SELF/Perioperative Nursing/Hemostasis Management

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This training module focuses on preparing and testing electro-surgical equipment (diathermy), surgical instruments, haemostatic materials, and patient-specific items (e.g., tourniquets) before surgery begins. It is performed by the scrub nurse and/or circulating nurse and is essential to ensure safety, efficiency, and surgical readiness. The procedure requires technical knowledge, device testing, communication with the surgical team, and attention to sterile technique.

• Define the physiological process of hemostasis and describe key factors influencing bleeding control.
• Explain the preparation, selection, and contraindications of hemostatic agents and tools.
• Describe mechanical and electrosurgical methods of achieving hemostasis and their operational principles.
• Explain the organization of instruments, sponges, and suction systems to maintain control of the operative field.
• Identify effective team communication strategies that support coordination and patient safety during bleeding events.
• Explain adaptations and safe practices for managing hemostasis in low-resource or high-stress surgical environments.

Hemostasis is the body’s natural process of stopping bleeding. Physiologically, hemostasis involves three sequential stages: vascular constriction, platelet plug formation, and coagulation cascade activation leading to fibrin clot stabilization. Nurses must appreciate how these stages are influenced by systemic factors such as hypothermia, acidosis, or medication use. For example, patients on anticoagulants such as warfarin or direct oral anticoagulants have impaired secondary hemostasis, while those with thrombocytopenia cannot form effective platelet plugs. These considerations influence how aggressively and with what tools bleeding will need to be controlled intraoperatively.

Before the surgical case starts, the scrub nurse should confirm whether the patient has a history of coagulopathy, malnutrition, liver disease, or chronic dialysis, since each condition affects hemostatic potential. This information should be cross-checked against the anesthesia chart and surgical plan. If the patient is anticoagulated, the nurse should expect the surgeon to request adjunctive pharmacologic or mechanical hemostatic agents. Additionally, awareness of contraindications is crucial: diathermy use (high-frequency electric currents to cut tissue or stop bleeding by coagulation) is unsafe in patients with certain implanted cardiac devices or metallic implants near the surgical field, and must be substituted with mechanical or chemical control methods.

Hypothermia is a common complication during longer operations and directly reduces the effectiveness of clotting enzymes. To reduce this risk, the nurse should confirm that warming blankets are functioning and that irrigation fluids are warmed before the sterile setup is completed. With these systemic factors addressed, attention can shift back to the operative field, where the first line of hemostasis relies on simple tools. Sponges should be counted and arranged by size before incision — smaller gauze for fine oozing and larger laparotomy pads for deeper bleeding. Organizing them in this way ensures the team can escalate smoothly from minor to major bleeding control without losing time once surgery is underway.

Finally, the circulating nurse plays a key role in ensuring blood products, if anticipated, are either in the room or rapidly available. Even if transfusion is not planned, the nurse should verify that type and crossmatch information is documented and that the blood bank has been alerted when high-risk surgery is scheduled. A clear understanding of these fundamentals allows perioperative nurses to anticipate needs and keep the surgical field safe.

Hemostatic agents serve as critical adjuncts to mechanical and electrosurgical methods, and must be prepared, tested, and positioned for immediate access. Topical agents include:

• oxidized cellulose sheets
• gelatin sponges
• microfibrillar collagen

These should be opened onto the sterile field, moistened if required (e.g., gelatin sponges), and laid out by increasing size on a dedicated hemostasis tray: smallest sheets closest to the surgeon, followed by progressively larger sizes, and finally adjuncts like collagen powder. This prevents time loss during escalating bleeding situations. The scrub nurse must verify that the correct agent is provided, as cellulose is contraindicated in infected or contaminated fields due to risk of bacterial growth.

Pharmacologic options such as tranexamic acid (TXA) should be confirmed as available and properly dosed by anesthesia prior to incision if high-risk bleeding is expected. Nurses must recognize that TXA is contraindicated in patients with active thromboembolic disease or severe renal impairment. In the operating field, fibrin sealants or thrombin-based topical solutions, if stocked, should be kept refrigerated until just before use; the scrub nurse should confirm reconstitution protocols with the circulating nurse to avoid delays once requested by the surgeon.

Blood products represent the most powerful pharmacologic hemostatic tools, but their preparation requires anticipation. The circulating nurse should verify with anesthesia whether fresh frozen plasma, platelets, or cryoprecipitate might be required, and confirm transport arrangements from the blood bank. During preparation, scrub nurses should reserve sterile suction tubing and wide-bore lines specifically for blood product administration to prevent cross-contamination. Rapid access to appropriate blood products often means the difference between controlled and uncontrolled hemorrhage.

