Clinical Practice Review

Journal of Veterinary Emergency and Critical Care 18(1) 2008, pp 4053 doi:10.1111/j.1476-4431.2007.00265.x

Clinical evaluation and management of hemoperitoneum in dogs

Lee V. Herold, DVM, DACVECC, Jennifer J. Devey, DVM, DACVECC, Rebecca Kirby, DVM, DACVIM, DACVECC and Elke Rudloff, DVM, DACVECC

Abstract
Objective: Review the clinical presentation, assessment, resuscitation, and medical and surgical management of dogs with hemoperitoneum. Etiology: Hemoperitoneum is dened as free intra-abdominal hemorrhage. Hemoperitoneum occurs from traumatic and nontraumatic causes. Common etiologies include atraumatic rupture of intra-abdominal masses, coagulopathies, as well as blunt, and penetrating trauma to the abdomen. Diagnosis: Denitive diagnosis of hemoperitoneum entails demonstration of free intra-abdominal blood via paracentesis or diagnostic peritoneal lavage. Imaging and other diagnostic tests including coagulation studies may help to determine underlying causes of hemoperitoneum or concurrent organ dysfunction. Therapy: Goals of therapy for patients with hemoperitoneum include maintenance and restoration of effective circulating volume, maintenance and restoration of oxygen-carrying capacity, and arrest of hemorrhage. These goals can be achieved via uid resuscitation, administration of blood products or hemoglobin-based oxygen carriers, as well as application of abdominal counterpressure, and surgical intervention. Surgery usually is required for bleeding intra-abdominal neoplasms. Emergency surgery is recommended for hemorrhaging patients with penetrating trauma, gastric dilatation and volvulus, bleeding cysts, liver lobe torsion, splenic torsion, and any other condition resulting in organ ischemia. Prognosis: Prognosis in patients with hemoperitoneum may depend on the underlying cause and concurrent injuries. (J Vet Emerg Crit Care 2008; 18(1): 4053) doi: 10.1111/j.1476-4431.2007.00265.x

Keywords: damage-control surgery, hemorrhagic shock, hemostasis, intra-abdominal hemorrhage, trauma

Introduction
Hemoperitoneum (or hemoabdomen) is dened as free hemorrhage within the peritoneal cavity. The incidence of animals presented for hemoperitoneum is difcult to estimate because mild hemoperitoneum may go undetected.1 Hemoperitoneum is a frequent nding in small animal emergency practice and can vary in severity; however, recommendations for management of various forms of the syndrome are not clearly dened.1,2 Few reports exist in the veterinary literature evaluating the success of various interventions for patients with hemoperitoneum. Controversy remains regarding the clinical approach to these patients including uid resuscitation methods, abdominal counterpressure for hemostasis,
From the Dove Lewis Emergency Animal Hospital, Portland, OR (Herold), Calgary Animal Referral and Emergency Centre, Calgary, Canada (Devey), and Animal Emergency Center, Glendale, WI (Kirby and Rudloff). Address correspondence and reprint requests to: Dr. Lee V. Herold, 1945 NW Pettygrove Street, Portland, OR 97209. E-mail: lvherold@juno.com

and surgical intervention for catastrophic hemorrhage. 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.

Etiology of Hemoperitoneum
Etiologies of hemoperitoneum in dogs can be categorized into traumatic and nontraumatic causes.24 Blunt or penetrating trauma can cause hemoperitoneum, with motor vehicle injury recognized as the leading traumatic etiology.3 In a study of 40 dogs sustaining motor vehicle trauma, 38 dogs were found to have hemoperitoneum as diagnosed by ultrasound and uid analysis.5 Nontraumatic causes of hemoperitoneum include coagulation defects, organ malposition/ischemia, hematoma, or rupture of an intra-abdominal neoplasm.46 A restrospective study of dogs with nontraumatic hemoperitoneum identied malignant neoplasia as
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the cause for hemoperitoneum in 24 of 30 dogs with a denitive diagnosis.4 Splenic,4,68 hepatic,4 and adrenal9 masses have been associated with nontraumatic hemoperitoneum in the dog with the spleen reported as the most common source of hemorrhage.68 Dogs with renal and gastrointestinal masses can also present with hemoperitoneum. Reported causes of nontraumatic, nonneoplastic intra-abdominal hemorrhage include liver lobe torsion,10 splenic torsion,11 splenic infarction,12 splenic hematoma,6 gastric dilatation volvulus complex (GDV),13,14 and coagulopathies.4,15 Anticoagulant rodenticide ingestion has been reported to cause spontaneous hemoperitoneum in dogs of any age and breed.15

History and Clinical Signs

Historical information obtained from pet owners may include recent trauma, exposure to anticoagulant rodenticide, abdominal distension, or weakness.1 Physical exam ndings that can alert the veterinarian to consider hemoperitoneum in the dog include abdominal distension,1,2 a palpable uid wave,1,2 cranial abdominal tympany (with GDV),13 a palpable abdominal mass, or abdominal pain.1,2 At least 40 mL/kg of peritoneal uid is required to detect a uid wave, making abdominal distension an insensitive indicator of early or slow forming free abdominal uid.16 Occasionally umbilical and peri-testicular skin discoloration may be observed when signicant intra-abdominal hemorrhage dissects through the abdominal muscle planes and subcutis.17 Careful triage, with close evaluation of perfusion parameters will help to categorize the patient according to level of severity of presenting clinical signs (i.e., catastrophic, severe, or mild).1,2 Dogs presenting with catastrophic hemorrhage will be in late decompensatory shock and at risk for sudden death. Clinical signs can include white mucous membrane color, absent peripheral pulses, absent capillary rell time (CRT), tachycardia or bradycardia, hypothermia, tachypnea, obtunded mentation, palpable abdominal uid wave, and abdominal distension. Respiratory distress may be the result of reduced tidal volume secondary to abdominal distension or pleural space disease. Pulmonary parenchymal hemorrhage may contribute to respiratory distress as well. Dogs presenting with severe clinical signs are in the early decompensatory stage of shock with pale mucous membranes, prolonged CRT, weak or absent peripheral pulses, tachycardia, mental depression, and generalized weakness. The abdominal and respiratory signs can be variable. Catastrophic and severe clinical signs suggest acute or large volume hemorrhage and the need for immediate resuscitation.

