RESUMEN
Paracentesis has been considered a relatively safe procedure; however, hemorrhagic complications do occur and can be fatal, especially in the context of coagulopathy. We describe the case of a 47-year-old man with coagulopathy secondary to end-stage liver disease, whose hospital course was complicated by paracentesis-related hemoperitoneum leading to abdominal compartment syndrome. Emergent laparotomy revealed left inferior epigastric artery laceration caused by paracentesis. Despite operative control of bleeding, postoperatively, the patient developed severe metabolic acidosis, disseminated intravascular coagulation, and ultimately died from complications of hemorrhagic shock. Understanding key anatomic structures is essential for patient safety in the setting of paracentesis. While recognizing the lack of clinical studies demonstrating the effectiveness of ultrasonography use in paracentesis, we discuss the benefit of bedside abdominal ultrasonography to locate ascites and avoid intraabdominal structures, as well as vascular ultrasonography, during needle insertion to avoid abdominal wall vessels.
Asunto(s)
Arterias Epigástricas/lesiones , Hemoperitoneo/etiología , Paracentesis/efectos adversos , Sistemas de Atención de Punto/tendencias , Choque Hemorrágico/etiología , Ultrasonografía/métodos , Abdomen/diagnóstico por imagen , Vasos Sanguíneos/diagnóstico por imagen , Enfermedad Hepática en Estado Terminal/terapia , Arterias Epigástricas/diagnóstico por imagen , Resultado Fatal , Hemoperitoneo/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Choque Hemorrágico/prevención & controlRESUMEN
BACKGROUND: Early damage-control resuscitation (DCR) indicators have not been clearly discerned in patients with penetrating abdominal trauma. Our objective was to identify these clinical indicators that could standardize a DCR initiation policy in this subset of patients. METHODS: Prospective data collection from January 2003 to October 2010 at a Level I trauma center in Cali, Colombia. All adult (>15 years) patients with abdominal gunshot wounds (GSWs) were included. They were divided into two groups: those who underwent DCR and those who did not. Both groups were compared by demographics, clinical variables, severity scores, and overall mortality. Other scores were compared with our newly devised model using the area under the receiver operating characteristic curve (AUROC). RESULTS: There was a total of 331 abdominal GSWs. Of these, a total of 162 (49%) underwent DCR. The overall mortality was 11.2%. Multivariate analysis identified (A) acidosis (base deficit ≥ 8); (B) blood loss (hemoperitoneum > 1,500 mL); (C) cold (temperature < 35 °C); (D) damage (New Injury Severity Score > 35) as significant clinical indicators that aided in the decision process of early implementation of DCR. The Trauma-Associated Severe Hemorrhage (AUROC, 0.8333), McLaughlin (AUROC, 0.8148), ABC (AUROC, 0.7372) scores and our ABCD mnemonic (AUROC, 0.8745) were all good predictors of DCR, and the difference between them was statistically significant (p < 0.001). CONCLUSION: We have identified (A) acidosis (base deficit ≥ 8); (B) blood loss (hemoperitoneum > 1,500 mL); (C) cold (temperature < 35 °C); (D) damage (New Injury Severity Score > 35) as significant clinical indicators that aided in the decision process of early implementation of DCR for patients with abdominal GSWs. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level III.
Asunto(s)
Traumatismos Abdominales/terapia , Servicio de Urgencia en Hospital , Selección de Paciente , Resucitación , Triaje , Heridas por Arma de Fuego/terapia , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/diagnóstico , Acidosis/diagnóstico , Acidosis/etiología , Acidosis/prevención & control , Adulto , Protocolos Clínicos , Estudios de Cohortes , Femenino , Hemoperitoneo/diagnóstico , Hemoperitoneo/etiología , Hemoperitoneo/prevención & control , Humanos , Hipotermia/diagnóstico , Hipotermia/etiología , Hipotermia/prevención & control , Masculino , Índices de Gravedad del Trauma , Heridas por Arma de Fuego/complicaciones , Heridas por Arma de Fuego/diagnóstico , Adulto JovenRESUMEN
This article discusses the possible etiology and the preoperative, operative, and postoperative management of five ovarian pregnancies based on the initial nonspecific signs and symptoms and the high risk of hemoperitoneum and/or hypovolemic shock of a ruptured ovarian pregnancy with the associated diagnostic problems. The advances made in transvaginal ultrasonography and monitoring of serum ß-hCG levels in blood samples, as well as the substantial progress made in diagnostic pelviscopy and operative laparoscopy, have led to an early minimal invasive surgical management with the main emphasis on an organ-preserving procedure, i.e., a simple enucleation of the gestational sac with the utmost protection of the surrounding ovarian tissue.
