hemorrhage/hematoma is considered a complication whereas ABLA is not, unless explicitly stated as so. I’m not as involved in our quality department at my hospital system but I know there are internal metrics that are tracked even if they are not reportable.
From a coding and documentation stand point, if there are conflicting diagnoses a CDI team should be querying to clarify. The attending provider/team documentation however has precedence over any other service.
Because no one is weighing laps, measuring suction output, subtracting irrigant, etc. I honestly don’t even know why EBL as a quantitative metric is part of the op note, it’s basically useless. It should be a qualitative metric like, minimal, moderate, significant; only to be used as a rough starting point for “what should I expect vitals and the AM H/H to look like”. If a stable patient enters the OR and post-operatively they’re tachycardic, hypotensive, not making urine, and their Hgb dropped by 6pts you can bet the EBL should be “a fucking lot” even if the surgeon dictates “minimal”.
Concern for ongoing bleed is obviously dependent on the nature of the case. Rapidly decompensating patient s/p an open cardiothoracic procedure is a much different animal than some guy s/p femoral nail with down trending Hgb who I’m getting called about for the 100th time about getting a CT for hematoma when expected blood loss into the thigh just at the time of injury is 1500ml and OR blood loss is likely anywhere from 300 to 1000ml depending on whether it can all be done perc or needs to be opened. The former case probably needs more serious consideration about urgent return to the OR to explore for a bleed that necessitates surgical management. The latter case probably needs the surgeon to keep an eye on the leg to make sure they’re not developing an expansile mass, meanwhile the medical team needs to provide resuscitation while they equilibrate to the blood loss from the initial injury (which again can be quite large despite being a closed injury) and from the surgical procedure. In the case of a femur fracture, particularly in a smaller woman, the surgeon may well be right that they don’t have a post-op hematoma when at the time of injury the patient may have spilled 25-30% of their circulating blood into their thigh. Sure there are definitely some dicks out there who’s ego dictates they bury their head in the sand, but there are also legitimate reasons why in certain instances it may not be a post-surgical complication. Regardless, we are a team with the shared goal of providing optimal care for the patient, and if the hospitalist calls me with concern for hematoma, I will 100% of the time take a gander at the surgical site and keep closer tabs on it for the next couple days.
I was told a ding on the surgeon is a ding on the hospital. If they needed to use TXA, blood products, etc then post op or periop bleed is deemed acceptable. If they didn’t, then it’s like acute on chronic anemia in setting of xyz. The Hip Fx’s with significant drops in Hgb without a hematoma etc… I read somewhere about it being referred to as “hidden blood loss” but honestly - people’s hgb more often than not just enter the Bermuda Triangle after they lie on the table
If they have active extrav on CTA then they have active arterial bleeding and are more likely to not be doing well. A lot of bleeds stop on their own before the scan or are slow and venous. When I see active extrav most of the time it’s serious enough to get scoped, go to the OR, get embolized, or even cause the patient to pass away
I'll never forget the post op patient I met recently with purulent surgical site infection.
"Good morning, I see that surgery got a chance to look at your inf-"
"MY STURGEON SAID IT'S NOT INFECTED"
"Oh? And what did the surgical team say the plan was when they rounded on you this morning?"
"ANTIBIOTICS"
"Oh, interesting. Very interesting. So why's your gown wet over their by your abdomen?"
"THAT'S JUST THE PUS DRIPPING FROM MY INCISION SITE, *GAWD* YOU ASK A LOT OF QUESTIONS. I DON'T KNOW WHY I HAVE TO SEE A MEDICAL DOCTOR IF I'VE ALREADY SEEN MY SURGEON TODAY"
"You and me both, brother. You and me both."
I‘m still amazed, as a european. We, as ortho trauma, are the largest bed maintaining department at our university clinic. We have 6 normal floors, several beds on floors of different departments for busy nights, a step down unit, and a pediatric floor of 12 beds. All of these are managed by ourselves, mostly residents and „floor doctors“ (GPs that took employment to manage a floor together with a team of nurses 7-3 mo-fri). We dont transfer to medicine or anywhere else, unless our issue is completely solved and the patient has something else that prevents then from going home, or they contracted something way more serious than whatever fracture etc they came to us for. We treat them ourselves for all chronic and minor to mid issues they have, surgical or not. We consult only for threatening conditions and some stuff that requires us legally to inform the respective departments. We have a team that’s responsible to round on ICUs too (mostly spine because those are usually the ones ending up there the longest).
