The Risk of Unrecognised Post-Operative Haematoma

A Case Example

In this case, the patient underwent a routine mastectomy. Following the surgery, a drain was placed to remove low volume bleeding and post-operative seroma.

The patient bled overnight in the recovery area and the following morning the nursing care team noted the patient was pale, nauseated and the wound was significantly swollen. When the patient was reviewed by the surgeon the drain was opened and a large amount of blood drained.

A plan was made to repeat observations and reassess. On reassessment at midday, there was bruising around the wound and the drain was emptied of a large amount of fluid, mainly blood.

The patient was returned to theatre for evacuation of a haematoma. Large amounts of blood clots were removed, and multiple oozing points were found, but no obvious bleed was noted. The patient continued to require drainage for several months.

Learning points

  • The drain was not opened correctly, and the patient bled internally for 25-30 hours.

  • The patient was on the recovery ward following bed pressure on other wards.

  • The patient did not receive intravenous fluids until surgery.

TMLEP Recommendations

  • Cancer patients should be managed in an appropriate same sex, ward with adequately trained surgical nursing staff who understand drain management, wound care and risks of bleeding. In this case, the patient should have been over seen in a ward by an experienced breast care surgical nurse.

  • A review of winter bed management and patient flow with clear instructions for the night matrons is required. Patients from ICU returning from a ward should not be moved.

  • A Surgical registrar performing mastectomy and inserting a drain should be aware of it’s operating function and give clear post-operative instructions as to how the drain should be maintained by nursing staff and when the drain should be removed.

  • When bleeding is recognised, resuscitation with venous access is the priority and should not be left to junior staff. Intravenous fluids should be started once the drain had been opened and the patient’s pale colour and wound swelling was noted.

In Summary

Patients recovering from mastectomy surgery should be cared for by an appropriately experienced surgical nurse, who should be clearly informed of post-operative instructions including management of drains.

Once post-operative complications are noted, patients should receive appropriate care and regular observation and reassessment.