Attention to contraindications is essential. For example, patients with known allergies to bovine collagen must not receive collagen-based hemostatic sponges, and gelatin sponges must be avoided in infected wounds to reduce risk of abscess formation. Nurses must review patient history, confirm with anesthesia, and cross-check all products before introducing them to the sterile field.

Mechanical methods remain the most universally applicable and immediately available strategies to stop bleeding. Direct pressure is the first-line technique and should be supported by preparing multiple layers of dry sponges or gauze, folded and arranged in stacks for immediate handoff. Pressure must be applied directly over the bleeding point, and the nurse should anticipate the surgeon’s request by preparing dry sponges ahead of visible bleeding.

Vascular clamps, such as hemostats and bulldog clamps, should be counted and arranged in graduated order of size. Smaller mosquito clamps should be positioned on the near right of the tray, progressing to medium and then large clamps toward the left, with bulldog clamps separated on a designated holder. This arrangement allows immediate, intuitive selection without fumbling during urgent bleeding control. When passing clamps, the scrub nurse must orient them with tips angled toward the surgeon and ratchets unlocked, minimizing wasted time.

For ligation, sutures should be arranged with preloaded needle holders, with absorbable ties prepared on tonsil clamps for vessel ligature. Transfixion sutures should be pre-threaded and arranged in separate sterile packs to avoid delay. If a tourniquet is anticipated, the circulating nurse must test inflation equipment before surgery and have a manometer ready to record inflation pressures. Correct tourniquet duration must be logged visibly, usually on a whiteboard or in the chart, with alerts given at 60- and 90-minute marks.

Stapling devices, if available, should be checked for cartridge load and cutting function before draping. If unavailable, the scrub nurse must ensure alternatives such as multiple suture packs or vascular clips are arranged. Proper preparation of these mechanical methods ensures immediate response when electrosurgical or pharmacologic control is insufficient.

Self-Assessment

Please complete the following: Quiz 1: Hemostasis Management - ECSACONM

Refer to module on Electro-Surgical Units - ECSACONM for ESU fundamental operation and considerations.

The scrub nurse must confirm that both the monopolar pencil and the bipolar forceps are present on the sterile field, tested, and positioned on the Mayo stand where they can be reached quickly. Their corresponding ESU settings should be checked with the circulating nurse before incision, so that switching between coagulation modes can be done without delay when bleeding occurs. Ensure the monopolar foot pedal is connected, and that the dispersive (return) electrode pad is available and will be placed on the patient at the first sign of active bleeding. Placing both coagulation cables side-by-side (monopolar and bipolar) in a dedicated zone of the sterile field reduces delays when switching modes mid-case.

During the procedure, as soon as bleeding begins—especially from capillary or small venous sources—the scrub nurse should pass the monopolar coagulation handpiece, set at coagulate mode. This achieves rapid thermal clot formation. If bleeding persists or becomes more focal, the next step is to introduce bipolar forceps in coagulation mode, which delivers energy directly between the two tips, minimizing thermal spread and improving precision in confined vascular areas.

When surgeons request coagulation escalation—for example, for a bleeding arterial branch—the scrub nurse should provide the appropriate ESU handpiece (usually the monopolar pencil) while the circulating nurse adjusts the generator to the surgeon’s requested setting, such as blended cut or a higher coagulation level. Since blended waveforms combine cutting and coagulation, they provide effective hemostasis when precise vessel sealing is needed without full tissue dissection. This must be pre-confirmed during set-up so the modes can be activated quickly, and the correct probe or pencil positioned instantly at the bleeding site.

Finally, safety cannot be compromised even in the urgency of bleeding control. The scrub nurse ensures the dispersive pad is properly applied (with full skin contact, avoiding scars, bony areas, or moist dressings), and that coagulation tips have been tested on a moist pad before use. If smoke or eschar build-up compromises visibility or efficacy, the nurse should be ready to provide antistick solution or saline for tip cleaning, and activate smoke evacuation as requested. These proactive steps help sustain effective, safe coagulation throughout the case—even in dynamic bleeding situations.

Assisting in hemostasis requires anticipation as well as technical fluency. Suction must be tested before draping, with tubing secured to collection canisters and tips fitted with adapters. On the Mayo stand, the Yankauer or Frazier suction tip should be coiled neatly at the left front for immediate pickup. During use, nurses must hold suction tips close enough to clear blood but avoid direct contact with tissue or clots, maintaining visibility without causing trauma. Irrigation basins should be filled with warmed fluid, labeled, and placed at the back row of the stand to reduce spillage. Saline should be exchanged regularly to prevent cooling, and syringes passed with the plunger oriented toward the surgeon’s hand.

