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Abdominal packing for surgically uncontrollable hemorrhage in ruptured abdominal aortic aneurysm repair
TECHNICAL NOTE
Abdominal packing for surgically uncontrollable hemorrhage in ruptured abdominal aortic aneurysm repair Joost A. van Herwaarden, MD, and Theo J. M. V. van Vroonhoven, MD, PhD, Utrecht, The Netherlands Emergency surgery for ruptured abdominal aortic aneurysms is accompanied with massive blood loss and is correlated with high incidences of coagulopathy. Following established results with abdominal packing to control hepatic hemorrhage, we present this technique for uncontrollable hemorrhage in patients with ruptured abdominal aortic aneurysm. The experience with this technique in 46 patients is described. (J Vasc Surg 2001;33:195-6.)
Mortality rates for repair of ruptured abdominal aortic aneurysms (RAAAs) have not changed greatly in the past decades.1-5 Factors affecting survival are analyzed in several studies,1-4,6 but most positive prognostic factors are based on demographic features or on the patient’s condition and are therefore not within the surgeon’s control.1,3 Irreversible coagulopathy is a well-known, frequently lethal complication during RAAA repair, but specific solutions or suggestions about how to deal with it have never been mentioned in the literature. In the surgical treatment of severe hepatic injuries, intra-abdominal packing has been shown to be valuable in obtaining hemostasis in the patient with coagulopathy.7-9 We present abdominal packing as an adjunct technique for patients with coagulopathy in RAAA repair. OPERATIVE TECHNIQUE After the exclusion of the aneurysm and insertion of a tube or bifurcation graft, the decision to pack is based on the surgeon’s opinion that irreversible coagulopathy has developed and ongoing diffuse bleeding cannot be controlled by usual surgical techniques. Large dry abdominal gauzes are tightly compressed over the bleeding sites. Usually, these bleeding sites are the prevertebral periaortic dissection site, the paracolic gutter on the side of the retroperitoneal hematoma, and, in case an anastomosis has been made to the iliac vessels, the pelvic inlet as well. When initial control has been achieved by clamping the supraceliac aorta, tamponading this area is sometimes advisable, too. The gauzes are From the Division of Vascular Surgery, Department of Surgery, University Medical Center. Competition of interest: nil. Reprint requests: Joost A. van Herwaarden, MD, Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3584 CX Utrecht, The Netherlands. Copyright © 2001 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2001/$35.00 + 0 24/4/109766 doi:10.1067/mva.2001.109766
compactly stuffed into the surrounding tissues to enhance the tamponading effect. The abdomen is purposely closed under some tension, and more gauzes are inserted between the abdominal wall and viscera when necessary to achieve this. Drains are not used because they would interfere with the increased intra-abdominal pressure. A relaparotomy to remove the gauzes is planned to be performed 1 to 2 days later. During this period, every effort is made in an intensive care unit setting to stabilize cardiopulmonary function and to correct hypothermia, acidosis, and coagulation disorders. After removal of the gauzes, a plain abdominal x-ray film is always made for verification of total removal. CLINICAL EXPERIENCE Between January 1993 and September 1998, 185 patients with RAAA were operated on in our hospital (165 men; mean age, 71.1 ± 8.8 years). Fifteen patients died during, and five died directly after the operation; all died as a result of uncontrollable hemorrhage, cardiogenic shock, or both. In 46 patients abdominal packing was performed as described. The poor condition of these patients is shown in the Table. In 30 patients bleeding could be controlled with packing, and the gauzes were successfully removed 24 to 48 hours after the initial operation. In the other 16 patients, however, a relaparotomy had to be considered earlier than planned because of unstable hemodynamic parameters and signs of ongoing blood loss. The very poor condition in three patients led to the decision to refrain from reoperation, and these patients died. One other patient died after cardiac arrest on arrival in the operating room. The other 12 patients underwent reoperation in an ultimate effort to control the bleeding. In one patient irreversible transmural ischemia of the left colon led to the decision to refrain from further treatment. In three patients adequate hemostasis could be obtained, and the gauzes could be removed during this reoperation, while in eight patients, repacking was performed when the original gauzes were removed and hemostasis still 195
JOURNAL OF VASCULAR SURGERY January 2001
196 van Herwaarden and van Vroonhoven
Intraoperative data (mean ± SD) Patients Systolic blood pressure (mm Hg)* Blood loss (mL) Hemoglobin (mmol/L)† Hematocrit (L/L)† Platelet count (103)† Core temperature (C)† pH† Prothrombin time (s)‡ Control value (s) Partial thromboplastin time (s)‡ Control value (s) Transfused blood (U) Transfused fresh frozen plasma (U)
92.8 8533 3.9 0.19 65.0 34.0 7.13 29.0 12.4 86.2 32.6 13.6 7.0
46 ± 33.6 ± 5188 ± 1.4 ± 0.06 ± 40.4 ± 1.3 ± 0.13 ± 21.3 ± 0.4 ± 32.4 ± 1.6 ± 8.3 ± 4.3
*At start of operation. †At lowest level during surgery. ‡At highest level during surgery.
