Clinical evaluation and management of hemoperitoneum in dogs
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Journal of Veterinary Emergency and Critical Care 18(1) 2008, pp 40–53
Clinical Practice Review doi:10.1111/j.1476-4431.2007.00265.x
Clinical evaluation and management of
hemoperitoneum in dogs
Lee V. Herold, DVM, DACVECC, Jennifer J. Devey, DVM, DACVECC, Rebecca Kirby, DVM,
DACVIM, DACVECC and Elke Rudloff, DVM, DACVECC
Abstract
Objective: Review the clinical presentation, assessment, resuscitation, and medical and surgical management
of dogs with hemoperitoneum.
Etiology: Hemoperitoneum is defined as free intra-abdominal hemorrhage. Hemoperitoneum occurs from
traumatic and nontraumatic causes. Common etiologies include atraumatic rupture of intra-abdominal
masses, coagulopathies, as well as blunt, and penetrating trauma to the abdomen.
Diagnosis: Definitive diagnosis of hemoperitoneum entails demonstration of free intra-abdominal blood via
paracentesis or diagnostic peritoneal lavage. Imaging and other diagnostic tests including coagulation studies
may help to determine underlying causes of hemoperitoneum or concurrent organ dysfunction.
Therapy: Goals of therapy for patients with hemoperitoneum include maintenance and restoration of
effective circulating volume, maintenance and restoration of oxygen-carrying capacity, and arrest of
hemorrhage. These goals can be achieved via fluid resuscitation, administration of blood products or
hemoglobin-based oxygen carriers, as well as application of abdominal counterpressure, and surgical
intervention. Surgery usually is required for bleeding intra-abdominal neoplasms. Emergency surgery is
recommended for hemorrhaging patients with penetrating trauma, gastric dilatation and volvulus, bleeding
cysts, liver lobe torsion, splenic torsion, and any other condition resulting in organ ischemia.
Prognosis: Prognosis in patients with hemoperitoneum may depend on the underlying cause and concurrent
injuries.
(J Vet Emerg Crit Care 2008; 18(1): 40–53) doi: 10.1111/j.1476-4431.2007.00265.x
Keywords: damage-control surgery, hemorrhagic shock, hemostasis, intra-abdominal hemorrhage, trauma
Introduction and surgical intervention for catastrophic hemorrhage.
This clinical review combines a search of the veterinary
Hemoperitoneum (or hemoabdomen) is defined as free
literature with the clinical experience of the authors to
hemorrhage within the peritoneal cavity. The incidence
provide a resource for the emergency management of
of animals presented for hemoperitoneum is difficult to
hemoperitoneum in dogs.
estimate because mild hemoperitoneum may go unde-
tected.1 Hemoperitoneum is a frequent finding in small
animal emergency practice and can vary in severity; Etiology of Hemoperitoneum
however, recommendations for management of various
forms of the syndrome are not clearly defined.1,2 Few Etiologies of hemoperitoneum in dogs can be catego-
reports exist in the veterinary literature evaluating the rized into traumatic and nontraumatic causes.2–4 Blunt
success of various interventions for patients with hemo- or penetrating trauma can cause hemoperitoneum, with
peritoneum. Controversy remains regarding the clinical motor vehicle injury recognized as the leading trau-
approach to these patients including fluid resuscitation matic etiology.3 In a study of 40 dogs sustaining motor
methods, abdominal counterpressure for hemostasis, vehicle trauma, 38 dogs were found to have hemoperi-
toneum as diagnosed by ultrasound and fluid analysis.5
From the Dove Lewis Emergency Animal Hospital, Portland, OR (Herold), Nontraumatic causes of hemoperitoneum include
Calgary Animal Referral and Emergency Centre, Calgary, Canada (Devey),
and Animal Emergency Center, Glendale, WI (Kirby and Rudloff).
coagulation defects, organ malposition/ischemia, hem-
atoma, or rupture of an intra-abdominal neoplasm.4–6
Address correspondence and reprint requests to:
Dr. Lee V. Herold, 1945 NW Pettygrove Street, Portland, OR 97209. A restrospective study of dogs with nontraumatic
E-mail: lvherold@juno.com hemoperitoneum identified malignant neoplasia as
40 & Veterinary Emergency and Critical Care Society 2008Hemoperitoneum in dogs
the cause for hemoperitoneum in 24 of 30 dogs with a Diagnostic procedures are delayed except for para-
definitive diagnosis.4 Splenic,4,6–8 hepatic,4 and adre- centesis and blood tests that can be performed during
nal9 masses have been associated with nontraumatic resuscitative efforts.1,2 Patients presenting with mild
hemoperitoneum in the dog with the spleen reported as clinical signs may have normal perfusion parameters
the most common source of hemorrhage.6–8 Dogs with or signs characteristic of compensatory shock (rapid
renal and gastrointestinal masses can also present CRT, bounding pulses, tachycardia). The patient may
with hemoperitoneum. Reported causes of nontrau- have alert mentation, with variable abdominal find-
matic, nonneoplastic intra-abdominal hemorrhage ings. Mild signs may suggest chronic or small volume
include liver lobe torsion,10 splenic torsion,11 splenic hemorrhage.
infarction,12 splenic hematoma,6 gastric dilatation– Four objectives must be met during resuscitation
volvulus complex (GDV),13,14 and coagulopathies.4,15 efforts: (1) to re-establish and maintain effective circu-
Anticoagulant rodenticide ingestion has been reported lating volume, (2) to diagnose hemoperitoneum and
to cause spontaneous hemoperitoneum in dogs of any identify database abnormalities, (3) to maintain oxygen-
age and breed.15 carrying capacity, and (4) to arrest ongoing hemor-
rhage. The actions to achieve these goals are often
undertaken simultaneously depending on the severity
History and Clinical Signs
of clinical signs. When clinical signs indicating decom-
Historical information obtained from pet owners may pensatory shock are present, immediate resuscitation
include recent trauma, exposure to anticoagulant will preclude definitive diagnostic evaluation; however,
rodenticide, abdominal distension, or weakness.1 Phys- a rapid assessment of the packed cell volume (PCV),
ical exam findings that can alert the veterinarian to total solids (TS), and abdominocentesis results can be
consider hemoperitoneum in the dog include abdom- evaluated to confirm a diagnosis of hemoperitoneum
inal distension,1,2 a palpable fluid wave,1,2 cranial ab- (Figure 1).
