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Intra-abdominal hypertension due to heparin - induced retroperitoneal hematoma in patients with ventricle assist devices: report of four cases and review of the literature.

Daliakopoulos SI, Schaedel M, Klimatsidas MN, Spiliopoulos S, Koerfer R, Tenderich G - J Cardiothorac Surg (2010)

Bottom Line: ACS is the natural progression of pressure-induced end-organ changes and develops if IAP is not recognized and treated in a timely manner.Failure to recognize and appropriately treat ACS is fatal while timely intervention - if indicated - is associated with improvements in organ function and patient survival.Means for surgical decision making are based on clinical indicators of adverse physiology, rather than on a single measured parameter.

View Article: PubMed Central - HTML - PubMed

Affiliation: Herzzentrum Essen, Herwarthstrasse 100, 45138 Essen, Germany. sdaliakopoulos@hotmail.de

ABSTRACT

Introduction: Elevated intra-abdominal pressure (IAP) has been identified as a cascade of pathophysiologic changes leading in end-organ failure due to decreasing compliance of the abdomen and the development of abdomen compartment syndrome (ACS). Spontaneous retroperitoneal hematoma (SRH) is a rare clinical entity seen almost exclusively in association with anticoagulation states, coagulopathies and hemodialysis; that may cause ACS among patients in the intensive care unit (ICU) and if treated inappropriately represents a high mortality rate.

Case presentation: We report four patients (a 36-year-old Caucasian female, a 59-year-old White-Asian male, a 64-year-old Caucasian female and a 61-year-old Caucasian female) that developed an intra-abdominal hypertension due to heparin-induced retroperitoneal hematomas after implantation of ventricular assist devices because of heart failure. Three of the patients presented with dyspnea at rest, fatigue, pleura effusions in chest XR and increased heart rate although b-blocker therapy. A 36-year old female (the forth patient) presented with sudden, severe shortness of breath at rest, 10 days after an "acute bronchitis". At the time of the event in all cases international normalized ratio (INR) was <3.5 and partial thromboplastin time <65 sec. The patients were treated surgically, the large hematomas were evacuated and the systemic manifestations of the syndrome were reversed.

Conclusion: Identifying patients in the ICU at risk for developing ACS with constant surveillance can lead to prevention. ACS is the natural progression of pressure-induced end-organ changes and develops if IAP is not recognized and treated in a timely manner. Failure to recognize and appropriately treat ACS is fatal while timely intervention - if indicated - is associated with improvements in organ function and patient survival. Means for surgical decision making are based on clinical indicators of adverse physiology, rather than on a single measured parameter.

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1st case. CT - axial plan demonstrating a retroperitoneal hematoma adherent to the right psoas muscle, shifting the right renal lateral.
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Figure 1: 1st case. CT - axial plan demonstrating a retroperitoneal hematoma adherent to the right psoas muscle, shifting the right renal lateral.

Mentions: On the 7th ICU-day the patient developed a tense, distended abdomen and became oliguric. Pulmonary vascular resistance was 305 dyn × sec/cm5. Abdominal ultrasound revealed an empty bladder with a urinary catheter in situ and kidneys of normal size. Despite to an adequate mean arterial pressure (65 mm Hg) and passage of a nasogastric tube to decompress the stomach, oliguria persisted. Intraabdominal pressure (IAP) was measured via a urinary catheter and was shown to be 27 mm Hg, which confirmed abdominal compartment syndrome (ACS) [12]. CT of the abdomen and pelvis showed a large retroperitoneal hematoma (Figure 1). The patient was initially treated with transfusion of 8 units of packed red cells (PRC) and 4 units of fresh frozen plasma (FFP). Despite adequate fluid and blood product resuscitation the patient remained unstable so that the large retroperitoneal hematoma had to be surgically removed on the 8th ICU-day. The patient remained in the ICU for 47 days.