Diagnostic procedures are delayed except for paracentesis and blood tests that can be performed during resuscitative efforts.1,2 Patients presenting with mild clinical signs may have normal perfusion parameters or signs characteristic of compensatory shock (rapid CRT, bounding pulses, tachycardia). The patient may have alert mentation, with variable abdominal ndings. Mild signs may suggest chronic or small volume hemorrhage. Four objectives must be met during resuscitation efforts: (1) to re-establish and maintain effective circulating volume, (2) to diagnose hemoperitoneum and identify database abnormalities, (3) to maintain oxygencarrying capacity, and (4) to arrest ongoing hemorrhage. The actions to achieve these goals are often undertaken simultaneously depending on the severity of clinical signs. When clinical signs indicating decompensatory shock are present, immediate resuscitation will preclude denitive diagnostic evaluation; however, a rapid assessment of the packed cell volume (PCV), total solids (TS), and abdominocentesis results can be evaluated to conrm a diagnosis of hemoperitoneum (Figure 1).

Re-Establish and Maintain Effective Circulating Volume

Traditional methods of uid resuscitation for the treatment of hypovolemic shock involve the rapid infusion of large volumes of crystalloids. Evidence in human and animal studies on uncontrolled hemorrhage has led to critical reassessment of aggressive untitrated uid administration.18,19 Large volume rapid infusions of intravenous uids has been associated with prolonged coagulation times that can potentiate hemorrhage and the rapid increase in hydrostatic pressure can disrupt clots important in effective hemostasis.18,19 Two resuscitation strategies have been proposed to reduce the negative consequences of rapid large volume uid resuscitation in humans with traumatic hemorrhage.1922 However, no consensus exists for the most effective uid resuscitation plan in humans to reduce mortality from abdominal hemorrhage.20 One proposed strategy is for uid infusion to be withheld until there is rapid and denitive surgical control of the hemorrhage.19,21 This recommendation was made in the setting of rapid ambulance transportation of humans to a trauma center, where a skilled surgical team is prepared for rapid surgical intervention. These are not the typical circumstances surrounding the presentation of most dogs with hemoperitoneum. Therefore, this delayed resuscitation technique cannot be recommended for dogs at this time.
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Catastrophic clinical signs Blood on paracentesis Oxygen +/ Secure airway and ventilate IV fluid resuscitation Blood transfusion/Oxy +/ Analgesia +/ Abdominal drainage/Autotransfusion Abdominal counterpressure

Severe clinical signs Blood on paracentesis Oxygen IV fluid resuscitation +/ Blood transfusion/Oxy +/ Analgesia +/ Abdominal drainage/Autotransfusion +/ Abdominal counterpressure

Mild clinical signs Suspect hemoabdomen (+/ blood on paracentesis)

IV fluid resuscitation +/ Blood transfusion/Oxy +/ Analgesia

Stable HR, BP, PCV/Hgb? CBC/Serum chemistry Coagulation testing Yes Consider: Fluid Challenge Blood transfusion/Oxy Abdominal counterpressure Vasopressors

No

Abdominal ultrasound TXR & AXR

Slowly remove abdominal counterpressure if stable

Yes

Stable HR, BP, PCV/Hgb?

No Surgical problem? GDV Organ Ischemia Penetrating Injury Septic Peritonitis Bleeding mass Yes Monitor perfusion parameters, BP, CVP, PCV/Hgb, Coagulation, ECG, Abdominal girth Emergency Surgery

No

Figure 1: Clinical algorithm for the therapeutic intervention and diagnostic evaluation in dogs suspected of having hemoperitoneum based on their severity of clinical signs. IV, intravenous; BP, blood pressure; PCV, packed cell volume; Hgb, hemoglobin; Oxy-HBOC, hemoglobin-based oxygen-carrying solution; CBC, complete blood count; TXR, thoracic radiographs; AXR, abdominal radiographs; CVP, central venous pressure; GDV, gastric dilatation and volvulus; ECG, electrocardiogram.

A second proposed resuscitation regimen, described for both humans and veterinary patients, seeks to balance the circulatory support of vital organs while minimizing the risk of sudden elevations in intravascular hydrostatic pressure and potential clot disruption.19,22 25 This technique incorporates titration of small volume boluses of crystalloids alone or crystalloids in combination with colloids to reach low normal resuscitation endpoints.25 Resuscitation goals include a mean arterial pressure (MAP) of 60 mmHg and systolic blood pressure of 90 mmHg and improved physical examination perfusion parameters. At an MAP of 6070 mmHg, cerebral26 and renal blood ow27 are maintained by autoregulation when there is no concurrent renal or head trauma. In a swine model of hemorrhagic shock via aortic injury, rebleeding occurred predictably at a MAP 460 mmHg,28 therefore resuscitation to a MAP of 60 mmHg is recommended to reduce risk for ongoing hemorrhage but still maintain vital organ perfusion. A titrated resuscitation strategy can be performed with crystalloid or colloid or both types of uid. When using balanced isotonic replacement crystalloids alone, boluses of 2030 mL/kg increments should be titrated and repeated to provide the smallest volume of crystalloid necessary to achieve and maintain low-normal resuscitation endpoints. Boluses of 5 mL/kg of synthetic colloid (e.g., hetastarch) or a hemoglobin-based ox42

ygen-carrying solution (HBOC) can be added to the resuscitation protocol. These colloid uid boluses should be rapidly repeated as necessary to assist in shock reversal. Ideally synthetic colloid volumes administered should be below 40 mL/kg/day to avoid prolongation of coagulation times. HBOC doses should be limited to 30 mL/kg/day.18 If a hypocoagulable state is identied, then plasma transfusions may be administered in addition to synthetic colloids or HBOCs.18 Hypertonic saline (7% solution) can also be administered as a single bolus of 24 mL/kg in conjunction with the colloid and isotonic crystalloid infusions for rapid volume expansion.23,29 Experimental studies have not demonstrated an increase in survival with the addition of colloids to the resuscitation regimen; however, the use of colloids allows smaller volumes of uids to be used to rapidly achieve resuscitation end points.23,29 Colloid uids will exert an oncotic effect and retain uid within vessels that have an intact endothelium.25 HBOCs in the plasma deliver oxygen to regions where red blood cells cannot ow.30,31 The soluble hemoglobin molecule has a much smaller diameter than the diameter of the red blood cell and is able to deliver oxygen through partially obstructed capillaries.30,31 HBOCs have been reported to be useful for patients with traumatic injuries, maldistribution of blood ow, and microvascular

