Acute Retroperitoneal Hematoma After Psoas Catheter Placement in a Patient with Myeloproliferative Thrombocytosis and Aspirin Therapy

Spontaneous Retroperitoneal Hematoma After Total Hip Arthroplasty

Spontaneous retroperitoneal hematomas are a rare yet potentially devastating occurrence associated with antiplatelet and anticoagulant therapies. We present a case of a spontaneous retroperitoneal hematoma post-operatively after a total hip arthroplasty surgery performed under a midline approach spinal anesthetic. A 79-year-old male with a BMI of 25.72 kg/m² presented for anterior total hip arthroplasty. A midline approach with an uncomplicated spinal anesthetic was performed. On the night of postoperative day 0, the patient received a prophylactic dose of dalteparin. The patient reported back pain, contralateral leg numbness, and weakness that began overnight on postoperative day 0. A computed tomography (CT) scan confirmed a 10 cm, contralateral retroperitoneal hematoma. The patient underwent interventional radiology embolization followed by surgical evacuation and demonstrated improvement in the neurologic function of his affected leg. Despite the rarity of a spontaneous retroperitoneal hematoma formation in the perioperative period, it could be simultaneously evaluated when performing an MRI to rule out spinal hematoma if a patient suffers a post-op neurologic deficit after a neuraxial technique. Understanding the evaluation and timely treatment of patients at risk for a perioperative retroperitoneal hematoma could help clinicians prevent a permanent neurologic deficit.

[SBA 2020: Regional anesthesia guideline for using anticoagulants update]

The development of protocols to prevent perioperative Venous Thromboembolism (VTE) and the introduction of increasingly potent antithrombotic drugs have resulted in concerns of increased risk of neuraxial bleeding. Since the Brazilian Society of Anesthesiology (SBA) 2014 guideline, new oral anticoagulant drugs were approved by international regulating agencies, and by ANVISA. Societies and organizations that try to approach concerns through guidelines have presented conflicting perioperative management recommendations. As a response to these issues and to the need for a more rational approach, managements were updated in the present narrative revision, and guideline statements made. They were projected to encourage safe and quality patient care, but cannot assure specific results. Like any clinical guide recommendation, they are subject to review as knowledge grows, on specific complications, for example. The objective was to assess safety aspects of regional analgesia and anesthesia in patients using antithrombotic drugs, such as: possible technique-associated complications; spinal hematoma-associated risk factors, prevention strategies, diagnosis and treatment; safe interval for discontinuing and reinitiating medication after regional blockade.