dominal tympany (with GDV),13 a palpable abdominal
mass, or abdominal pain.1,2 At least 40 mL/kg of peri-
toneal fluid is required to detect a fluid wave, making
Re-Establish and Maintain Effective Circulating
abdominal distension an insensitive indicator of early
Volume
or slow forming free abdominal fluid.16 Occasionally
umbilical and peri-testicular skin discoloration may Traditional methods of fluid resuscitation for the treat-
be observed when significant intra-abdominal hemor- ment of hypovolemic shock involve the rapid infusion
rhage dissects through the abdominal muscle planes of large volumes of crystalloids. Evidence in human
and subcutis.17 and animal studies on uncontrolled hemorrhage has led
Careful triage, with close evaluation of perfusion pa- to critical reassessment of aggressive untitrated fluid
rameters will help to categorize the patient according to administration.18,19 Large volume rapid infusions of
level of severity of presenting clinical signs (i.e., cata- intravenous fluids has been associated with prolonged
strophic, severe, or mild).1,2 Dogs presenting with coagulation times that can potentiate hemorrhage and
catastrophic hemorrhage will be in late decompensatory the rapid increase in hydrostatic pressure can disrupt
shock and at risk for sudden death. Clinical signs can clots important in effective hemostasis.18,19
include white mucous membrane color, absent periph- Two resuscitation strategies have been proposed
eral pulses, absent capillary refill time (CRT), tachycar- to reduce the negative consequences of rapid large
dia or bradycardia, hypothermia, tachypnea, obtunded volume fluid resuscitation in humans with traumatic
mentation, palpable abdominal fluid wave, and ab- hemorrhage.19–22 However, no consensus exists for the
dominal distension. Respiratory distress may be the most effective fluid resuscitation plan in humans to
result of reduced tidal volume secondary to abdominal reduce mortality from abdominal hemorrhage.20 One
distension or pleural space disease. Pulmonary paren- proposed strategy is for fluid infusion to be withheld
chymal hemorrhage may contribute to respiratory until there is rapid and definitive surgical control of the
distress as well. Dogs presenting with severe clinical hemorrhage.19,21 This recommendation was made in
signs are in the early decompensatory stage of shock the setting of rapid ambulance transportation of hu-
with pale mucous membranes, prolonged CRT, weak or mans to a trauma center, where a skilled surgical team
absent peripheral pulses, tachycardia, mental depres- is prepared for rapid surgical intervention. These are
sion, and generalized weakness. The abdominal and not the typical circumstances surrounding the presen-
respiratory signs can be variable. Catastrophic and tation of most dogs with hemoperitoneum. Therefore,
severe clinical signs suggest acute or large volume this delayed resuscitation technique cannot be recom-
hemorrhage and the need for immediate resuscitation. mended for dogs at this time.
& Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.x 41L.V. Herold et al.
Catastrophic clinical signs Severe clinical signs Mild clinical signs
Blood on paracentesis Blood on paracentesis Suspect hemoabdomen
(+/− blood on paracentesis)
Oxygen Oxygen
+/− Secure airway and ventilate IV fluid resuscitation
IV fluid resuscitation +/− Blood transfusion/Oxy IV fluid resuscitation
Blood transfusion/Oxy +/− Analgesia +/− Blood transfusion/Oxy
+/− Analgesia +/− Abdominal drainage/Autotransfusion +/− Analgesia
+/− Abdominal drainage/Autotransfusion +/− Abdominal counterpressure
Abdominal counterpressure
Stable HR, BP, PCV/Hgb?
Consider: Fluid Challenge
CBC/Serum chemistry Yes Blood transfusion/Oxy
Coagulation testing No
Abdominal counterpressure
Vasopressors
Abdominal ultrasound
TXR & AXR Slowly remove abdominal Yes Stable HR, BP, PCV/Hgb?
counterpressure if stable
No
Surgical problem?
GDV Monitor perfusion parameters, BP,
Organ Ischemia CVP, PCV/Hgb, Coagulation, Emergency
Penetrating Injury No ECG, Abdominal girth Surgery
Septic Peritonitis
Bleeding mass
Yes
Figure 1: Clinical algorithm for the therapeutic intervention and diagnostic evaluation in dogs suspected of having hemoperitoneum
based on their severity of clinical signs. IV, intravenous; BP, blood pressure; PCV, packed cell volume; Hgb, hemoglobin; Oxy-HBOC,
hemoglobin-based oxygen-carrying solution; CBC, complete blood count; TXR, thoracic radiographs; AXR, abdominal radiographs;
CVP, central venous pressure; GDV, gastric dilatation and volvulus; ECG, electrocardiogram.
A second proposed resuscitation regimen, described ygen-carrying solution (HBOC) can be added to the
for both humans and veterinary patients, seeks to bal- resuscitation protocol. These colloid fluid boluses
ance the circulatory support of vital organs while min- should be rapidly repeated as necessary to assist in
imizing the risk of sudden elevations in intravascular shock reversal. Ideally synthetic colloid volumes ad-
hydrostatic pressure and potential clot disruption.19,22– ministered should be below 40 mL/kg/day to avoid
25
This technique incorporates titration of small volume prolongation of coagulation times. HBOC doses should
boluses of crystalloids alone or crystalloids in combi- be limited to 30 mL/kg/day.18 If a hypocoagulable state
nation with colloids to reach low normal resuscitation is identified, then plasma transfusions may be admin-
endpoints.25 Resuscitation goals include a mean arterial istered in addition to synthetic colloids or HBOCs.18
pressure (MAP) of 60 mmHg and systolic blood pres- Hypertonic saline (7% solution) can also be adminis-
sure of 90 mmHg and improved physical examination tered as a single bolus of 2–4 mL/kg in conjunction
perfusion parameters. At an MAP of 60–70 mmHg, with the colloid and isotonic crystalloid infusions for
cerebral26 and renal blood flow27 are maintained by rapid volume expansion.23,29
autoregulation when there is no concurrent renal or Experimental studies have not demonstrated an in-
head trauma. In a swine model of hemorrhagic shock crease in survival with the addition of colloids to the
via aortic injury, rebleeding occurred predictably at a resuscitation regimen; however, the use of colloids al-
MAP 460 mmHg,28 therefore resuscitation to a MAP of lows smaller volumes of fluids to be used to rapidly
60 mmHg is recommended to reduce risk for ongoing achieve resuscitation end points.23,29 Colloid fluids will
hemorrhage but still maintain vital organ perfusion. exert an oncotic effect and retain fluid within vessels
A titrated resuscitation strategy can be performed that have an intact endothelium.25 HBOCs in the plas-
with crystalloid or colloid or both types of fluid. When ma deliver oxygen to regions where red blood cells
using balanced isotonic replacement crystalloids alone, cannot flow.30,31 The soluble hemoglobin molecule has
boluses of 20–30 mL/kg increments should be titrated a much smaller diameter than the diameter of the
and repeated to provide the smallest volume of crys- red blood cell and is able to deliver oxygen through
talloid necessary to achieve and maintain low-normal partially obstructed capillaries.30,31 HBOCs have been
resuscitation endpoints. Boluses of 5 mL/kg of synthet- reported to be useful for patients with traumatic inju-
ic colloid (e.g., hetastarch) or a hemoglobin-based ox- ries, maldistribution of blood flow, and microvascular
42 & Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.xHemoperitoneum in dogs
Table 1: Suggested analgesic and anesthetic drug doses tional coagulation tests such as fibrin degradation
products or proteins induced by vitamin K antagonism
Analgesics/sedatives Dose
(PIVKA) can further define coagulation defects.15
Hydromorphone 0.025–0.2 mg/kg IV, IM or SC; Resuscitation efforts should not be delayed while
CRI 5 0.025–0.05 mg/kg/hr awaiting laboratory results.
