RESUSCITATION IN RETROPERITONEAL

HAEMORRHAGE

Tommy Sunartomo
Anestesiology  &  Reanima0on  Departement  
Medical  Faculty  of  Airlangga  University  
RSUD  Dr.  Soetomo  Surabaya  
 Retroperitoneal Structures

•  Kidneys •  Aorta
•  Ureters •  Inferior vena cava
•  Bladder •  Iliac vessel
•  Pancreas •  Seminal vesicles
•  Duodenum (D2 and D3) •  Vas deferens
•  Adrenal gland •  Lymphatics (cysterna chyli)
•  Ascending colon •  Vagina (upper most)
•  Descending colon •  Ovaries
•  Rectum (upper two •  Nerves (lumbar
thirds) sympathetics)
 Retroperitoneal space

Retroperitoneal space are classified on an anatomic

basis :
•  zone 1 is the central area, bounded laterally by the
kidneys and extending from the diaphragmatic hiatus to
the bifurcation of the vena cava and the aorta
•  zone 2 comprises the lateral area of the
retroperitoneum, from the kidneys laterally to the
paracolic gutters
•  zone 3 is the pelvic portion
Retroperitoneal  Regions
Retroperitoneal  regions
Cause of Retroperitoneal Haematoma

•  Trauma
−  Blunt
−  Penetrating

•  Iatrogenic
−  Surgery
−  Endovascular Intervention
−  Endoscopic Surgery
−  Lumbar Sympathectomy Injury
−  Percutaneus Nephrostomy
 …. Cause of Retroperitoneal Haematoma

•  Spontaneous Haemorrhage
−  Anticoagulation
−  Anti Platelet
−  Ruptur tumor (angio myolipoma)
−  Ruptur aneurysma
−  Factor IX and X deficiency
Sources of Potential Blood Loss
•  Internal bleeding
−  Chest
−  Abdomen
−  Pelvis
−  Retroperitoneal
−  Extremities
•  External bleeding
Diagnostic
•  Mechanism of Injury
•  Physical examination
•  Urine Catheterisation
•  Plain radiography
−  Abdomen → Loss of Psoas Shadow
−  Chest
−  Pelvic
•  FAST / eFAST
−  RPH free fluid intra peritoneal in 16%
•  DPL
•  CT-Scan
•  MRI
Clinical Presentation
•  Depend on Estimate Blood Loss
•  Class I : < 15% EBV
•  Class II : 15 – 30% EBV }   Hemodynamic Stable

•  Class III : 30 – 40% EBV

•  Class IV : > 40% EBV }   Hemodynamic Unstable
Estimate Blood Loss
RESPONSE to INITIAL FLUID THERAPY

RAPID RESPONSE

TRANSIENT RESPONSE

NO RESPONSE
Basic Principal Management
•  Stop the bleeding
•  Restore the volume
•  The goals :
−  minimize haemorrhage
−  restore organ perfusion and tissue oxygenation
−  prevent hypothermia, coagulopathy and acidosis
−  optimize patient outcome  
 Interventions

Hemostatic Direct
resuscitation Pressure/
tourniquet

Angio STOP Reduce pelvic

embolization the volume
bleeding

Splint fractures Operation

Hemostatic Agents
Haemodynamic Stable

•  Closed observation & monitoring

•  Maintenance fluid
•  Further diagnostic examination
•  Endovascular intervention ?
•  Correction of coagulopathy
•  Haemostatic agents ?
Haemodynamic Unstable

•  < C > ABC resuscitation

•  Permissive hypotension
•  Limitation of crystalloid
•  Early use of blood and blood products
•  Early use of TXA
•  Surgical exploration
 Permissive Hypotension
(Hypotensive Resuscitation)

•  Targetting lower blood pressure until definitive haemostatic is

achieved
•  Limitation of crystalloid resuscitation
•  Early use of blood and blood products
•  Raising intravascular pressure, reducing blood viscosity and
dislodgement haemostatic plug → increase blood loss
•  SBP 80-90mmHg, MAP 50-60mmHg
•  Blunt trauma ?, TBI ?
 Trauma pembuluh darah

Vasospasme

Mengerutkan robekan
Menurunkan aliran darah

Agregasi trombosit

Sumbat lunak
20 mnt
Beb.
Cascade koagulasi Hari s/d
Terbentuk fibrin
minggu
Sumbat lebih keras
24 jam
Fibrin yang lengkap Penyembuhan
Tahan terhadap tensi normal pembuluh darah
 Pemberian Cairan Agresif

↑ MAP Hemodilusi

Dilusi Dilusi Viskositas

F.pembekuan eritrosit

Vasospasme hilang
Cascade Oksigenasi
koagulasi jaringan ↓
terganggu
Trombus Vasospasme
rusak/hanyut

Perdarahan bertambah
 Restrictive Fluid Administration

§  intravenous fluids should be minimized.

§  Aggressive fluid resuscitation results:

§  in worse coagulopathy,
§  an exaggerated trauma-related systemic inflammatory
response syndrome (SIRS),
§  an increased incidence of adult respiratory distress syndrome
(ARDS), pulmonary edema, compartment syndrome, anemia,
thrombocytopenia, pneumonia, electrolyte disturbances, and
overall worse survival
 Role of Hemostatic Adjuncts

These agents may:

§  Decrease :
§  mortality,
§  transfusion requirements,
§  rates of transfusion-related organ failure among
certain trauma patients.