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Table 1: Suggested analgesic and anesthetic drug doses

Analgesics/sedatives
Hydromorphone Morphine Fentanyl Opioid reversal: Naloxone Diazepam Midazolam Benzodiazepine reversal agent: Flumazenil Ketamine Induction agents Propofol Etomidate Ketamine/Diazepam

Dose
0.0250.2 mg/kg IV, IM or SC; CRI 5 0.0250.05 mg/kg/hr 0.10.5 mg/kg IM or SC CRI 5 0.10.5 mg/kg/hr 0.0050.04 mg/kg IV CRI 5 0.0050.01 mg/kg/hr 0.010.02 mg/kg IV, IM or SC 0.20.5 mg/kg IV; CRI 5 0.20.8 mg/kg/hr 0.20.5 mg/kg IV, IM or SC CRI 5 0.10.25 mg/kg/hr 0.010.02 mg/kg IV, IM, or SC CRI 5 0.10.4 mg/kg/hr 58 mg/kg IV induction, CRI 5 0.10.4 mg/kg/min 12 mg/kg IV 5 mg/kg ketamine IV10.5 mg/kg diazepam IV

tional coagulation tests such as brin degradation products or proteins induced by vitamin K antagonism (PIVKA) can further dene coagulation defects.15 Resuscitation efforts should not be delayed while awaiting laboratory results. Abdominocentesis Abdominocentesis is a rapid method for diagnosing hemoperitoneum and can be performed during resuscitation efforts using a closed or open-blind paracentesis technique to sample two or four abdominal quadrants directly.32 Alternatively ultrasound guidance can be used to visualize abdominal uid for sampling.5 Non-clotting whole blood that is obtained from the peritoneal space conrms the diagnosis of hemoperitoneum and can be assessed by gross examination of the uid.1,33 Repeated paracentesis during stabilization and hospitalization provides information to monitor the progression of intra-abdominal bleeding.16,34 An increasing trend in the abdominal PCV that parallels a decreasing trend in the peripheral PCV indicates ongoing or active hemorrhage. Blind paracentesis technique for abdominal uid collection can be performed with the dog in lateral recumbency or standing.32 The uid is collected from the most gravity-dependant portion of the abdomen to increase yield.32 A 22- or 20-G needle with syringe attached is used for closed paracentesis and aspiration. An open-blind single needle technique can be performed by inserting a 20- or 22-G hypodermic needle through the abdominal wall at the level of the umbilicus or most dependent portion of the abdomen.32 The hub of the needle is observed for uid, and a sample is collected for analysis. A two or four quadrant paracentesis can be performed by inserting hypodermic needles simultaneously in two or four abdominal quadrants centered around the umbilicus.32 The uid should rst be allowed to ow by gravity because aspiration may cause omentum or other abdominal organs to occlude the needle bevel.32 When gravity ow does not yield a uid sample, gentle aspiration with a 36 mL syringe can be performed. Ultrasound-guided paracentesis allows visualization of uid pockets for direct uid aspiration and may improve the accuracy of uid collection over blind techniques and reduce the risk of inadvertent organ laceration. An alternative to using hypodermic needles is the use of a 14- or 16-G over-the-needle intravenous catheter modied by making three to ve small fenestrations with a number 15 scalpel blade.34,35 The catheter can be placed percutaneously but may require making a small-releasing incision in the skin. The catheter and stylet are inserted just into the peritoneal cavity, then the catheter is gently advanced over the needle as the
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IV, intravenous; IM, intramuscular; SC, subcutaneous; CRI, constant rate infusion.

angiopathy.30,31 HBOCs have an additional benet of increasing systemic vascular resistance by scavenging the potent vasodilator nitric oxide.30,31 The use of HBOCs at this time is limited by the availability. Dogs demonstrating signs of pain and anxiety during the initial resuscitation may require analgesia or sedation. Combinations of titrated doses of m agonist opioids or benzodiazepines or both can be used to provide analgesia and reduce anxiety with minimal adverse effects on cardiovascular function. Should adverse effects occur, antagonists can be administered for both opioids and benzodiazepines (Table 1).

Diagnosing Hemoperitoneum: Clinical Laboratory Evaluation and Abdominocentesis

PCV, TS, activated clotting time (ACT), prothrombin time (PT), activated partial thromboplastin time (aPTT), venous blood gas and lactate results can provide information about patients suspected or conrmed to have hemoperitoneum. A low PCV and TS is very suggestive of blood loss; however, the presence of a normal or elevated PCV with concurrent low TS also may be the consequence of acute bleeding with splenic contraction and release of sequestered red blood cells. Poor tissue perfusion caused by hypovolemia and anemia can cause metabolic acidosis with elevated serum lactate. Additional laboratory evaluation including complete blood count, serum biochemistry analysis, and urinalysis may reveal organ dysfunction. Prolonged ACT, PT, aPTT can support a diagnosis of coagulopathy. Addi-