Morphine 0.1–0.5 mg/kg IM or SC
CRI 5 0.1–0.5 mg/kg/hr
Fentanyl 0.005–0.04 mg/kg IV Abdominocentesis
CRI 5 0.005–0.01 mg/kg/hr Abdominocentesis is a rapid method for diagnosing
Opioid reversal: Naloxone 0.01–0.02 mg/kg IV, IM or SC hemoperitoneum and can be performed during resus-
Diazepam 0.2–0.5 mg/kg IV; CRI 5 0.2–0.8 mg/kg/hr citation efforts using a closed – or open-blind para-
Midazolam 0.2–0.5 mg/kg IV, IM or SC
centesis technique to sample two or four abdominal
CRI 5 0.1–0.25 mg/kg/hr
Benzodiazepine reversal 0.01–0.02 mg/kg IV, IM, or SC quadrants directly.32 Alternatively ultrasound guidance
agent: Flumazenil can be used to visualize abdominal fluid for sampling.5
Ketamine CRI 5 0.1–0.4 mg/kg/hr Non-clotting whole blood that is obtained from the
Induction agents peritoneal space confirms the diagnosis of hemoperito-
Propofol 5–8 mg/kg IV induction,
neum and can be assessed by gross examination of the
CRI 5 0.1–0.4 mg/kg/min
Etomidate 1–2 mg/kg IV fluid.1,33 Repeated paracentesis during stabilization and
Ketamine/Diazepam 5 mg/kg ketamine IV10.5 mg/kg hospitalization provides information to monitor the
diazepam IV progression of intra-abdominal bleeding.16,34 An in-
creasing trend in the abdominal PCV that parallels a
IV, intravenous; IM, intramuscular; SC, subcutaneous; CRI, constant rate
decreasing trend in the peripheral PCV indicates on-
infusion.
going or active hemorrhage.
Blind paracentesis technique for abdominal fluid col-
angiopathy.30,31 HBOCs have an additional benefit of lection can be performed with the dog in lateral re-
increasing systemic vascular resistance by scavenging cumbency or standing.32 The fluid is collected from the
the potent vasodilator nitric oxide.30,31 The use of most gravity-dependant portion of the abdomen to
HBOCs at this time is limited by the availability. increase yield.32 A 22- or 20-G needle with syringe
Dogs demonstrating signs of pain and anxiety during attached is used for closed paracentesis and aspiration.
the initial resuscitation may require analgesia or seda- An open-blind single needle technique can be per-
tion. Combinations of titrated doses of m agonist opi- formed by inserting a 20- or 22-G hypodermic needle
oids or benzodiazepines or both can be used to provide through the abdominal wall at the level of the umbi-
analgesia and reduce anxiety with minimal adverse licus or most dependent portion of the abdomen.32 The
effects on cardiovascular function. Should adverse hub of the needle is observed for fluid, and a sample is
effects occur, antagonists can be administered for both collected for analysis. A two or four quadrant para-
opioids and benzodiazepines (Table 1). centesis can be performed by inserting hypodermic
needles simultaneously in two or four abdominal quad-
rants centered around the umbilicus.32 The fluid should
Diagnosing Hemoperitoneum: Clinical Laboratory
first be allowed to flow by gravity because aspiration
Evaluation and Abdominocentesis
may cause omentum or other abdominal organs to
PCV, TS, activated clotting time (ACT), prothrombin occlude the needle bevel.32 When gravity flow does not
time (PT), activated partial thromboplastin time (aPTT), yield a fluid sample, gentle aspiration with a 3–6 mL
venous blood gas and lactate results can provide infor- syringe can be performed. Ultrasound-guided para-
mation about patients suspected or confirmed to have centesis allows visualization of fluid pockets for direct
hemoperitoneum. A low PCV and TS is very suggestive fluid aspiration and may improve the accuracy of fluid
of blood loss; however, the presence of a normal or collection over blind techniques and reduce the risk of
elevated PCV with concurrent low TS also may be the inadvertent organ laceration.
consequence of acute bleeding with splenic contraction An alternative to using hypodermic needles is the
and release of sequestered red blood cells. Poor tissue use of a 14- or 16-G over-the-needle intravenous cath-
perfusion caused by hypovolemia and anemia can eter modified by making three to five small fenestra-
cause metabolic acidosis with elevated serum lactate. tions with a number 15 scalpel blade.34,35 The catheter
Additional laboratory evaluation including complete can be placed percutaneously but may require making
blood count, serum biochemistry analysis, and urinal- a small-releasing incision in the skin. The catheter and
ysis may reveal organ dysfunction. Prolonged ACT, PT, stylet are inserted just into the peritoneal cavity, then
aPTT can support a diagnosis of coagulopathy. Addi- the catheter is gently advanced over the needle as the
& Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.x 43L.V. Herold et al.
needle is removed. Fluid is collected by gravity flow evaluation is given in Table 2.33–35 Complications asso-
or with gentle aspiration by a syringe. The use of a ciated with DPL include inadvertent organ or vessel
catheter for paracentesis has been reported to be more laceration or penetration, subcutaneous placement of
accurate in identifying intra-abdominal fluid.34 DPL catheter, subcutaneous leakage of lavage fluid,
Diagnostic peritoneal lavage (DPL) is reported to subcutaneous hematoma formation, and introduction
have increased accuracy in the detection of intra-ab- of infection.
dominal pathology over blind paracentesis techniques
and is performed when paracentesis techniques do not
Maintain Oxygen-Carrying Capacity
provide a positive diagnosis and ultrasound is not
available.34,35 Sedation and local anesthesia may be Loss of red blood cells along with decreased effective
necessary for the placement of a DPL catheter.36 DPL circulating volume leads rapidly to tissue hypoxia in
can be performed using a 5.25-in., 14- or 16-G over-the- hemorrhaging patients. The provision of supplemental
needle intravenous catheter (with additional sampling oxygen via flow-by, nasal catheter, hood, or cage can
holes created in the catheter) or with the placement of a help to increase the arterial partial pressure of oxygen.
commercially available lavage catheter.a,b DPL catheter Once volume resuscitation has been initiated, and
placement techniques are described in detail else- hemoperitoneum diagnosed, transfusion therapy can
where.36 The bladder ideally should be empty for be considered to optimize oxygen-carrying capacity.