§  BUT, increase thromboembolic events

 Hemostatic Adjuncts

§  Tranexamic acid:

§  Prevent fibrinolysis
§  Useful within 3 hours of injury
§  Recombinant human factor VIIa:
§  Does not decrease mortality
§  é thrombo-embolic complications
§  Prothrombin complex, which contains factors II, VII, IX,
X, C,and S:
§  ê mortality, ê transfusion requirements, ê
complications, & ê lengths of stay
 Hemostatic Adjuncts

§  Anti-fibrinolytic agents

§  Early administration of tranexamic acid (TXA), an anti-
fibrinolytic agent, (slightly decrease the risk of death from
bleeding)

§  Factor-concentrates
§  recombinant factor VIIa or prothrombin complex
concentrates (PCCs) (lack of evidence)
 Resuscitation Goals and Monitoring

"  Coagulation test is inappropiate opiate

"  PRBCs should be given to target a hemoglobin >7 g/dL,

"  FFPs to target an international normalized ratio (INR) <2,

"  Platelets to target a count >50,000,

"  Cryoprecipitate to target a fibrinogen level >100 mg/dL.

"  Theuse of thrombo-elastography-based protocols

(promising results)
THEORY OF TRAUMATIC COAGULOPATHY
As secondary event

Mc Leod, JBA, Arch Surg 143, Aug.2008

THEORY OF TRAUMATIC COAGULOPATHY
As primary event modified by promoters

Mc Leod, JBA, Arch Surg 143, Aug.2008

 Problems in Hemorrhagic Shock
Coagulopathy

Acidosis

Severe trauma Bleeding Tissue

hypoxia

Hypothermia

Colloid and Dilution of

Crystalloid infusion Coagulation factors
And platelets

Massive RBC
transfusion

Moore EE : Am J Surg 172: 405-410 1996

THINK DAMAGE CONTROL
t  Core temperature : < 35 o C
t  PH : < 7,2
t  Base deficit :
• < -15 mmol/L (<55 years)‫‏‬
• < -6 mmol/L (>55 years)‫‏‬
t  Serum lactate : > 5 mmol/L
t  Coagulopathy : PPT – APTT > 50% N
t  Length of operation more than 90 minutes

t  Massive transfusion > 10 units PRBC

 Damage Control Sequence
PART 0 – Prehosp → ED
n  Primary Survey
PART III - OR
n  Resuscitation/DCR
n  pack removal
n  RSI-Intubation
n  definitive repair
n  Early rewarming

Transfer problems
PART I - OR Transfer problems
§  control hemorrhage
PART II - ICU
§  control contamination
n  core rewarming
§  intraabdominal packing
n  correct coagulopathy
§  temporary closure
n  correct acidosis

n  maximize hemodynamics

Transfer problems n  ventilatory support

n  injury identification

(tertiary survey)
 H.M.  A.  Kaafarani,  G.  C.  Velmahos  
 Scandinavian  Journal  of  Surgery  0:  1–8,  2014  

Damage  Control  ResuscitaMon  and  Surgery  Algorithm  

Pre hospital Care
Scoop and Run Injury  

Minimize Fluid Resuscitation

Prevent Hypothermia

GOAL:
Pre  Hospital  Care  
Get the patient to the trauma Less  than  20  minutes  
center
 Resuscitation

Allow permissive hypotension

Administer blood and blood
products early
Minimize fluid resuscitation
Start Tranexamic Acid
Start massive transfusion
protocol

Emergency  Room  
Less  than  30  minutes  
GOAL:

Mobilize promptly to OR/IR

Suite
 Operating Theater

Allow permissive hypotension

Aim for 1:1:1 PRBC/FFP/
Platelets ratio
Administer cryoprecipitate
Abdominal packing
Temporary abdominal closure

Abbreviated  surgical  
GOAL: Procedure  
 
Control surgical bleeding Less  than  90  minutes  
Control contamination
 Intensive Care (1)

Reverse hypothermia

Reverse coagulopathy

Reverse acidosis

Support hemodynamics

GOAL: Intensive  Care  Unit  

12  –  36  hours  
Resuscitate
Reverse Triads of death
 Operating Theater

Remove packing
Definitive Surgical Repair
Serial primary abdominal
closure

GOAL: Defini0ve  surgical    

procedure  
Definitive Surgical Repair (2  –  8  days)  
 Intensive Care (2)

Diuresis

GOAL:

Decrease fluid overload to

allow:
1. Definitive abdominal  
Intensive  Care  Unit  Stay  
closure
(2  –  8  days)  
2. Postoperative liberation
from ventilator
 SUMMARY

"  The successful resuscitation of the massively bleeding

and unstable trauma patient will depend on:
➢  effective trauma team leadership,
➢  identification of early trauma-related coagulopathy,
➢  sound decision-making in the emergency and
operating rooms
➢  prompt implementation of a DCR and a damage
control surgery.