General Surgery · Year 3 · from General Surgery

Case 3: Postoperative Hemorrhagic Shock

Patient Demographics

  • Age: 62 years
  • Sex: Female
  • Occupation: Office manager

Chief Complaint

Nurse call: "Her blood pressure is dropping and the drain output is increasing."

History of Present Illness

The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy for uterine cancer 6 hours ago. The procedure was uncomplicated with estimated blood loss of 400 mL. She was extubated in the OR and transferred to the PACU in stable condition. Over the past 2 hours, the nurse has noted progressive tachycardia and now hypotension. The Jackson-Pratt drain output has been 350 mL of bloody drainage in the past 4 hours (increasing).

Timeline of Events

  • OR end: BP 118/72, HR 78
  • PACU +2 hours: BP 110/68, HR 88
  • PACU +4 hours: BP 98/62, HR 104, drain 200 mL
  • PACU +6 hours: BP 82/54, HR 122, drain 350 mL total → called for evaluation

Physical Examination

  • Vitals: BP 82/54, HR 122, RR 24, SpO2 96% on 2L NC
  • General: Pale, anxious, restless
  • Cardiovascular: Tachycardic, weak pulses
  • Abdomen: Soft, mild distension, diffuse tenderness, incision intact with small ecchymosis
  • Drain output: Bloody, actively draining
  • Urine output: 15 mL in past 2 hours (oliguric)

Hemorrhagic Shock Classification

Class III Hemorrhagic Shock (30-40% blood loss):

  • Heart rate: 120-140
  • Blood pressure: Decreased
  • Pulse pressure: Decreased
  • Urine output: 5-15 mL/hr
  • Mental status: Anxious, confused
  • Estimated blood loss: 1500-2000 mL

Initial Laboratory Results

  • Hemoglobin: 7.2 g/dL (preop 12.8)
  • Hematocrit: 21%
  • Platelets: 152,000/μL
  • INR: 1.2
  • Fibrinogen: 180 mg/dL
  • Lactate: 4.2 mmol/L
  • ABG: pH 7.31, metabolic acidosis

Resuscitation

  1. IV access: Confirm large-bore access, add second line
  2. Fluid resuscitation: Crystalloid bolus initiated
  3. Blood products: Type and screen confirmed, uncrossmatched O-negative blood requested, then type-specific when available
  4. Massive transfusion protocol: Activated given ongoing hemorrhage

Decision Point

Operative vs. Non-operative management:

  • Hemodynamically unstable
  • Ongoing hemorrhage (high drain output + dropping Hgb)
  • Source likely surgical bleeding

Decision: Return to OR for emergent exploration

Operative Re-Exploration

Findings:

  • 1.5 L hemoperitoneum
  • Active arterial bleeding from uterine artery pedicle
  • Suture had partially loosened
  • Clot evacuated, bleeder identified and suture-ligated
  • Abdomen irrigated, inspected for other bleeding sources
  • Drain replaced, abdomen closed

Intraoperative Blood Products

  • 4 units PRBCs
  • 2 units FFP
  • 1 unit platelets

Postoperative ICU Management

  • Continued resuscitation to endpoints:
  • Lactate normalization
  • Urine output >0.5 mL/kg/hr
  • MAP >65
  • Serial hemoglobin monitoring
  • Coagulation parameters monitored

Clinical Course

  • Post-reexploration: Hemodynamically stable
  • 4 hours post-OR: Lactate 1.8, improving
  • POD 1: Hemoglobin stable at 9.2
  • POD 2: Transferred to floor
  • POD 5: Discharged home

Root Cause Analysis

  • Likely inadequate hemostasis of uterine artery pedicle during initial surgery
  • Contributing factors: Patient on aspirin preoperatively (held, but residual effect)
  • Prevention: Meticulous hemostasis, inspection before closure, consider leaving drains in high-risk cases

Teaching Points

  1. Tachycardia is often the earliest sign of hemorrhagic shock
  2. Young patients can maintain blood pressure despite significant blood loss
  3. Don't wait for obvious hypotension - trending vital signs is key
  4. Drain output can be a useful indicator of ongoing hemorrhage
  5. If source is surgical, return to OR for definitive control
  6. Massive transfusion: 1:1:1 ratio (RBC:FFP:Platelets)
  7. Resuscitation targets: Lactate, urine output, mental status, blood pressure

Clinical Image

Image Description: Clinical monitoring during resuscitation of hemorrhagic shock demonstrating key parameters including continuous blood pressure monitoring, fluid and blood product administration, and trending of vital signs to assess response to therapy.

Attribution: Image from Wikimedia Commons, Category:Medical ultrasound. Source: https://commons.wikimedia.org/wiki/Category:Medical_ultrasound

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