DPL catheter placement.36 Arterial oxygen content can be maintained by replacing
Warm sterile 0.9% saline is infused into the peritoneal the lost hemoglobin (Hgb) with allogenic or autologous
cavity through the DPL catheter (20 mL/kg), the fluid is packed red blood cell or whole blood transfusion or
allowed to mix with fluid present in the abdominal with HBOCs. If readily available, HBOCs can be used
cavity. The fluid is collected by gravity flow into a ster- immediately during severe hemorrhage and hypo-
ile closed collection system and analyzed. The amount volemia to allow time to prepare a transfusion.30,31
of fluid retrieved is often much less than the infused The decision to administer a red blood cell transfu-
volume but only a small sample is needed for analy- sion is not based solely on a ‘transfusion trigger’ pro-
sis.36 Samples collected following DPL will be diluted vided by low PCV or low Hgb value.32,33 The decision to
so absolute cell counts and TS evaluation may be mis- transfuse the critically ill hemorrhaging patient should
leading. A guideline for interpretation of DPL PCV be based on physiologic factors affecting oxygenation
including cardiopulmonary reserve, rate and magnitude
Table 2: Evaluation of paracentesis and lavage fluid33–35 of blood loss, and oxygen consumption.37 Transfusions
should be considered when there are signs compatible
Fluid parameter Interpretation with severe anemia and hemorrhagic shock (tachycar-
Packed cell volume dia, tachypnea, bounding pulses, collapse) and there is a
Diagnostic peritoneal lavage When infusing 500 mL of declining trend in PCV, TS and Hgb values after initial
packed cell volume fluid, every 1% PCV represents fluid resuscitation. As a guideline, the authors recom-
10–20 mL of blood within the
mend transfusion at a PCV o25% and Hgb o8 g/dL in
abdomen
Creatinine patients that may require surgical intervention. Patients
Greater than serum Urinary tract leakage and with severe acute hemorrhage may need transfusions at
uroabdomen much higher PCV levels. Hemoglobin levels should
Potassium be monitored when HBOCs have been administered
Greater than serum Urinary tract leakage and
because the PCV will not accurately reflect oxygen-
uroabdomen
Glucose carrying capacity due to soluble Hgb.30,31
Abdominal glucose less Septic peritonitis The choice of blood product will be based on avail-
than serum glucose by 20 mg/dL ability, presence of a coagulopathy, and hemodynamic
Bilirubin status38 (Table 3). Blood product transfusions are
Greater than serum Biliary tract leakage or upper
warmed to body temperature when time allows. The
intestinal leakage
Cytology infusion line can also be run through a commercial fluid
Intracellular bacteria Septic peritonitis warmerc,d and an in-line filter is recommended. First-
Ingesta and/or bacteria Intestinal tract leakage time blood transfusions in dogs may not require cross-
with inflammatory cells matching because severe transfusion reactions in canine
Ingesta or bacteria without Inadvertent intestinal sample
patients during first-time transfusions are rare. When
inflammatory cells
Neoplastic cells Intra-abdominal neoplasia greater than one donor is used or repeated transfusions
are required during hospitalization, a major crossmatch
PCV, packed cell volume. is recommended. If the clinical deterioration of the
44 & Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.xHemoperitoneum in dogs
Table 3: Use of blood products and hemoglobin-based oxygen carrying solutions for hemoperitoneum in dogs
Blood productn Selection criteriaw Dosage
Fresh whole bloodz Rapid volume resuscitation in acute hemorrhage 10–20 mL/kg or until PCV can support tissue
Anemia with hypoalbuminemia oxygenation (generally PCV 5 25–30%)
Significant bleeding from coagulopathy due to secondary
hemostatic defects
Stored whole bloodz Same indications as fresh whole blood except not in Same dose as fresh whole blood
bleeding from factor V or VIII deficiency
Autotransfused blood Rapid volume resuscitation for life threatening Transfuse any volume that can be salvaged
hemorrhage when no allogenic transfusion is available
Packed red blood cellsz Anemia without coagulopathy 10–20 mL/kg of reconstituted solution (1:1 with 0.9%
NaCl) or until PCV can support tissue oxygenation
(generally PCV 5 25–30%)
Hemoglobin-based oxygen- Rapid small volume resuscitation for life-threatening 5–15 mL/kg over 15–30 minutes, up to 30 mL/kg/day
carrying solutions hemorrhage when no transfusion is immediately
available
Maldistribution of blood flow
Life-threatening anemia
Fresh frozen plasma Factor deficiency 6–20 mL/kg over 4–6 hour, until coagulopathy is
Disseminated intravascular coagulation corrected
Low antithrombin
Frozen plasma Same indications as fresh frozen plasma except not for Same dose as fresh frozen plasma
factor V or VIII deficiency
n
All blood products should be administered within 4–6 hours to prevent contamination. Whole blood is administered as quickly as possible in acute life-
threatening hemorrhagic shock.
wMultiple blood products can be combined based on patient requirements.
PCV patient PCV
zVolume in milliliters of blood to be transfused 5 body weight (kilograms) 90 desired
PCV of donor unitblood .
PCV, packed cell volume.
patient necessitates multiple consecutive transfusions ease dissemination.37,40 Desmond et al.41 reviewed the
without time for crossmatching or blood-typing, then risk of neoplastic dissemination associated with salvage
transfusion of blood from a dog erythrocyte antigen 1.1 and autotransfusion of intra-abdominal blood during
negative donor is recommended.37,38 oncologic surgery in humans. No increase in tumor re-
Autotransfusion is an effective method for rapidly currence or decrease in survival rate was reported.41
providing red blood cells and intravascular volume The use of leukocyte depletion filters over the standard
when imminent death precludes the preparation of red blood cell transfusion filters has been recommend-
allogenic transfusion or when other blood products are ed to reduce risk of tumor dissemination by autotrans-
not available. Intra-abdominal blood is collected asep- fusion in humans.42 Leukocyte depletion filters are not
tically by aspirating into a sterile syringe with para- readily available in most veterinary practices and may
centesis or by suctioning into a sterile container at the be costly to utilize. There are no studies of metastatic
time of surgery.16,39 Abdominal blood associated with risk with autotransfusion in veterinary patients.