Intra-abdominal hypertension due to heparin - induced retroperitoneal hematoma in patients with ventricle assist devices: report of four cases and review of the literature.

Daliakopoulos SI, Schaedel M, Klimatsidas MN, Spiliopoulos S, Koerfer R, Tenderich G - J Cardiothorac Surg (2010)

1st case. CT - axial plan demonstrating a retroperitoneal hematoma adherent to the right psoas muscle, shifting the right renal lateral.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2992055&req=5

Figure 1: 1st case. CT - axial plan demonstrating a retroperitoneal hematoma adherent to the right psoas muscle, shifting the right renal lateral.
Mentions: On the 7th ICU-day the patient developed a tense, distended abdomen and became oliguric. Pulmonary vascular resistance was 305 dyn × sec/cm5. Abdominal ultrasound revealed an empty bladder with a urinary catheter in situ and kidneys of normal size. Despite to an adequate mean arterial pressure (65 mm Hg) and passage of a nasogastric tube to decompress the stomach, oliguria persisted. Intraabdominal pressure (IAP) was measured via a urinary catheter and was shown to be 27 mm Hg, which confirmed abdominal compartment syndrome (ACS) [12]. CT of the abdomen and pelvis showed a large retroperitoneal hematoma (Figure 1). The patient was initially treated with transfusion of 8 units of packed red cells (PRC) and 4 units of fresh frozen plasma (FFP). Despite adequate fluid and blood product resuscitation the patient remained unstable so that the large retroperitoneal hematoma had to be surgically removed on the 8th ICU-day. The patient remained in the ICU for 47 days.

Bottom Line: ACS is the natural progression of pressure-induced end-organ changes and develops if IAP is not recognized and treated in a timely manner.Failure to recognize and appropriately treat ACS is fatal while timely intervention - if indicated - is associated with improvements in organ function and patient survival.Means for surgical decision making are based on clinical indicators of adverse physiology, rather than on a single measured parameter.

View Article: PubMed Central - HTML - PubMed

Affiliation: Herzzentrum Essen, Herwarthstrasse 100, 45138 Essen, Germany. sdaliakopoulos@hotmail.de

ABSTRACT

Introduction: Elevated intra-abdominal pressure (IAP) has been identified as a cascade of pathophysiologic changes leading in end-organ failure due to decreasing compliance of the abdomen and the development of abdomen compartment syndrome (ACS). Spontaneous retroperitoneal hematoma (SRH) is a rare clinical entity seen almost exclusively in association with anticoagulation states, coagulopathies and hemodialysis; that may cause ACS among patients in the intensive care unit (ICU) and if treated inappropriately represents a high mortality rate.

Case presentation: We report four patients (a 36-year-old Caucasian female, a 59-year-old White-Asian male, a 64-year-old Caucasian female and a 61-year-old Caucasian female) that developed an intra-abdominal hypertension due to heparin-induced retroperitoneal hematomas after implantation of ventricular assist devices because of heart failure. Three of the patients presented with dyspnea at rest, fatigue, pleura effusions in chest XR and increased heart rate although b-blocker therapy. A 36-year old female (the forth patient) presented with sudden, severe shortness of breath at rest, 10 days after an "acute bronchitis". At the time of the event in all cases international normalized ratio (INR) was <3.5 and partial thromboplastin time <65 sec. The patients were treated surgically, the large hematomas were evacuated and the systemic manifestations of the syndrome were reversed.

Conclusion: Identifying patients in the ICU at risk for developing ACS with constant surveillance can lead to prevention. ACS is the natural progression of pressure-induced end-organ changes and develops if IAP is not recognized and treated in a timely manner. Failure to recognize and appropriately treat ACS is fatal while timely intervention - if indicated - is associated with improvements in organ function and patient survival. Means for surgical decision making are based on clinical indicators of adverse physiology, rather than on a single measured parameter.

Show MeSH
Related in: MedlinePlus