What is the management of a retroperitoneal hematoma?

From the Guidelines

The management of a retroperitoneal hematoma should prioritize a multidisciplinary approach, focusing on hemodynamic stability, with conservative management for stable patients and immediate surgical or endovascular intervention for unstable patients or those with expanding hematomas, as supported by recent guidelines 1. The approach to managing a retroperitoneal hematoma depends on several key factors, including the cause of the hematoma, its size, and most importantly, the patient's hemodynamic stability.

Key Considerations

• For stable patients with small, non-expanding hematomas, conservative management is recommended, including bed rest, serial hemoglobin monitoring every 6-8 hours, and close vital sign observation 1.
• Fluid resuscitation with crystalloids (such as normal saline or lactated Ringer's at 1-2 L bolus followed by maintenance) and blood transfusion (packed red blood cells) should be initiated if the patient shows signs of hypovolemia or if hemoglobin drops below 7-8 g/dL 1.
• Pain control with acetaminophen 1000 mg every 6 hours or opioids like morphine 2-4 mg IV every 4 hours may be necessary.

Interventional Approaches

• For unstable patients or those with expanding hematomas, immediate surgical intervention is required, which may involve exploratory laparotomy, evacuation of the hematoma, and control of the bleeding source 1.
• Endovascular techniques like angioembolization are increasingly used as first-line treatment for active bleeding, particularly for hematomas caused by pelvic fractures or iatrogenic vascular injuries 1.
• Pre-peritoneal pelvic packing (PPP) has emerged as a valuable technique for controlling bleeding in hemodynamically unstable pelvic fractures, often used in conjunction with external fixation 1.

Reversal of Anticoagulation

• Anticoagulation therapy should be reversed if present: for warfarin, administer vitamin K 10 mg IV and prothrombin complex concentrate; for direct oral anticoagulants, specific reversal agents like idarucizumab for dabigatran or andexanet alfa for factor Xa inhibitors should be used 1.

Underlying Causes

• Underlying causes such as trauma, anticoagulation, vascular rupture, or malignancy must be addressed to prevent recurrence 1. Given the complexity and potential morbidity associated with retroperitoneal hematomas, a tailored approach considering the patient's specific condition and the availability of resources is crucial for optimizing outcomes.

From the Research

Management of Retroperitoneal Hematoma

The management of retroperitoneal hematoma can be divided into several approaches, including:

• Conservative management: This approach is typically reserved for patients who are hemodynamically stable, and involves fluid resuscitation, correction of coagulopathy, and blood transfusion 2.
• Endovascular treatment: This approach involves selective intra-arterial embolisation or the deployment of stent-grafts over the punctured vessel, and is becoming increasingly important in the management of retroperitoneal hematoma 2, 3.
• Open surgery: This approach is typically reserved for cases where there is failure of conservative or endovascular measures to control the bleeding, or where the patient is unstable 2, 4.

Diagnosis and Treatment

The diagnosis of retroperitoneal hematoma is often delayed due to nonspecific symptoms, and can be facilitated by the use of multi-slice CT and arteriography 2. The treatment of retroperitoneal hematoma depends on the anatomical position of the hematoma, visceral injury, and the hemodynamic status of the patient 4. A systematic review of the literature has shown an increasing trend towards nonsurgical management of retroperitoneal injuries 5.

Complications and Mortality

Retroperitoneal hematoma is a life-threatening condition with a high mortality rate if not treated promptly and correctly 5, 4. Complications of retroperitoneal hematoma can include wound infection, deep vein thrombosis, gastric fistula, and duodenal fistula 4. The mortality rate for traumatic retroperitoneal hematoma has been reported to be as high as 6.5% 4.

Special Considerations

In cases of spontaneous retroperitoneal hemorrhage, anticoagulant therapy can precipitate a massive hemorrhage, and high clinical suspicion is crucial for early diagnosis and treatment 6. The decision to surgically evacuate or conservatively treat retroperitoneal hematomas should be made on a case-by-case basis, taking into consideration the patient's general condition and the possibility of permanent nerve damage due to compression syndrome 6.