Surgical and Endovascular Complications: Infection and Hemorrhage

Abstract

In all cases of hemorrhage, the Advanced Trauma Life Support (ATLS) algorithm should be followed, with prompt recognition, rapid resuscitation, and immediate decision making and action [ 1 ]. Retroperitoneal Hemorrhage EtiologyRetroperitoneal hematoma (RPH) describes bleeding into the potential space between the peritoneum and the musculoskeletal elements of the back. Several conditions can cause RPH including ruptured aortic aneurysm, traumatic vascular injury, retroperitoneal neoplasms, and coagulopathy. RPH occurs most frequently as a complication of percutaneous femoral artery puncture for interventional procedures. The reported incidence of RPH after cardiac catheterization is 0.15 % for diagnostic procedures, 0.8 % for balloon angioplasty, and 3 % for coronary stents. Three dichotomous variables were identifi ed as independent predictors of RPH: female gender (odds ratio [OR] 5.4), body surface area (BSA) less than 1.73 m 2 (OR 7.1), and high femoral artery puncture site (OR 5.3) [ 2 ]. Twenty-fi ve percent of retroperitoneal bleeds were remote from the femoral artery puncture site, with the majority of these being contralateral to the side of the puncture. PresentationThe diagnosis of retroperitoneal hematoma requires clinical acumen, and an awareness of the scenarios in which this complication is likely to occur. Patients with signifi cant groin, fl ank, abdominal, or back pain or hemodynamic instability following an interventional procedure should be evaluated for a retroperitoneal hematoma. The nonspecifi c symptoms associated with RPH often delay the diagnosis. Approximately 23-54 % of retroperitoneal hematoma patients have documented clinical evidence of femoral neuropathy caused by compression of the femoral nerve [ 3 ]. Seventy-fi ve percent of cases presented within the fi rst 3 h after conclusion of the procedure, with a rapid decline in frequency after this time period [ 4 ]. Spontaneous hemorrhage usually occurs in patients receiving anticoagulation. Idiopathic retroperitoneal hematoma may present symptomatically in the form of acute abdominal pain, nausea, and anorexia. Upon physical examination, the patient may have a tender abdomen and hypovolemic shock. ImagingContrast-enhanced computed tomography (CT) scan is the imaging modality of choice to identify and categorize a retroperitoneal hemorrhage (Fig. 23.1 ). TreatmentAlthough a widely accepted consensus on the management of patients with RPH does not exist, a reasonable treatment algorithm is shown in Fig. 23.2 . Conservative TherapyHemodynamically stable patients with RPH can be managed with fl uid resuscitation, correction of coagulopathy, and blood transfusion. Non-interventional therapy mandates close observation for the development of abdominal compartment syndrome (ACS) which can be fatal if it is not promptly recognized and treated. ACS is defi ned as sustained intra-abdominal pressure greater than 20 mmHg with end-organ dysfunction manifested as respiratory insuffi ciency, oliguria, and decreased venous return resulting in severe hy...