Abdominal packing for severe hemorrhage.

BACKGROUND

Diffuse abdominal or retroperitoneal hemorrhage is potentially lethal particularly when associated with coagulopathy, hypothermia, and acidosis. Temporary abdominal packing (PACKS) can control hemorrhage and provide crucial time to correct these physiological and metabolic derangements.

METHODS

The author reviewed the combined experience of pediatric surgeons at 13 institutions to determine the efficacy of this technique.

RESULTS

Twenty-two patients with refractory hemorrhage (ages, 6 days to 20 years) were treated with PACKS. The etiology of hemorrhage was trauma in 13, solid organ tumor bed in four, liver bleeding during necrotizing enterocolitis surgery in two, hemorrhagic pancreatitis in one, iliac artery injury while on extracorporeal membrane oxygenation (ECMO) in one, and biliary reconstruction after liver transplant in one. The anatomic site of hemorrhage was the liver or hepatic veins in 14, retroperitoneum or pelvis in seven, and the pancreatic bed in one. Twenty patients (91%) were coagulopathic, hypothermic, and acidotic at the time of packing. Fifteen patients (68%) had PACKS inserted during a primary operative procedure, whereas seven patients (32%) had PACKS inserted during a reexploration for persistent hemorrhage. The mean volume of intraoperative transfusion before PACKS was 190 mL/kg (range, 50 to 600). Primary fascial closure was accomplished in 12 (55%) patients, and temporary skin closure or prosthetic material was used in the other ten. PACKS controlled hemorrhage in 21 of 22 (95%) patients. Removal of PACKS was possible within 72 hours in 18 (82%) patients. No patient experienced rebleeding after PACKS removal; however, two patients died with PACKS in place. An abdominal abscess developed in seven patients (32%); all were successfully drained. Eighteen patients (82%) survived after abdominal packing. Two deaths were caused by multisystem organ failure, one was caused by cardiac failure from uncorrectable cardiac anomalies, and one was from exsanguination after blunt traumatic liver injury. There were no differences in volume of intraoperative blood product transfusion, time to initiate PACKS, physiological status, or type of abdominal closure between survivors and nonsurvivors.

CONCLUSION

The author concludes that temporary abdominal packing can be life saving in children with refractory abdominal or retroperitoneal hemorrhage associated with coagulopathy, hypothermia, and acidosis.