chronic hemorrhage can usually be collected and in-
fused without anticoagulant because the blood is defi-
Arresting Hemorrhage
brinated when it comes in contact with the peritoneal
surface.37 However, when hemorrhage is acute and When ongoing hemorrhage is identified, efforts are
rapid there may be insufficient time for defibrination made to arrest hemorrhage by correcting any coagulo-
and anti-coagulation of abdominal blood is necessary pathies, providing abdominal counterpressure, or
before autotransfusion (7 mL of citrate–phosphate through surgical intervention as indicated. Coagulation
dextrose adenine should be added to each 50 mL of defects diagnosed by prolonged PT, aPTT, ACT or
abdominal blood collected).37 The blood should be ad- PIVKA, which can contribute to further intra-abdominal
ministered through a blood administration set or in-line hemorrhage or that may be the cause of the abdominal
blood filter. hemorrhage, can be corrected by administration of
Reported contraindications for autologous transfu- plasma or whole blood (Table 2). Vitamin K1 (2.5–
sion of abdominal blood include the presence of septic 5.0 mg/kg/day SQ or PO) can be administered if
peritonitis and the presence of ruptured neoplastic ab- anticoagulant rodenticide exposure or hepatic dysfunc-
dominal masses due to the potential for systemic dis- tion are suspected.
& Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.x 45L.V. Herold et al.
Abdominal Counterpressure of ischemic organ damage or changes in tidal volume
were observed.45 The application of counterpressure
Abdominal counterpressure can be quickly applied in devices in humans has also been reported to increase
dogs for rapid control of intra-abdominal hemorrhage central venous pressure, intracranial pressure, and in-
regardless of etiology.16,39 This procedure can provide trathoracic pressure.48–50 For these reasons abdominal
hemostasis, and may be the only option for hemostasis counterpressure should be used with extreme caution
when owners reject surgical intervention. With appli- in dogs with respiratory distress, pleural space disease,
cation of abdominal counterpressure even a small re- thoracic hemorrhage, diaphragmatic hernia and intra-
duction in the radius of a vessel is translated into a cranial trauma. Furthermore, it remains controversial as
reduction in flow to the power of 4 (Poiseuille’s law43), to whether pneumatic garments reduce mortality in
and it is often enough to reduce or even stop hemor- humans.51–53 Though experimental data demonstrated
rhage from vascular defects. In addition the application improved survival, no clinical evaluations of external
of abdominal counterpressure also may produce a tam- counterpressure have been reported in veterinary pa-
ponade effect on bleeding abdominal organs and ves- tients.45 In the experience of the authors, when hemo-
sels, reduce the size of peritoneal space and reduce peritoneum and ongoing hemorrhage prevents patient
hemorrhage volume.44 In a study of dogs with exper- stabilization, and no contraindications exist, the appli-
imentally produced hemoperitoneum, application of an cation of counterpressure may correct hypotension and
abdominal bandage to provide counterpressure im- reduce or eliminate the need for immediate surgical
proved survival.45 intervention to control hemorrhage in dogs.
A modification of this technique is the incorporation The duration of counterpressure application should
of the pelvic limbs into the counterpressure wrap be minimized to reduce any potential complications.
(hindlimb and abdominal counterpressure-HLAC) to The abrupt removal of the counterpressure wrap can
avoid the compartmentalization of blood in the pelvic cause life-threatening hypotension due to rapid redis-
limb vasculature and to avoid occluding the caudal tribution of blood or hemorrhage from vessels where
abdominal vena cava.16,39 This is similar to the place- tamponade was previously achieved. The counterpres-
ment of pneumatic garments over the legs and abdo- sure wrap is removed gradually by first loosening the
men to treat hypovolemic shock in humans.46
Application of these garments is thought to produce
an autotransfusion effect by shunting blood from the
large capacitance veins of the hind legs and abdomen to
the heart and organs above the level of counterpressure
application.47
In dogs abdominal counterpressure and HLAC can
be applied rapidly by circumferentially wrapping the
abdomen with or without the hindlimbs with towels
and tape, or bandaging materials (Figure 2).16 Heavy
sedation and analgesia may be required when incor-
porating the hindlimbs and pelvis. Incorporating the
hind limbs is not recommended in patients with pelvic
or hind limb fractures. Urinary catheter placement with
a closed collection set may be utilized to maintain hy-
giene, facilitate nursing care and monitor urinary out-
put. When possible the hair can be clipped from the
ventral abdomen before wrapping in anticipation of Figure 2: Hind limb and abdominal counterpressure applica-
rapid surgical entry into the abdomen should the pa- tion in a dog. A towel is rolled lengthwise and placed between
tient fail to stabilize. the hind legs. Another towel is wrapped circumferentially
Abdominal compartment syndrome is defined as ab- around both hind legs as a single unit. Duct tape is wrapped in
a spiral pattern from the digits proximally over the towel. As an
dominal hypertension with evidence of renal, pulmo-
option a towel can be rolled and placed parallel to and along the
nary or hemodynamic compromise. Decreased
ventral midline of the abdomen to provide cushioning and pre-
glomerular filtration rate, metabolic and respiratory ac- vent over-compression during taping. Another towel is
idosis, and reduced ventilatory function have been as- wrapped circumferentially around the abdomen, spiraling for-
sociated with the use of pneumatic garments in ward from the pelvis to the xiphoid. The duct tape used to
humans.46,48 In an experimental study of abdominal secure the towels around the hind limbs is continued around
counterpressure application in dogs, no gross evidence the abdomen, in the same spiral pattern.
46 & Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.xHemoperitoneum in dogs
wrap at its most cranial portion (each layer of duct tape previous abdominal surgery can lead to iatrogenic
or bandaging material can be cut) and then moving pneumoperitoneum.54
caudally at 15-minute intervals toward the hind limbs. Thoracic radiography is indicated for dogs with
Heart rate, blood pressure and physical perfusion hemoperitoneum to detect concurrent thoracic trauma
parameters are evaluated at 15-minute intervals. A or hemorrhage, and as a screen for metastasis.3,4 A
precipitous drop in blood pressure requires that the complete thoracic radiographic evaluation for metasta-
wrap be re-tightened and additional fluid therapy may sis would include a three-view thoracic radiographic
be required to restore acceptable vital organ perfusion. series (right and left lateral projections and a ventro-
Dogs that do not stabilize their cardiovascular param- dorsal [VD] or dorsoventral views). Patients with sig-
eters after fluid resuscitation and application of count- nificant abdominal distension may not tolerate
erpressure are candidates for emergency surgical positioning for VD radiographic projections. Two-view
intervention. thoracic radiographic projections may be sufficient as a
screening tool.