Asunto(s)
Laparoscopía , Ovario/cirugía , Embarazo Ectópico/cirugía , Adulto , Biomarcadores/sangre , Gonadotropina Coriónica Humana de Subunidad beta/sangre , Diagnóstico Precoz , Femenino , Alemania , Edad Gestacional , Saco Gestacional/diagnóstico por imagen , Saco Gestacional/cirugía , Hemoperitoneo/etiología , Hemoperitoneo/prevención & control , Humanos , Ovario/diagnóstico por imagen , Valor Predictivo de las Pruebas , Embarazo , Embarazo Ectópico/diagnóstico , Embarazo Ectópico/etiología , Radioinmunoensayo , Factores de Riesgo , Choque/etiología , Choque/prevención & control , Factores de Tiempo , Resultado del Tratamiento , Ultrasonografía PrenatalRESUMEN
UNLABELLED: This observational, analytical cohort consisted of 35 consecutive liver transplant (OLT) patients with no intra-abdominal drain and a control cohort of 35 subjects operated immediately before the former who had placement of an intra-abdominal drain. We sought to assess the impact of abdominal drainage on the diagnosis and prevention of early postoperative complications: hemoperitoneum, reinterventions, biliary leaks, or percutaneous drainage. We assessed variables related to the recipient (age, indication, pretransplant ascites, body mass index, Model for End-Stage Liver Disease score and rejection), the donor (age, steatosis, ischemia time) and intra- and postoperative factors (surgery time, blood product use, and coagulopathy). The end point was defined as the need for a reintervention, paracentesis, appearance, and drainage of collections as well as lengths of hospital and intensive care unit (ICU) stays. The postoperative ICU and in-hospital stays were similar between groups (3.7 vs 3.9 days and 12 vs 14 days, respectively). Two patients in the group with drainage were reoperated due to hemoperitoneum, whereas we did not reoperate any patients in the group without drainage. No patient from either group developed a biliary fistula or required drainage of an intra-abdominal collections. The need for paracentesis was greater among the group without drainage (23% vs 5.7%; P < .04) and among those with a prior history of severe ascites. Patients with drainage displayed a greater incidence of perihepatic hematomas by ultrasound (53% vs 21%; P < .08) and required more postoperative blood products, especially platelets (P > .04) and plasma (P < .01). CONCLUSION: OLT without intra-abdominal drainage is safe, not increasing morbidity. It seems likely that drainage may be responsible for intra-abdominal hematomas and greater consumption of blood products.
Asunto(s)
Abdomen/fisiología , Drenaje/métodos , Hemoperitoneo/prevención & control , Fallo Hepático/cirugía , Trasplante de Hígado/métodos , Adulto , Anciano , Transfusión Sanguínea , Estudios de Cohortes , Femenino , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/prevención & controlRESUMEN
BACKGROUND: The use of pelvic x-rays (PXRs) as an early diagnostic adjunct in the evaluation of blunt trauma patients has become widely accepted, and computed tomographic (CT) scanning is now used universally in the assessment of abdominal and pelvic injuries. In this study, we have attempted to identify patients with pelvic fractures who might be at risk for vessel hemorrhage and determine if early angioembolization was required in these patients. MATERIAL AND METHODS: We retrospectively reviewed patients who presented with pelvic fractures from June 2005 to August 2007. Both PXRs and CT scans were reviewed. Patients who presented with bleeding due to other associated injuries or who did not receive a CT scan were excluded. Patients with either initial hemodynamic instability or contrast extravasation on enhanced CT scan underwent angioembolization. Patient demographics, Injury Severity Score, the amount of blood transfused, and the relationship between the fracture pattern and angioembolization were analyzed. RESULTS: A total of 54 patients were enrolled. A diagnosis of an unstable pelvic fracture on PXR was associated with a higher probability of angioembolization. Seven patients received incompatible diagnoses from the PXR and CT scan; these patients received larger amounts of transfused blood and demonstrated an increased need for angioembolization. CONCLUSIONS: Although CT scan is more sensitive in the identification of acetabular or small pelvic fractures, PXR is sufficient for the early evaluation of pelvic fracture stability. Based on the current series, early angioembolization is suggested for patients with an initial diagnosis of an unstable pelvic fracture. In addition, patients receiving large amounts of transfused blood are more likely to require early angioembolization.
