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