Canine Haemoabdomen - Part 2

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Part 2 of the two-part mini-series on canine haemoabdomen based loosely around:

Herold LV, Devey J, Kirby R, Rudloff E. Clinical evaluation and management of hemoperitoneum in dogs. J Vet Emerg Crit Care 2008. 18(1):40-53.

“This clinical review combines a search of the veterinary literature with the clinical experience of the authors to provide a resource for the emergency management of hemoperitoneum in dogs.”

See Part 1 HERE.

1. Maintaining Oxygen-Carrying Capacity

Bleeding – peritoneal or otherwise – involves loss of all blood components including red cells with their oxygen-carrying haemoglobin
Majority of blood oxygen content is haemoglobin-bound; much smaller proportion dissolved in plasma (the two components are inter-related)
Oxygen supplementation plus improving effective circulation by volume resuscitation will help to improve tissue oxygen delivery to a variable extent; but replacing oxygen-carrying capacity – i.e. haemoglobin – is the major factor. 
Haemoglobin is replenished either by transfusing red blood cells and/or by using a haemoglobin-based oxygen-carrying solution (HBOC) – Oxyglobin®
Red cell transfusions: packed/stored or fresh, just red cells or whole blood, allogenic or autologous

“Once volume resuscitation has been initiated, and hemoperitoneum diagnosed, transfusion therapy can be considered to optimize oxygen-carrying capacity.”

Decision to transfuse is multifactorial depending on e.g.

  • Manual PCV/haematocrit – individual and trend
  • Signs suggesting anaemia has become clinically significant
  • Whether red cell loss is on-going and how soon likely to stop/be stopped
  • Cause
  • Etc.

Not all dogs with haemoabdomen will meet transfusion criteria but certainly a number will.

In some cases improving oxygen-carrying capacity will be life-saving; in others it will be (very) helpful but not absolutely necessary for survival.

Transfusing patients with active haemorrhage will inevitably result in loss of some of the transfused product into the peritoneal cavity with only transient benefit on systemic oxygen-carrying capacity. Is this the best short-term use of the product?
Does it make more sense in some cases to withhold red cell transfusion until active bleeding has been stopped?

2. Arresting On-going Haemorrhage

DEPENDS ON CAUSE

Vitamin K anticoagulant rodenticide: replenish clotting factors with plasma
Angiostrongylosis: coagulopathy is complex, multifactorial, poorly understood; plasma may help but may not resolve coagulopathy.

MALIGNANT TUMOUR RUPTURE most common; haemangiosarcoma most common – especially splenic rupture

Timing of surgery (after exclusion of detectable lung metastases of course!) in these cases?

Depends on individual patient, practice circumstances, timing of day etc.

Many cases can be stabilised with volume resuscitation +/- red cell transfusion, monitored closely and have diagnostic imaging +/- surgery with less urgency and more stable for general anaesthesia – e.g. next day if patient presents in the evening. But some will not be stabilised, continue to bleed, dump resuscitation fluids into their abdomen…and need surgery with greater urgency.

Alternative approach is to start volume resuscitation, exclude detectable lung metastases, and operate with emergency approach. Until the bleeding lesion is removed on-going haemorrhage will not be stopped and the patient will not be definitively stabilised?

Especially if your ability to give a red cell transfusion is very limited maybe you don’t want to risk the patient continuing to bleed?

And indeed are you set up in a way that makes it easy or practical to monitor the patient closely for an extended period of time before surgery?

Spectrum of cases and multiple considerations. What is your most common approach? Let me know.

3. Autologous Transfusion (Cell Salvage)

Blood transfusion products and options may be (severely) limited. Can we harvest blood lost into peritoneal cavity and give it back to the patient?

Benefits e.g.

  • Readily available source of transfusion
  • Likely to be cheaper to client
  • Avoids compatibility issues of using allogenic red cells
  • Avoids potential risks associated with storage of red cells
“Autotransfusion is an effective method for rapidly providing red blood cells and intravascular volume when imminent death precludes the preparation of allogenic transfusion or when other blood products are not available.”

