Procedural Haemorrhage

Procedural haemorrhage is bleeding that occurs during or after a medical procedure. While common to most invasive procedures, the risk varies depending on the type of procedure, patient-specific factors, and the experience of the healthcare team performing the procedure.

Table of contents

• What is Procedural Haemorrhage?
• Risk Factors for Bleeding
• Bleeding Risk in Common Procedures
• Methods to Reduce Bleeding Risk
• Understanding Coagulation Tests

What is Procedural Haemorrhage?

Patients who are critically ill and hospitalized often require invasive procedures as part of their medical care. Each procedure carries a unique set of risks and associated complications, but common to all of them is the risk of haemorrhage, which is bleeding from a damaged blood vessel.^[1]

A haemorrhage is a loss of blood from a damaged blood vessel. The bleeding can be trapped inside your body, called internal haemorrhage, or it can flow outside of your body, called external haemorrhage, from a wound or body opening. The blood loss can be minor or major.^[2]

Bleeding is associated with both short-term and long-term illness and death, leading to increased length of hospitalization and costs.^[1] Common procedures performed in hospitals include central venous catheterization, arterial catheterization, paracentesis, thoracentesis, tube thoracostomy, and lumbar puncture.^[1]

Risk Factors for Bleeding

There are several patient-specific factors that may influence the risk of haemorrhage during procedures. These include decreased ability to achieve hemostasis, which is the body’s natural ability to stop bleeding, because of problems with blood clotting. These clotting problems can be due to the patient’s own condition or because of medications they are taking.^[1]

Other patient factors include medical conditions such as kidney disease and abnormal anatomy. Several provider-related factors also relate to the risk of haemorrhage, such as inadequate training in performing the procedure, the number of needle passes during a procedure, and whether ultrasonography is used.^[1]

The combination of these factors leads to a unique risk profile for each patient. On top of this, consideration must be given to both the usefulness and risk associated with corrective treatments commonly used before procedures, such as transfusions in patients with blood clotting disorders.^[1]

Bleeding Risk in Common Procedures

The risk of bleeding varies depending on the type of procedure being performed. Central venous catheterization, which involves inserting a tube into a large vein, is performed approximately 5 million times annually and carries a bleeding risk of 0.5% to 1.6%.^[1]

Bleeding risk factors for this procedure include anatomical abnormalities, the number of needle passes, accidentally puncturing an artery, lack of operator experience, and lack of ultrasound guidance.^[1]

Several procedures are classified based on their bleeding risk. High-risk procedures like major surgeries and certain endoscopic procedures have an estimated risk of major bleeding of 1.5% or more. They are considered high risk because bleeding is difficult to control, and significant illness and death might occur even from minor bleeding during these procedures.^[11]

Low-risk procedures like transjugular liver biopsy are associated with bleeding that is easily detectable and controllable. These include most vascular procedures and local interventions.^[11]

Methods to Reduce Bleeding Risk

To reduce bleeding risk during procedures, recommendations include having an experienced operator perform the procedure and using real-time ultrasound guidance.^[1] These measures help minimize complications and improve patient safety.

Many doctors correct blood clotting problems before procedures to decrease bleeding risk, but there is minimal evidence to support this practice.^[1] Operators must be familiar with indications, anticipated risks, and possible complications to establish informed consent and to perform the procedures competently.^[1]

Several steps can be taken to prevent bleeding complications. As in more traditional forms of combat, the best offense against surgical bleeding is a good defense. A serious effort should be made before any procedure to identify patients who have an elevated risk for bleeding related to abnormalities of blood clotting function.^[8]

Understanding Coagulation Tests

Doctors often use blood tests to assess bleeding risk before procedures. One commonly used test is the international normalized ratio (INR), which is derived from the prothrombin time (PT). The PT reflects the activity of certain clotting factors made by the liver.^[11]

However, in patients with liver dysfunction, the INR alone is not a good measure of bleeding risk. This is because PT and INR reflect only certain clotting factors and do not account for significant deficiencies of other important clotting factors that prevent bleeding.^[11]

The INR was originally designed for patients taking blood-thinning medications like warfarin, to standardize results among these patients. In patients with liver disease or other conditions, it is common to have prolonged PT and INR, but this does not necessarily mean the patient will bleed during a procedure.^[11]