Case Report Severe Intraperitoneal Haemorrhage following Suprapubic Catheter...
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Hindawi Publishing Corporation Case Reports in Urology Volume 2013, Article ID 724685, 2 pages http://dx.doi.org/10.1155/2013/724685 Case Report Severe Intraperitoneal Haemorrhage following Suprapubic Catheter Insertion in a Patient Treated with Iloprost R. A. J. Spence, A. Thwaini, and Aidan O’Brien Department of Urology, Craigavon Area Hospital, 68 Lurgan Road, Portadown BT63 5QQ, UK Correspondence should be addressed to A. waini; [email protected] Received 22 April 2013; Accepted 24 July 2013 Academic Editors: S. K. Hong and E. Tuzel Copyright © 2013 R. A. J. Spence et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Suprapubic catheter (SPC) insertion is a common urological procedure, performed both in the elective and emergency settings. e authors present an unusual case of severe intraperitoneal bleeding following the insertion of an SPC under direct vision, where the use of prostacyclin analogue may have been a contributing factor. 1. Introduction Prostacyclin analogue (Iloprost) is used in a variety of clinical conditions, for example, pulmonary hypertension and Ray- naud’s phenomenon. We report a case of a 42-year-old female who had an elective insertion of SPC. She had an intravenous infusion of Iloprost earlier that day. Following catheter inser- tion, she developed severe postoperative bleeding requiring laparotomy. To our knowledge this is the first case reported in the literature with a complication related to prostacyclin infusion. 2. Case Report A 42-year-old female patient with advanced multiple sclerosis (MS) for the last 13 years was admitted electively under the medical team with a new diagnosis of Reynaud’s phe- nomenon. During her admission she expressed an interest in having an SPC inserted instead of her long term urethral catheter. She had been recently commenced on daily intravenous infusion of prostacyclin analogue (Iloprost) to treat her Reynaud’s phenomenon. Aſter counselling, the patient was booked for cystoscopy (under general anaesthesia) and SPC insertion. She had finished her fiſth day of iloprost at 12 pm. She had her procedure performed at 4 pm with no intraoperative issues. ree hours later, whilst back on the ward, the patient developed severe generalised abdominal pain and became unstable with hypotension and tachycardia. Her haemoglo- bin dropped from 12 gm/L to 8 gm/L. She was stabilised with intravenous plasma expanders and packed red blood cells. An emergency computed tomography (CT) scan confirmed intraabdominal bleeding (Figure 1). She was immediately taken to the theatre for an emer- gency laparotomy. ere was approximately 3 litres of blood within her abdomen, with intra-peritoneal blood clots visible. e catheter was found to be in the urinary bladde, but had followed an intraperitoneal path, with a small haematoma on the peritoneal surface of the bladder. No active bleeding was found, and it was assumed that the bleeding was from the dome of the bladder. She recovered well from the operation and was discharged in a good health. 3. Discussion Insertion of SPC is a common procedure in urology. Despite the fact that this procedure is relatively safe, it is not without risks, and there is a paucity of evidence published in the literature about its potential complications. e incidence of such complications is usually minimised by performing
Transcript of Case Report Severe Intraperitoneal Haemorrhage following Suprapubic Catheter...
Hindawi Publishing CorporationCase Reports in UrologyVolume 2013, Article ID 724685, 2 pageshttp://dx.doi.org/10.1155/2013/724685
Case ReportSevere Intraperitoneal Haemorrhage following SuprapubicCatheter Insertion in a Patient Treated with Iloprost
R. A. J. Spence, A. Thwaini, and Aidan O’Brien
Department of Urology, Craigavon Area Hospital, 68 Lurgan Road, Portadown BT63 5QQ, UK
Correspondence should be addressed to A. Thwaini; [email protected]
Received 22 April 2013; Accepted 24 July 2013
Academic Editors: S. K. Hong and E. Tuzel
Copyright © 2013 R. A. J. Spence et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Suprapubic catheter (SPC) insertion is a common urological procedure, performed both in the elective and emergency settings.The authors present an unusual case of severe intraperitoneal bleeding following the insertion of an SPC under direct vision, wherethe use of prostacyclin analogue may have been a contributing factor.
1. Introduction
Prostacyclin analogue (Iloprost) is used in a variety of clinicalconditions, for example, pulmonary hypertension and Ray-naud’s phenomenon.We report a case of a 42-year-old femalewho had an elective insertion of SPC. She had an intravenousinfusion of Iloprost earlier that day. Following catheter inser-tion, she developed severe postoperative bleeding requiringlaparotomy. To our knowledge this is the first case reportedin the literature with a complication related to prostacyclininfusion.