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needle is removed. Fluid is collected by gravity ow or with gentle aspiration by a syringe. The use of a catheter for paracentesis has been reported to be more accurate in identifying intra-abdominal uid.34 Diagnostic peritoneal lavage (DPL) is reported to have increased accuracy in the detection of intra-abdominal pathology over blind paracentesis techniques and is performed when paracentesis techniques do not provide a positive diagnosis and ultrasound is not available.34,35 Sedation and local anesthesia may be necessary for the placement of a DPL catheter.36 DPL can be performed using a 5.25-in., 14- or 16-G over-theneedle intravenous catheter (with additional sampling holes created in the catheter) or with the placement of a commercially available lavage catheter.a,b DPL catheter placement techniques are described in detail elsewhere.36 The bladder ideally should be empty for DPL catheter placement.36 Warm sterile 0.9% saline is infused into the peritoneal cavity through the DPL catheter (20 mL/kg), the uid is allowed to mix with uid present in the abdominal cavity. The uid is collected by gravity ow into a sterile closed collection system and analyzed. The amount of uid retrieved is often much less than the infused volume but only a small sample is needed for analysis.36 Samples collected following DPL will be diluted so absolute cell counts and TS evaluation may be misleading. A guideline for interpretation of DPL PCV
Table 2: Evaluation of paracentesis and lavage uid3335

evaluation is given in Table 2.3335 Complications associated with DPL include inadvertent organ or vessel laceration or penetration, subcutaneous placement of DPL catheter, subcutaneous leakage of lavage uid, subcutaneous hematoma formation, and introduction of infection.

Maintain Oxygen-Carrying Capacity

Loss of red blood cells along with decreased effective circulating volume leads rapidly to tissue hypoxia in hemorrhaging patients. The provision of supplemental oxygen via ow-by, nasal catheter, hood, or cage can help to increase the arterial partial pressure of oxygen. Once volume resuscitation has been initiated, and hemoperitoneum diagnosed, transfusion therapy can be considered to optimize oxygen-carrying capacity. Arterial oxygen content can be maintained by replacing the lost hemoglobin (Hgb) with allogenic or autologous packed red blood cell or whole blood transfusion or with HBOCs. If readily available, HBOCs can be used immediately during severe hemorrhage and hypovolemia to allow time to prepare a transfusion.30,31 The decision to administer a red blood cell transfusion is not based solely on a transfusion trigger provided by low PCV or low Hgb value.32,33 The decision to transfuse the critically ill hemorrhaging patient should be based on physiologic factors affecting oxygenation including cardiopulmonary reserve, rate and magnitude of blood loss, and oxygen consumption.37 Transfusions should be considered when there are signs compatible with severe anemia and hemorrhagic shock (tachycardia, tachypnea, bounding pulses, collapse) and there is a declining trend in PCV, TS and Hgb values after initial uid resuscitation. As a guideline, the authors recommend transfusion at a PCV o25% and Hgb o8 g/dL in patients that may require surgical intervention. Patients with severe acute hemorrhage may need transfusions at much higher PCV levels. Hemoglobin levels should be monitored when HBOCs have been administered because the PCV will not accurately reect oxygencarrying capacity due to soluble Hgb.30,31 The choice of blood product will be based on availability, presence of a coagulopathy, and hemodynamic status38 (Table 3). Blood product transfusions are warmed to body temperature when time allows. The infusion line can also be run through a commercial uid warmerc,d and an in-line lter is recommended. Firsttime blood transfusions in dogs may not require crossmatching because severe transfusion reactions in canine patients during rst-time transfusions are rare. When greater than one donor is used or repeated transfusions are required during hospitalization, a major crossmatch is recommended. If the clinical deterioration of the

Fluid parameter
Packed cell volume Diagnostic peritoneal lavage packed cell volume

Interpretation
When infusing 500 mL of uid, every 1% PCV represents 1020 mL of blood within the abdomen Urinary tract leakage and uroabdomen Urinary tract leakage and uroabdomen Septic peritonitis

Creatinine Greater than serum Potassium Greater than serum Glucose Abdominal glucose less than serum glucose by 20 mg/dL Bilirubin Greater than serum Cytology Intracellular bacteria Ingesta and/or bacteria with inammatory cells Ingesta or bacteria without inammatory cells Neoplastic cells PCV, packed cell volume.

Biliary tract leakage or upper intestinal leakage Septic peritonitis Intestinal tract leakage Inadvertent intestinal sample Intra-abdominal neoplasia

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Table 3: Use of blood products and hemoglobin-based oxygen carrying solutions for hemoperitoneum in dogs

Blood productn
Fresh whole bloodz

Selection criteriaw
Rapid volume resuscitation in acute hemorrhage Anemia with hypoalbuminemia Signicant bleeding from coagulopathy due to secondary hemostatic defects Same indications as fresh whole blood except not in bleeding from factor V or VIII deciency Rapid volume resuscitation for life threatening hemorrhage when no allogenic transfusion is available Anemia without coagulopathy

Dosage
1020 mL/kg or until PCV can support tissue oxygenation (generally PCV 5 2530%)

Stored whole bloodz Autotransfused blood Packed red blood cellsz

Same dose as fresh whole blood Transfuse any volume that can be salvaged 1020 mL/kg of reconstituted solution (1:1 with 0.9% NaCl) or until PCV can support tissue oxygenation (generally PCV 5 2530%) 515 mL/kg over 1530 minutes, up to 30 mL/kg/day

Hemoglobin-based oxygencarrying solutions

Fresh frozen plasma

Frozen plasma

Rapid small volume resuscitation for life-threatening hemorrhage when no transfusion is immediately available Maldistribution of blood ow Life-threatening anemia Factor deciency Disseminated intravascular coagulation Low antithrombin Same indications as fresh frozen plasma except not for factor V or VIII deciency

620 mL/kg over 46 hour, until coagulopathy is corrected Same dose as fresh frozen plasma

All blood products should be administered within 46 hours to prevent contamination. Whole blood is administered as quickly as possible in acute lifethreatening hemorrhagic shock. wMultiple blood products can be combined based on patient requirements. PCV patient PCV zVolume in milliliters of blood to be transfused 5 body weight (kilograms) 90 desired PCV of donor unitblood . PCV, packed cell volume.
n

patient necessitates multiple consecutive transfusions without time for crossmatching or blood-typing, then transfusion of blood from a dog erythrocyte antigen 1.1 negative donor is recommended.37,38 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. 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.16,39 Abdominal blood associated with chronic hemorrhage can usually be collected and infused without anticoagulant because the blood is debrinated when it comes in contact with the peritoneal surface.37 However, when hemorrhage is acute and rapid there may be insufcient time for debrination and anti-coagulation of abdominal blood is necessary before autotransfusion (7 mL of citratephosphate dextrose adenine should be added to each 50 mL of abdominal blood collected).37 The blood should be administered through a blood administration set or in-line blood lter. 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 dis-

ease dissemination.37,40 Desmond et al.41 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.41 The use of leukocyte depletion lters over the standard red blood cell transfusion lters has been recommended to reduce risk of tumor dissemination by autotransfusion in humans.42 Leukocyte depletion lters 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.

