Post-operative haemorrhage on a night shift: fluid maths, blood and the nurse's judgement
Mr R, a 62-year-old man weighing 70 kg, is 6 hours post emergency laparotomy for a perforated duodenal ulcer. He returned to the surgical ward with a nasogastric tube, a urinary catheter and a Jackson-Pratt drain. In the last hour the drain has collected 250 mL of fresh blood and the dressing is soaked through. He is restless and keeps asking where he is. Observations: pulse 122/min, thready; BP 92/58 mmHg; respiratory rate 24/min; SpO2 96% on room air; extremities cold; capillary refill 4 seconds; urine 15 mL in the last hour. The ward stocks three 500 mL bags of Ringer's lactate and one unit of packed red cells is held in the blood bank refrigerator; there is no rapid infuser or blood warmer on the ward. The blood bank is 40 minutes away by road. The surgical resident is scrubbed in theatre and has left a written order: "RL 20 mL/kg bolus now, then one unit PRBC over 30 minutes, repeat vitals." The staff nurse on duty is the only registered nurse for 26 patients, with one nursing attendant.
1. Classify this patient's haemorrhagic shock and list, in priority order with reasons, the first five actions you would take in the next 20 minutes.
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Classification: Class III (severe) haemorrhagic shock, estimated blood loss 30–40% (about 1,500–2,000 mL). The grounds are tachycardia above 120/min, systolic BP below 100 mmHg, urine output under 15 mL/h, capillary refill over 2 seconds and altered mentation. Class II would show a normal systolic pressure with urine output 20–30 mL/h; class IV would be markedly confused or unconscious with an unrecordable systolic pressure.
Actions, in order:
- Call for help and escalate. Phone the on-call surgeon and the blood bank, and inform the nursing supervisor. One nurse for 26 patients cannot safely manage a bleeding patient; this is the first act, not the last.
- Airway, breathing, oxygen. Keep him flat, protect the airway (he is restless and has an NG tube), give high-flow oxygen, and have suction ready.
- Two large-bore cannulae (16–18 G) and blood sampling for crossmatch, full blood count, coagulation profile and renal function; start the ordered crystalloid through one line while the crossmatch sample goes.
- Continuous monitoring: pulse, BP, respiratory rate, SpO2 and conscious level every 5–10 minutes; hourly (or more frequent) urine output; measure and record drain and dressing losses. Keep him warm - hypothermia worsens coagulopathy.
- Prepare for definitive control: keep him nil by mouth, mark and time the dressing, prepare theatre paperwork and the blood administration set. Fluid only buys time; stopping the bleeding and replacing oxygen-carrying capacity are what save him.
2. Calculate the ordered crystalloid bolus, state how many bags are needed, and explain how you would actually give it and what you would assess between aliquots.
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Calculation: 20 mL/kg × 70 kg = 1,400 mL. Each bag is 500 mL, so two full bags give 1,000 mL and a third bag supplies the remaining 400 mL. Three bags must be spiked, but only 1,400 mL is infused - the third bag is not run to completion.
How to give it: do not hang 1,400 mL wide open. Give it in 250–500 mL aliquots over 5–10 minutes each, reassessing between aliquots. The target in uncontrolled surgical bleeding is a palpable radial pulse and a systolic pressure of about 90 mmHg (permissive hypotension) until the bleeding is controlled, not a textbook-normal blood pressure. Over-filling before surgical control dislodges clot, dilutes clotting factors and worsens hypothermia.
Assess between aliquots: radial pulse volume and rate, BP, capillary refill, conscious level, lung bases for new crackles, jugular venous filling, drain volume and urine output. If 500 mL produces no improvement in pulse or pressure, the patient is still bleeding and blood, not more crystalloid, is the priority - say so to the surgeon.
Document the time each aliquot started and finished, the volume in, the drain and urine output, and the observations before and after, so the response to resuscitation is visible to the next clinician.
3. The order directs one unit of packed red cells over 30 minutes. What is your judgement as the registered nurse, and what will you communicate and document?
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Judgement: transfuse, but not at 30 minutes as written. A unit of packed cells is normally given over 2–4 hours and must be completed within 4 hours of spiking. On a ward without a blood warmer, a rapid infuser or an activated massive transfusion protocol, a 30-minute infusion risks hypothermia, citrate toxicity (perioral tingling, tetany, arrhythmia), circulatory overload and - most importantly - makes a transfusion reaction almost impossible to detect in time.
However, rapid transfusion can be correct in ongoing haemorrhage when delivered through a warmer and pressure device under a massive transfusion protocol. That is a clinical decision, and it must be documented as such.
What I would do:
- Start the unit as soon as cross-matched blood arrives, using a blood administration set with 0.9% sodium chloride only (no Ringer's lactate, no drugs in the line).
- Telephone the resident, state the concern and the patient's current observations, and ask for a documented rate or for protocol activation.
- Stay with the patient for the first 15 minutes; record observations at baseline, 15 minutes, then every 30 minutes; watch for fever, rash, back pain, breathlessness and falling urine output.
- Document the original order, the query raised, the response received, times and the patient's condition. The nurse administers safely while escalating - she does not silently refuse or silently comply.