2. Case Report
A42-year-old female patientwith advancedmultiple sclerosis(MS) for the last 13 years was admitted electively underthe medical team with a new diagnosis of Reynaud’s phe-nomenon. During her admission she expressed an interestin having an SPC inserted instead of her long term urethralcatheter.
She had been recently commenced on daily intravenousinfusion of prostacyclin analogue (Iloprost) to treat herReynaud’s phenomenon. After counselling, the patient wasbooked for cystoscopy (under general anaesthesia) and SPCinsertion. She had finished her fifth day of iloprost at12 pm. She had her procedure performed at 4 pm with nointraoperative issues.
Three hours later, whilst back on the ward, the patientdeveloped severe generalised abdominal pain and becameunstable with hypotension and tachycardia. Her haemoglo-bin dropped from 12 gm/L to 8 gm/L.
She was stabilised with intravenous plasma expandersand packed red blood cells. An emergency computedtomography (CT) scan confirmed intraabdominal bleeding(Figure 1).
She was immediately taken to the theatre for an emer-gency laparotomy. There was approximately 3 litres of bloodwithin her abdomen, with intra-peritoneal blood clots visible.The catheter was found to be in the urinary bladde, but hadfollowed an intraperitoneal path, with a small haematoma onthe peritoneal surface of the bladder. No active bleeding wasfound, and it was assumed that the bleeding was from thedome of the bladder.
She recoveredwell from the operation andwas dischargedin a good health.
3. Discussion
Insertion of SPC is a common procedure in urology. Despitethe fact that this procedure is relatively safe, it is not withoutrisks, and there is a paucity of evidence published in theliterature about its potential complications. The incidenceof such complications is usually minimised by performing
2 Case Reports in Urology
Figure 1: CT scan demonstrating significant intraperitoneal bleed-ing.
the procedure under direct vision of the cystoscope. Howeverit is not completely safe, even in the experienced hands [1].
There have been several complications reported fromSPC insertion, under direct vision, yet excessive bleedingnecessitating operative exploration has not been reported asfar as we are aware.
In our case, the patient has been commenced on Iloprostfor Reynaud’s phenomenon. Iloprost has been used for avariety of conditions, with one example being limb ischaemia.It is thought that Iloprost has mild yet sustained inhibition ofplatelets aggregation, hence it is useful in peripheral vasculardisease [2].
In addition, it has been used to preserve the plateletsin extracorporeal circulation. This is achieved via inhibitionof platelets aggregation and hence protects platelets fromconsumption [3].
At time of laparotomy there was approximately 3 litres ofintraperitoneal blood, with only small amounts of blood clot.The SPC, in fact, was draining clear urine despite the massiveintraperitoneal bleeding. The coagulation profile was normalprior to the SPC insertion and remainedwithin normal valuesprior to laparotomy. However, selective platelets functiontests were not performed as therewas no suspicion of plateletsdysfunction at the time. Intraperitoneal placement of the SPCmay have been a further factor in the continuing bleeding.This might have abolished the tamponading effect of theextraperitoneal placement of the SPC.
4. Conclusions
The insertion of SPC should not be underestimated as itcarries significant morbidity, and reported mortality. Inaddition, the effect of Iloprost on the platelets function is tobe considered prior to any surgical intervention, with con-templation of functional platelets studies prior to any surgicalundertaking.
References
[1] R. S. Ahluwalia, N. Johal, C. Kouriefs, G. Kooiman, B. S. I.Montgomery, and R. O. Plail, “The surgical risk of suprapubiccatheter insertion and long-term sequelae,” Annals of the RoyalCollege of Surgeons of England, vol. 88, no. 2, pp. 210–213, 2006.
[2] M. Beghetti, G. Reber, P. de Moerloose et al., “Aerosolized ilo-prost induces a mild but sustained inhibition of platelet aggre-gation,” European Respiratory Journal, vol. 19, no. 3, pp. 518–524,2002.
[3] A. Bernabei, N. Gikakis, M. A. Kowalska, S. Niewiarowski, andL. H. Edmunds Jr., “Iloprost and echistatin protect plateletsduring simulated extracorporeal circulation,”Annals ofThoracicSurgery, vol. 59, no. 1, pp. 149–153, 1995.
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