Arresting Hemorrhage
When ongoing hemorrhage is identied, efforts are made to arrest hemorrhage by correcting any coagulopathies, providing abdominal counterpressure, or through surgical intervention as indicated. Coagulation defects diagnosed by prolonged PT, aPTT, ACT or PIVKA, which can contribute to further intra-abdominal hemorrhage or that may be the cause of the abdominal hemorrhage, can be corrected by administration of plasma or whole blood (Table 2). Vitamin K1 (2.5 5.0 mg/kg/day SQ or PO) can be administered if anticoagulant rodenticide exposure or hepatic dysfunction are suspected.
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Abdominal Counterpressure
Abdominal counterpressure can be quickly applied in dogs for rapid control of intra-abdominal hemorrhage regardless of etiology.16,39 This procedure can provide hemostasis, and may be the only option for hemostasis when owners reject surgical intervention. With application of abdominal counterpressure even a small reduction in the radius of a vessel is translated into a reduction in ow to the power of 4 (Poiseuilles law43), and 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.44 In a study of dogs with experimentally produced hemoperitoneum, application of an abdominal bandage to provide counterpressure improved survival.45 A modication of this technique is the incorporation of the pelvic limbs into the counterpressure wrap (hindlimb and abdominal counterpressure-HLAC) to avoid the compartmentalization of blood in the pelvic limb vasculature and to avoid occluding the caudal abdominal vena cava.16,39 This is similar to the placement of pneumatic garments over the legs and abdomen to treat hypovolemic shock in humans.46 Application of these garments is thought to produce an autotransfusion effect by shunting blood from the large capacitance veins of the hind legs and abdomen to the heart and organs above the level of counterpressure application.47 In dogs abdominal counterpressure and HLAC can be applied rapidly by circumferentially wrapping the abdomen with or without the hindlimbs with towels and tape, or bandaging materials (Figure 2).16 Heavy sedation and analgesia may be required when incorporating the hindlimbs and pelvis. Incorporating the hind limbs is not recommended in patients with pelvic or hind limb fractures. Urinary catheter placement with a closed collection set may be utilized to maintain hygiene, facilitate nursing care and monitor urinary output. When possible the hair can be clipped from the ventral abdomen before wrapping in anticipation of rapid surgical entry into the abdomen should the patient fail to stabilize. Abdominal compartment syndrome is dened as abdominal hypertension with evidence of renal, pulmonary or hemodynamic compromise. Decreased glomerular ltration rate, metabolic and respiratory acidosis, and reduced ventilatory function have been associated with the use of pneumatic garments in humans.46,48 In an experimental study of abdominal counterpressure application in dogs, no gross evidence
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of ischemic organ damage or changes in tidal volume were observed.45 The application of counterpressure devices in humans has also been reported to increase central venous pressure, intracranial pressure, and intrathoracic pressure.4850 For these reasons abdominal counterpressure should be used with extreme caution in dogs with respiratory distress, pleural space disease, thoracic hemorrhage, diaphragmatic hernia and intracranial trauma. Furthermore, it remains controversial as to whether pneumatic garments reduce mortality in humans.5153 Though experimental data demonstrated improved survival, no clinical evaluations of external counterpressure have been reported in veterinary patients.45 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. The duration of counterpressure application should be minimized to reduce any potential complications. The abrupt removal of the counterpressure wrap can cause life-threatening hypotension due to rapid redistribution of blood or hemorrhage from vessels where tamponade was previously achieved. The counterpressure wrap is removed gradually by rst loosening the

Figure 2: Hind limb and abdominal counterpressure application in a dog. A towel is rolled lengthwise and placed between the hind legs. Another towel is wrapped circumferentially around both hind legs as a single unit. Duct tape is wrapped in a spiral pattern from the digits proximally over the towel. As an option a towel can be rolled and placed parallel to and along the ventral midline of the abdomen to provide cushioning and prevent over-compression during taping. Another towel is wrapped circumferentially around the abdomen, spiraling forward from the pelvis to the xiphoid. The duct tape used to secure the towels around the hind limbs is continued around the abdomen, in the same spiral pattern.

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wrap at its most cranial portion (each layer of duct tape or bandaging material can be cut) and then moving caudally at 15-minute intervals toward the hind limbs. Heart rate, blood pressure and physical perfusion parameters are evaluated at 15-minute intervals. A precipitous drop in blood pressure requires that the wrap be re-tightened and additional uid therapy may be required to restore acceptable vital organ perfusion. Dogs that do not stabilize their cardiovascular parameters after uid resuscitation and application of counterpressure are candidates for emergency surgical intervention.

Diagnostic Imaging
Imaging studies should be delayed until after patient stabilization. Abdominal radiographic changes described for patients with hemoperitoneum are nonspecic and include changes associated with accumulation of peritoneal uid such as loss of serosal detail.54 Radiographic signs of organomegaly or a soft tissue mass effect or both may suggest an etiology for abdominal hemorrhage when trauma is not apparent.1,4 When trauma has occurred, abdominal radiography can be helpful in identifying concurrent pneumoperitoneum suggestive of hollow viscus rupture, or anaerobic bacterial infection.1 Open abdominal paracentesis techniques performed before abdominal imaging or

previous abdominal surgery can lead to iatrogenic pneumoperitoneum.54 Thoracic radiography is indicated for dogs with hemoperitoneum to detect concurrent thoracic trauma or hemorrhage, and as a screen for metastasis.3,4 A complete thoracic radiographic evaluation for metastasis would include a three-view thoracic radiographic series (right and left lateral projections and a ventrodorsal [VD] or dorsoventral views). Patients with signicant abdominal distension may not tolerate positioning for VD radiographic projections. Two-view thoracic radiographic projections may be sufcient as a screening tool. Focused abdominal sonography for trauma (FAST) was developed in humans for the evaluation of blunt and penetrating abdominal trauma, and evaluation for the presence of free abdominal uid.55,56 A FAST protocol has been described for dogs and consists of examination of four intra-abdominal regions (patient in left lateral recumbency): (1) immediately caudal to the xiphoid process, (2) on the ventral midline over the bladder, (3) over the right ank (gravity-independent region), (4) over the most gravity-dependent area of the left ank (Figure 3).5 In a prospective study of 100 dogs presenting for motor vehicle trauma, a FAST examination was found to have 96% sensitivity and 100% specicity for the detection of free abdominal uid but it is not specic for hemoperitoneum.5 Ultrasound