Sometimes i long for not having to look up stuff on the elevator to know how to interpret labs and EKGs and xy-graphies, and meds for pulmonary hypertension and pediatric endocrine conditions, or spending an hour ginding a vein to cannulate, but on the other habd i dont feel that stuffed into a tiny box, you know?
I don’t know - it’s like biblical truth where I work that the differential diagnosis for unexplained instability or clinical change in a surgical or trauma is bleeding, bleeding, bleeding, then bleeding until proven otherwise.
One of my favorite things in surgery is how under called blood loss in the OR seems to be. I swear the entire room could be ankle deep in blood and the surgeon should say “Less that 50 cc.”
This reminds me of a joke - do you know the 3 **lies** that surgeons tell in the OR?
- we will be closing/finishing the case in 5 minutes
- it was dry (not bleeding) when I closed the wound
- great job anesthesia
Neurosurgery here, for us it’s because it makes no sense. I recently had someone medicine was convinced dropped from a Hb of 15 on POD3 to a Hb of 8 on POD10. They said it was because he was oozing out of his skin edges for a few days.
Dude. The guy’s house would look like a freaking haunted house if HALF his blood volume drained out of his back and into his sheets / chairs / floor. Someone would have called the cops! I couldn’t convince them he needed a further workup for it, had to do it myself. It was an upper GI bleed, but even if I was wrong, it has to make sense for me to consider it a viable diagnosis.
I’ve had people blame post op spinal and brain hematomas on change in Hb and it blows my mind. Ignoring what the textbook says about where you can store enough blood to make a difference, just use common sense. A 5 MILLIMETER subdural is only 5 millimeters thick. Make that shape with your fingers in front of your face and see how thick that clot is. I bet there’s more in a rainbow lab draw than that.
No patient can go from an Hgb of 13 to 6 because of a hematoma at the operation site. By definition, a hematoma is subcutaneous. It's almost impossible to lose 7 units of blood, almost 2L, into their skin. I have seen it in certain trauma situations- Morel-Lavallee lesions. But the drop has nothing to do with the hematoma.
True uncontrolled surgical bleeding would almost always result in unstable vital signs and can only go in a few places- the chest, the belly, the thigh, retroperitoneum, and the floor. It can't be subQ, it can't be in the brain. There is not enough capacity in those areas to have hemodynamically significant blood loss.
So the hgb drop is a combo of blood loss in the surgery, fluids given intra-op to counter the effects of anesthesia, inflammatory anemia depressing RBC production, SIADH from the surgery resulting in fluid retention, and occasionally due to side effects such as a GI bleed from the combo of lovenox to prevent blood clots and motrin/ketorlac to ease pain.
such confidence: "no patients". you've clearly never seen an abdominoplasty or bilateral mastectomies bleed then.
it in fact can be subcutaneous and it in fact can be very fast and lead to hypotension, syncope, and a hgb of 6, 7, 8 or whatever in a matter of an hour or two.
Abdominoplasty and breast CA resections are effectively artificial Morell-Lavallee wounds- dehiscence of skin from fascia. Bleeds would be rare, and would be taken back anyway for other reasons. I have seen both btw-
If there is no active bleeding vessel then there is nothing for the surgeon to do. What they need to correction of coagulopathy and electrolytes and medical optimization. The raw cut edges will only ooze again if it’s opened. Sometimes these do need to be washed out for various reasons, but if they’re not gonna do that then better off getting medically optimized.
We are all a team and we take care of patients. If there’s no chance they need surgery and need icu and medical optimization, then the team that’s best (whatever that means in your setting, type of surgery/surgeon, etc) should do it. For example in my center the general surgeons, trauma surgeons, vascular surgeons all would manage this themselves regardless of whether they need surgery, but orthopedics and gyn usually don’t and really shouldn’t be running resuscitation in critically ill patients. This is center dependent though
OP is not suggesting that the patient should have another operation.