Asunto(s)
Fracturas Óseas/complicaciones , Fracturas Óseas/diagnóstico por imagen , Hemoperitoneo/prevención & control , Huesos Pélvicos/diagnóstico por imagen , Huesos Pélvicos/lesiones , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico por imagen , Acetábulo/lesiones , Adulto , Transfusión Sanguínea , Embolización Terapéutica , Extravasación de Materiales Terapéuticos y Diagnósticos , Femenino , Hemoperitoneo/etiología , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
Hemoperitoneum is a serious and often life-threatening bleeding manifestation. This is particularly true for women who carry congenital bleeding disorders. We describe here a hemoperitoneum occurring in 1 patient with congenital prothrombin deficiency and another with congenital factor V deficiency. Both patients have been followed by us for many years. The patient with prothrombin deficiency underwent laparoscopy but was treated consecutively with whole blood, plasma transfusions and 1,000 units of prothrombin complex concentrates. Response was good and she was then placed on oral contraceptives (OC) which prevented any recurrence. The patient with factor V deficiency presented several episodes of ovulation-related bleeding which required hospitalization and fresh frozen plasma transfusions. On the fifth occasion, the patient had to undergo surgery, and a left oophorectomy was carried out. After this last episode, she was also placed on OC which were very effective in preventing further recurrences. Both patients tolerated the medications very well which, in addition, were able to control menometrorrhagia with a consequent decrease over time in transfusional needs. OC are the treatment of choice in congenital bleeding disorders to control both the menorrhagia and, more importantly, ovulation-related hemoperitoneum.
Asunto(s)
Anticonceptivos Orales/administración & dosificación , Deficiencia del Factor V/complicaciones , Hemoperitoneo/etiología , Hemoperitoneo/prevención & control , Hipoprotrombinemias/complicaciones , Inhibición de la Ovulación/efectos de los fármacos , Adulto , Transfusión de Componentes Sanguíneos/métodos , Deficiencia del Factor V/terapia , Femenino , Hemoperitoneo/terapia , Humanos , Hipoprotrombinemias/terapia , Laparoscopía/métodos , Menorragia/prevención & control , RecurrenciaRESUMEN
Haemoperitoneum secondary to ruptured corpus luteum is a rare complication for women on anticoagulants and with certain congenital bleeding disorders. A surgical approach is often taken, leading to oophorectomy in many cases. We describe three patients presenting with haemoperitoneum in association with factor VII deficiency, factor X deficiency and sitosterolaemia. In two of the patients, recurrent episodes occurred prior to introduction of the oral contraceptive pill. Conservative management with blood product and factor concentrate support was successful in avoiding surgery in three of the five episodes of bleeding. These cases demonstrate that preservation of ovarian function is possible with a conservative approach and recurrent episodes may be prevented by suppression of ovulation.