Figure 3: Focused assessment with sonography for trauma (FAST) views in a dog positioned in left lateral recumbency. 1. Right ank longitudinal view, 2. Subxiphoid transverse view, 3. Longitudinal view midline over the bladder, and 4. Left ank longitudinal view. Special thanks to Dr. Soren R. Boysen for providing the images.
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examination often is not able to localize the specic source of bleeding but can aid in the identication of intra-abdominal masses and evaluation of organ parenchyma. Computed tomography (CT) is the standard diagnostic and monitoring tool used in the management of hemoperitoneum in humans, allowing for evaluation of hepatic and splenic injuries, as well as peritoneal uid accumulations that are used to guide the nonoperative management of human trauma patients.57,58 The advantages of using CT in the diagnosis and monitoring of the hemoperitoneum patient are that it provides excellent evaluation of abdominal organs, allows the amount of peritoneal uid to be quantied, and may indicate active hemorrhage with contrast blush or pooling.58 Disadvantages of standard CT in veterinary medicine include the need for an anesthetic procedure, limited availability, cost, and the need for specially trained operators. Spiral or helical CT scanners have shortened times for image acquisition and may eliminate the disadvantage of a prolonged anesthetic procedure in critical canine patients.59,60 Although there are no descriptions of CT for evaluation of hemoperitoneum in dogs, availability of CT scanning is becoming more prevalent in specialty and emergency referral hospitals and may soon become a useful tool in the management of these patients.

Table 4: Indications to pursue surgical management in dogs with hemoperitoneum

 Abdominal wall or diaphragmatic hernia  Penetrating abdominal trauma  Pneumoperitoneum  Septic or bile peritonitis  Hemorrhage from abdominal mass  Organ ischemia: GDV, splenic torsion, liver lobe torsion, mesenteric volvulus  Continually decreasing peripheral PCV in conjunction with increasing abdominal uid PCV on serially collected samples  Inability to correct perfusion abnormalities with uid and transfusion therapy  Continued drop in blood pressure with attempts to remove abdominal counterpressure GDV, gastric dilatation and volvulus; PCV, packed cell volume.

Monitoring
The goals of monitoring the dog with hemoperitoneum are to assess the progress of resuscitative efforts and to detect early evidence of ongoing or recurrent hemorrhage. Heart rate, CRT, pulse quality, and blood pressure are assessed to monitor perfusion with the trends of change often being more important than the absolute values. Measuring increases in abdominal diameter may indicate ongoing hemorrhage. Serial peripheral PCV or Hgb values should be evaluated for trends of change. When available, central venous pressure (CVP) trends may be used as an indirect measurement of intravascular volume changes.61 Increases in CVP occurring following abdominal counterpressure may be attributable to application of the wrap. The electrocardiogram should be monitored for presence or development of cardiac arrhythmias. Systematic and comprehensive monitoring of the patient can be guided by the principles contained in Kirbys Rule of 20.62 Ongoing hemorrhage may be detected by a declining peripheral PCV or Hgb after initial resuscitation, repeat ultrasound nding of enlarging uid pockets, failure to achieve stable cardiovascular parameters, or clinical decompensation of the patient, and expansion of the abdominal diameter.
48

In the experience of the authors, most abdominal hemorrhage in dogs due to coagulopathies or blunt trauma can be managed medically through a combination of uid resuscitation, abdominal counterpressure and transfusion therapy. When cardiovascular parameters fail to stabilize, a diagnosis of a ruptured mass, organ ischemia or GDV is made, surgical intervention will be required. Other indications for surgical intervention are listed in Table 4. The urgency of the surgery as well as the intensity of the preparation and procedures employed, will depend upon whether or not there is catastrophic ongoing hemorrhage.63 Success depends upon careful preoperative planning, a skilled surgeon and vigilant postoperative monitoring.64

Surgical Readiness
It is ideal to have three people, a primary surgeon, a surgical assistant and an anesthetist dedicated to the surgery and anesthesia of the decompensated patient. Several factors may contribute to increased patient morbidity and mortality: prolonged operative time may lead to hypothermia, decreased tissue perfusion and tissue hypoxia can worsen metabolic acidosis, dilutional effects of uids, as well as loss of clotting factors through hemorrhage, and ineffective coagulation with hypothermia can cause decreased hemostatic function.65,66 Blood products, crystalloids, and colloids (synthetic and biologic) should be in the surgical area available for rapid infusion. Dosages of drugs for maintaining balanced anesthesia, pressure support, and emergency resuscitation should be calculated in advance.64 Infusion rates for drugs given by constant rate infusion (CRI) should be calculated, with the volumes of drugs to add to the uids predetermined for rapid formulation and administration.64 Anesthesia in unstable patients can be extremely challenging; the dosages of most anesthetic drugs are