was insufficient. In six of these eight patients, repacking proved to be successful, whereas the other two patients died of exsanguination. Overall, packing helped to control bleeding in 39 of 46 of these patients with coagulopathy. Postoperative complications after packing were compared with those seen in the group of 119 patients with RAAA who were treated during the same period but without abdominal packing. The only complication that occurred more frequently in patients with packing was renal dysfunction, which necessitated hemodialysis treatment (24% vs 9%). In both groups only one patient who needed postoperative hemodialysis survived. These two patients subsequently required long-term dialysis. Wound infections or intra-abdominal abscesses were not encountered in the patients with packing, and none of the surviving patients had a graft infection during a median follow-up of 39 months. Twenty-seven of 46 patients with packing died in the hospital: 3 of transmural colonic ischemia, 4 as a result of myocardial infarction, 5 as a consequence of ongoing blood loss, and 15 with multiple organ failure. The in-hospital mortality rate for patients with packing was 59% (27/46). Consequently, 41% of these patients, with surgically uncontrollable bleeding, survived. The in-hospital mortality rate for patients with RAAA who did not have abdominal packing during this period was 23.5% (28/119). Overall, inhospital mortality rate was 40.5% (75/185). DISCUSSION Abdominal packing is described here as an adjunct technique to cope with surgically uncontrollable bleeding during surgical repair of RAAA. Improvement of survival after RAAA repair with such a measure is hard or impossible to prove. It does seem encouraging that more than 40% of the 46 patients in whom temporary abdominal packing was instituted and who, without exception, were in an very poor condition with hypothermia, acidosis, and irreversible coagulopathy survived. Because coagulopathy in these patients is a complex phenomenon in which multiple factors are implicated, we could not deduce from our data a certain moment when packing should be started. In clinical practice, how-
ever, the experienced surgeon can readily tell when hemostasis becomes impossible. This is the moment when intraabdominal gauze packing has to be considered. A high incidence of infectious complications has been reported7 in abdominal packing for traumatic liver injuries. In contrast, these infectious complications were not seen after temporary packing in RAAA repair. This can be readily explained by the fact that liver injuries are frequently accompanied with additional organ injuries (eg, gastrointestinal tract) and invariably lead to some necrotic areas and leakage of bile. On the other hand, the surgical field during RAAA repair generally remains uncontaminated, and the gauzes in our patients were removed earlier than reported in most series with hepatic trauma. Because (permanent) renal impairment might be caused by increased intra-abdominal pressure,10 the somewhat higher incidence of this complication in patients with packing compared with patients without packing might be induced, in part, because of the use of this technique. However, the prolonged period of hypotension in this severely ill group of patients could also be a sufficient explanation. Intra-abdominal pressures were not monitored in our group, but even when packing should play a distinctive role in the development of renal impairment, the added morbidity is probably outweighed by the expected improved survival. In summary, we think that the technique of intra-abdominal packing deserves to be considered during RAAA repair when patients become coagulopathic and conventional surgical techniques cannot stop diffuse aongoing bleeding. REFERENCES 1. Barry MC, Burke PE, Sheehan S, Leahy A, Broe PJ, Bouchier Hayes DJ. An “all comers” policy for ruptured abdominal aortic aneurysms: how can results be improved? Eur J Surg 1998;164:263-70. 