Asunto(s)
Trastornos de la Coagulación Sanguínea/complicaciones , Anticonceptivos Hormonales Orales/uso terapéutico , Hemoperitoneo/prevención & control , Ovulación/efectos de los fármacos , Adulto , Trastornos de la Coagulación Sanguínea/tratamiento farmacológico , Cuerpo Lúteo/lesiones , Deficiencia del Factor VII/complicaciones , Deficiencia del Factor X/complicaciones , Femenino , Hemoperitoneo/tratamiento farmacológico , Hemoperitoneo/etiología , Humanos , Rotura Espontánea , Sitoesteroles/sangreRESUMEN
Peritoneal dialysis is commonly preformed by patients and their caregivers in the home, in nursing homes, and in both acute and rehabilitation hospitals. The success of the therapy requires that the nurse overseeing the care of the patient on peritoneal dialysis in the acute, sub-acute, and chronic settings has the skills and knowledge to identify specific non-infectious issues, choose an appropriate and effective intervention activity, document the findings and outcomes, and educate the patient to assist in the resolution of the non-infectious issues, and avoid future recurrence. This article reviews the most common non-infectious complications that occur in patients on peritoneal dialysis and discusses an organized clinical process to troubleshoot the issues and achieve the desired clinical outcomes.
Asunto(s)
Vías Clínicas/organización & administración , Planificación de Atención al Paciente/organización & administración , Diálisis Peritoneal/efectos adversos , Diálisis Peritoneal/enfermería , Falla de Equipo , Hemoperitoneo/diagnóstico , Hemoperitoneo/etiología , Hemoperitoneo/prevención & control , Hernia Abdominal/diagnóstico , Hernia Abdominal/etiología , Hernia Abdominal/prevención & control , Humanos , Hidrotórax/diagnóstico , Hidrotórax/etiología , Hidrotórax/prevención & control , Hipovolemia/diagnóstico , Hipovolemia/etiología , Hipovolemia/prevención & control , Fallo Renal Crónico/terapia , Mantenimiento , Rol de la Enfermera , Evaluación en Enfermería , Evaluación de Resultado en la Atención de Salud , Dolor/diagnóstico , Dolor/etiología , Dolor/prevención & control , Educación del Paciente como Asunto , Diálisis Peritoneal/estadística & datos numéricos , Insuficiencia del Tratamiento , Intoxicación por Agua/diagnóstico , Intoxicación por Agua/etiología , Intoxicación por Agua/prevención & controlRESUMEN
El embarazo heterotópico es una entidad poco frecuente cuya incidencia ha ido en aumento al igual que la del embarazo ectópico. La valoración ecográfica de anejos y espacio de Douglas es obligada a pesar de verse un saco intrauterino, pudiendo ser de ayuda la utilización del Doppler. En todos los casos de aborto intauterino el material debe ser remitido a anatomía patológica para comprobar la existencia de vellosidades coriales. El pronóstico materno está siempre en relación directa con la precocidad del diagnóstico, que es lo que permitirá preservar la fecundidad posterior de la mujer y evitar la mortalidad materna por hemoperitoneo e intervención quirúrgica urgente. En cuanto al pronóstico fetal, solamente el 64-67% de los embarazos intrauterinos llega a término (AU)
Asunto(s)
Humanos , Femenino , Embarazo , Adulto , Embarazo Heterotópico/diagnóstico , Laparotomía/métodos , Diagnóstico Precoz , Hemoperitoneo/prevención & control , Factores de RiesgoRESUMEN
Intraperitoneal (i.p.) bleeding causes intense inflammatory reactions and extensive adhesions. The relationship between i.p. bleeding and adhesions is well documented in both animal and human studies. Over an 8-year period, we performed 362 permanent peritoneal dialysis (PD) catheter placements in 317 patients, using the laparoscopic technique. In the first 203 procedures (group I), we observed intra-operative bleeding in 12 patients (intra-operative i.p. bleeding seen laparoscopically, and significant blood-tinged dialysate irrigation). Patients were left dry for 3-5 days before dialysate instillation during the break-in period. During the break-in period, 7 of the 12 patients (58%) developed primary catheter failure requiring catheter removal (p = 0.03). All 7 patients underwent repeat laparoscopy for placement of a new catheter. In all 7 patients, laparoscopy showed significant adhesions. In the subsequent 159 procedures (group II), we observed intra-operative bleeding in 10 patients. We irrigated the peritoneal cavity repeatedly, until clear dialysate was obtained, then instilled 500-1000 mL 1.5% Dianeal solution (Baxter Healthcare Corporation, Deerfield, IL, U.S.A.) and capped the catheter. These patients were then placed on low-volume continuous cycling peritoneal dialysis [(CCPD) 700-1200 mL, based on the patient's size, every 2 hours, until the effluent became clear]. Following this, patients underwent daily irrigation and PD fluid cell count, and were left with 700-1200 mL dialysate to dwell. The process was continued until PD fluid drainage showed no red blood cells or until the patient was started on routine peritoneal dialysis. None of these patients were drained dry. Compared with group I, no patient among the 10 in group II developed catheter failure (p = 0.001), and mean catheter survival was 31 +/- 7 months. Of the 10 patients, 2 developed exist-site leaks, both after clearance of red blood cells from the drained dialysate. None developed peritonitis. We conclude that intra-operative i.p. bleeding associated with significant blood-tinged dialysate irrigation may lead to local adhesions if the peritoneum is drained dry. The result may be loss of the PD catheter in about 60% of cases. Continuous irrigation, combined with a moderate amount of Dianeal solution left to dwell, or early initiation of low-volume PD, or both, prevents this complication.