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Hemoperitoneum in dogs

reduced and titrated to effect. Rapid induction with injectable agents, intubation, and immediate institution of positive-pressure ventilation are essential. The anesthetic goal is to maintain tissue oxygenation and perfusion in the critical patient that is receiving vasodilatory anesthetic agents. Patients frequently develop hypotension when maintained on inhalant anesthetics alone, making balanced protocols using CRIs of opioids, ketamine, benzodiazepines or combinations ideal to reduce the dosage of inhalant (Table 1). The use of continuous positive-pressure ventilation may be benecial to ensure adequate ventilation. Intensive monitoring is required throughout the anesthetic period. Blood pressure should be assessed by direct or indirect methods.61 Capnography detects changes in exhaled carbon dioxide and can be used as a reection of the effectiveness of assisted ventilation, possible airway obstruction or severe low ow states that may indicate impending arrest.67 Electrocardiographic monitoring helps detect arrhythmias as well as signs of myocardial hypoxia. Passive external warming using circulating warm air or warm-water blankets, as well as in-line uid warmersc,d will reduce the degree of hypothermia that can occur during anesthesia and surgery. The dog that is hemodynamically stable at the time of surgery should be clipped and surgically prepared from the cranial thorax to the caudal abdomen. The inguinal regions are included to allow access to the femoral veins to place large bore catheters for rapid uid infusions, if necessary.63 In the dog with signs of catastrophic hemorrhage a very rapid clip is performed of the ventral thoracic and abdominal midline region; possibly with only one quick pass of the clipper blades. Waterless scrub solutionse that minimize evaporative heat loss, and those providing rapid bacterial kill with minimal contact time f,g are ideal for this situation.

Surgical Intervention
In the patient with large-volume and ongoing hemorrhage, the sudden decrease in abdominal pressure through the release of abdominal counterpressure or in making the abdominal incision can result in massive hemorrhage and rapid decompensation to the point of hemodynamic collapse. If abdominal counterpressure is in place and hemodynamic collapse is a possibility when the counterpressure is removed, then it is not removed until the surgeon is gowned and gloved and the instrument pack is opened. After abdominal counterpressure is removed a rapid surgical prep is performed. The authors suggest a surgical approach to the catastrophically hemorrhaging patient as a guideline for

the practioner. The initial incision into the peritoneal cavity is made just long enough to allow insertion of a Poole suction tip. Blood is suctioned, ideally into a sterile container to save for possible autotransfusion. The incision is then extended just large enough to permit insertion of the assistants hand. The abdominal aorta at the level of the celiac artery is digitally compressed. The assistant will slide a hand dorsally along the left peritoneal wall, palpating the cranial pole of the left kidney and then moving the hand cranial and medial to the left adrenal gland to compress the aorta digitally. The aorta may not be palpable in very low ow states requiring location of the midline by identifying the vertebrae. This maneuver effectively controls arterial hemorrhage from the celiac artery distally. As the blood is suctioned, the abdominal incision is opened rapidly using Mayo scissors. If large-volume hemorrhage is ongoing and the source is not immediately identied then the abdomen is packed with laparotomy sponges or sterile towels. The packs are then parted enough to be able to visualize where the abdominal aorta is being occluded. Digital compression can be maintained until the hemorrhage is controlled or alternatively a window in the para-aortic fascia can be made with curved forceps to isolate the aorta and a Rumel tourniquet (Figure 4) can be applied. The towels are removed in a caudal to cranial direction and all sources of hemorrhage are controlled at least temporarily. Temporary hemostasis can be performed by placing hemostats on all vessels to be ligated. If atraumatic vascular occlusion is required a Rumel tourniquet, Johns Hopkins bulldog clamp or Satinsky vascular clamp is placed. Once all sources of hemorrhage have been identied then the surgeon should proceed to denitively control the hemorrhaging sites. Electrosurgery, especially bipolar electrocautery, is ideal for controlling hemorrhage from vessels smaller than 2 mm in diameter. Larger vessels must be ligated using suture or vascular clips. Vascular pedicles with previously placed hemostats should be ligated with ashing of the hemostat to prevent slippage of the ligature especially if the vascular pedicle incorporates soft tissue, or if multiple vessels are being ligated simultaneously. As the ligature is tightened, the hemostat is loosened temporarily to allow the ligature to tighten on the pedicle. The hemostat is then clamped again while the knot is completed. If a more secure ligature is desired then the ends of the suture material can be brought around the pedicle and the procedure can be repeated. When vessels cannot be grasped easily with hemostats, stick ties can be placed in a simple interrupted or cruciate pattern by placing a suture through the tissue surrounding the bleeding vessel; the soft tissue traps and helps occlude the vessel.
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L.V. Herold et al.

Figure 4: Modied Rumel tourniquet is made by sliding a 3.5 or 5 Fr red rubber tube, or penrose drain around the vessel or pedicle and pulling the ends together. A hemostat is placed across the two ends of the tubing against the vessel to occlude it. Arrows identify a red rubber catheter placed as a modied Rumel tourniquet.

Bleeding from most supercial lacerations in the liver, spleen, and kidney may be sufciently controlled with direct pressure for 1015 minutes. Supercial or minor lacerations that bleed despite application of direct pressure and deeper lacerations must be sutured with mattress sutures. Excision procedures such as a partial or complete liver lobectomy,68 partial or complete splenectomy,69 or partial or complete nephrectomy70,71 may be required to control hemorrhage. In certain situations (e.g., severely bleeding organs, retroperitoneal hemorrhage) the arterial supply proximal to and venous supply distal to the affected area may need to be exposed and temporarily occluded before being able to visualize the bleeding site for direct ligation. Vascular occlusion of the blood supply to major organ systems can be performed safely for nite time periods depending on the organ involved, and in some cases complete ligation can be performed when collateral blood supply is adequate (Table 5).16,7275 Another option for hemorrhage control is the omentum, which has procoagulant properties and can be sutured into wounds in the spleen or liver.76,77 Topical
Table 5: Suggested time limits for vascular occlusion in normothermic animals7275

