Clinical Features and Nursing Strategies of Reexploration for Hematomas after Thyroid Surgery: Insights from a 7-Year Single-Center Study in China

doi:10.21203/rs.3.rs-4946088/v1

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Clinical Features and Nursing Strategies of Reexploration for Hematomas after Thyroid Surgery: Insights from a 7-Year Single-Center Study in China

https://doi.org/10.21203/rs.3.rs-4946088/v1

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Objective

To explore clinical characteristics of postoperative hemorrhage following thyroid or parathyroid surgery, and to discuss the nursing strategies for its prevention.

Methods

A retrospective analysis was conducted on all patients who underwent thyroid or parathyroid surgery from February 2016 to September 2023. The clinical data of patients who experienced postoperative hemorrhage and required reoperation were collected and analyzed.

Results

Among the 5579 patients who underwent surgery, 42 patients experienced postoperative hemorrhage and required reoperation. Hemorrhage occurred within 6 hours in 19 cases (45.2%) and within 24 hours in 35 cases (83.3%). The most common bleeding sites were the anterior cervical muscle group (44.2%) and branches of the superior or inferior thyroid artery (20.9%). Underlying diseases such as hypertension, diabetes, hemophilia, and postoperative activities like neck movements, coughing, vomiting, and drainage tube manipulation were potential risk factors for postoperative hemorrhage. Clinical manifestations of postoperative hemorrhage included neck swelling or tightness, increased drainage fluid with clots, incision bleeding, pain, skin bruising, and worsening dyspnea.

Conclusion

Understanding the potential risk factors and characteristics of postoperative hemorrhage in thyroid surgery is crucial for specialized thyroid nursing care, as it can aid in its prevention and treatment.

Thyroid surgery

Hemorrhage

Nursing strategies

Postoperative care

Reexploration

In the past thirty years, the incidence of thyroid cancer has significantly increased in many countries worldwide [1]. According to 2022 data, there were 466,100 new cases of thyroid cancer in China, ranking third among all new malignant tumors [2]. Thyroid surgery is the preferred treatment for most thyroid cancers. Postoperative hemorrhage is a well-known complication of thyroid and parathyroid surgery and can be life-threatening because of acute airway obstruction. The incidence of this complication varies from 0 to 6.5% [3]. It is estimated that one-quarter of these patients will require immediate life-saving clot evacuation and 0.3 percent may require a tracheostomy [4]. Close observation, early detection, and airway management are keys to managing this complication. A better understanding of clinical features of hematoma will help in identifying those who are at risk of this complication. Although many studies have focused on how to reduce bleeding complications through surgical techniques, such as the use of ultrasonic or radiofrequency scalpels, hemostats, and the placement of suction or gravity drainage, relatively fewer studies have focused on the clinical characteristics and nursing strategies of postoperative hemorrhage. This study reviews the characteristics, causes, clinical manifestations, and main inducing factors of postoperative hemorrhage thyroid surgery to explore how to reduce the incidence of hemorrhage from a nursing perspective and how to identify and manage postoperative hemorrhage early, avoiding the unpredictability of disease progression and potential death risk.

A retrospective analysis was conducted on 5,579 patients who underwent thyroid or parathyroidectomy at a tertiary hospital in Shenzhen, China, from February 2016 to August 2023, focusing on those who required reoperation due to postoperative hemorrhage. Asymptomatic patients with minimal swelling/ecchymosis requiring observation only were not included in the study group. General patient information, disease course records, nursing records, and surgical records of patients with postoperative hemorrhage were collected through the clinical medical record system. General information included gender, age, systemic diseases, postoperative pathology type, and concurrent thyroid autoimmune diseases. Disease course records and nursing records included hemorrhage time, inducing factors (coughing, vomiting, elevated blood pressure, vigorous activities, etc.), clinical manifestations (neck swelling, subcutaneous bruising, dyspnea, cyanosis, decreased blood oxygen saturation), treatment methods, and prognosis. Surgical records included surgery time, intraoperative blood loss, surgical method, bleeding site, or cause.

Statistical Analysis

SPSS 26.0 software was used for data analysis. Measurement data conforming to normal distribution were expressed as mean ± standard deviation; measurement data not conforming to normal distribution were expressed as median and interquartile range [M(P25, P75)]. Non-parametric tests were used for intergroup comparisons; count data were statistically described using the number of cases and percentages (%). Differences were considered statistically significant at P < 0.05.

