Adult with suspected bleeding after surgery
Signs: rising heart rate (often first), low BP, falling Hb, more blood in drains, wound or neck swelling, agitation or confusion, low urine output, cool skin. Adults only.
All Pathways
General SurgeryEmergency
Postoperative Hemorrhage Management
Postoperative Hemorrhage Management: Adult with suspected bleeding after surgery → Rapid assessment and senior help → ⚠️ Neck surgery with airway compro...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Rapid assessment and senior help
ABCDE. Tell the operating surgeon now. Two large-bore IV lines.
- Bloods: FBC, PT/INR, APTT, fibrinogen, UEC, blood gas with lactate and ionised calcium; group and screen (crossmatch if not done)
- Check wound, drains, neck and limbs; look for a closed-space haematoma
- Review the operation note and drug chart: anticoagulants, antiplatelets, heparin given in theatre
- Ask about refusal of blood products and check any advance care directive
03Warning ⚠️ Neck surgery with airway compromise: open the wound now
After thyroid, parathyroid, carotid or other neck surgery. Do not wait for theatre.
- Call for help now: senior anaesthetist and surgeon. Warning signs (DESATS): difficulty swallowing, early warning score rise, swelling, anxiety, tachypnoea, stridor
- Airway compromise: open the wound at the bedside with SCOOP (skin exposure, cut sutures, open skin, open muscles, pack)
- Oxygen and sit head-up. If the airway does not improve, intubate (expect a difficult airway), then go to theatre
04Warning ⚠️ Closed space, after cardiac surgery, or after birth: use the specific plan
Small bleeds in these settings need a different plan. Do not wait for a fall in Hb.
- Closed space (skull, spine or epidural, limb compartment): new neurological deficit or compartment signs need urgent imaging and surgical decompression
- After cardiac surgery: suspect tamponade; call the cardiac surgical team now (emergency resternotomy may be needed)
- After caesarean section or birth: use the postpartum haemorrhage pathway
05Decision Unstable or in shock?
Yes if any: SBP <90 mmHg, MAP <65 mmHg, HR >120/min or rising, rising lactate, confusion, poor perfusion, oliguria, or BP needs repeated fluid or blood. Beta-blockers, pacemakers, older age and spinal or epidural block can hide tachycardia or blunt the response.
- If Yes
- Yes: unstable
06Warning ⚠️ Unstable: transfuse now, do not wait for lab results
Hb falls late. A normal first Hb does not exclude major bleeding.
- Treat the patient, not the Hb
- Call the operating surgeon and a senior anaesthetist now
- Limit clear fluids; give blood
07Action Unstable: resuscitate and activate the major haemorrhage protocol
Adults: activate the local major haemorrhage protocol (MHP) for life-threatening bleeding likely to need 5 or more units of red cells in 4 hours. Children: use the paediatric protocol.
- Give red cells now. Blood group unknown: emergency group O (O RhD negative for females 50 years or younger; others per local policy). Change to group-specific blood as soon as possible
- Ratio RBC:FFP:platelets of at least 2:1:1: at least 1 unit FFP per 2 units red cells and 1 adult platelet unit per 8 units red cells
- Measure early and repeat after every 4 units red cells: temperature, pH, lactate, ionised calcium, Hb, platelets, PT/INR, APTT, fibrinogen
- Critical values: temperature <35 °C, pH <7.2, lactate >4 mmol/L, ionised calcium <1 mmol/L, INR >1.5, fibrinogen <2.0 g/L
- Warm all blood through a warmer and keep core temperature 35 °C or higher. Keep ionised calcium in the normal range (dose per local MHP)
- Patient declines blood products: follow their directive; involve senior staff early; use non-blood measures and early surgical control
08Action Ongoing bleeding: correct coagulopathy and reverse anticoagulants
Use viscoelastic testing (ROTEM/TEG) with the MHP where available. Life-threatening bleeding: reverse now, even with a mechanical valve or recent coronary stent; get cardiology or haematology advice on when to restart.
