HEMORRHAGIC SHOCK SECONDARY TO LUMBAR ARTERY RUPTURE

SESSION TITLE: Critical Cardiovascular Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Hemorrhagic shock is a life-threatening condition in which severe blood loss results in cellular and tissue hypoxia. The bleeding can be external or internal. Internal bleeding to one of the body cavities;retroperitoneum, as well as the proximal thigh. Diagnosing nontraumatic bleeding can be challenging and needs a high index of clinical suspension. Here we present a case of hemorrhagic shock secondary to spontaneous lumbar artery rupture causing retroperitoneal bleeding. CASE PRESENTATION: Here we present a 73-year-old male patient with a history of renal cell carcinoma metastatic to the lungs and stage 3 chronic kidney disease (CKD), who presented with confusion, one day after he tested positive for covid after he had a fever and flu-like symptoms for about 4 days. On admission, he was hemodynamically stable and saturating well on ambient air. Head computed tomography (CT) scan and Chest radiograph were negative for acute insults. On the day after admission, his mental status deteriorated, developed acute hypoxic respiratory failure requiring 4 liters of oxygen per minute, tachycardia, and skin mottling over his hands and feet. Labs revealed elevated serum D-dimer. He was started on full-dose anticoagulation with Enoxaparin, and a CT angiogram of the chest was done and revealed new multifocal infiltrates consistent with COVID pneumonia but no pulmonary embolism. He was treated started on IV antibiotics, in addition to Remdesivir and hydrocortisone were started. On the fourth day of admission, he collapsed suddenly and became profoundly hypotensive. Repeat labs revealed a significant hemoglobin drop from 12 to 7.5 g/dl, and creatinine went up to 2.8 mg/dl. An emergent CT of the abdomen revealed an acute retroperitoneal hematoma with active extravasation. After adequate resuscitation and vasopressor support, an aortic angiogram was done showing lumbar artery bleeding requiring embolization, which was done, however, he remained hypotensive and went into cardiac arrest with failed resuscitation. DISCUSSION: Spontaneous lumbar artery rupture is a rare entity (1). Most of the reported cases had chronic kidney disease and were receiving anticoagulation (2,3). It can result in retroperitoneal hematoma, which can present with abdominal pain, hemodynamic instability, and nonspecific symptoms. Abdomen pelvis CT scan with contrast is needed to evaluate for the presence of retroperitoneal hematoma. In addition to resuscitation with fluid and blood products, urgent angiography is needed to confirm the bleeding site and to control it (e.g. embolization). CONCLUSIONS: Spontaneous Lumbar artery rupture should be considered in patients with chronic kidney disease and/or on anticoagulation who are in shock without obvious cause. It's a life threatening condition that needs immediate recognition. Reference #1: Kim JY, Lee SA, Hwang JJ, Park JB, Park SW, Kim YH, et al. Spontaneous lumbar artery rupture and massive retroperitoneal hematoma, successfully treated with arteriographic embolization. Pak J Med Sci. 2019;35(2):569-574. doi: https://doi.org/10.12669/pjms.35.2.639 (Literature review) Reference #2: Hwang NK, Rhee H, Kim IY, et al. Three cases of spontaneous lumbar artery rupture in hemodialysis patients. Hemodial Int 2017;21: E18-21 Reference #3: Sun, PL., Lee, YC. & Chiu, KC. Retroperitoneal hemorrhage caused by enoxaparin-induced spontaneous lumbar artery bleeding and treated by transcatheter arterial embolization: a case report. Cases Journal 2, 9375 (2009). https://doi.org/10.1186/1757-1626-2-9375 DISCLOSURES: No relevant relationships by Mohamad Al-Momani No relevant relationships by Rami Dalbah No relevant relationships by Mohammad Darweesh No relevant relationships by Ratib Mahfouz No relevant relationships by nizar obeidat No relevant relationships by Ahmad Othman

Retroperitoneal Hemorrhage in Patients with COVID-19 Undergoing Hemodialysis: Three Case Reports.

A 73-year-old man receiving hemodialysis and antiplatelets was admitted with a mild case of COVID-19. Heparin was added, and iliopsoas hemorrhage developed. He was successfully treated by interventional radiology. A 76-year-old man receiving hemodialysis and antiplatelets was admitted with mild COVID-19. Heparin was added, and iliacus hemorrhage developed. Despite heparin discontinuation, he died of worsening pneumonia. A 74-year-old man undergoing hemodialysis was admitted with severe COVID-19. Gastrointestinal bleeding developed during continuous hemodiafiltration with heparin. Upon switching to nafamostat and increasing the dose, iliopsoas hemorrhage developed. Despite interventional radiology, he died of infectious complications. Attention to hemorrhagic complications is therefore needed in patients with COVID-19.