Focused abdominal sonography for trauma (FAST)
Diagnostic Imaging
was developed in humans for the evaluation of blunt
Imaging studies should be delayed until after patient and penetrating abdominal trauma, and evaluation for
stabilization. Abdominal radiographic changes de- the presence of free abdominal fluid.55,56 A FAST pro-
scribed for patients with hemoperitoneum are nonspe- tocol has been described for dogs and consists of ex-
cific and include changes associated with accumulation amination of four intra-abdominal regions (patient in
of peritoneal fluid such as loss of serosal detail.54 left lateral recumbency): (1) immediately caudal to the
Radiographic signs of organomegaly or a soft tissue xiphoid process, (2) on the ventral midline over the
mass effect or both may suggest an etiology for ab- bladder, (3) over the right flank (gravity-independent
dominal hemorrhage when trauma is not apparent.1,4 region), (4) over the most gravity-dependent area of the
When trauma has occurred, abdominal radiography left flank (Figure 3).5 In a prospective study of 100 dogs
can be helpful in identifying concurrent pneumoperi- presenting for motor vehicle trauma, a FAST examin-
toneum suggestive of hollow viscus rupture, or anaer- ation was found to have 96% sensitivity and 100%
obic bacterial infection.1 Open abdominal paracentesis specificity for the detection of free abdominal fluid
techniques performed before abdominal imaging or but it is not specific for hemoperitoneum.5 Ultrasound
Figure 3: Focused assessment with sonography for trauma (FAST) views in a dog positioned in left lateral recumbency. 1. Right flank
longitudinal view, 2. Subxiphoid transverse view, 3. Longitudinal view midline over the bladder, and 4. Left flank longitudinal view.
Special thanks to Dr. Soren R. Boysen for providing the images.
& Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.x 47L.V. Herold et al.
examination often is not able to localize the specific Table 4: Indications to pursue surgical management in dogs
source of bleeding but can aid in the identification of with hemoperitoneum
intra-abdominal masses and evaluation of organ pa- Abdominal wall or diaphragmatic hernia
renchyma. Penetrating abdominal trauma
Computed tomography (CT) is the standard diag- Pneumoperitoneum
nostic and monitoring tool used in the management of Septic or bile peritonitis
Hemorrhage from abdominal mass
hemoperitoneum in humans, allowing for evaluation of
Organ ischemia: GDV, splenic torsion, liver lobe torsion, mesenteric
hepatic and splenic injuries, as well as peritoneal fluid volvulus
accumulations that are used to guide the nonoperative Continually decreasing peripheral PCV in conjunction with increasing
management of human trauma patients.57,58 The ad- abdominal fluid PCV on serially collected samples
vantages of using CT in the diagnosis and monitoring Inability to correct perfusion abnormalities with fluid and transfusion
therapy
of the hemoperitoneum patient are that it provides ex-
Continued drop in blood pressure with attempts to remove abdominal
cellent evaluation of abdominal organs, allows the counterpressure
amount of peritoneal fluid to be quantified, and may
indicate active hemorrhage with contrast blush or pool- GDV, gastric dilatation and volvulus; PCV, packed cell volume.
ing.58 Disadvantages of standard CT in veterinary med-
icine include the need for an anesthetic procedure, In the experience of the authors, most abdominal
limited availability, cost, and the need for specially hemorrhage in dogs due to coagulopathies or blunt
trained operators. Spiral or helical CT scanners have trauma can be managed medically through a combina-
shortened times for image acquisition and may elimi- tion of fluid resuscitation, abdominal counterpressure
nate the disadvantage of a prolonged anesthetic proce- and transfusion therapy. When cardiovascular param-
dure in critical canine patients.59,60 Although there are eters fail to stabilize, a diagnosis of a ruptured mass,
no descriptions of CT for evaluation of hemoperitone- organ ischemia or GDV is made, surgical intervention
um in dogs, availability of CT scanning is becoming will be required. Other indications for surgical inter-
more prevalent in specialty and emergency referral vention are listed in Table 4. The urgency of the surgery
hospitals and may soon become a useful tool in the as well as the intensity of the preparation and proce-
management of these patients. dures employed, will depend upon whether or not
there is catastrophic ongoing hemorrhage.63 Success
depends upon careful preoperative planning, a skilled
Monitoring
surgeon and vigilant postoperative monitoring.64
The goals of monitoring the dog with hemoperitoneum
are to assess the progress of resuscitative efforts and to
Surgical Readiness
detect early evidence of ongoing or recurrent hemor-
rhage. Heart rate, CRT, pulse quality, and blood pres- It is ideal to have three people, a primary surgeon, a
sure are assessed to monitor perfusion with the trends surgical assistant and an anesthetist dedicated to the
of change often being more important than the absolute surgery and anesthesia of the decompensated patient.
values. Measuring increases in abdominal diameter Several factors may contribute to increased patient
may indicate ongoing hemorrhage. Serial peripheral morbidity and mortality: prolonged operative time may
PCV or Hgb values should be evaluated for trends of lead to hypothermia, decreased tissue perfusion and
change. When available, central venous pressure (CVP) tissue hypoxia can worsen metabolic acidosis, dilution-
trends may be used as an indirect measurement of in- al effects of fluids, as well as loss of clotting factors
travascular volume changes.61 Increases in CVP occur- through hemorrhage, and ineffective coagulation with
ring following abdominal counterpressure may be hypothermia can cause decreased hemostatic func-
attributable to application of the wrap. The electrocar- tion.65,66 Blood products, crystalloids, and colloids
diogram should be monitored for presence or develop- (synthetic and biologic) should be in the surgical area
ment of cardiac arrhythmias. Systematic and available for rapid infusion. Dosages of drugs for main-
comprehensive monitoring of the patient can be guid- taining balanced anesthesia, pressure support, and
ed by the principles contained in Kirby’s Rule of 20.62 emergency resuscitation should be calculated in ad-
Ongoing hemorrhage may be detected by a declining vance.64 Infusion rates for drugs given by constant rate
peripheral PCV or Hgb after initial resuscitation, repeat infusion (CRI) should be calculated, with the volumes
ultrasound finding of enlarging fluid pockets, failure to of drugs to add to the fluids predetermined for rapid
achieve stable cardiovascular parameters, or clinical formulation and administration.64
decompensation of the patient, and expansion of the Anesthesia in unstable patients can be extremely
abdominal diameter. challenging; the dosages of most anesthetic drugs are
48 & Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.xHemoperitoneum in dogs
reduced and titrated to effect. Rapid induction with the practioner. The initial incision into the peritoneal
injectable agents, intubation, and immediate institution cavity is made just long enough to allow insertion of a
of positive-pressure ventilation are essential. The anes- Poole suction tip. Blood is suctioned, ideally into a
thetic goal is to maintain tissue oxygenation and per- sterile container to save for possible autotransfusion.