A total of 42 patients underwent reoperation due to postoperative hemorrhage, including 16 males and 26 females, with an average age of 42.81 ± 12.12 years. The surgical procedures included unilateral thyroidectomy in 11 cases, unilateral thyroidectomy with central lymph node dissection in 13 cases, unilateral thyroidectomy with central and lateral neck lymph node dissection in 1 case, total thyroidectomy with central lymph node dissection in 10 cases, total thyroidectomy with central and unilateral lateral neck lymph node dissection in 4 cases, total thyroidectomy with central and bilateral lateral neck lymph node dissection in 1 case, and parathyroidectomy in 2 cases. Pathological diagnoses included 19 malignant cases and 23 benign cases. All thyroid surgeries were performed by the same treatment team. Among the patients, 12 had diabetes, hypertension, and/or coronary atherosclerotic heart disease; 5 had hyperthyroidism; and 1 had hemophilia. There were a total of 12 cases with significant hemorrhage inducing factors, including postoperative severe coughing and vomiting in 6 cases, abnormal blood pressure rise in 4 cases, drainage tube manipulation in 1 case, and anticoagulant use in 1 case. All patients underwent reoperation within 2 hours of detecting hemorrhage. Postoperatively, there were no further hemorrhages, and all wounds healed without infection or other complications. General patient information is detailed in Table 1.

Table 1

General Characteristics of Patients
Characteristic	Value
Gender [cases (%)]
Male	16 (38.1)
Female	26 (61.9)
Education Level [cases (%)]
Junior high school or below	6 (14.3)
High school or vocational	15 (35.7)
College or above	21 (50)
Underlying Diseases [cases (%)]
Yes	15 (35.7)
No	27 (64.3)
Scope of Surgery [cases (%)]
Hemithyroidectomy	11 (26.2)
Hemithyroidectomy + CLND	13 (30.9)
Hemithyroidectomy + CLND + LLND	1 (2.4)
Total thyroidectomy + CLND	10 (23.8)
Total thyroidectomy + CLND + unilateral LLND	4 (9.5)
Total thyroidectomy + CLND + bilateral LLND	1 (2.4)
Parathyroidectomy	2 (4.8)
Surgical Method [cases (%)]
Traditional surgery	36 (85.7)
Endoscopic surgery	6 (14.3)
Surgery Time [M(P25, P75)]	70 (52.75, 134.25)
Pathological Diagnosis [cases (%)]
Malignant	19 (45.2)
Benign	23 (54.8)
Hospital Stay [M(P25, P75)]	6 (5, 8.5)
*Note: CLND = central lymph node dissection; LLND = lateral neck lymph node dissection

Hemorrhage Time/Estimated Blood Volume: The fastest case of hemorrhage was detected 15 minutes postoperatively, and the latest case was detected 10 days postoperatively, with a median time of 6 hours 24 minutes. Among these, 83.3% of hemorrhages occurred within 24 hours postoperatively. The estimated blood accumulation during reoperation for hemorrhage ranged from 20 ml to 300 ml. Detailed statistics on hemorrhage time and volume are provided in Table 2 and Fig. 1.

Table 2

Statistics of Hemorrhage Time and Volume
Hemorrhage Time and Volume	Cases (%)
Time
< 3h	8 (19.0)
3−6h	11 (26.2)
6−12h	9 (21.4)
12−24h	7 (16.7)
24−48h	4 (9.5)
> 48h	3 (7.1)
Median time from surgery end to hemorrhage detection	6h24min
Volume Range [ml (cases %)]
< 50	22 (52.4)
51–100	11 (26.2)
101–200	5 (11.9)
> 200	4 (9.5)

Clinical Manifestations: Most patients exhibited neck swelling at the incision site, with some experiencing incision bleeding, subcutaneous bruising, and pain. Two patients developed rapid breathing difficulties and chest tightness, with one showing a rapid drop in blood oxygen saturation from 99–32% within 5 minutes, accompanied by unresponsiveness. Detailed data on clinical manifestations are provided in Fig. 2.

Hemorrhage Sites: The most common hemorrhage sites were the anterior cervical muscle group (44.2%) and branches of the superior or inferior thyroid artery (20.9%), with one patient exhibiting multiple bleeding sites, including the laryngeal entrance and strap muscles. Detailed data on hemorrhage sites are provided in Table 3.