hemostatic agentsg,h can be placed into wounds that are oozing to help control hemorrhage. New agentsi,j being developed by the military to control signicant hemorrhage show great promise. Patients with coagulopathy might benet from administration of recombinant human Factor VIIa.k,78 There is little information currently in veterinary medicine on the use of some of these newer products. When all efforts at hemostasis fail to control hemorrhage from parenchymal organs and there remains a large amount of hemorrhage or ooze from multiple sites, the abdomen can be repacked with towels to provide direct pressure to oozing wounds and the abdomen is closed temporarily over the towels. The patient is recovered from anesthesia and hypothermia, acidosis and coagulation abnormalities are corrected. Reoperation is planned within 2448 hours when the patient is more stable. Liver hemorrhage The liver is most often the source of active hemorrhage into the abdomen when digital aortic compression fails to control bleeding. Large-volume liver hemorrhage can result from injury involving the deep parenchyma, a central branch of the portal vein, hepatic artery, hepatic veins, or the retrohepatic vena cava. A modied Pringle maneuver may help to control hemorrhage from the liver.16,68 A vascular clamp, Rumel tourniquet or digital compression is used to occlude the portal triad consisting of the hepatic artery, portal vein, and common bile duct as they course through the gastroduodenal ligament.68 This maneuver will control approximately 70% of the blood supply to the liver. Intravenous broadspectrum antibiotics, including anaerobic coverage should be administered before vascular occlusion and occlusion should not exceed 1020 minutes releasing for 60 seconds every 10 minutes.68 Simultaneous occlusion of the cranial mesenteric artery should be performed to prevent acute portal hypertension. If

Blood vessels
Descending thoracic aorta Portal triad (hepatic artery, portal vein, common bile duct Hepatic artery Hepatic vein Splenic artery and vein Renal artery and vein Abdominal aorta Caudal vena cava (caudal to liver) Iliac vessels Femoral vessels
n

Occlusion time limit (minutes)

510 1015 30 Can ligaten 1520 30 30 Can ligaten Can ligaten Can ligaten

With normal collateral circulation.

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Hemoperitoneum in dogs

bleeding from the liver persists despite occlusion of the hepatic artery and portal vein then retrograde ow must be occurring from tears to the hepatic veins or the vena cava as they pass through the liver. This intrahepatic location makes isolation, and visualization of these vessels for ligation difcult. Bleeding from this site carries a grave prognosis.16,63 In order to improve access to the liver and diaphragm a paracostal incision can be made. In some situations a caudal sternotomy or parasternotomy may be indicated to gain complete access to the liver and diaphragm.63,68 If a liver lobectomy is indicated then an encircling ligature, such as Millers knot or multiple overlapping ligatures can be placed around the base of the liver lobe. A stapling device can also be used for liver lobectomy.79,80,l,m When stapling devices are used there is often some mild persistent hemorrhage that can then be controlled using vascular clips or hemostatic agents. If a liver lobe torsion is present, lobectomy should be attempted without derotating the lobe because derotation will cause a massive release of inammatory mediators. Up to 70% of the canine liver can be removed safely.68 Splenic hemorrhage When signicant splenic hemorrhage persists despite packing or digital pressure, a rapid splenectomy can be performed by double clamping splenic vessels, short gastric vessels and omental attachments.81 Care is taken to preserve the pancreatic branch of splenic artery. The vessels are transected between the clamps and the spleen is removed. Ligatures are placed after the spleen is removed. Alternatively, temporary hemostasis can be achieved by placing a vascular clamp or Rumel tourniquet around the splenic pedicle. This controls hemorrhage and allows time to individually isolate and ligate splenic vessels. It is ideal to preserve as much of the spleen as possible because of its function as a blood reservoir, lter, and as part of the immune system.69 However, partial splenectomy is performed rarely because it frequently takes more time to complete than a total splenectomy and complications following a total splenectomy are rare in dogs. If a splenic torsion is present then splenectomy should be attempted without derotating the spleen16,69 Vascular clips or ligatures or a combination of the two can be used when a splenectomy is indicated.63,69 Renal hemorrhage When major subcapsular hemorrhage is identied intraoperatively, the area should be observed for an expanding or pulsating hematoma, which would warrant nephrectomy. Before a nephrectomy is performed, con-

rmation that the patient has adequate function of the opposite kidney should take place. An intravenous pyelogram can be performed before surgery in stable patients to evaluate renal blood supply and urine production. If doubt exists about the functionality of a traumatized kidney or the opposite kidney then a cystotomy can be performed and the ureteral openings observed for urine ow before nephrectomy.70 The presence of owing urine indicates a functional kidney. When the patient is unstable and active renal hemorrhage is not observed, but doubt exists about renal function, then it is best to leave the kidney in place and continue evaluation of renal function postoperatively.70,71 Closure Before closure appropriate biopsies should be taken of all abnormal tissue as time permits. The abdomen is irrigated thoroughly with warm saline, suctioned and closed. If infection is a concern aerobic and anaerobic cultures should be procured. Closed or open abdominal drainage may be indicated in patients with peritonitis.

Prognosis
The long-term prognosis for dogs with hemoperitoneum will depend on the etiology of abdominal bleeding and the success of resuscitation efforts. The short-term prognosis may depend on the clinicians ability to assess and treat perfusion abnormalities, recognize the presence of intra-abdominal hemorrhage and ongoing bleeding, and perform emergency surgery when indicated. In a retrospective review of 28 cases of traumatic hemoperitoneum in dogs, the overall mortality rate was 27%.3 The prognosis for dogs with nontraumatic hemoperitoneum is variable.4

Footnotes
a b c

d e f g h i j k l m

Oxyglobin, Biopure Company, Cambridge, MA. Peritoneal Lavage Catheter Sets PLS 100, Surgivet Inc., Waukesha, WI. Tempcare-TC 1 Veterinary uid warmer, Paragon Medical, Coral Springs, FL. VetOne IV uid warmer Model 102, DRE Medical Inc., Louisville, KY. Technicare, Care-Tech Laboratories, St. Louis, MO. Nolvalsan Surgical Scrub, Fort Dodge Animal Health, Fort Dodge, IA. HemaBlock, Abbott Laboratories, Abbott Park, IL. Gelfoam, Pharmacia & Upjohn, Kalamazoo, MI. Hemcon Bandage, Hemcon Inc., Portland, OR. Quikclot, Z-Medica Corp., Wallingford, CT. rFVIIa, Novo Seven, Novo Nordisk A/S, Bagsvaerd, Denmark. TA 55 or TA 90 instrument, U.S. Surgical Corp., Norwalk, CT. 55-3.5 or 90-3.5 blue disposable loading unit, U.S. Surgical Corp.

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