Timing of Major Postoperative Bleeding Among Patients Undergoing Surgery
Authors: Halme Alex L. E. , Roshanov Pavel S. , Tornberg Sara V. , Lavikainen Lauri I. , Devereaux P. J. , Tikkinen Kari A. O. ,   VISION Investigators, DeBeer Justin , Kearon Clive , Mizera Richard , Pinthus Jehonathan , Ribas Sebastian , Sheth Tej , Simunovic Marko , Tandon Vikas , VanHelder Tomas , Winemaker Mitchell , Paul James , Punthakee Zubin , Raymer Karen , Adili Anthony , Clase Catherine , Cook Deborah , Douketis James , Gangji Azim , Jackson Paul , Lim Wendy , Lovrics Peter , Mazzadi Sergio , Tiboni Maria , Eikelboom John , Ganame Javier , Hankinson James , Hill Stephen , Jolly Sanjit , Ling Elizabeth , Magloire Patrick , Pare Guillaume , Szalay David , Tittley Jacques , Salehian Omid , Gerstein Hertzel , Srinathan Sadeesh K , Ramsey Clare , St. John Philip , Thorlacius Laurel , Siddiqui Faisal S , Grocott Hilary P , McKay Andrew , Lee Trevor WR , Amadeo Ryan , Funk Duane , McDonald Heather , Zacharias James , Acedillo Rey , Garg Amit , Hildebrand Ainslie , Lam Ngan , MacNeil Danielle , Mrkobrada Marko , Roshanov Pavel , Sessler Daniel I , Kurz Andrea , Gorgun Emre , Naylor Amanda , Hutcherson Matt , Sun Zhuo , Nguyen Bianka , Palma Michael , Cuko Avis , Shahinyan Aram , Nadar Vinayak , Perilla Mauricio , Maheshwari Kamal , Turan Alparslan , Pearse Rupert , Niebrzegowska Edyta , Wrag Andrew , Archbold Andrew , Kam Elisa , Everingham Kirsty , Bodger Phoebe , Creary Thais , Bloom Ben , Carter Alice , Abbott Tom E F , Shah Nirav , Mrozek Katarzyna , Richardson Amy , Fowler Alex , Rob Zakaria , Ackland Gareth , Stephens Robert , Reyes Anna , Gallego Paredes Laura , Sultan Pervez , Cain David , Whittle John , Gutierrez del Arroyo Ana , Karmali Shamir , Williams C , Rushton A , Welters I , Leuwer M , Parker Jane , Sapsford Robert J , Barth Julian , Scott Julian , Hall Alistair , Howell Simon , Lobley Michaela , Woods Janet , Howard Susannah , Fletcher Joanne , Dewhirst Nikki , Szczeklik Wojciech , Gorka Jacek , Gorka Karolina , Kaczmarek Bogusz , Polok Kamil , Gasior Jolanta , Włudarczyk Anna , Duchińska Magdalena , Fronczek Jakub , Wojnarska Aleksandra , Kozka Mateusz , Halek Andrzej , Coriat Pierre , Monneret Denis , Fléron Marie-Hélène , Goarin Jean Pierre , Ibanez Esteve Cristina , Royer Catherine , Daas Georges , Abraham Valsa , George Preetha , Xavier Denis , Sigamani Alben , Faruqui Atiya , Dhanpal Radhika , Almeida Smitha , Cherian Joseph , Furruqh Sultana , Wang CY , Ong GSY , Mansor M , Tan Alvin SB , Shariffuddin II , Hashim NHM , Undok A Wahab , Lai HY , Ahmad WAW , Loh PS , Chong CY , Razack AHA , Chan Matthew TV , Choi Gordon YS , Lit Lydia CW , Gin Tony , Wan Alex , Lai Linda , Chan Polly , Malaga German , Valderrama-Victoria Vanessa , Loza-Herrera Javier D , De Los Angeles Lazo Maria , Rotta-Rotta Aida , Berwanger Otavio , Suzumura Erica , Santucci Eliana , Leite Katia , Amalth do Espirirto Santo Jose , Jardim Cesar AP , Biasi Cavalcanti Alexandre , Guimaraes Helio Penna , Polanczyk Carisi A , Furtado Mariana V , Cortés Olga Lucía , Montes Félix R , Alvarado Paula A , Villar Juan Carlos , Vásquez Skarlett , Biccard Bruce , Cassimjee Hussein , Gopalan Dean , Kisten Theroshnie , Mugabi Aine , Naidoo Prebashini , Naidoo Rubeshan , Rodseth Reitze , Skinner David , Torborg Alex , Chow Clara K , Hillis Graham S , Halliwell Richard , Li Stephen , Lee Vincent W , Mooney John 
Published: April 2024

Importance

Although major bleeding is among the most common and prognostically important perioperative complications, the relative timing of bleeding events is not well established. This information is critical for preventing bleeding complications and for informing the timing of pharmacologic thromboprophylaxis.

Objective

To determine the timing of postoperative bleeding among patients undergoing surgery for up to 30 days after surgery.

Design, Setting, and Participants

This is a secondary analysis of a prospective cohort study. Patients aged 45 years or older who underwent inpatient noncardiac surgery were recruited in 14 countries between 2007 and 2013, with follow-up until December 2014. Data analysis was performed from June to July 2023.

Exposure

Noncardiac surgery requiring overnight hospital admission.

Main Outcomes and Measures

The primary outcome (postoperative major bleeding) was a composite of the timing of the following bleeding outcomes: (1) bleeding leading to transfusion, (2) bleeding leading to a postoperative hemoglobin level less than 7 g/dL, (3) bleeding leading to death, and (4) bleeding associated with reintervention. Each of the components of the composite primary outcome (1-4) and bleeding independently associated with mortality after noncardiac surgery, which was defined as a composite of outcomes 1 to 3, were secondary outcomes.

Results

Among 39 813 patients (median [IQR] age, 63.0 [54.8-72.5] years; 19 793 women [49.7%]), there were 5340 major bleeding events (primary outcome) in 4638 patients (11.6%) within the first 30 days after surgery. Of these events, 42.7% (95% CI, 40.9%-44.6%) occurred within 24 hours after surgery, 77.7% (95% CI, 75.8%-79.5%) by postoperative day 7, 88.3% (95% CI, 86.5%-90.2%) by postoperative day 14, and 94.6% (95% CI, 92.7%-96.5%) by postoperative day 21. Within 48 hours of surgery, 56.2% of major bleeding events, 56.2% of bleeding leading to transfusion, 56.1% of bleeding independently associated with mortality after noncardiac surgery, 51.8% of bleeding associated with hemoglobin less than 7 g/dL, and 51.8% of bleeding associated with reintervention had occurred.

Conclusions and Relevance

In this cohort study, of the major postoperative bleeding events in the first 30 days, more than three-quarters occurred during the first postoperative week. These findings are useful for researchers for the planning future clinical research and for clinicians in prevention of bleeding-related surgical complications and in decision-making regarding starting of pharmacologic thromboprophylaxis after surgery.