Severe Retroperitoneal Hemorrhage in a COVID-19 Patient on a Therapeutic Dose of Low Molecular Weight Heparin: A Case Report.

Extensive drug treatment for coronavirus disease 2019 (COVID-19) includes low molecular weight heparin (LMWH). At therapeutic doses of LMWH, there is an increased risk of bleeding complications. Spontaneous, non-traumatic bleeding into the retroperitoneum is a life-threatening condition that can progress very rapidly. We describe a complication of COVID-19 bronchopneumonia treatment in which a patient developed a shock condition caused by non-traumatic bleeding into the retroperitoneum and abdominal wall due to LMWH overdose. The patient was operated on under difficult conditions - in biosafety level 3 (BSL-3). This case is exceptionally fascinating and informative. Nowadays, it is essential to point out possible complications associated with the treatment of COVID-19. Based on this report, we emphasize the need for careful LMWH dosing and quick and accurate diagnosis. Surgeons should maintain a higher index of suspicion for spontaneous bleeding in non-specific abdominal pain patients with COVID-19 or patients receiving therapeutic doses of LMWH.

Retroperitoneal hemorrhage in a patient with coronavirus disease 2019 (COVID-19):A case report.

INTRODUCTION: Early prophylactic administration of anticoagulants is recommended in patients with coronavirus disease 2019 (COVID-19). A case of retroperitoneal hemorrhage during inpatient treatment for COVID-19 is reported. CASE PRESENTATION: A 69-year-old man was diagnosed with COVID-19 6 days after symptom onset. After admission for difficulty of breathing, he was treated with steroid pulse therapy, remdesivir, and heparin sodium. On day 16 after admission, his hemoglobin and blood pressure dropped. Computed tomography showed a left retroperitoneal hematoma and multiple areas of extravasation in bilateral iliopsoas muscles. Anticoagulation therapy was stopped, and blood transfusion therapy was chosen by considering poor general condition caused by severe pneumonia. On day 19, the hemoglobin and blood pressure improved, and blood transfusion was stopped. However, he died on day 25 due to pneumonia. CONCLUSION: When retroperitoneal hemorrhage occurs as a complication of COVID-19, appropriate treatment decision, transcatheter arterial embolization or conservative treatment, should be chosen based on patient's condition. J. Med. Invest. 69 : 148-151, February, 2022.

Spontaneous retroperitoneal bleeding in COVID-19 patients - two case reports.

INTRODUCTION: COVID-19 disease is associated with a high risk of thromboembolic events, especially in patients with a severe course of the disease. At the same time, however, there is a risk of bleeding. These complications have a significant impact on patient morbidity and mortality. Thus, determining an optimal approach to thromboembolic disease prophylaxis can be challenging. CASE REPORTS: This paper presents two cases of polymorbid female patients suffering from COVID-19. Both patients experienced retroperitoneal hemorrhage while on low molecular weight heparins in the process of deintensification of the treatment of their moderate to severe disease. Although both patients were treated surgically with a good local effect on the hemorrhage, their deterioration progressed, finally resulting in death in both the cases. CONCLUSION: Despite the proven benefit of prophylaxis of thromboembolic events using low molecular weight heparins in patients with COVID-19, care should be taken to monitor coagulation laboratory parameters in proper time intervals. The risk of a fatal course of bleeding complications is extremely high in critically ill patients and patients with multiple comorbidities.

THE RELATIONSHIP BETWEEN ADIPOSITY/SARCOPENIA AND DEATH AMONG PATIENTS WITH COVID-19 DIFFERS BASED ON THE PRESENCE OF GASTROINTESTINAL SYMPTOMS