- PT/INR or APTT >1.5 x normal: FFP. Platelets <50 x10^9/L: 1 adult unit of platelets
- Fibrinogen <2.0 g/L (critical bleeding): 3-4 g fibrinogen as cryoprecipitate (9 whole-blood or split apheresis units, or 3 apheresis units) or fibrinogen concentrate (off-label)
- Warfarin: stop warfarin; vitamin K 5-10 mg IV plus 4-factor PCC (Beriplex): INR 2.0-3.9: 25 IU/kg; INR 4.0-6.0: 35 IU/kg; INR >6.0 or life-threatening bleeding: 50 IU/kg. Dose on weight up to 100 kg (max 5000 IU). FFP is not needed with 4-factor PCC. Known HIT: do not give PCC (contains heparin); give FFP and ask haematology
- Dabigatran: idarucizumab 5 g IV (2 x 2.5 g vials, one after the other)
- Apixaban or rivaroxaban with life-threatening bleeding: andexanet is not on the ARTG; consider 4-factor PCC 25-50 IU/kg (max 5000 IU; off-label) with haematology advice (not with known HIT)
- Unfractionated heparin: protamine 1 mg per 100 units of heparin still active (reduce the dose as time passes); slow IV over 10 min, max 50 mg per dose. Too much protamine is itself anticoagulant
- Enoxaparin in the last 8 h: protamine 1 mg per 1 mg enoxaparin (0.5 mg per 1 mg if more than 8 h ago), max 50 mg per dose; reversal is partial. Protamine risk: prior protamine insulin, fish allergy, vasectomy
- Antiplatelet drugs: routine platelet transfusion is not recommended; ask haematology if bleeding continues. Uraemia or von Willebrand disease: ask haematology about desmopressin
- Tranexamic acid (adult): consider 1 g IV over 10 min. Do not give with active venous or arterial thrombosis or with upper urinary tract bleeding (clot retention). Reduce repeat doses in renal impairment. Seizure risk
09Action Find the source and call for definitive control
Most postoperative bleeding needs surgical or radiological control. Correcting coagulopathy alone rarely stops a surgical bleed.
- Surgical source likely: fast wound, drain or haematoma bleeding; bleeding from one site
- Coagulopathy likely: oozing from many sites, abnormal coagulation tests or ROTEM/TEG; often mixed with a surgical source
- Stable enough and source unclear: CT angiography to find active arterial bleeding. Unstable: do not go to CT; go to theatre
10Decision Surgical control needed now?
Yes if any: shock that does not respond to resuscitation, expanding haematoma, a clear surgical source (wound, anastomosis), or ongoing bleeding with no embolisation option now. No if bleeding has stopped or slowed, or the patient responds to resuscitation and CT angiography shows a discrete arterial source that interventional radiology can treat now.
- If Yes
11Action Surgical control needed: return to theatre
Emergency case. Tell theatre and the anaesthetist now.
- Continue resuscitation and blood products during transfer
- In theatre: evacuate haematoma, find the source, achieve haemostasis
- Coagulopathic, acidotic or cold: damage control (pack, temporary closure, planned return)
- HDU or ICU care after surgery
12Action Bleeding controlled: ongoing care
HDU or ICU monitoring after critical bleeding, return to theatre or embolisation.
- Stop the MHP when bleeding is controlled; then correct coagulation, temperature, calcium and other values one by one
- Repeat Hb and coagulation tests until stable. Once bleeding stops, transfuse red cells only below the threshold: Hb <70 g/L (<80 g/L with cardiovascular disease)
- Mechanical VTE prophylaxis now. Start drug prophylaxis when the surgeon agrees bleeding is controlled
- Plan restart of anticoagulant and antiplatelet drugs with the surgeon and prescriber, based on thrombosis risk
- Treat iron deficiency. Record the event and review it
13Outcome Bleeding controlled
Haemostasis achieved and vital signs stable. Continue postoperative recovery with a plan for VTE prophylaxis and antithrombotic restart.
If No14Decision Arterial source suitable for embolisation?
Yes if CT angiography shows active arterial bleeding at a site suited to embolisation, the patient responds to resuscitation, and interventional radiology is available now. No active bleeding and stable: continue care. Bleeding continues and no embolisation option, or shock returns: return to theatre.
