A Diagnostic Dilemma: Hematoma In The Massive Weight Loss Patient
Bao Tram Nghiem, MD, Jacqueline Haas, MD, Tianna Negron, BS, Ronald P. Bossert, MD.
University of Rochester Medical Center, Rochester, NY, USA.
PURPOSE: Hematoma following abdominal contouring procedures in the massive weight loss (MWL) patient can be subtle and difficult to recognize, but with devastating consequences if left untreated. It is critical to recognize early signs of bleeding before progression to hemorrhagic shock. A loss of approximately one liter of blood or 15% of circulating blood volume may be masked by compensatory mechanisms, without change in blood pressure, pulse, or capillary refill. Tachycardia is among the first signs of hemorrhage, as the body aims to increase cardiac output and maintain perfusion pressure. Continued bleeding is classically associated with hypotension, tachypnea, and oliguria. The purpose of this study is to examine the clinical patterns of hematoma presentation following abdominoplasty or panniculectomy in MWL patients, as well as timing to intervention.
METHODS: A retrospective chart review of patients who underwent abdominoplasty or panniculectomy between January 1, 2012 to January 31, 2018. Both objective data (postoperative changes in vital signs, drain output, urine output, hematocrit) and subjective cues (staff concerns or patient complaints) were collected. Time to intervention and blood transfusion rate was also recorded.
RESULTS: Of 141 MWL patients who underwent abdominoplasty or panniculectomy, the overall hematoma rate was 7.1%. Specifically, 5.7% (8/10) developed acute hematoma (within 72 hours postoperatively) that required immediate operative evacuation, 0.7% underwent delayed intervention for persistent symptomology, and 0.7% had clinically insignificant hematoma that resolved spontaneously. Focusing on the eight patients who developed acute hematoma, six patients (75%) had documented postoperative hypotension (systolic blood pressure <90 mmHg), one (20%) displayed both tachycardia (heart rate >100 bpm) and hypotension, one had vital signs within normal limits, and none had isolated tachycardia. Two patients had hematocrit drop of at least 10 units. Five patients had noticeably increased drain output and one patient had decreased urine output. The majority (62.5%, 5/8) of patients had significantly increased pain on one side, as quantified by patient report and/or more than 5 point increase from baseline on self-reported 10-point pain scale. In terms of clinical exam, 50% of hematomas were noted by the nursing staff and 90% identified by the house officer. Upon hematoma evacuation, an identifiable bleeding vessel was found in 50% of cases. Two patients required blood transfusion, which translated to an overall transfusion rate of 1.4%. The majority (80%) of patients were discharged one or two days following hematoma evacuation.
CONCLUSIONS: Postoperative hematoma can be difficult to assess in the abdominal body-contouring MWL patient. Acute pain and hypotension were most correlated with hematoma in our cohort. Reliance on vital signs alone may be inadequate. As demonstrated by our study population, none of the patients demonstrated the classic triad of tachycardia, hypotension, and tachypnea. Clinical assessment is imperative to ensure rapid intervention and improved outcomes. Immediate hematoma evacuation may also lead to lower transfusion rates and shorter hospital stays.
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