Table 3

Hemorrhage points
Hemorrhage points	Cases (%)n = 43*	Hemorrhage Time[M(P25, P75)] (minutes)	Hemorrhage Volume [M(P25,P75)](ml)
Anterior cervical muscle group	19 (44.2)	600(244,1260)	50 (50,100)
Branches of the superioror inferior thyroid artery	9 (20.9)	480(326.5,567)	60(47.5, 216)
Entrance of thelarynx/around nerves	5 (11.6)	280 (179, 1080)	80 (35, 100)
Skin/subcutaneous tunnel	4 (9.3)	156 (44.25,255)	183.5 (52.5, 219.25)
Thyroid stump	4 (9.3)	600(270,16410)	35 (20,162.5)
Anterior jugular vein	1 (2.3)	564	20
Drainage tube opening	1 (2.3)	2400
H value		3.975
P value		0.409

*Note: Some patients had multiple hemorrhage sites, so the total exceeds 42.

The thyroid is richly vascularized and bleeding is one of the complications that may arise in the immediate post-operative course of thyroidectomy. In recent years, less invasive alternatives to surgery, such as ablation therapy and active surveillance, have been explored for low-risk thyroid cancer [5–7]. Despite these advancements providing more treatment options, thyroid surgery remains necessary for some patients. Consequently, the rising prevalence of thyroid disease has led to an increase in the number of thyroid operations performed.

Postoperative hemorrhage is a severe complication in thyroid surgery, which can lead to respiratory distress, airway compression, and even death[8]. This study observed 42 cases of postoperative hemorrhage among 5579 thyroidectomy patients, yielding a hemorrhage rate of 0.75%, which is consistent with the literature[9].A study analyzed data from UK endocrine and thyroid surgeries from 2004 to 2018 and found that the reoperation rate for hemorrhage following thyroidectomy was 1.2% [10]. Similarly, over a 40-year period at the Royal North Shore Hospital, 10,201 thyroidectomies were performed, and 124 patients (1.2%) required reoperation for hemorrhage, with 31 (0.3%) necessitating a tracheostomy [11]. Bergamaschi et al. reported 19 hematomas out of 1,192 thyroidectomies (1.6%), with 10 cases (0.8%) requiring reexploration [12]. Although the incidence is relatively low, postoperative hemorrhage is a rare but life-threatening event. Understanding its clinical characteristics is crucial for developing appropriate nursing strategies and ensuring early detection to reduce and manage this complication.

Hemorrhage Time and points:

Postoperative hemorrhage can occur within a wide time frame, from 10 minutes to a week post-surgery. There have been reports of delayed hemorrhage occurring up to 13 days postoperatively, often related to anticoagulant use and blood disorders. The shortest time to hemorrhage in this study was 15 minutes, and the longest was 10 days, with 83.3% occurring within the first 24 hours. The bleeding sites were most commonly the anterior cervical muscle group (44.2%) and branches of the superior or inferior thyroid artery (20.9%). One patient experienced multiple bleeding sites, including the laryngeal entrance and strap muscles. Early hemorrhage (within 24 hours) is often associated with arterial or venous bleeding at the surgical site, while later hemorrhage can be due to infection-related vascular erosion. Clinical manifestations of postoperative hemorrhage in thyroid surgery patients can vary depending on the points of the bleeding. Postoperative hemorrhage sites can be classified into two categories: superficial to the strap muscles and deep to the strap muscles. Hemorrhage superficial to the strap muscles typically presents with subcutaneous bruising and neck swelling. In contrast, hemorrhage deep to the strap muscles can quickly lead to airway compression, resulting in airway obstruction. Since the majority of bleeding occurs within the first 6 hours after surgery, it is recommended to perform nursing rounds to check on the patient at least once every hour during the first 6 hours postoperatively.

Clinical Manifestations of Hemorrhage:

Postoperative hemorrhage in thyroid or parathyroid surgery presents several typical signs and symptoms. According to the clinical manifestations of the 42 patients in this study, common symptoms included neck swelling or tightness, increased drainage fluid with clots, incision bleeding, pain, skin bruising, and progressively worsening dyspnea. Two patients experienced rapid breathing difficulties and chest tightness, with one showing a significant drop in blood oxygen saturation from 99–32% within minutes, accompanied by unresponsiveness. H.A. Iliff et al. reported that using the "DESATS" mnemonic (difficulty swallowing/discomfort, early warning symptoms and signs, swelling, anxiety, tachypnea/difficulty breathing, stridor) can be an important tool for early recognition of postoperative hemorrhage [13]. Among the 42 patients, 41 exhibited neck swelling, making it the most common clinical manifestation. Increased drainage fluid with a bright red color and clots is a specific indicator of hemorrhage. Therefore, during each nursing round, it is necessary to check the condition of the wound dressing, the amount and characteristics of the drainage fluid, neck circumference, respiration, pulse, blood pressure, heart rate, blood oxygen saturation, pain score, and the patient's response. Postoperative care for endoscopic thyroid surgery should include enhanced monitoring of the port site and endoscopic tunnel,[14] paying close attention to any swelling or bleeding, as these areas are often more concealed due to clothing.

