Reducing the Risk of Significant Bleeding After Thyroid and Parathyroid Surgery - the Role of a Protocol Driven Approach

Abstract Aim Post-operative haemorrhage following thyroid and parathyroid surgery is a well-recognised life-threatening complication. Following an audit reporting a reoperation for bleeding rate of 1.3% in 1913 patients (World J Surg 2020), a protocol driven approach involving the implementation of several specific measures at the time of wound closure (captured by the ‘ITSRED Fred’ mneumonic - Irrigation of wound, Time, Systolic blood pressure >100 mm Hg, relieving neck extension, Elevating venous pressure, Drain avoidance and Flap evaluation) was implemented and evaluated. Method The operative and clinical records of 1525 thyroid and/or parathyroid surgical procedures in a single tertiary unit between 2017 and 2022 were reviewed following the implementation of the ‘ITSRED Fred’ protocol. The rates of re-bleeding requiring surgery were examined. Results The median (interquartile range) age of the cohort was 53 (39-66) years with a male: female ratio of 1:4.946 had thyroid surgery, 541 had parathyroid surgery and 38 had both. 0.8% were re-do operations and 20% of procedures included neck dissection. Twelve (0.79%) patients had re-operation for bleeding (lower than previously reported rate of 1.3% from the same unit). Of these, 5 (0.3%) required re-operation before leaving theatre; 5 (0.3%) had bleeding within 6 hours and two (0.13%) after 6 hours. Bleeding rates were 1.1% (n = 10) in thyroid surgery compared to 0.4% (n = 2) in parathyroid surgery. Conclusions A protocol driven implementation of specific measures (such as the ‘ITSRED Fred’ protocol) may reduce the rate of re-operation for bleeding after thyroid and parathyroid surgery.