fusion in the critical patient that is receiving The incision is then extended just large enough to per-
vasodilatory anesthetic agents. Patients frequently mit insertion of the assistant’s hand. The abdominal
develop hypotension when maintained on inhalant aorta at the level of the celiac artery is digitally com-
anesthetics alone, making balanced protocols using pressed. The assistant will slide a hand dorsally along
CRIs of opioids, ketamine, benzodiazepines or combi- the left peritoneal wall, palpating the cranial pole of the
nations ideal to reduce the dosage of inhalant (Table 1). left kidney and then moving the hand cranial and me-
The use of continuous positive-pressure ventilation dial to the left adrenal gland to compress the aorta
may be beneficial to ensure adequate ventilation. digitally. The aorta may not be palpable in very low
Intensive monitoring is required throughout the an- flow states requiring location of the midline by iden-
esthetic period. Blood pressure should be assessed by tifying the vertebrae. This maneuver effectively controls
direct or indirect methods.61 Capnography detects arterial hemorrhage from the celiac artery distally.
changes in exhaled carbon dioxide and can be used as As the blood is suctioned, the abdominal incision is
a reflection of the effectiveness of assisted ventilation, opened rapidly using Mayo scissors. If large-volume
possible airway obstruction or severe low flow states hemorrhage is ongoing and the source is not immedi-
that may indicate impending arrest.67 Electrocardio- ately identified then the abdomen is packed with
graphic monitoring helps detect arrhythmias as well as laparotomy sponges or sterile towels. The packs are
signs of myocardial hypoxia. Passive external warming then parted enough to be able to visualize where the
using circulating warm air or warm-water blankets, abdominal aorta is being occluded. Digital compression
as well as in-line fluid warmersc,d will reduce the de- can be maintained until the hemorrhage is controlled or
gree of hypothermia that can occur during anesthesia alternatively a window in the para-aortic fascia can be
and surgery. made with curved forceps to isolate the aorta and a
The dog that is hemodynamically stable at the time of Rumel tourniquet (Figure 4) can be applied. The towels
surgery should be clipped and surgically prepared are removed in a caudal to cranial direction and all
from the cranial thorax to the caudal abdomen. The sources of hemorrhage are controlled at least tempo-
inguinal regions are included to allow access to the rarily. Temporary hemostasis can be performed by
femoral veins to place large bore catheters for rapid placing hemostats on all vessels to be ligated. If atrau-
fluid infusions, if necessary.63 In the dog with signs of matic vascular occlusion is required a Rumel tourni-
catastrophic hemorrhage a very rapid clip is performed quet, Johns Hopkins bulldog clamp or Satinsky
of the ventral thoracic and abdominal midline region; vascular clamp is placed. Once all sources of hemor-
possibly with only one quick pass of the clipper blades. rhage have been identified then the surgeon should
Waterless scrub solutionse that minimize evaporative proceed to definitively control the hemorrhaging sites.
heat loss, and those providing rapid bacterial kill with Electrosurgery, especially bipolar electrocautery, is
minimal contact time f,g are ideal for this situation. ideal for controlling hemorrhage from vessels smaller
than 2 mm in diameter. Larger vessels must be ligated
using suture or vascular clips. Vascular pedicles with
Surgical Intervention
previously placed hemostats should be ligated with
In the patient with large-volume and ongoing hemor- ‘flashing’ of the hemostat to prevent slippage of the
rhage, the sudden decrease in abdominal pressure ligature especially if the vascular pedicle incorporates
through the release of abdominal counterpressure or in soft tissue, or if multiple vessels are being ligated si-
making the abdominal incision can result in massive multaneously. As the ligature is tightened, the hemostat
hemorrhage and rapid decompensation to the point is loosened temporarily to allow the ligature to tighten
of hemodynamic collapse. If abdominal counterpres- on the pedicle. The hemostat is then clamped again
sure is in place and hemodynamic collapse is a possi- while the knot is completed. If a more secure ligature is
bility when the counterpressure is removed, then it desired then the ends of the suture material can be
is not removed until the surgeon is gowned and gloved brought around the pedicle and the procedure can be
and the instrument pack is opened. After abdominal repeated. When vessels cannot be grasped easily with
counterpressure is removed a rapid surgical prep is hemostats, stick ties can be placed in a simple inter-
performed. rupted or cruciate pattern by placing a suture through
The authors suggest a surgical approach to the cat- the tissue surrounding the bleeding vessel; the soft tis-
astrophically hemorrhaging patient as a guideline for sue traps and helps occlude the vessel.
& Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.x 49L.V. Herold et al.
Figure 4: Modified Rumel tourniquet is made by sliding a 3.5 or 5 Fr red rubber tube, or penrose drain around the vessel or pedicle
and pulling the ends together. A hemostat is placed across the two ends of the tubing against the vessel to occlude it. Arrows identify
a red rubber catheter placed as a modified Rumel tourniquet.
Bleeding from most superficial lacerations in the liv- hemostatic agentsg,h can be placed into wounds that are
er, spleen, and kidney may be sufficiently controlled oozing to help control hemorrhage. New agentsi,j being
with direct pressure for 10–15 minutes. Superficial or developed by the military to control significant hemor-
minor lacerations that bleed despite application of di- rhage show great promise. Patients with coagulopathy
rect pressure and deeper lacerations must be sutured might benefit from administration of recombinant hu-
with mattress sutures. Excision procedures such as a man Factor VIIa.k,78 There is little information currently
partial or complete liver lobectomy,68 partial or complete in veterinary medicine on the use of some of these
splenectomy,69 or partial or complete nephrectomy70,71 newer products.
may be required to control hemorrhage. In certain sit- When all efforts at hemostasis fail to control hemor-
uations (e.g., severely bleeding organs, retroperitoneal rhage from parenchymal organs and there remains a
hemorrhage) the arterial supply proximal to and ve- large amount of hemorrhage or ooze from multiple
nous supply distal to the affected area may need to be sites, the abdomen can be repacked with towels to pro-
exposed and temporarily occluded before being able to vide direct pressure to oozing wounds and the abdo-
visualize the bleeding site for direct ligation. Vascular men is closed temporarily over the towels. The patient
occlusion of the blood supply to major organ systems is recovered from anesthesia and hypothermia, acidosis
can be performed safely for finite time periods de- and coagulation abnormalities are corrected. Reopera-
pending on the organ involved, and in some cases tion is planned within 24–48 hours when the patient is
complete ligation can be performed when collateral more stable.
