What is the management for post angio (angiography) embolization shock?

Management of Post-Angiographic Embolization Shock

In patients experiencing shock following angiographic embolization, immediate resuscitation with fluid volume replacement, vasopressor support, and consideration of repeat angiography for potential rebleeding is the recommended approach. 1

Initial Assessment and Stabilization

• Assess hemodynamic status immediately, including blood pressure, heart rate, urine output, and mental status to determine severity of shock 1
• Establish adequate intravenous access with large-bore catheters for rapid fluid administration 1
• Initiate continuous hemodynamic monitoring with arterial line and consider central venous pressure monitoring in severe cases 1
• Obtain baseline laboratory studies including complete blood count, coagulation profile, arterial blood gas, base deficit, and serum lactate to assess shock severity and guide resuscitation 1

Volume Resuscitation

• Correct blood volume depletion as fully as possible before or concurrently with vasopressor administration 2
• Administer crystalloid solutions rapidly for initial volume expansion 1
• Consider blood product transfusion (packed red blood cells, fresh frozen plasma) if hemorrhage is suspected 1
• Target a systolic blood pressure of 80-100 mmHg, sufficient to maintain vital organ perfusion 2
• In previously hypertensive patients, aim for a systolic blood pressure no higher than 40 mmHg below the preexisting systolic pressure 2

Vasopressor Support

• Initiate vasopressors if fluid resuscitation fails to restore adequate blood pressure and tissue perfusion 2, 3
• Norepinephrine is the first-line vasopressor for shock after angioembolization:
  • Dilute in 5% dextrose solution (4 mg in 1000 mL)
  • Start at 2-3 mL/min (8-12 mcg/min) and titrate to response
  • Average maintenance dose ranges from 0.5-1 mL/min (2-4 mcg/min) 2
• Dopamine may be considered as an alternative:
  • Begin at 2-5 mcg/kg/min for patients likely to respond to modest increases in heart force and renal perfusion
  • For more seriously ill patients, start at 5 mcg/kg/min and increase gradually in 5-10 mcg/kg/min increments up to 20-50 mcg/kg/min as needed 3

Evaluation for Rebleeding

• Consider rebleeding as a primary cause of post-embolization shock, which occurs in approximately 12% of cases 4
• Maintain the arterial access port with anti-reflux valve in place for 24 hours after initial embolization to facilitate repeat angiography if needed 1
• Rebleeding may occur due to:
  • Collateral vessels and anastomoses in the vascular bed
  • Reopening of injured vessels initially subject to vasospasm during shock state
  • Recanalization of previously embolized vessels 1, 5
• Perform repeat CT scan if the patient's condition deteriorates to identify potential rebleeding sites 1

Repeat Angiography and Embolization

• If rebleeding is suspected, perform repeat angiography without delay 1, 4
• Repeat angioembolization is successful in most cases of rebleeding, with an organ salvage rate of approximately 93% 4
• Selective embolization should be performed whenever possible to minimize tissue ischemia 1
• In hemodynamically unstable patients with multiple bleeding sites, non-selective embolization may be necessary 1

Surgical Management

• Consider surgical intervention if:
  • Angioembolization fails to control bleeding
  • Patient remains hemodynamically unstable despite repeat embolization
  • Surgical packing is needed as a bridge to definitive hemostasis 1, 6
• Pre-peritoneal pelvic packing in association with external fixation may be necessary in cases of severe hemodynamic instability when angioembolization cannot be performed within 60 minutes 1

Monitoring for Complications

• Monitor for organ-specific complications (19% incidence), especially abscess formation and organ infarction 4
• Watch for contrast-induced nephropathy (24% incidence) and provide appropriate prophylaxis 4
• Assess for puncture site-related complications, which occur in approximately 3% of patients 4
• Most organ-specific and puncture site-related complications can be managed conservatively or with percutaneous treatment 4

Ongoing Care

• Continue monitoring in an intensive care setting for at least 24 hours following embolization 1
• For severe abdominal injuries treated non-operatively, maintain clinical and biological observation for a minimum of 3-5 days 1
• Monitor intra-abdominal pressure in patients at risk for abdominal compartment syndrome 1
• When discontinuing vasopressor support, reduce dosage gradually while expanding blood volume with intravenous fluids to prevent marked hypotension 2, 3