Unrecognised Post-Operative Haematoma Risks: Example Case
In a recently published case analysis, medical experts TMLEP examined the risk of failure to recognise postoperative haematoma. In the incident concerned, a breast cancer patient had undergone routine mastectomy surgery. As is usual following excision and closure of the wound, surgeons inserted a drain to deal with low-volume bleeding and seroma* during the early stages of recovery.
While in the recovery area or overnight on the ward, the patient bled. Subsequently, nurses on the oncoming day shift noted her pallor and nausea, along with noticeable swelling in the postoperative wound. However, at that point, ward staff opted to continue observation – but not to act immediately.
Subsequently, on reassessment at midday, bruising had appeared around the wound area. On further review by the surgeon and emptying of the drain, there was a significant amount of fluid – principally blood. As a result, the patient had to return to theatre for evacuation of the haematoma. There, doctors removed a considerable volume of blood clots.
Although there were several oozing points, no obvious source of bleeding was noticeable. In the months after the procedure, the patient continued to require drainage of the wound.
The patient suffered internal bleeding for between twenty-five and thirty hours. In exacerbation, the drain was not correctly open
Due to pressure on other wards in the hospital concerned, the patient was on a general recovery ward.
Notably, nursing staff did not administer intravenous fluids until the start of surgery.
Patient Care Recommendation
Experts determined that in this surgical case, the patient should have been under the care of an experienced breast cancer nurse during the hours immediately after the mastectomy. In addition, she ought to have been assigned to an appropriate cancer ward.
Additionally, care staff involved must receive adequately training. They should also be fully aware of the risk of bleeding and competent in drain management.
If and when staff notice bleeding, treatment is to take priority and be under the supervision of experienced staff. On opening a drain, nursing teams are to ensure intravenous fluid supply. In this case, after opening the drain and in view of the swollen wound and pale patient complexion, IV fluid administration should have started immediately.
In retrospect, hospital ward and bed management, patient allocation and instructions to the night staff may have fallen short of the required standards. In particular, patients returning from ICU ought not to be moved.
Mastectomy patients recovering from surgery are to receive care from an experienced and specialised nurse, who should receive clear instructions from the surgical team – including the proper management of drains.
On noting post-operative complications, patients are to receive priority care, regular observation and prompt reassessment. Where necessary, corrective treatment must follow without undue delay.
*Seroma is a build-up of clear plasma and other bodily fluid after the surgical removal of tissue. Typically, it occurs within seven to ten days of breast lumpectomy, mastectomy and lymph node removal, especially following the removal of post-surgery drainage tubes.