Occult Post-Surgical Blood Loss in Postmenopausal Females leading to Increased Risk of Orthopedic Injury from Trauma

Abstract

Background: Use of VTE prophylaxis following abdominal surgeries is complicated by factors such as bleeding risk and malignancy. Enoxaparin is commonly prescribed for post procedure prophylaxis following hemicolectomy. A known complication following these surgeries is postoperative bleeding which can lead to weakness and syncope. Case Description: A 73-year-old female presented with RLQ abdominal pain and had an open hemicolectomy due to a poorly differentiated adenocarcinoma identified at the base of the appendix. Postoperative VTE prophylaxis used was enoxaparin. During hospitalization, her hemoglobin and hematocrit were downtrending. Hours after discharge she was readmitted status post multiple bloody bowel movements causing a syncopal episode and femur fracture. She required a transfusion due to low hemoglobin and hypotension. Her enoxaparin was discontinued. Clinical Significance: Thromboprophylaxis requires a balance of VTE and bleeding risks that vary between surgical procedures and patient risk factors such as malignancy. Colorectal resections are associated with high rates of postoperative VTE, and guidelines recommend extended prophylaxis with LMWH for up to 4 weeks. While prophylaxis is necessary, known complications should be monitored and treated prior to discharge. Occult postoperative bleeding should be watched for, especially in populations such as postmenopausal women at increased risk for severe sequelae from falls. Conclusions: Hospital discharge in elderly postmenopausal women after large abdominal surgery should be carefully considered. This population should be monitored for complications such as unexpected blood loss that can increase the risk of weakness or syncope resulting in traumatic injury with orthopedic complications. Risk of traumatic fracture secondary to fall is much greater in elderly females due to increased osteopenia. Within current guidelines the increased risk of VTE prophylaxis should be considered, and lab values should be carefully monitored for signs of occult post-surgical bleeding.