blood supply is adequate (Table 5).16,72–75
Another option for hemorrhage control is the omen-
Liver hemorrhage
tum, which has procoagulant properties and can be
The liver is most often the source of active hemorrhage
sutured into wounds in the spleen or liver.76,77 Topical
into the abdomen when digital aortic compression fails
to control bleeding. Large-volume liver hemorrhage can
Table 5: Suggested time limits for vascular occlusion in normo- result from injury involving the deep parenchyma, a
thermic animals72–75 central branch of the portal vein, hepatic artery, hepatic
veins, or the retrohepatic vena cava. A modified Pringle
Occlusion time maneuver may help to control hemorrhage from the
Blood vessels limit (minutes)
liver.16,68 A vascular clamp, Rumel tourniquet or digital
Descending thoracic aorta 5–10 compression is used to occlude the portal triad consist-
Portal triad (hepatic artery, 10–15 ing of the hepatic artery, portal vein, and common bile
portal vein, common bile duct
duct as they course through the gastroduodenal liga-
Hepatic artery 30
Hepatic vein Can ligaten ment.68 This maneuver will control approximately 70%
Splenic artery and vein 15–20 of the blood supply to the liver. Intravenous broad-
Renal artery and vein 30 spectrum antibiotics, including anaerobic coverage
Abdominal aorta 30 should be administered before vascular occlusion and
Caudal vena cava (caudal to liver) Can ligaten
occlusion should not exceed 10–20 minutes releasing
Iliac vessels Can ligaten
Femoral vessels Can ligaten for 60 seconds every 10 minutes.68 Simultaneous occlu-
sion of the cranial mesenteric artery should be per-
n
With normal collateral circulation. formed to prevent acute portal hypertension. If
50 & Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.xHemoperitoneum in dogs
bleeding from the liver persists despite occlusion of the firmation that the patient has adequate function of the
hepatic artery and portal vein then retrograde flow opposite kidney should take place. An intravenous
must be occurring from tears to the hepatic veins or the pyelogram can be performed before surgery in stable
vena cava as they pass through the liver. This intrahe- patients to evaluate renal blood supply and urine
patic location makes isolation, and visualization of production. If doubt exists about the functionality of a
these vessels for ligation difficult. Bleeding from this traumatized kidney or the opposite kidney then a
site carries a grave prognosis.16,63 cystotomy can be performed and the ureteral openings
In order to improve access to the liver and dia- observed for urine flow before nephrectomy.70 The
phragm a paracostal incision can be made. In some sit- presence of flowing urine indicates a functional kidney.
uations a caudal sternotomy or parasternotomy may be When the patient is unstable and active renal hemor-
indicated to gain complete access to the liver and di- rhage is not observed, but doubt exists about renal func-
aphragm.63,68 If a liver lobectomy is indicated then an tion, then it is best to leave the kidney in place and
encircling ligature, such as Miller’s knot or multiple continue evaluation of renal function postoperatively.70,71
overlapping ligatures can be placed around the base of
the liver lobe. A stapling device can also be used for Closure
liver lobectomy.79,80,l,m When stapling devices are used Before closure appropriate biopsies should be taken of
there is often some mild persistent hemorrhage that can all abnormal tissue as time permits. The abdomen is
then be controlled using vascular clips or hemostatic irrigated thoroughly with warm saline, suctioned and
agents. If a liver lobe torsion is present, lobectomy closed. If infection is a concern aerobic and anaerobic
should be attempted without derotating the lobe be- cultures should be procured. Closed or open abdominal
cause derotation will cause a massive release of in- drainage may be indicated in patients with peritonitis.
flammatory mediators. Up to 70% of the canine liver
can be removed safely.68
Prognosis
Splenic hemorrhage The long-term prognosis for dogs with hemoperitone-
When significant splenic hemorrhage persists despite um will depend on the etiology of abdominal bleeding
packing or digital pressure, a rapid splenectomy can be and the success of resuscitation efforts. The short-term
performed by double clamping splenic vessels, short prognosis may depend on the clinician’s ability to as-
gastric vessels and omental attachments.81 Care is taken sess and treat perfusion abnormalities, recognize the
to preserve the pancreatic branch of splenic artery. The presence of intra-abdominal hemorrhage and ongoing
vessels are transected between the clamps and the bleeding, and perform emergency surgery when indi-
spleen is removed. Ligatures are placed after the spleen cated. In a retrospective review of 28 cases of traumatic
is removed. Alternatively, temporary hemostasis can be hemoperitoneum in dogs, the overall mortality rate was
achieved by placing a vascular clamp or Rumel tour- 27%.3 The prognosis for dogs with nontraumatic hemo-
niquet around the splenic pedicle. This controls hem- peritoneum is variable.4
orrhage and allows time to individually isolate and
ligate splenic vessels.
It is ideal to preserve as much of the spleen as pos- Footnotes
sible because of its function as a blood reservoir, a
Oxyglobin, Biopure Company, Cambridge, MA.
filter, and as part of the immune system.69 However, b
Peritoneal Lavage Catheter Sets PLS 100, Surgivet Inc., Waukesha, WI.
c
Tempcare-TC 1 Veterinary fluid warmer, Paragon Medical, Coral
partial splenectomy is performed rarely because it fre-
Springs, FL.
quently takes more time to complete than a total d
VetOne IV fluid warmer Model 102, DRE Medical Inc., Louisville, KY.
e
splenectomy and complications following a total Technicare, Care-Tech Laboratories, St. Louis, MO.
f
Nolvalsan Surgical Scrub, Fort Dodge Animal Health, Fort Dodge, IA.
splenectomy are rare in dogs. If a splenic torsion is g
HemaBlock, Abbott Laboratories, Abbott Park, IL.
h
present then splenectomy should be attempted without i
Gelfoam, Pharmacia & Upjohn, Kalamazoo, MI.
Hemcon Bandage, Hemcon Inc., Portland, OR.
derotating the spleen16,69 Vascular clips or ligatures or a j
Quikclot, Z-Medica Corp., Wallingford, CT.
combination of the two can be used when a splenec- k
rFVIIa, Novo Seven, Novo Nordisk A/S, Bagsvaerd, Denmark.
l
tomy is indicated.63,69 m
TA 55 or TA 90 instrument, U.S. Surgical Corp., Norwalk, CT.
55-3.5 or 90-3.5 blue disposable loading unit, U.S. Surgical Corp.
Renal hemorrhage
When major subcapsular hemorrhage is identified in- References
traoperatively, the area should be observed for an ex-
1. Brockman DJ, Mongil CM, Aronson LR, et al. The practical ap-
panding or pulsating hematoma, which would warrant proach to hemoperitoneum in the dog and cat. Vet Clin North Am
nephrectomy. Before a nephrectomy is performed, con- Sm Anim Pract 2000; 30(3):657–668.
& Veterinary Emergency and Critical Care Society 2008, doi: 10.1111/j.1476-4431.2007.00265.x 51You can also read