- If Yes
15Action Arterial source and responding: angioembolisation
Interventional radiology for a discrete arterial source (for example liver, spleen, pelvis, kidney).
- Continue resuscitation and blood products in the angiography suite
- Bleeding continues or the patient deteriorates: go to theatre
- Path rejoins step 12Shared downstream outcome
If No- Path rejoins step 12Shared downstream outcome
If No- No: stable
16Action Stable: senior review and find the cause
Tell the operating surgeon. Stable now does not mean safe: recheck vital signs often.
- Repeat Hb every 4-6 h; repeat coagulation tests
- Hold therapeutic anticoagulants; get cardiology or haematology advice for a mechanical heart valve. Do not stop antiplatelets after a recent coronary stent without cardiology advice
- Imaging if the source is unclear: CT angiography, or ultrasound for a collection
- Crossmatch red cells
17Decision Ongoing bleeding?
Yes if Hb keeps falling, drain output stays high, repeated transfusion is needed, or the patient becomes unstable. No if Hb is stable or falls slowly and drain output is slowing.
- If Yes
- Yes: ongoing
- Path rejoins step 08Shared downstream outcome
If No- No: slowing
18Action Bleeding slowing and stable: observe
Monitor 24-48 h. Any deterioration: treat as unstable and reassess.
- Hb every 6-8 h
- Stable adult: transfuse red cells if Hb <70 g/L (<75 g/L after cardiac surgery; <80 g/L after orthopaedic surgery or with cardiovascular disease)
- Correct coagulopathy
- Restart VTE prophylaxis when the surgeon agrees it is safe
- Path rejoins step 13Shared downstream outcome
Guideline Source
National Blood Authority. Patient Blood Management Guideline for Adults with Critical Bleeding (2023; v2.0, 4 Sep 2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Neck haematoma, closed-space bleeding, bleeding after cardiac surgery and postpartum haemorrhage need their specific protocols.
- Tranexamic acid for postoperative bleeding is extrapolated from trauma and surgical prophylaxis trials; NBA 2023 recommends it only in trauma and obstetric critical bleeding.
- Follow your local major haemorrhage protocol and the PCC product your hospital stocks.
- Decision to return to theatre needs senior surgical judgement; interventional radiology access varies.
Contraindicated Populations
Children (paediatric major haemorrhage protocols and doses differ)Postpartum haemorrhage (use the postpartum haemorrhage pathway)Bleeding or tamponade after cardiac surgery (use the cardiac surgical protocol)
Applicable Regions
AUNZGlobal
AU: Transfusion and MHP per NBA critical bleeding guideline (v2.0, 2025) and local MHP. Warfarin reversal uses 4-factor PCC (Beriplex) per MJA 2025 update; if only Prothrombinex-VF is stocked, follow the local protocol. Andexanet is not on the ARTG.
Global: Principles apply broadly; transfusion products, PCC type and thresholds follow local protocols.
Version 2Next review: 2027-09-30
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Frequently Asked Questions
What is the Postoperative Hemorrhage Management?
The Postoperative Hemorrhage Management is a emergency clinical algorithm for General Surgery. It provides a structured decision tree to guide clinical decision-making, based on National Blood Authority. Patient Blood Management Guideline for Adults with Critical Bleeding (2023; v2.0, 4 Sep 2025).
What guideline is the Postoperative Hemorrhage Management based on?
This algorithm is based on National Blood Authority. Patient Blood Management Guideline for Adults with Critical Bleeding (2023; v2.0, 4 Sep 2025).
What are the limitations of the Postoperative Hemorrhage Management?
Known limitations include: Adults only. Neck haematoma, closed-space bleeding, bleeding after cardiac surgery and postpartum haemorrhage need their specific protocols.; Tranexamic acid for postoperative bleeding is extrapolated from trauma and surgical prophylaxis trials; NBA 2023 recommends it only in trauma and obstetric critical bleeding.; Follow your local major haemorrhage protocol and the PCC product your hospital stocks.; Decision to return to theatre needs senior surgical judgement; interventional radiology access varies.. Individual patient factors may require deviation from these recommendations.
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