When is a patient with a retroperitoneal renal hematoma ready for discharge?

Discharge Criteria for Patients with Retroperitoneal Renal Hematoma

A patient with retroperitoneal renal hematoma is ready for discharge when they are hemodynamically stable with stable hematocrit values over time, have adequate pain control, and show no evidence of ongoing bleeding or expanding hematoma. 1

Hemodynamic Stability Assessment

Hemodynamic stability is the primary determinant for safe discharge and includes:

• Stable vital signs without evidence of shock for at least 24-48 hours
• Stable serial hematocrit/hemoglobin values over multiple measurements
• No requirement for blood transfusions in the preceding 24 hours
• Normalized or improving renal function parameters

Imaging Considerations Before Discharge

• Follow-up CT scan may be necessary to confirm:
  • No expansion of the hematoma
  • No evidence of active contrast extravasation
  • Resolution or stability of any urinary extravasation if present 1

Clinical Parameters for Discharge Readiness

• Adequate pain control with oral analgesics
• Ability to ambulate independently
• Tolerating oral intake
• No signs of infection (normal temperature, white blood cell count)
• Resolution of any gross hematuria if initially present

Special Considerations Based on Management Approach

For Non-operatively Managed Patients

• Most hemodynamically stable patients with renal injuries can be managed non-operatively 1
• These patients should demonstrate:
  • Stable size of hematoma on repeat imaging
  • Resolution of any urinary extravasation or placement of appropriate drainage if needed
  • No evidence of complications such as infection or abscess formation 1

For Patients Who Underwent Angioembolization

• Ensure access site is without complications (no hematoma, pseudoaneurysm)
• Confirm post-procedure imaging shows successful embolization without new bleeding
• Monitor for post-embolization syndrome (pain, fever, nausea) which can be managed as outpatient if mild 1

For Surgically Managed Patients

• Surgical wounds should show appropriate healing
• Surgical drains, if present, should be removed or have minimal output
• Post-surgical complications should be ruled out

Follow-up Planning Requirements Before Discharge

Discharge should only occur after establishing:

• Clear follow-up appointment schedule
• Instructions for activity restrictions (typically 4-6 weeks of limited physical activity)
• Indications for when to return to emergency care
• Plan for subsequent imaging to monitor hematoma resolution

Pitfalls and Caveats

• Beware of premature discharge: Retroperitoneal bleeding can be concealed in the potential space and result in delayed hypovolemic shock 1
• Monitor for rebleeding: Patients with certain underlying conditions (anticoagulation, renal tumors) have higher risk of rebleeding 2, 3
• Consider underlying etiology: Discharge planning should account for the cause of the hematoma (trauma, spontaneous, iatrogenic, tumor-related) 1, 3
• Recognize high-risk patients: Those with single functioning kidney, underlying coagulopathy, or renal masses require more cautious discharge planning 4

Discharge Contraindications

Patients should not be discharged if they have:

• Persistent hemodynamic instability
• Evidence of ongoing bleeding
• Uncontrolled pain
• Expanding hematoma on serial imaging
• Fever or other signs of infection
• Significant urinary extravasation without appropriate drainage

Following these criteria ensures patient safety while allowing for appropriate resource utilization in managing patients with retroperitoneal renal hematomas.