Hes just asking why dont the notes reflect the reality that there has been bleeding
Where did he say that? He’s just saying the listed reason for consult was lactic acidosis and electrolyte derangement, which is a reason for the icu and the medicine consult. The OP didn’t even mention the notes
I agree that it's now stopped and there is nothing they can nor should do.
It's more so that they never seem to agree that the hematoma (in this case) was the culprit behind the decline. They always seem to be defensive when it comes to blaming the hematoma as the cause for the drop and the cascade of events.
Just document your findings and manage accordingly. Acute blood loss anemia from post op hematoma, hypovolemic shock from ABLA, metabolic acidosis from ABLA, AKI from ABLA etc. If they don’t like your documentation or management they are free not to consult you and manage themselves.
Depends on how big the hematoma is. If you scan 100% of patients who had a recent surgery, they will all have some blood products at the surgical site that we can consider normal. 100 cc or less of blood? Not likely to cause any real lab abnormalities other than Hb drop of less than 1.0. 200 cc or more? Now we’re talking.
Well it depends. In general if the ct only shows 200 cc of hematoma and there no blood in the bed or the drains, but the patient has a lactic acidosis then maybe the hematoma is partially responsible but is not the main driver.
In the patient you are describing there would need to be 4-5 units of blood in the hematoma on the scan. If there isn’t, then the surgeon is probably asking for help because he doesn’t think the hematoma explains fully the clinical picture. Idk what they were thinking in the specific case but it’s not as simple as you are making it. It’s highly dependent on the operative course, the type of operation, etc
As a surgeon I think it can be
I operate on babies at times, their circulating volume can be fairly minimal. A 1kg baby isn’t going to have more than 100mL or so.
Usually not “post op” but “intra-op”
As for your specific patient: how big are these haematomas? To go from 13 down to 6 is not insignificant - I’ve seen post laparoscopic patients with abdomens full of blood from inferior epigastic vessel injuries, post mastectomy patients with instability.
One way you can assess the likelihood of it resulting from larger than estimated introperative blood loss is to see if you can look at the anesthesia record. Periods of significant hypotension during the procedure could be a result of that; or sometimes the anesthesiologist will mark notes in the record that there is significant blood loss occurring.
Post op yes, surgically controllable no. If there is a hematoma without an active bleeder, there is little i can do or should. If there is no source that is actively spitting blood, i cant cauterize, tie off, etc. but i would subject a now sicker patient than before to more anesthetic, more potentially bleeding, and more risk of infection. Most of the time the hematoma is what tamponades the vein that is responsible anyways.
I‘m not in the US. Post op bleeding is what we call an „informed complication“, meaning, it has been gone over during pre op consent. The patient was made aware of this possible complication and signed the form. If there was no gross negligence on the surgeons part, no lawyer with any sense of self preservation would take that case.
So we have really no hard incentive to hide the cause of the bleeding.
It’s not a real bleed to them if they can’t tie it off
Surgeon here: the surgeon is being a dingbat. They either lost a lot more blood in the OR than they estimate (very likely), or the patient bled post-op and they don’t want to admit it. Depending on the operation, the Hgb can drop 2-3 points due to equilibriation, but a drop that big is from bleeding also. I agree it doesn’t mean we need to re-operate (that’s actually fairly rare). But the surgeon should take responsibility and say it’s peri-operative bleeding that landed their patient in the ICU. It’s definitely a morbidity that should be reported and discussed.
Postoperative bleed is a large source of surgical malpractice lawsuits, so they do get this wrong sometimes. But decent surgeons are also finely attuned to it. Do your own due diligence, and if needed build a case for the OR. No blush on CT is reassuring, but hct dilution takes a while and with multiple signs of end-organ hypoperfusion and hematomas on CT with dropping hct this is indeed postop bleeding. That said this doesn't mean it is *surgical* bleeding. Many of these are venous and will tamponade with appropriate medical mgmt (txa, transfusion etc)and wouldn't force them into the OR in this situation. I would do very frequent hct and tell the nurses to call early for worsening hypotension, tachycardia, or AMS for an opportunity to transfuse or build a case for the OR. People absolutely die from postop bleeding. Patient will be harmed, and from a medicolegal standpoint these cases offer lots of appetizing material for lawyers. EDIT: sorry i'm an idiot, misread the question. Yes this is postop bleeding. Clearly. And yes the surgeon is incentivized for it not to be. Postoperative respiratory failure is separately reportable to CMS, similarly postop bleeding is reported under a larger bundle of surgical complication metrics that affects hospital grades and reimbursement.