Background: Patients with SARS-CoV-2 who initially present with gastrointestinal (GI) symp-toms, with or without respiratory symptoms, have a milder clinical course than those who do not have GI complaints. Risk factors for severe COVID-19 disease include increased adiposity and sarcopenia, but whether these risk factors are similarly associated with worse outcomes among patients with GI symptoms has not been established. Methods: This was a retrospective study of hospitalized patients with COVID-19 who underwent abdominal CT scan for clinical indications within 30 days of positive SARS-COV-2 test. Abdominal body composition measures including skeletal muscle index (SMI), intramuscular adipose tissue index (IMATI), visceral adipose tissue index (VATI), subcutaneous adipose tissue index (SATI), and visceral-to-subcutaneous adipose tissue ratio (VAT/SAT Ratio) were measured on a single axial CT slice at the L3 vertebral level. Hepatic steatosis was measured by absolute liver attenuation and by liver/spleen attenuation ratio. Clinical characteristics and outcomes were collected from the electronic medical record. GI symptoms were classified at time of first positive SARS-CoV-2 test. The association between body composition measurements and the primary outcome of death or discharge to hospice within 30 days after positive SARS-CoV-2 test was tested. Results: Of 190 patients with COVID-19 who had abdominal CT scans, 117 (62%) had GI symptoms including nausea, vomiting, diarrhea, or abdominal pain. Among those without GI symptoms at presentation, the most common reasons for abdominal CT scan were as part of a multi-organ evaluation of fever/sepsis, evaluation of GI symptoms that developed later during the hospital course, and evaluation for retroperitoneal hemorrhage. There were no differences in baseline patient characteristics comparing those with or without GI symptoms (Table 1). Patients with GI symptoms were less likely to be admitted to the ICU than patients without GI symptoms (16% versus 37% respectively;p <0.01) but had similar 30-day mortality (15% versus 18% respectively;p=0.66). Among patients with GI symptoms, those who died or were discharged to hospice had significantly increased IMATI (unadjusted p=0.025) and no differences in other measures (Table 2). On the other hand, among patients without GI symptoms, those who died or were discharged to hospice within 30 days had increased IMATI (p=0.049), reduced SMI (p=0.010), and increased VAT/SAT Ratio that was not statistically significant (p=0.419). Conclusions: Among patients with COVID-19, the relationship between measures of adiposity/sarcopenia and death differs in patients with and without GI symptoms.(Table Presented)Table 1. Clinical Characteristics among 190 patients hospitalized for COVID-19 based on presence of GI symptoms.(Table Presented)Table 2. Body composition measurements among 117 patients with GI symptoms and 73 patients with no GI symptoms based on death/hospice at 30 days.

Delayed retroperitoneal hemorrhage during extracorporeal membrane oxygenation in COVID-19 patients: A case report and literature review.

BACKGROUND: Retroperitoneal hemorrhage (RPH) is a rare and severe complication in patients undergoing extracorporeal membrane oxygenation (ECMO). Clinical diagnosis is difficult. CASE SUMMARY: Three cases of RPH patients with corona virus disease-19 (COVID-19) were included in this study. All three suffered from respiratory failure, were treated with veno-venous or veno-arterial-venous ECMO, and experienced RPH during ECMO treatment. Two of the COVID-19 cases were diagnosed after the patients experienced abdominal pain. The other patient exhibited decreases in the ECMO circuit flow rate and hemoglobin level. Two cases were treated by transcatheter arterial embolization, and one was treated conservatively. The hemorrhage in each of the three cases did not deteriorate. Satisfactory treatment results were achieved for the three patients because of prompt diagnosis and treatment. CONCLUSION: Although the incidence of RPH during ECMO treatment is low, the risk is increased by anticoagulant use and local mechanical injury. If declines in blood flow velocity and hemoglobin are detected, RPH should be considered, and prompt aggressive therapy should be started.

Life-Threatening Psoas Hematoma due to Retroperitoneal Hemorrhage in a COVID-19 Patient on Enoxaparin Treated With Arterial Embolization: A Case Report.

Respiratory failure is presumptively caused by microvascular thrombosis in some patients with coronavirus disease 2019 (COVID-19) requiring therapeutic anticoagulation. Anticoagulation treatment may cause life-threatening bleeding complications such as retroperitoneal hemorrhage. To the best of our knowledge, we report first case of a COVID-19 patient treated with therapeutic anticoagulation resulting in psoas hematoma due to lumbar artery bleeding. A 69-year-old patient presented with fever, malaise and progressive shortness of breath to our hospital. He was diagnosed with COVID-19 by RT-PCR. Due to an abnormal coagulation profile, the patient was started on enoxaparin. Over the course of hospitalization, the patient was found to have hypotension with worsening hemoglobin levels. Computed tomography scan of the abdomen and pelvis revealed a large psoas hematoma. Arteriogram revealed lumbar artery bleeding which was treated with embolization. Anticoagulation therapy, while indicated in COVID-19 patients, has its own challenges and guidelines describing dosages and indications in this disease are lacking. Rare bleeding complications such as psoas hematoma should be kept in mind in patients who become hemodynamically unstable, warranting prompt imaging for diagnosis and treatment with arterial embolization, thus eliminating need of surgical intervention.