2. Halpern VJ, Kline RG, D’Angelo AJ, Cohen JR. Factors that affect the survival rate of patients with ruptured abdominal aortic aneurysms. J Vasc Surg 1997;26:939-45. 3. Wakefield TW, Whitehouse WM Jr, Wu S, Zelenock GB, Cronenwett JL, Erlandson EE, et al. Abdominal aortic aneurysm rupture: statistical analysis of factors affecting outcome of surgical treatment. Surgery 1982;91:586-95. 4. Marty Ane CH, Alric P, Picot MC, Picard E, Colson P, Mary H. Ruptured abdominal aortic aneurysm: influence of intraoperative management on surgical outcome. J Vasc Surg 1995;22:780-6. 5. Oung CM, Li MS, Shum-Tim D, Chiu RC-J, Hinchey EJ. In vivo study of bleeding time and arterial hemorrhage in hypothermic versus normothermic animals. J Trauma 1993;35:251-4. 6. Ouriel K, Geary K, Green RM, Fiore W, Geary JE, DeWeese JA. Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and the patient. J Vasc Surg 1990;11:493-6. 7. Cue JI, Cryer HG, Miller FB, Richardson JD, Polk HC Jr. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique. J Trauma 1990;30:1007-11. 8. Feliciano DV, Mattox KL, Burch JM, Bitondo CG, Jordan GL. Packing for control of hepatic hemorrhage. J Trauma 1986;26:738-43. 9. Baracco-Gandolfo V, Vidarte O, Baracco-Miller V, Castillo del M. Prolonged closed liver packing in severe hepatic trauma: experience with 36 patients. J Trauma 1986;26:754-6. 10. Richards WO, Scovill W, Shin B, Reed W. Acute renal failure associated with increased intra-abdominal pressure. Ann Surg 1983;197:183-7.
Submitted Jan 7, 2000; accepted Apr 6, 2000.
Abdominal packing for surgically uncontrollable hemorrhage in ruptured abdominal aortic aneurysm repair Joost A. van Herwaarden, MD, and Theo J. M. V. van Vroonhoven, MD, PhD, Utrecht, The Netherlands Emergency surgery for ruptured abdominal aortic aneurysms is accompanied with massive blood loss and is correlated with high incidences of coagulopathy. Following established results with abdominal packing to control hepatic hemorrhage, we present this technique for uncontrollable hemorrhage in patients with ruptured abdominal aortic aneurysm. The experience with this technique in 46 patients is described. (J Vasc Surg 2001;33:195-6.)
Mortality rates for repair of ruptured abdominal aortic aneurysms (RAAAs) have not changed greatly in the past decades.1-5 Factors affecting survival are analyzed in several studies,1-4,6 but most positive prognostic factors are based on demographic features or on the patient’s condition and are therefore not within the surgeon’s control.1,3 Irreversible coagulopathy is a well-known, frequently lethal complication during RAAA repair, but specific solutions or suggestions about how to deal with it have never been mentioned in the literature. In the surgical treatment of severe hepatic injuries, intra-abdominal packing has been shown to be valuable in obtaining hemostasis in the patient with coagulopathy.7-9 We present abdominal packing as an adjunct technique for patients with coagulopathy in RAAA repair. OPERATIVE TECHNIQUE After the exclusion of the aneurysm and insertion of a tube or bifurcation graft, the decision to pack is based on the surgeon’s opinion that irreversible coagulopathy has developed and ongoing