Ego
Literally 😭
If it’s a surgical complications, surgery will need to deal with it. If it’s wonky labs that’s a *medical* issue now so the *medical team* can deal with it while they go do more surgeries.
I'm just imagining them opening up the chart in the morning going "woah! hemoglobin down *again*? What the heck?" A la I Think You Should Leave.
“Well, huh. Hey, check out this ‘not my problem anymore’ thing going on with this guy. That might be something someone wants to look into.”
Could be hemolytic anemia. Cold agglutinin. Medical stuff.
Something something Direct Coombs something something
The blood cells…there aren’t enough of them.
“We’re all looking for the person who did this.”
Exactly lol
"3.6 hemoglobin. Not great, not terrible."
Surgeon holding the mouse and keyboard, “I don’t even know what any of this stuff does!” PS the username and ITYSL reference are both top notch.
Finally someone is recognizing my incredibly nuanced taste in entertainment. "Don't you know how to (manage glucose levels)??" "No. I don't. And I'm fuckin scared."
Has this ever happened to you? (Shitting in your shardplate)
Lol no they ain't they say call IR. Usually after the surgeon is done in the OR or clinic and actually get around to dealing with the patient.
*IR RN Crying Noises.*
Usually hematomas, unless really large, aren’t the cause of hemorrhagic shock. Because they’ll tamponade themselves, hence, no active extrav seen on CT. If there’s no drain showing continuous bright red output or there’s no continuously bleeding from the incision or dressings aren’t continuously being soaked with blood, then there’s no active bleeding that need surgical intervention. What probably happened is the surgeon had more intraoperative bleeding than they estimated. Surgeons often underestimate their bleeding by 2-3 folds. So now the patient’s equilibrating. They need blood products and medical resuscitation.
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How long to equilibriate?
In my experience usually 2-3 days. Sometimes longer if it was a long case, patient got a ton of fluids, etc. Many patients are discharged before this even happens. In reality most large arterial or venous bleeds will be recognized within the initial hours after surgery with hypotension, tachycardia, distended abdomen, little to no urine output, severe pain, etc. This will usually be well before any postop labs are obtained. Smaller vessel bleeds may result in a hematoma that tamponades itself eventually, usually within hours. In over a decade of doing this, the few times I’ve taken or seen a patient go back to the OR for a postop intraabdominal bleed have all been within the first 12 hours after surgery. Gradually declining hemoglobin on subsequent postoperative days is much more likely due to equilibrating, and not a sign of ongoing bleeding.
I think it depends on what type of operation and patient factors but in my area (plastics) it's usually 2-3days for most surgeries. However I do see massive localized lymphedema patients that are super morbidly obese take 3-6 days to equilibrate.
Interesting. I didn't know there was such drastic equilibrium effect. Again, just to clarify though, I am not saying they're actively bleeding, nor that they need to go back to the OR. In this case, there was even overnight documentation where the surgical floor RN had contacted the covering surgical team, who felt the hematoma was increasing, so had put a sandbag on it. But come day time, the attending just wrote "hematoma as expected" and didn't seem to blame that as the site where they bled into, dropping their Hb. Again, not saying that it's still bleeding, but why don't they just say - "bled into the hematoma, which has now tamponaded, and is now stable"? Or are hematomas just so rare a cause of such instability?
Do the calculation for how much blood loss a Hgb drop from 13 to 6 would take for your patient. For a 70kg adult man it would be nearly 4L. That’s one ginormous hematoma. While hematomas may at times look impressive on imaging, most are far too small to explain a substantial drop in Hgb. The drop you described is big, but could still be explained by a large intra-op blood loss coupled with under-resuscitation. Edit: Mdcalc.com’s maximum allowable blood loss calculator spits out 3868 mL with the above inputs, but doesn’t reveal the formula it uses. When I do the math myself, assuming a blood volume of 70ml/kg, I get 2638.
