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Abstract: FR-PO570

Peritoneal Dialysate Tamponading a Massive Retroperitoneal Hemorrhage

Session Information

Category: Trainee Case Report

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Gutowski, Emily Deena, Harvard Medical School, Boston, Massachusetts, United States
  • Tio, Maria Clarissa, Brigham and Women's Hospital, Massachusetts General Hospital, Boston, Massachusetts, United States
  • Burch, Ezra, Brigham and Women's Hospital, Boston, Massachusetts, United States
  • Leaf, David E., Brigham and Women's Hospital, Boston, Massachusetts, United States
Introduction

Spontaneous retroperitoneal (RP) bleeding is a rare but potentially fatal event. Due to its late manifestations, diagnosis is often delayed until blood loss is profound. We describe a patient in whom an RP bleed was suspected due to hypotensive episodes during peritoneal dialysis (PD) drainage.

Case Description

We describe a 47-year-old male with end stage renal disease (ESRD) on PD, on warfarin with a goal INR of 2.5-3.5 for mechanical mitral and aortic valves, who underwent a total hip arthroplasty for a left femoral fracture. Postoperatively he was continued on his home PD regimen (2L dwell, 2.5% dextrose, 5 exchanges per day) and restarted on warfarin. On postoperative day 17 he became unresponsive during PD drainage, with a blood pressure of 62/34 mm Hg. Hemoglobin dropped from 8.4 to 4.5 g/dL, and the INR was 2.2. Packed red blood cells and norepinephrine were administered, and he was transferred to the cardiac care unit, where he had a PEA arrest requiring CPR and intubation. Following return of spontaneous circulation, his blood pressure recovered and vasopressors were discontinued. Subsequent PD exchanges on the same day were complicated by repeated hypotensive episodes requiring vasopressors. This was observed only during PD drainage and resolved when fluid was re-infused. A CT scan showed a large left RP hematoma (14x11x23 cm). Angiography demonstrated a left L3 lumbar artery pseudoaneurysm as the source of bleeding. Coil embolization was performed, bleeding was well-controlled, and subsequent PD exchanges were well-tolerated.

Discussion

We report an unusual case of spontaneous RP hemorrhage in a patient with ESRD for whom PD drainage led to life-threatening hypotension. We speculate that the RP bleed was partially tamponaded by PD fluid via transmission of pressure retroperitoneally.