Retroperitoneal Bleeding

[ambersky004, BSN, RN]

How does retroperitoneal bleed develop after post pci? What are the possible causes of it developing?

I was assisting in removal of arterial sheath with my co-worker, I was not able to monitor the patient constantly on our medsurg floor but was there during pt arrival. 5 or 6 hrs after the procedure, my co-worker was removing the arterial sheath on the left femoral artery. She held it for about 12 or 15 mins then she asked me to check on the pt abdomen because he was complaining of belly pain. I checked his lower belly and he said it is tender to the touch on a certain spot and I feel a hard lump. His BP started to drop to 80s systolic as well as the HR to low 50s. I called the cardiologist while my co worker was holding pressure. I thought she did great because I did not see any significant bleeding or hematoma below pt's thigh or around the groin area.  So we thought he had a vasovagal episode. we did a ct of abdomen and it confirms a moderate RH. Pt was was stable but his bp drops especially when pressure is applied to groin. H and H drops from 11 to 9.1 and the next day to 8.6 with ongoing abdominal pain. he eventually got a unit of blood in ICU and air lifted for a vascular surgeon.  

I thought about the scenario, I am not sure what had happened? Was it a slow bleed during and after the procedure and coincidentally we just noticed it when we were removing the sheath 5 hrs after?

what do you think are your thoughts on this? I am now anxious if pressure was not held correctly on the femoral artery or it was a high stick puncture by a cardiologist? But why did it happened so fast during removal of sheath?

[offlabel]

This can present immediately in the cath lab as well as, as you've seen, in a delayed timing. It's a 'rare' complication but since PCI in all it's permutations occurs over a million times a year, it happens in thousands of cases. There are risk groups for this event that should be known to nurses caring for these patients. 

 

A couple of case reports that are instructive to your questions:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617546/

[Sally2013, BSN, RN]

I have experienced one patient with a retroperitoneal bleed. She had abdominal pain, nausea, and hypotension. It was diagnosed approximately 2 hours after the procedure. The cause was that when the interventional cardiologist accessed the artery, he went through it. So, the actual site to me looked fine, but the patient was bleeding on the back side of the artery which was internal.

[Nurse Alexa, MSN, RN]

Even though it appears that the provider held pressure for an extended amount of time - it might not have been enough for this particular patient.
 

During PCIs, the patients receive blood thinners (ie. Heparin, Angiomax) so taking the sheath out too soon can cause these RPBs. 
 

It was a great use of your assessment skills, seeing his BP drop and trending the H/H. Hindsight is sometimes 20/20 in these situations. What could be done next time, wait another day or so before the provider removes the sheath.

Other safety measures include:

Noting Platelet Count, aPTT, and PT/INE prior to removal of any catheter/sheath.

[BeatsPerMinute, BSN, RN]

This this was more than 5 years back so I don't remember all of the specifics of this case: 

I had a patient in ICU: Septic shock, intubated, on propofol, fentanyl, levophed, vasopressin, a heparin gtt, ABX, electrolyte protocols... She had a PICC line and A-line (upper only, no fem insertions that I remember) placed a few days prior but those were the most invasive procedures she had received. 

The night I was assigned to take care of her I was told during report that goals were to improve BPs, wean sedation, and then pressors if tolerated. Strangely no matter how low we went with sedation, the patient's bp kept going down, steadily during day shift and then through my night shifts. Labs were borderline but OK when I assumed care. 

The night while trying to reduce sedation the patient kept grimacing whenever I touched her abd and it was like she kept wanting to hold her abd or point to it. The patient was obese, and abd was rounded however not "hard." I had to keep increasing pressors while reducing sedation but nothing was fixing the BP and the patient appeared to be in pain. Concerned that something was up, I drew her labs early from her A-line. Several labs were criticals and were all over the place, including a significant H&H drop (hgb was like 7-8s, now only in the 6s). Was ordered to redraw labs by MD just in case the H&H and anything else was wrong. While waiting for results, the MD's were thinking to start CRRT (as she was trending that way anyway). The patient didn't tolerate it though, nearly coded when we initiated it, so we stopped it right away. 

Her second H&H was LOWER than the first I had drawn (hgb 4.6 I believe) and we initiated mass transfusion. We also took her to CT and showed a spontaneous RP bleed. Hep gtt stopped. OR consulted. 

I stayed until 10AM trying to help oncoming nurse stabilize this patient. I still don't know what happened nor why she developed this RP bleed like this. 

[BeatsPerMinute, BSN, RN]

also related specifically to cardiac cath procedures: if it was femoral access and was considered a "high stick" that can certainly lead to problems with controlling bleeding