Ultrasound-guided drainage of soft tissue haematomas

Transcription

1 Ultrasound-guided drainage of soft tissue haematomas Poster No.: C-0876 Congress: ECR 2016 Type: Authors: Scientific Exhibit E. Almazán, C. Parra-Fariñas, A. Rivas García; Barcelona/ES Keywords: Hemorrhage, Blood, Puncture, Drainage, Ultrasound, Soft tissues / Skin, Musculoskeletal system DOI: /ecr2016/C-0876 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Aims and objectives - To present our experience and results about percutaneous drainage of soft tissue haematomas treated by multiple puncture and injecting urokinase. Methods and materials We reviewed the percutaneous haematomas aspirations performed on musculoskeletal system from June 2014 to November 2015 in our hospital. All of them received fibrinolytic treatment (urokinase). Soft tissue haematomas are easily diagnosed by ultrasounds. We can see an asymmetric muscle enlargement with an anechoic collection if acute, developing later irregular echoic areas (the appearance is often heterogeneous due to blood products of different stages). Color Doppler show no internal color flow. In addition, we can find associated abnormalities like muscle or tendon tears, surrounding muscular edema/inflammation or fractures. Diagnostic and subsequent interventional examinations were performed using a linear (7-12 MHz) transducer. Haematomas treatment consist in: - Conservative treatment: if asymptomatic or small hematomas, awaiting spontaneous resorption. - Evacuation: if symptomatic (pain, fever, skin necrosis, compartment syndrome, functional impotence ) or large haematomas. Evacuation: The drainage can relieve the associated symptoms and reduce the time required to heal the lesion because the reapproximation of the muscle fibers facilitates the scar formation. Our indications were: Page 2 of 18

3 - Symptomatic haematomas. - Large haematomas. - High- risk surgical patients. We used intracavitary urokinase at a dose of to IU, depending of the haematoma volume, injected by a 22G needle. Each vial contains UI of urokinase powder to be dissolved in 2 ml of physiological serum (Figure 1). About three hours after the urokinase injection it is possible to start the drainage. We used a 13G Ostycut biopsy needle. It was introduced directly in the collection by a direct puncture through the skin. A free-hand technique was used, in which the transducer was controlled with one hand and the catheter was introduced with the other hand along the plane of imaging. Once inside the haematoma, the stylet was removed and the 20 ml syringe was connected to the cannula to aspirate the blood (Figures 2 and 3). It is possible to put an extension between the canula and the syringe (Figure 4). The contraindications of this procedure were: - Active bleeding. - Coagulopathy. Before the procedure Before starting the procedure it is important to have a recent blood test (until three months ago in the general population or one week ago if the patient have some disease that can affect coagulation) including Prothrombin Time, INR and a platelet count. Our requirements were Prothrombin Time (PT) > 70% and a platelet count > /mm³ In case of anticoagulation therapy, the patient had to move from oral warfarin to low molecular weight heparin. In case of antiplatelet therapy, it is removed 3-4 days before. Antibiotic coverage is not necessary before this technique. Page 3 of 18

4 To maintain the procedure aseptic we used sterile needle, we sterilized the puncture site by chlorhexidine 0.5% and we covered the area with a fenestrated drape and the trasducer with a sterile cover. All procedures were carried out with local anesthesia (2% mepivacaine) injected into the puncture site and the needle tract. After the procedure Compression bandaging was used during 48h (Figure 5). 24 hours later, patients were monitored (Table 1) : - If the haematoma was solved, we did an ultrasound control in 1 or 2 weeks. Then, if there was a good evolution, we did a new control in 1 or 2 months. - If the haematoma was not solved we injected intracavitary urokinase again with posterior aspiration. In some case, if ultrasound appearance suggested liquefied hematoma, aspiration by needle was enough, without previous injection of urokinase. In those cases, we did a new control in 24-72h. Then, if the haematoma was solved, we did an ultrasound control in 1 or 2 weeks, but if the haematoma was not solved, a new aspiration by needle with or without previous urokinase administration was done. We considered resolution when the haematoma had disappeared or there was a little residual collection which did not requires drainage. A partial resolution of an haematoma were not considered as a technical failure since the aim was to relieve symptoms and reduce the healing period. We defined the failure of the haematoma drainage when surgical treatment was required or the evacuation was not achieved. Images for this section: Page 4 of 18

5 Fig. 1: Urokinase and physiological serum phials. Page 5 of 18

6 Fig. 2: Ostycut biopsy needle (arrow). Page 6 of 18

7 Fig. 3: Ostycut biopsy needle introduced inside the haematoma. The syringe is connected to the cannula to aspirate the blood, which is thrown in a recipient. Page 7 of 18