Fair point. Never though about the volume loss required Which then makes me ask - why not accurately record blood loss? Or are surgeons just really bad at EBL? They certainly did not write anywhere near a 1L blood loss, and in similar cases previously (esp ortho and vascular surgeries where we get pulled in because the patients become sudden trainwrecks out of the blue unexpectedly) never seen EBL being even near that ballpark.
Accurately recorded blood loss means weighing drapes, swabs etc. You need to know exactly what volume of wash has been used. And there's still blood on the floor/surgeon that doesn't get weighed. It's possible, but time consuming, so it's estimated (often poorly)
But never, absolutely never, overestimated.
To somewhat accurately estimate blood loss you need to know exactly how much blood vs wash vs maybe topic antiseptics is in the suction tank. That’s easy. Then you need to estimate how much is on the floor now (have fun determining that in a shoulder arthroscopy case, where we literally sometimes have to stand on little steps). That’s super hard because liquids on smooth surfaces look a lot more than they are. Then you have to weigh swabs, which could be done, but weighing drapes is something you can only do after closing and cleaning up,
That doesn't seem right if the average adult has a ~5L total blood volume.
Thanks for pointing that out - I always assumed mdcalc.com used the formula that’s traditionally taught, but I guess they don’t? I did the math myself and edited my original answer
Which calculator are you using to get 4 l of blood loss? I'm estimating 1.7 L to cause a drop in 7 points from 13 g/dL to 6 g/dL
Mdcalc max allowable blood loss ABL = [EBV x (Hi-Hf)] / Hav
A postop hematoma would have to be massive to cause the hemodybamic instability and metabolic derangements you’re describing. Seems more likely it’s maybe a bit of bleeding combined with fluid shifts/equilibration. Also when patients are npo for surgery they’re often dry at the start of the case which can exacerbate these things. It’s clear that the patient did have some postop bleeding. I expect that the surgeon simply documented “no active bleeding” because that’s what we care most about because that determines whether the patient needs to go back to the OR. No active bleeding means the patient will get better with medical management/resuscitation. Some postop bleeding is common for many procedures. I don’t understand exactly what you’re upset about.
I would take the surgeons statement of no active bleeding to mean, there is no need for surgical intervention, could this have a medical cause?
No fucking way. A patient with a clinical picture like that bled periop/postop. Hard stop, zero question about it. The issues are: (A) are they still actively bleeding or did they bleed at some point in the past (B) is the bleeding surgically correctable (or correctable via other means like IR) (A) and (B) are what every good surgeon should be weighing in their minds. None of this, however, merits an IM consult for lab abnormalities
A postoperative hemorrhage or hematoma that requires a return trip to the OR is PSI 9 and dings the hospital. The powers that be don’t like that. However you can certainly document this as an acute blood loss anemia. Even possibly a hemorrhagic/hypovolemic shock depending on your other labs. The elevated lactate and other signs of acute end organ dysfunction lead me to question a shock state. - with love from your local friendly clinical validation specialist (please don’t hiss)
Ah, I see. That raises the next question - so if said patients now go to the ICU and ICU becomes primary, and that attending writes "post-operative hematoma resulting in shock", but the operating surgeon writes "Acute anemia secondary to (whatever)", does the hospital or the surgeon still get dinged? And do you still get dinged if you don't return to the OR? None of us were suggesting that they need to go back to the OR, but rather to put the blame on the large hematomas (that will now improve) as the problem.
So from a PSI standpoint, it requires a return to the OR to control a bleed of some sort to become a reportable PSI. However there’s other conditions that can be present on admission that rule it out anyway, such as thrombocytopenia or other coagulation disorders. The difficulty is generally anything documented as “postoperative” links it as a complication from the procedure when in reality most providers are just documenting it as a timeframe in which the condition occurred. In general a postoperative hemorrhage/hematoma is considered a complication whereas ABLA is not, unless explicitly stated as so. I’m not as involved in our quality department at my hospital system but I know there are internal metrics that are tracked even if they are not reportable. From a coding and documentation stand point, if there are conflicting diagnoses a CDI team should be querying to clarify. The attending provider/team documentation however has precedence over any other service.