Risk Factors for Thyroid Hemorrhage:

Multiple risk factors contribute to postoperative hemorrhage in thyroid surgery. These include malignant tumors, Graves' disease, low serum HDL levels, large or multiple nodular goiters, previous thyroid surgery, prolonged surgery time, and the surgeon's experience [10, 15, 16],Scott Samona et al. found that factors such as patient age, gender, tumor size, extent of lymph node dissection, Graves' disease, and hypertension (defined as systolic blood pressure > 150 mmHg) were significant risk factors for postoperative hemorrhage, with hypertension increasing the risk by 20.3 times [17]. H.E. Doran's study highlighted the significant correlation between retrosternal goiters, preoperative hyperthyroidism, male gender, total thyroidectomy, patient age, and the surgeon's monthly surgical volume with the risk of hemorrhage requiring reoperation[10]. Liu J et al. similarly identified male gender, older age, Graves' disease, reoperation, and bilateral thyroid surgery as risk factors for postoperative hemorrhage[18–20]. Actively manage underlying diseases that present risk factors for postoperative bleeding, such as administering antithyroid treatment and iodine preparation for hyperthyroidism, correcting coagulation disorders, and controlling blood pressure and blood sugar levels in patients with hypertension and hyperglycemia. The frequency of monitoring can be adjusted based on the patient's risk of hemorrhage. In addition to underlying diseases and surgery-related factors, inducing factors such as severe choking, coughing, vomiting, and excessive pulling of the drainage tube can also cause postoperative bleeding. In our study, there were 12 cases with significant bleeding inducing factors, most commonly associated with severe coughing or vomiting. For patients with coughing or vomiting, it is necessary to actively use medication to control these symptoms that increase pressure in the neck and chest areas. Patients should be instructed to speak less, swallow frequently, and cough effectively with hand support on the neck to reduce vibrations. Proper fixation and patency of the drainage tube are essential to prevent tugging and blockage.

Limitation:

The study has several areas for improvement. It focuses on a single-center experience, limiting generalizability. Including multiple centers and a larger sample size could enhance reliability. The study lacks a control group of patients without postoperative hemorrhage, which would help identify risk factors more accurately. More detailed statistical analysis, such as multivariate analysis, could control for confounding factors and identify independent predictors. Including long-term follow-up data would provide insights into long-term outcomes and complications. Additionally, future studies could aim to offer more specific nursing protocols and interventions, and evaluate their effectiveness in preventing and managing postoperative hemorrhage.

Postoperative hemorrhage in thyroid surgery has distinct clinical features, including its presentation, timing, risk factors, and inducing factors. This study highlights the critical importance of early detection and intervention in managing postoperative hemorrhage. Key clinical manifestations include neck swelling, subcutaneous bruising, tachycardia, dyspnea, hypotension, and stridor. Significant risk factors include hypertension, diabetes, and hyperthyroidism. Effective nursing strategies involve close monitoring, particularly in the first 6 hours post-surgery, managing underlying conditions, and providing comprehensive postoperative care instructions. Future research should focus on developing and evaluating specific nursing protocols to further reduce the incidence of postoperative hemorrhage.

Ethics approval and consent to participate

The studies involving human participants were reviewed and approved by the University of Hong Kong - Shenzhen Hospital. All methods were carried out in accordance with relevant guidelines and regulations. The patients/participants provided their written informed consent to participate in this study.

Consent for publication

Not applicable.

Competing interests

All the authors declare that they have no competing interests.

Funding

There was no Funding

Author Contribution

All authors reviewed the manuscript. ZXT and HBL contributed equallyto this article. ZXT and HBL collected the data, performed statistical analysis, and drafted this manuscript. XJY and ZXS interpreted the data and revised this manuscript. KYB, ZJY, ZLQ made important revisions to this manuscript. All authors read and approved the final manuscript. WYJ designed and guided this study. The corresponding authors declared that all listed authors meet authorship criteria, and no other authors was omitted.

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No competing interests reported.

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You are reading this latest preprint version

Clinical Features and Nursing Strategies of Reexploration for Hematomas after Thyroid Surgery: Insights from a 7-Year Single-Center Study in China

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Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Methods

Statistical Analysis

Results

Discussion

Hemorrhage Time and points:

Clinical Manifestations of Hemorrhage:

Risk Factors for Thyroid Hemorrhage:

Limitation:

Conclusion

Declarations

Funding

Author Contribution

References

Additional Declarations

Status:

Version 1