Post-Operative Haemorrhage

Reactionary haemorrhage (<24h post-op) results from vessel slip or ligation failure; secondary haemorrhage (day 7–14) is caused by infective arterial erosion. The lethal triad of acidosis, hypothermia, and coagulopathy must be actively prevented…

Massive Haemorrhage Protocol (MHP)

The pathway

1 · Recognise haemorrhage

Tachycardia (earliest sign), hypotension, pallor, oliguria
Wound bleeding: soaked dressings, haematoma expansion
Drain output >200ml/hr or >1.5L total: indicates significant bleeding
Post-operative drop in Hb on bloods

2 · Classify haemorrhagic shock

Class I: <750ml, HR <100, BP normal — compensated
Class II: 750–1500ml, HR 100–120, mild hypotension
Class III: 1500–2000ml, HR 120–140, SBP 70–90 — activate MHP
Class IV: >2000ml, HR >140, SBP <70 — life-threatening

3 · Activate Massive Haemorrhage Protocol

Call switchboard: activate MHP code
Request 1:1:1 ratio: pRBC : FFP : platelets
Assign team roles: airway, IV access, documentation, communication
Alert senior surgeon + anaesthetist + haematologist
2 large-bore IV cannulas (≥16G) or IO access

4 · Tranexamic acid (TXA)

TXA 1g IV over 10 minutes, then 1g over 8 hours if bleeding continues
Antifibrinolytic: prevents clot breakdown
Follow the local surgical or major haemorrhage protocol — the 3-hour cut-off is a trauma rule from CRASH-2 and does not transfer to post-operative bleeding
Not for GI bleeding — see the GI haemorrhage pathways

5 · Correct the lethal triad

Hypothermia: warm IV fluids, warm blankets, warming devices (Bair Hugger) — target >36°C
Acidosis: treat cause (haemorrhage control), sodium bicarbonate only if pH <7.1
Coagulopathy: FFP 15ml/kg, cryoprecipitate if fibrinogen <1.5g/L, platelets if <75 × 10⁹/L
Ionised hypocalcaemia: calcium gluconate 10% 10ml IV with each 4 units pRBC

6 · Surgical decision

Return to theatre if: ongoing haemorrhage not controllable, packing required, vascular source identified
Interventional radiology (IR) embolisation: for pelvic or solid organ bleeding — less invasive
Damage control surgery: abbreviated surgery to control haemorrhage, definitive repair deferred
Senior surgical decision — do not delay

7 · Senior team communication

Haematologist: direct consultation for coagulopathy management and MHP guidance
Anaesthetist: airway, sedation, monitoring in theatre
ITU: post-operative critical care
Blood bank: keep informed of ongoing requirements; note group and screen vs crossmatch status

Drugs

Drug	Dose	Route	Notes
Tranexamic acid	1g over 10 minutes, then 1g over 8 hours	IV	Per the local surgical or major haemorrhage protocol. The 3-hour limit belongs to trauma (CRASH-2), not to post-operative bleeding. Not indicated in GI bleeding.
FFP (Fresh Frozen Plasma)	15ml/kg	IV	1:1 ratio with pRBC. Replaces all clotting factors.
Cryoprecipitate	2 pools (10 units)	IV	If fibrinogen <1.5g/L. Rich in fibrinogen, factor VIII, vWF.
Platelets	1 adult therapeutic dose	IV	Target platelets >75 × 10⁹/L during active bleeding.
Calcium gluconate 10%	10ml	IV	Give with every 4 units pRBC to correct ionised hypocalcaemia from citrate in blood products.

When to escalate

Shock class III or IV (HR >120, SBP <90) — activate MHP immediately,MHP activated — senior surgeon, anaesthetist, and haematologist all required,Lethal triad developing — active warming, calcium, coagulopathy correction,Coagulopathy not correcting despite FFP/cryo — haematology advice, consider factor VIIa,Return to theatre decision — consultant surgeon to decide, do not delay

Reference: NICE NG24 Major Trauma / ATLS 10th Edition / BSH Major Haemorrhage Protocol Guideline

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.