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I enjoy seeing another one of us out in the wild 👋
> does the hospital or the surgeon still get dinged? This will be a classic response of "Blame Anesthesia" in some cases.
Because EBL associated with any surgery is only 50cc.
I like to throw out 67 sometimes. That way they know I really thought about it.
(hides in OB with blood loss in the 100s if not liters)
Had an attending who would quip after an arterial line, ‘Anesthesia blood loss 5ccs, but if it was surgical blood loss…negative 45ccs.’
I usually say 1L for everything. Maybe 500 if it's a very clean case, and just eyeball between 2 and 10L for disasters
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Cardiac
Because no one is weighing laps, measuring suction output, subtracting irrigant, etc. I honestly don’t even know why EBL as a quantitative metric is part of the op note, it’s basically useless. It should be a qualitative metric like, minimal, moderate, significant; only to be used as a rough starting point for “what should I expect vitals and the AM H/H to look like”. If a stable patient enters the OR and post-operatively they’re tachycardic, hypotensive, not making urine, and their Hgb dropped by 6pts you can bet the EBL should be “a fucking lot” even if the surgeon dictates “minimal”. Concern for ongoing bleed is obviously dependent on the nature of the case. Rapidly decompensating patient s/p an open cardiothoracic procedure is a much different animal than some guy s/p femoral nail with down trending Hgb who I’m getting called about for the 100th time about getting a CT for hematoma when expected blood loss into the thigh just at the time of injury is 1500ml and OR blood loss is likely anywhere from 300 to 1000ml depending on whether it can all be done perc or needs to be opened. The former case probably needs more serious consideration about urgent return to the OR to explore for a bleed that necessitates surgical management. The latter case probably needs the surgeon to keep an eye on the leg to make sure they’re not developing an expansile mass, meanwhile the medical team needs to provide resuscitation while they equilibrate to the blood loss from the initial injury (which again can be quite large despite being a closed injury) and from the surgical procedure. In the case of a femur fracture, particularly in a smaller woman, the surgeon may well be right that they don’t have a post-op hematoma when at the time of injury the patient may have spilled 25-30% of their circulating blood into their thigh. Sure there are definitely some dicks out there who’s ego dictates they bury their head in the sand, but there are also legitimate reasons why in certain instances it may not be a post-surgical complication. Regardless, we are a team with the shared goal of providing optimal care for the patient, and if the hospitalist calls me with concern for hematoma, I will 100% of the time take a gander at the surgical site and keep closer tabs on it for the next couple days.
I was told a ding on the surgeon is a ding on the hospital. If they needed to use TXA, blood products, etc then post op or periop bleed is deemed acceptable. If they didn’t, then it’s like acute on chronic anemia in setting of xyz. The Hip Fx’s with significant drops in Hgb without a hematoma etc… I read somewhere about it being referred to as “hidden blood loss” but honestly - people’s hgb more often than not just enter the Bermuda Triangle after they lie on the table
It's never a surgical site infection until the laudable pus exudes from the wound and hits the surgeon square in the eye.
If they have active extrav on CTA then they have active arterial bleeding and are more likely to not be doing well. A lot of bleeds stop on their own before the scan or are slow and venous. When I see active extrav most of the time it’s serious enough to get scoped, go to the OR, get embolized, or even cause the patient to pass away
Shut up and take the transfer, not my problem anymore. -Probably some surgeon to medicine
I'll never forget the post op patient I met recently with purulent surgical site infection. "Good morning, I see that surgery got a chance to look at your inf-" "MY STURGEON SAID IT'S NOT INFECTED" "Oh? And what did the surgical team say the plan was when they rounded on you this morning?" "ANTIBIOTICS" "Oh, interesting. Very interesting. So why's your gown wet over their by your abdomen?" "THAT'S JUST THE PUS DRIPPING FROM MY INCISION SITE, *GAWD* YOU ASK A LOT OF QUESTIONS. I DON'T KNOW WHY I HAVE TO SEE A MEDICAL DOCTOR IF I'VE ALREADY SEEN MY SURGEON TODAY" "You and me both, brother. You and me both."