Asunto(s)
Catéteres de Permanencia/efectos adversos , Hemoperitoneo/etiología , Diálisis Peritoneal/efectos adversos , Enfermedades Peritoneales/etiología , Remoción de Dispositivos , Falla de Equipo , Hemoperitoneo/prevención & control , Humanos , Complicaciones Intraoperatorias , Laparoscopía , Diálisis Peritoneal/métodos , Enfermedades Peritoneales/prevención & control , Adherencias TisularesRESUMEN
The article presents a case of spontaneous rupture of the uterine venous plexus on the right side ih a 32 year old multipara in 26th week of pregnancy. Attention is called to diagnostic difficulties of this complication and methods of controlling venous bleeding are discussed.
Asunto(s)
Ligamento Ancho/irrigación sanguínea , Hemoperitoneo/prevención & control , Rotura Uterina/diagnóstico , Adulto , Femenino , Hemoperitoneo/etiología , Humanos , Laparotomía , Embarazo , Segundo Trimestre del Embarazo , Rotura Uterina/complicacionesRESUMEN
The initial management of life-threatening hemorrhage associated with severe pelvic fractures has long been a source of debate. A review of the literature reveals that many advocate emergent orthopedic external fixation (EX-FIX) for severe pelvic fractures, whereas others claim greater success with angiographic embolization (ANGIO) as the first line of treatment. Although many have attempted to classify management options by fracture pattern, to date there has been no prospective trial comparing outcomes for each method of treatment. We offer a prospective study of all pelvic fracture patients admitted to our Level I trauma center between July 1994 and July 1995. Patients were classified according to fracture pattern and degree of hemodynamic instability. Those with primarily anterior pelvic ring fractures underwent emergent EX-FIX for control of hemorrhage, whereas those with primarily posterior pelvic ring fractures underwent emergent ANGIO to control hemorrhage. We found that blood product requirements and hospital stay were similar in each group. However, the complication rate was higher in patients who underwent initial emergency EX-FIX, primarily because of failure to adequately control hemorrhage. We conclude that patients with anterior-posterior compression type 2 and 3, lateral compression type 2 and 3, or vertical shear injuries, who are hemodynamically unstable as a result of their pelvic fracture, should undergo immediate ANGIO if laparotomy is not indicated. If laparotomy is indicated, EX-FIX should be placed intraoperatively, followed by postoperative ANGIO.