diffuse bleeding cannot be controlled by usual surgical techniques. Large dry abdominal gauzes are tightly compressed over the bleeding sites. Usually, these bleeding sites are the prevertebral periaortic dissection site, the paracolic gutter on the side of the retroperitoneal hematoma, and, in case an anastomosis has been made to the iliac vessels, the pelvic inlet as well. When initial control has been achieved by clamping the supraceliac aorta, tamponading this area is sometimes advisable, too. The gauzes are From the Division of Vascular Surgery, Department of Surgery, University Medical Center. Competition of interest: nil. Reprint requests: Joost A. van Herwaarden, MD, Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3584 CX Utrecht, The Netherlands. Copyright © 2001 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2001/$35.00 + 0 24/4/109766 doi:10.1067/mva.2001.109766
compactly stuffed into the surrounding tissues to enhance the tamponading effect. The abdomen is purposely closed under some tension, and more gauzes are inserted between the abdominal wall and viscera when necessary to achieve this. Drains are not used because they would interfere with the increased intra-abdominal pressure. A relaparotomy to remove the gauzes is planned to be performed 1 to 2 days later. During this period, every effort is made in an intensive care unit setting to stabilize cardiopulmonary function and to correct hypothermia, acidosis, and coagulation disorders. After removal of the gauzes, a plain abdominal x-ray film is always made for verification of total removal. CLINICAL EXPERIENCE Between January 1993 and September 1998, 185 patients with RAAA were operated on in our hospital (165 men; mean age, 71.1 ± 8.8 years). Fifteen patients died during, and five died directly after the operation; all died as a result of uncontrollable hemorrhage, cardiogenic shock, or both. In 46 patients abdominal packing was performed as described. The poor condition of these patients is shown in the Table. In 30 patients bleeding could be controlled with packing, and the gauzes were successfully removed 24 to 48 hours after the initial operation. In the other 16 patients, however, a relaparotomy had to be considered earlier than planned because of unstable hemodynamic parameters and signs of ongoing blood loss. The very poor condition in three patients led to the decision to refrain from reoperation, and these patients died. One other patient died after cardiac arrest on arrival in the operating room. The other 12 patients underwent reoperation in an ultimate effort to control the bleeding. In one patient irreversible transmural ischemia of the left colon led to the decision to refrain from further treatment. In three patients adequate hemostasis could be obtained, and the gauzes could be removed during this reoperation, while in eight patients, repacking was performed when the original gauzes were removed and hemostasis still 195
JOURNAL OF VASCULAR SURGERY January 2001
196 van Herwaarden and van Vroonhoven
Intraoperative data (mean ± SD) Patients Systolic blood pressure (mm Hg)* Blood loss (mL) Hemoglobin (mmol/L)† Hematocrit (L/L)† Platelet count (103)† Core temperature (C)† pH† Prothrombin time (s)‡ Control value (s) Partial thromboplastin time (s)‡ Control value (s) Transfused blood (U) Transfused fresh frozen plasma (U)
92.8 8533 3.9 0.19 65.0 34.0 7.13 29.0 12.4 86.2 32.6 13.6 7.0
46 ± 33.6 ± 5188 ± 1.4 ± 0.06 ± 40.4 ± 1.3 ± 0.13 ± 21.3 ± 0.4 ± 32.4 ± 1.6 ± 8.3 ± 4.3
*At start of operation. †At lowest level during surgery. ‡At highest level during surgery.