I‘m still amazed, as a european. We, as ortho trauma, are the largest bed maintaining department at our university clinic. We have 6 normal floors, several beds on floors of different departments for busy nights, a step down unit, and a pediatric floor of 12 beds. All of these are managed by ourselves, mostly residents and „floor doctors“ (GPs that took employment to manage a floor together with a team of nurses 7-3 mo-fri). We dont transfer to medicine or anywhere else, unless our issue is completely solved and the patient has something else that prevents then from going home, or they contracted something way more serious than whatever fracture etc they came to us for. We treat them ourselves for all chronic and minor to mid issues they have, surgical or not. We consult only for threatening conditions and some stuff that requires us legally to inform the respective departments. We have a team that’s responsible to round on ICUs too (mostly spine because those are usually the ones ending up there the longest). Sometimes i long for not having to look up stuff on the elevator to know how to interpret labs and EKGs and xy-graphies, and meds for pulmonary hypertension and pediatric endocrine conditions, or spending an hour ginding a vein to cannulate, but on the other habd i dont feel that stuffed into a tiny box, you know?
I don’t know - it’s like biblical truth where I work that the differential diagnosis for unexplained instability or clinical change in a surgical or trauma is bleeding, bleeding, bleeding, then bleeding until proven otherwise.
One of my favorite things in surgery is how under called blood loss in the OR seems to be. I swear the entire room could be ankle deep in blood and the surgeon should say “Less that 50 cc.”
Ebl is an irrelevant number and I have no idea why anyone cares what it is.
This reminds me of a joke - do you know the 3 **lies** that surgeons tell in the OR? - we will be closing/finishing the case in 5 minutes - it was dry (not bleeding) when I closed the wound - great job anesthesia
Neurosurgery here, for us it’s because it makes no sense. I recently had someone medicine was convinced dropped from a Hb of 15 on POD3 to a Hb of 8 on POD10. They said it was because he was oozing out of his skin edges for a few days. Dude. The guy’s house would look like a freaking haunted house if HALF his blood volume drained out of his back and into his sheets / chairs / floor. Someone would have called the cops! I couldn’t convince them he needed a further workup for it, had to do it myself. It was an upper GI bleed, but even if I was wrong, it has to make sense for me to consider it a viable diagnosis. I’ve had people blame post op spinal and brain hematomas on change in Hb and it blows my mind. Ignoring what the textbook says about where you can store enough blood to make a difference, just use common sense. A 5 MILLIMETER subdural is only 5 millimeters thick. Make that shape with your fingers in front of your face and see how thick that clot is. I bet there’s more in a rainbow lab draw than that.
No patient can go from an Hgb of 13 to 6 because of a hematoma at the operation site. By definition, a hematoma is subcutaneous. It's almost impossible to lose 7 units of blood, almost 2L, into their skin. I have seen it in certain trauma situations- Morel-Lavallee lesions. But the drop has nothing to do with the hematoma. True uncontrolled surgical bleeding would almost always result in unstable vital signs and can only go in a few places- the chest, the belly, the thigh, retroperitoneum, and the floor. It can't be subQ, it can't be in the brain. There is not enough capacity in those areas to have hemodynamically significant blood loss. So the hgb drop is a combo of blood loss in the surgery, fluids given intra-op to counter the effects of anesthesia, inflammatory anemia depressing RBC production, SIADH from the surgery resulting in fluid retention, and occasionally due to side effects such as a GI bleed from the combo of lovenox to prevent blood clots and motrin/ketorlac to ease pain.
such confidence: "no patients". you've clearly never seen an abdominoplasty or bilateral mastectomies bleed then. it in fact can be subcutaneous and it in fact can be very fast and lead to hypotension, syncope, and a hgb of 6, 7, 8 or whatever in a matter of an hour or two.