Asunto(s)
Fracturas Óseas/cirugía , Hemoperitoneo/terapia , Huesos Pélvicos/lesiones , Acidosis Láctica/sangre , Adulto , Angiografía , Transfusión Sanguínea , Embolización Terapéutica , Fijadores Externos , Fijación de Fractura/efectos adversos , Fijación de Fractura/instrumentación , Fijación de Fractura/métodos , Fracturas Óseas/clasificación , Hematócrito , Hematoma/etiología , Hemoperitoneo/prevención & control , Humanos , Hipotensión/etiología , Hipotensión/terapia , Laparotomía , Tiempo de Internación , Estudios Prospectivos , Sepsis/etiología , Infecciones de los Tejidos Blandos/etiología , Tasa de Supervivencia , Resultado del TratamientoAsunto(s)
Afibrinogenemia/congénito , Afibrinogenemia/complicaciones , Anticonceptivos Orales/administración & dosificación , Trastornos de la Menstruación/tratamiento farmacológico , Adolescente , Anticonceptivos Orales/uso terapéutico , Esquema de Medicación , Femenino , Hemoperitoneo/prevención & control , HumanosRESUMEN
After 9 years of experience in gynaecology, the systematics of depot peritoneal lavage is now open for discussion. Intraoperatively, a liquid residual depot of 1.5-2.0 l Ringer's solution remains, while the abdominal cavity is continuously rinsed with varying amounts of liquid according to the indication. By maintaining the depot in all lavages, the formation of adhesions is therefore prevented. Forms and indications of the lavages: 1. "Postoperative Clear Lavage": a) Removal of blood and tissue residues must be removed b) Control/early diagnosis of secondary haemorrhage 2. "Adhesion Lavage": Prophylaxis 3. "Anti-septic Massive Lavage": In all cases of inflammatory diseases of the abdominal cavity, to prevent abscess and adhesion formation, and in peritonitis, to remove bacteria, endotoxins and detritus. In severe ascending infections, complete organ preservation was possible in 94% of 330 patients by combining early laparoscopy with an antiseptic massive lavage. Results of the first two indications will be published shortly.
Asunto(s)
Enfermedades de los Genitales Femeninos/cirugía , Lavado Peritoneal/métodos , Complicaciones Posoperatorias/prevención & control , Absceso/prevención & control , Drenaje/métodos , Femenino , Hemoperitoneo/prevención & control , Humanos , Soluciones Isotónicas/administración & dosificación , Laparoscopía/métodos , Peritonitis/prevención & control , Lactato de Ringer , Adherencias Tisulares/prevención & controlRESUMEN
Presents data on the clinical course and surgical treatment of 26 patients with retroperitoneal tumors and hemangiomas of the pelvis. The diagnosis was confirmed by x-ray, echographic, computer tomographic, and angiographic data on pelvic vessels. To prevent bleedings, embolization of the internal iliac arteries and their branches as far as the 3-4th order was carried out in 9 patients with angiodysplasias and 4 with retroperitoneal pelvic tumors. Endovascular occlusion of the main vessels not only permitted surgery with the minimal blood loss, but was conducive to better visualization of the tissues and made the operation less traumatic.
Asunto(s)
Embolización Terapéutica/métodos , Hemangioma/cirugía , Hemoperitoneo/prevención & control , Arteria Ilíaca , Complicaciones Intraoperatorias/prevención & control , Polihidroxietil Metacrilato , Neoplasias Retroperitoneales/cirugía , Adulto , Femenino , Hemangioma/irrigación sanguínea , Hemangioma/diagnóstico , Humanos , Persona de Mediana Edad , Neoplasias Retroperitoneales/irrigación sanguínea , Neoplasias Retroperitoneales/diagnóstico , Espacio Retroperitoneal/irrigación sanguíneaRESUMEN
The follicle ruptures at the time of ovulation and fills with blood, forming a corpus hemorrhagicum. Minor bleeding from the follicle into the abdominal cavity may cause peritoneal irritation and, when it occurs in a patient with a defect of primary hemostasis, hemoperitoneum can occur. Von Willebrand disease and afibrinogenemia are two important bleeding disorders in which both primary hemostasis and coagulation are involved. Bleeding during ovulation is one major clinical complication in women with these disease. We have studied three patients with this hemorrhagic complication. Our data show that oral contraceptives are an effective way to avoid hemoperitoneum.
PIP: The follicle ruptures at the time of ovulation and fills with blood, forming a corpus hemorrhagicum. Minor bleeding from the follicle into the abdominal cavity may cause peritoneal irritation and, when occurring in a patient with a defect of primary hemostasis, hemoperitoneum can occur. Von Willebrand disease and afibrinogenemia are 2 important bleeding disorders in which both primary hemostasis and coagulation are involved. Bleeding during ovulation is 1 major clinical complication in women with these diseases. The authors examined 3 patients with this hemorrhagic complication and data show that oral contraceptives are an effective means to avoid hemoperitoneum.