8 Fig. 4: Extension between the canula and the syringe (arrow). Page 8 of 18

9 Fig. 5: Compression bandaging. Page 9 of 18

10 Table 1: Follow-up after the procedure. Page 10 of 18

11 Results We did puncture-drainage of 16 acute or subacute haematomas under ultrasound guidance carried on 16 patients, 8 women and 8 men. The mean age was 75 (range years). Most of the haematomas were located in subcutaneous tissue (43.7%), all of them in the lower extremity (57% in leg, 43% in thigh). Table 2 Of all the locations, the lower extremity was the most frequent (87.5%). Haematomas were classified according to their etiology in spontaneous secondary to coagulation disorders, post-traumatic, post-traumatic in patients with coagulation disorder and postsurgical. The coagulation disorder was the first cause (43.7%) followed by post-traumatic cause in patients with coagulation disorder (25%). Table 3 The average number of urokinase injections was 1.75 with a minimum of 1 and a maximum of 3 injections per patient deferred in time The average number of punctures/aspirations performed was 2.4 per patient, with a minimun of 1 and a maximum of 4 needle puncture per patient deferred in time. The drainage was effective in 13 cases (81%), with a complete or almost complete resolution. Figures 6, 7 and 8. All of these patients had a significant clinical improvement. The average duration between the first punction and the resolution was 8 days. In 3 cases a satisfactory result was not achieved: - In one case, surgeons decided to continue with surgical evacuation due to bad evolution. - In one case, we could not aspire content in spite of twice urokinase injection (Figure 9). Nervertheless, the patient did not need another alternative treatment. Page 11 of 18

12 - In another case, the haematoma increased in size due to bleeding signs so we decided not to do more procedures. Both periarticular/articular upper extremity haematomas did not have a good response to the percutaneous drainage. There were no incidences during any procedure. During clinical/radiological follow-up (1 to 10 months) we have not identified any complications related to the technique. Images for this section: Fig. 6: 45 years old man that came to the emergency by persistent pain in his right thigh after fall down. Ultrasound shows: 1: Wide haematoma on quadriceps due to partial muscular rupture. 2: Residual cavity after UI urokinase injection and drainage. 3: 24h control. Increasing cavity size due to hematoma liquefaction. 4: Overall resolution Page 12 of 18

13 after aspiration by needle 5: 1 week control. Complete resolution of the intramuscular hematoma. Persists partial fibers rupture in initial cicatrization phase. Fig. 7: 98 years old man. Anticoagulant therapy, without traumatism. Ultrasound shows: 1: Subcutaneous haematoma located in thigh. After UI urokinasa injection only was possible to drain 16cc. 2: 24 hours control. Persist haematoma that was partially aspirated by needle. 3 and 4: 72 hours later. Persist haematoma (3) that was completely aspirated by needle (4). 5: 72 hous later there was a residual collection. It was not necessary to drain. Page 13 of 18

14 Fig. 8: 85 years old woman with postsurgery haematoma. 1. Left hip radiograph shows increased density of soft tissues adjacent to the osteosynthesis. Ultrasound shows: 2. Paraosteal haematoma. 3. Small residual haematoma after twice UI urokinase injections and posterior drainages. It was not necessary to drain. Page 14 of 18

15 Fig. 9: 94 years old man with post-traumatic haematoma. He was in treatment with anticoagulation therapy. Ultrasound shows: 1: Subcutaneous haematoma in thigh. 2: We could not aspire content in spite of twice UI urokinase injection and three punctures/aspirations. Page 15 of 18

16 Table 2: Haematomas localization Page 16 of 18

17 Table 3: Haematomas etiology Page 17 of 18

18 Conclusion Ultrasound-guided percutaneous drainage of soft tissue haematomas after urokinase injection: -Allows to achieve a symptomatic improvement and a complete o nearly complete resolution of the haematoma in most patients studied. -Is an accessible and secure procedure, without significant complications. -Is an efficacious alternative for the treatment of hematomas in musculoskeletal system. Personal information References - Del Cura J.L, Zabala R, Corta I: Intervencionismo guiado por ecografía: lo que todo radiólogo debe conocer. Radiología. 2010;52 (3): Del Cura J.L, Zabala R, Corta I: Intervencionismo guiado por ecografía en el sistema musculoesquelético Radiología.2010;52(6): Cardinal E, Chhem RK, Beauregard C. Ultrasound-guided interventional procedures in the musculoskeletal system. Radiol Clin North Am.1998;36: Bianchi S, Zamorani P. US-guided interventional procedures. En: Bianchi S, Martinolli C,editores. Ultrasound of the Musculoskeletal System. Berlin: Springer-Verlag; 2007.p Page 18 of 18