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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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2nd case. CT - sagittal plan of a large retroperitoneal hematoma - 17.76 cm.
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Figure 2: 2nd case. CT - sagittal plan of a large retroperitoneal hematoma - 17.76 cm.

Mentions: A 59-year-old White-Asian male was admitted to hospital and required support with Heart Mate II Thoratec(r) LVAS because of terminal heart insufficient due to idiopathic dilated cardiomyopathy. On the 6th ICU-day hemodynamic indicators included elevated heart rate (HF > 140 b/min), hypotension (Systolic/Diastolic BP 60/40 mm Hg), elevated Pulmonary Artery Wedge Pressure (27 mmHg) and Central Venous Pressure (CVP 16 mmHg) with elevated Systemic - SVR: 1500 dyn × sec/cm5 and Pulmonary - PVR: 345 dyn × sec/cm5 Vascular Resistance made the patient's mechanical ventilation difficult, requiring high peak inflating pressures (Pmax 34 mmHg and high positive expiratory end-pressure (PEEP > 10) in order to maintain adequate oxygenation. During the next hours the patient became anuric with IAP of 22 mmHg. CT revealed a 17,76 cm (Figure 2, 3) retroperitoneal hematoma that was surgically removed. The retroperitoneum had to be packed and a re-exploration was necessary 72 h later before the final closure. The patient was discharged from the ICU on 56th postoperative day (after LVAD implantation).


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)

2nd case. CT - sagittal plan of a large retroperitoneal hematoma - 17.76 cm.
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 2: 2nd case. CT - sagittal plan of a large retroperitoneal hematoma - 17.76 cm.
Mentions: A 59-year-old White-Asian male was admitted to hospital and required support with Heart Mate II Thoratec(r) LVAS because of terminal heart insufficient due to idiopathic dilated cardiomyopathy. On the 6th ICU-day hemodynamic indicators included elevated heart rate (HF > 140 b/min), hypotension (Systolic/Diastolic BP 60/40 mm Hg), elevated Pulmonary Artery Wedge Pressure (27 mmHg) and Central Venous Pressure (CVP 16 mmHg) with elevated Systemic - SVR: 1500 dyn × sec/cm5 and Pulmonary - PVR: 345 dyn × sec/cm5 Vascular Resistance made the patient's mechanical ventilation difficult, requiring high peak inflating pressures (Pmax 34 mmHg and high positive expiratory end-pressure (PEEP > 10) in order to maintain adequate oxygenation. During the next hours the patient became anuric with IAP of 22 mmHg. CT revealed a 17,76 cm (Figure 2, 3) retroperitoneal hematoma that was surgically removed. The retroperitoneum had to be packed and a re-exploration was necessary 72 h later before the final closure. The patient was discharged from the ICU on 56th postoperative day (after LVAD implantation).

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