was insufficient. In six of these eight patients, repacking proved to be successful, whereas the other two patients died of exsanguination. Overall, packing helped to control bleeding in 39 of 46 of these patients with coagulopathy. Postoperative complications after packing were compared with those seen in the group of 119 patients with RAAA who were treated during the same period but without abdominal packing. The only complication that occurred more frequently in patients with packing was renal dysfunction, which necessitated hemodialysis treatment (24% vs 9%). In both groups only one patient who needed postoperative hemodialysis survived. These two patients subsequently required long-term dialysis. Wound infections or intra-abdominal abscesses were not encountered in the patients with packing, and none of the surviving patients had a graft infection during a median follow-up of 39 months. Twenty-seven of 46 patients with packing died in the hospital: 3 of transmural colonic ischemia, 4 as a result of myocardial infarction, 5 as a consequence of ongoing blood loss, and 15 with multiple organ failure. The in-hospital mortality rate for patients with packing was 59% (27/46). Consequently, 41% of these patients, with surgically uncontrollable bleeding, survived. The in-hospital mortality rate for patients with RAAA who did not have abdominal packing during this period was 23.5% (28/119). Overall, inhospital mortality rate was 40.5% (75/185). DISCUSSION Abdominal packing is described here as an adjunct technique to cope with surgically uncontrollable bleeding during surgical repair of RAAA. Improvement of survival after RAAA repair with such a measure is hard or impossible to prove. It does seem encouraging that more than 40% of the 46 patients in whom temporary abdominal packing was instituted and who, without exception, were in an very poor condition with hypothermia, acidosis, and irreversible coagulopathy survived. Because coagulopathy in these patients is a complex phenomenon in which multiple factors are implicated, we could not deduce from our data a certain moment when packing should be started. In clinical practice, how-
ever, the experienced surgeon can readily tell when hemostasis becomes impossible. This is the moment when intraabdominal gauze packing has to be considered. A high incidence of infectious complications has been reported7 in abdominal packing for traumatic liver injuries. In contrast, these infectious complications were not seen after temporary packing in RAAA repair. This can be readily explained by the fact that liver injuries are frequently accompanied with additional organ injuries (eg, gastrointestinal tract) and invariably lead to some necrotic areas and leakage of bile. On the other hand, the surgical field during RAAA repair generally remains uncontaminated, and the gauzes in our patients were removed earlier than reported in most series with hepatic trauma. Because (permanent) renal impairment might be caused by increased intra-abdominal pressure,10 the somewhat higher incidence of this complication in patients with packing compared with patients without packing might be induced, in part, because of the use of this technique. However, the prolonged period of hypotension in this severely ill group of patients could also be a sufficient explanation. Intra-abdominal pressures were not monitored in our group, but even when packing should play a distinctive role in the development of renal impairment, the added morbidity is probably outweighed by the expected improved survival. In summary, we think that the technique of intra-abdominal packing deserves to be considered during RAAA repair when patients become coagulopathic and conventional surgical techniques cannot stop diffuse aongoing bleeding. REFERENCES 1. Barry MC, Burke PE, Sheehan S, Leahy A, Broe PJ, Bouchier Hayes DJ. An “all comers” policy for ruptured abdominal aortic aneurysms: how can results be improved? Eur J Surg 1998;164:263-70. 2. Halpern VJ, Kline RG, D’Angelo AJ, Cohen JR. Factors that affect the survival rate of patients with ruptured abdominal aortic aneurysms. J Vasc Surg 1997;26:939-45. 3. Wakefield TW, Whitehouse WM Jr, Wu S, Zelenock GB, Cronenwett JL, Erlandson EE, et al. Abdominal aortic aneurysm rupture: statistical analysis of factors affecting outcome of surgical treatment. Surgery 1982;91:586-95. 4. Marty Ane CH, Alric P, Picot MC, Picard E, Colson P, Mary H. Ruptured abdominal aortic aneurysm: influence of intraoperative management on surgical outcome. J Vasc Surg 1995;22:780-6. 5. Oung CM, Li MS, Shum-Tim D, Chiu RC-J, Hinchey EJ. In vivo study of bleeding time and arterial hemorrhage in hypothermic versus normothermic animals. J Trauma 1993;35:251-4. 6. Ouriel K, Geary K, Green RM, Fiore W, Geary JE, DeWeese JA. Factors determining survival after ruptured aortic aneurysm: the hospital, the surgeon, and the patient. J Vasc Surg 1990;11:493-6. 7. Cue JI, Cryer HG, Miller FB, Richardson JD, Polk HC Jr. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique. J Trauma 1990;30:1007-11. 8. Feliciano DV, Mattox KL, Burch JM, Bitondo CG, Jordan GL. Packing for control of hepatic hemorrhage. J Trauma 1986;26:738-43. 9. Baracco-Gandolfo V, Vidarte O, Baracco-Miller V, Castillo del M. Prolonged closed liver packing in severe hepatic trauma: experience with 36 patients. J Trauma 1986;26:754-6. 10. Richards WO, Scovill W, Shin B, Reed W. Acute renal failure associated with increased intra-abdominal pressure. Ann Surg 1983;197:183-7.
Submitted Jan 7, 2000; accepted Apr 6, 2000.