More people would be in favour than not as long as strict asepsis and rational technique is used and of course even more so if the perception is that the patient would die without it.

Blood aspirated from abdominal cavity can be processed using automated cell salvage machine (e.g. Cell Saver® 5+ Autologous Blood Recovery System) to separate out red cells, or administered without processing/separation. Either way strict asepsis is essential.

“Intra-abdominal blood is collected aseptically by aspirating into a sterile syringe with paracentesis or by suctioning into a sterile container at the time of surgery…Abdominal blood associated with chronic hemorrhage can usually be collected and infused without anticoagulant because the blood is defibrinated when it comes in contact with the peritoneal surface…However, when hemorrhage is acute and rapid there may be insufficient time for defibrination and anti-coagulation of abdominal blood is necessary before autotransfusion (7 mL of citrate–phosphate dextrose adenine should be added to each 50 mL of abdominal blood collected)…The blood should be administered through a blood administration set or in-line blood filter.”

Is Cell Salvage Contraindicated With Suspected Haemangiosarcoma?

Does aspirating and transfusing abdominal haemorrhage containing haemangiosarcoma cells disseminate cancer systemically? No worthwhile veterinary evidence; small amount of human evidence with other cancer types.
Canine haemangiosarcoma is reported to have metastasised in virtually all patients at the time of diagnosis; if cell salvage is deemed life-saving, should it be done regardless?

“Reported contraindications for autologous transfusion of abdominal blood include the presence of septic peritonitis and the presence of ruptured neoplastic abdominal masses due to the potential for systemic disease dissemination. Desmond et al. reviewed the risk of neoplastic dissemination associated with salvage and autotransfusion of intra-abdominal blood during oncologic surgery in humans. No increase in tumor recurrence or decrease in survival rate was reported. The use of leukocyte depletion filters over the standard red blood cell transfusion filters has been recommended to reduce risk of tumor dissemination by autotransfusion in humans. Leukocyte depletion filters are not readily available in most veterinary practices and may be costly to utilize. There are no studies of metastatic risk with autotransfusion in veterinary patients.”

Cite references from 1990's – nothing more recent?

4. Abdominal Counterpressure (Abdominal pressure bandage)

Intention: apply external pressure to increase intra-abdominal pressure and thereby tamponade bleeding. Realistically intra-abdominal pressure is only likely to be increased sufficiently to exceed venous pressure and reduce venous haemorrhage. Therefore excessively tight bandages do not necessarily offer any greater advantage and are likely to be associated with greater complications.

Contraindications:

  • Pelvic or femoral fractures
  • Respiratory distress due to pneumothorax or pleural effusion
  • Diaphragmatic rupture
  • Head trauma

Repeated abdominal free fluid scanning (potentially use of ‘abdominal fluid score’) increasingly used to monitor disease progression, including on-going blood loss – cannot be done with abdominal pressure bandage in place.

May significantly increase discomfort in post-operative patients, those with abdominal trauma etc.

Place abdominal bandage starting caudally approximately at level of pubis and move cranially up to xiphoid stopping before caudal rib margin.
Removed once patient has remained stable for a reasonable period ideally trying to minimise how long the bandage is in place to reduce potential complications.
Abrupt removal can potentially cause life-threatening hypotension due to rapid redistribution of blood or haemorrhage from vessels where tamponade was previously achieved.
Removal should commence at cranial end (i.e. in opposite direction to how bandage was placed); stagger by cutting a small section every 15-30 minutes.
Monitor patient closely throughout for deterioration.

Do abdominal pressure bandages do anything? Do they actually work?