Suture assistance requires careful preparation. Needle holders should be preloaded with sutures, positioning the needle two-thirds from the tip at a 90° angle for efficient handling. Preloaded instruments should be laid out in order of use — needle holders nearest, followed by clamps and ties. For expected transfixion stitches, longer curved needles should be prepared in advance, while shorter needles suffice for simple ligatures. Each instrument should be passed with tips directed toward the operative site, minimizing repositioning and delays during vessel ligation. For general suture assistance, refer to Surgical Assistance - ECSACONM.

For high-blood-loss procedures, a secondary hemostasis tray should be prepared with duplicate clamps, sutures, and sponges. This tray should mirror the arrangement of the primary Mayo stand so the team can transition seamlessly during emergencies. Standardized organization ensures the surgeon receives what is needed without confusion, supporting steady bleeding control even in high-stress scenarios.

Once the sterile field is established (see Setting up the Sterile Field – ECSACONM), the scrub nurse’s role shifts to active management during bleeding. Instruments and hemostatic materials must remain in their assigned areas on the Mayo stand, even as the case progresses and demands change. This consistency allows the surgeon to retrieve clamps, sutures, or sponges quickly without searching, which is especially important when urgent bleeding occurs.

Sponge management is central to field control. Dry sponges are stacked in groups of ten and kept within the sterile area, while used sponges are transferred immediately to kick buckets and never returned to the field. This strict separation preserves count accuracy and gives a visual record of blood loss. Nurses should avoid returning any used sponge to the working field, as this both confuses the count and risks contamination. The scrub and circulating nurse track sponge usage together, then estimate blood loss by weighing sponges on a calibrated scale if available, or by visual comparison against standard saturation volumes (e.g., a soaked laparotomy pad ≈ 100–150 mL).

When hemorrhage escalates, counts and organization become harder to maintain. In these situations, the scrub nurse should call out each additional clamp, tie, or sponge as it is introduced, while the circulating nurse documents in real time. Clamps should be lined up at the wound edges in an orderly row rather than scattered, and suction must be applied steadily to preserve visibility. These practices reduce the risk of lost items, prevent confusion during crisis, and help maintain orientation in a chaotic operative field.

Clear communication is essential during bleeding, and it begins before incision. The scrub and circulating nurses should confirm with the surgeon which areas are most likely to bleed and with anesthesia what resuscitation resources are ready. This upfront exchange ensures that suction, electrosurgical tools, sponges, and hemostatic agents are tested and positioned before they are urgently needed.

During surgery, information must be delivered concisely and aloud. Instead of vague alerts, nurses should state specific observations and actions, such as “Opening another pack of laparotomy pads” or “Blood loss is approaching 500 mL.” The circulating nurse should notify anesthesia immediately at set thresholds of blood loss so resuscitation can begin without delay. Continuous verbal updates on sponge counts and suction volumes keep all team members aligned on the patient’s status.

Closed-loop communication strengthens accuracy under stress. When the surgeon requests an item, the scrub nurse repeats the request back by name and size — for example, “Oxidized cellulose, 5 x 7 sheet.” Likewise, medication requests such as tranexamic acid should always be confirmed aloud with dose and route before preparation. This practice minimizes error, keeps the team synchronized, and maintains composure during high-pressure bleeding events.

When full arrays of hemostatic agents or advanced devices are not available, perioperative nurses must prioritize preparation and reuse strategies. For instance, when fibrin sealants or collagen sponges are unavailable, nurses should prepare multiple sterile packs of gauze and large laparotomy pads for layered tamponade. Tourniquets can be improvised with blood pressure cuffs, provided they are tested for inflation and carefully monitored for duration to avoid limb ischemia.

When personnel shortages limit the ability to perform dual counts or monitor massive transfusion protocols, the scrub nurse can establish a simplified yet reliable system by assigning sponge count responsibility to the circulating nurse and verbally confirming all opened items in real time. Where electrosurgical units are unreliable, reliance shifts to mechanical control, requiring extra preparation of clamps and pre-threaded sutures. Maintaining structured preparation and anticipating likely bleeding scenarios is the most effective adaptation in low-resource environments.

Self-Assessment

Please complete the following: Quiz 2: Hemostasis Management - ECSACONM

Cumulative Test

Please complete the following: Module Test: Hemostasis Management - ECSACONM

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