Medical innovations have extended patient lifespans while also increasing the clinical complexity associated with aging and chronic conditions. As patients live longer, surgeons may encounter an array of perioperative challenges including patients with multiple comorbidities. Consequently, surgical teams must manage bleeding risks while balancing potential thromboembolic complications. This retrospective observational study evaluated trends in perioperative bleeding management and associated surgical care challenges over 22 years, utilizing data from the Premier Perspective Hospital Database. The analysis included 13,358,404 adult surgical patients, examining patient complexity via Charlson Comorbidity Index (CCI), preoperative anticoagulant/antiplatelet usage, and topical hemostatic agent (THA) utilization. Patient complexity, as indicated by CCI, significantly increased annually across all surgical types, with the greatest increase in cardiovascular surgery (0.029/year). Overall preoperative use of anticoagulants and antiplatelets rose by 0.5 % per year, with marked variations across surgical cohorts. Notably, general surgery exhibited the highest annual increase (2.0 %), while knee and hip replacements showed a decline in anticoagulant/antiplatelet use. Overall, use of THA strategies increased by 0.56 % annually, particularly in neurosurgery, spinal, and cardiovascular procedures. Multivariate analysis demonstrated significant associations between patient complexity, anticoagulant/antiplatelet use, and higher use of THA strategies across various surgical disciplines. Elective surgeries were more likely to be associated with THA charges than emergent or urgent procedures. This large retrospective analysis describes evolving patient complexity, antithrombotic medication use, and associated use of THA strategies across surgical specialties over two decades. These findings characterize practice patterns and may inform future hypothesis-driven studies evaluating the clinical role of THAs in different surgical contexts.