No published good quality clinical evidence on this.
In absence of contraindications, decision at this time is opinion- rather than evidence-based

Authors write:

“it is often enough to reduce or even stop hemorrhage from vascular defects. In addition the application of abdominal counterpressure also may produce a tamponade effect on bleeding abdominal organs and vessels, reduce the size of peritoneal space and reduce hemorrhage volume.”

…but cite human medicine paper from 1979 as evidence – nothing more recent in people? Nothing more recent in dogs and cats??
[Pelligra R, Sandberg EC. Control of intractable abdominal bleeding by external counterpressure. J Am Med Assoc 1979. 241(7):708–713.]

Authors also write:

“In a study of dogs with experimentally produced hemoperitoneum, application of an abdominal bandage to provide counterpressure improved survival.”

…But cite experimental canine paper from 1986 with tiny sample size (5 dogs versus 3 dogs). Is this really reliable evidence of a clinically significant effect?
That’s great, right? Well, if you look at the reference that is cited it is an experimental paper from 1986 using 5 dogs in one group and 3 dogs in the other and a mechanism of haemorrhage that is not what we deal with clinically. So we must ask whether this is even evidence of a level that we should be paying attention to. Maybe.
[McAnulty JF, Smith GK. Circumferential external counterpressure by abdominal wrapping and its effect on simulated intra-abdominal hemorrhage. Vet Surg 1986. 15 (3):270–274.]

“No clinical evaluations of external counterpressure have been reported in veterinary patients…In the experience of the authors, when hemoperitoneum and ongoing hemorrhage prevents patient stabilization, and no contraindications exist, the application of counterpressure may correct hypotension and reduce or eliminate the need for immediate surgical intervention to control hemorrhage in dogs.”

Decision to use abdominal counterpressure depends on e.g.

  • You, your opinion and anecdotal experience
  • Individual patient and particular circumstances

Do you routinely use an abdominal pressure bandage?
If you don’t routinely do this, would you consider it in certain cases?
And if so, in what types of cases?

If you would like a copy of the main review article on which these episodes are loosely based then use the Contact form on the website, Tweet @VetEmCC or message me via the Veterinary ECC Small Talk Facebook page.

Papers that informed this episode:

Herold LV, Devey J, Kirby R, Rudloff E. Clinical evaluation and management of hemoperitoneum in dogs. J Vet Emerg Crit Care 2008. 18(1):40-53.

Desmond MJ, Thomas MJG, Gillon J, et al. Perioperative red cell salvage. Transfusion 1996. 36:644–651.

Edelman MJ, Potter P, Mahaffey KG, et al. The potential for reintroduction of tumor cells during intraoperative blood salvage: reduction of risk with use of RC-400 leukocyte depletion filter. Urology 1996. 47:179–181.

Hirst C, Adamantos S. Autologous blood transfusion following red blood cell salvage for the management of blood loss in 3 dogs with hemoperitoneum. J Vet Emerg Crit Care 2012. 22(3):355-360.

Kellett-Gregory LM, Seth M, Adamantos S, Chan D. Autologous canine red blood cell transfusion using cell salvage devices. J Vet Emerg Crit Care 2013. 23(1):82-86.

Kisielewicz C, Self IA. Canine and feline blood transfusions: controversies and recent advances in administration practices. Vet Anaesth Analg 2014. 41(3):233-242.

McAnulty JF, Smith GK. Circumferential external counterpressure by abdominal wrapping and its effect on simulated intra-abdominal hemorrhage. Vet Surg 1986. 15 (3):270–274.

Pelligra R, Sandberg EC. Control of intractable abdominal bleeding by external counterpressure. J Am Med Assoc 1979. 241(7):708–713.

Valbonesi M, Bruni R, Lercari G, et al. Autopharesis and intraoperative blood salvage in oncologic surgery. Transfus Sci 1999. 21:129–139.

*** If you find these podcasts useful and interesting, PLEASE click on the iTunes icon below, then the "View in iTunes" blue link, and then rate and/or review the podcast. That will be really great and much appreciated. Thank you! ***