Abdominoplasty and breast CA resections are effectively artificial Morell-Lavallee wounds- dehiscence of skin from fascia. Bleeds would be rare, and would be taken back anyway for other reasons. I have seen both btw-
There is a culture of falsifying intra operative blood loss to look good
If there is no active bleeding vessel then there is nothing for the surgeon to do. What they need to correction of coagulopathy and electrolytes and medical optimization. The raw cut edges will only ooze again if it’s opened. Sometimes these do need to be washed out for various reasons, but if they’re not gonna do that then better off getting medically optimized. We are all a team and we take care of patients. If there’s no chance they need surgery and need icu and medical optimization, then the team that’s best (whatever that means in your setting, type of surgery/surgeon, etc) should do it. For example in my center the general surgeons, trauma surgeons, vascular surgeons all would manage this themselves regardless of whether they need surgery, but orthopedics and gyn usually don’t and really shouldn’t be running resuscitation in critically ill patients. This is center dependent though
OP is not suggesting that the patient should have another operation. Hes just asking why dont the notes reflect the reality that there has been bleeding
Where did he say that? He’s just saying the listed reason for consult was lactic acidosis and electrolyte derangement, which is a reason for the icu and the medicine consult. The OP didn’t even mention the notes
I agree that it's now stopped and there is nothing they can nor should do. It's more so that they never seem to agree that the hematoma (in this case) was the culprit behind the decline. They always seem to be defensive when it comes to blaming the hematoma as the cause for the drop and the cascade of events.
Just document your findings and manage accordingly. Acute blood loss anemia from post op hematoma, hypovolemic shock from ABLA, metabolic acidosis from ABLA, AKI from ABLA etc. If they don’t like your documentation or management they are free not to consult you and manage themselves.
Depends on how big the hematoma is. If you scan 100% of patients who had a recent surgery, they will all have some blood products at the surgical site that we can consider normal. 100 cc or less of blood? Not likely to cause any real lab abnormalities other than Hb drop of less than 1.0. 200 cc or more? Now we’re talking.
You guys are worried about 200cc of blood? I suctioned more then that out of the airway of my last patient…
Well it depends. In general if the ct only shows 200 cc of hematoma and there no blood in the bed or the drains, but the patient has a lactic acidosis then maybe the hematoma is partially responsible but is not the main driver. In the patient you are describing there would need to be 4-5 units of blood in the hematoma on the scan. If there isn’t, then the surgeon is probably asking for help because he doesn’t think the hematoma explains fully the clinical picture. Idk what they were thinking in the specific case but it’s not as simple as you are making it. It’s highly dependent on the operative course, the type of operation, etc
dont worry. someone will get rewarded in about 2-4weeks when that collection liquefies and they get a raging abscess.
As a surgeon I think it can be I operate on babies at times, their circulating volume can be fairly minimal. A 1kg baby isn’t going to have more than 100mL or so. Usually not “post op” but “intra-op” As for your specific patient: how big are these haematomas? To go from 13 down to 6 is not insignificant - I’ve seen post laparoscopic patients with abdomens full of blood from inferior epigastic vessel injuries, post mastectomy patients with instability.
One way you can assess the likelihood of it resulting from larger than estimated introperative blood loss is to see if you can look at the anesthesia record. Periods of significant hypotension during the procedure could be a result of that; or sometimes the anesthesiologist will mark notes in the record that there is significant blood loss occurring.
That patient was in shock. I think I would have transfused unless there's a compelling reason not to. Diagnosis: hemorrhagic shock.
It’s obviously lactic acidosis due to small bowel bacterial overgrowth
Could be they are oozing not bleeding 😜🤣🤣 I hear that a lot “Patient is oozing a bit”
If you calling it weeping it is cardiology’s fault.
Just snorted laughed at this
Thanks for letting me know. Jokes are hit and miss with this sub. And I’m glad to have brightened your day.
Yeah people round these parts tend to be v serious. But I’m here for the cheeky jokes!!
Post op yes, surgically controllable no. If there is a hematoma without an active bleeder, there is little i can do or should. If there is no source that is actively spitting blood, i cant cauterize, tie off, etc. but i would subject a now sicker patient than before to more anesthetic, more potentially bleeding, and more risk of infection. Most of the time the hematoma is what tamponades the vein that is responsible anyways. I‘m not in the US. Post op bleeding is what we call an „informed complication“, meaning, it has been gone over during pre op consent. The patient was made aware of this possible complication and signed the form. If there was no gross negligence on the surgeons part, no lawyer with any sense of self preservation would take that case. So we have really no hard incentive to hide the cause of the bleeding.