Post-hepatectomy haemorrhage (PHH)

>RICHTLIJN >Post-hepatectomy haemorrhage (PHH)
Auteur: J. Sprakel, MD - Laatste update: 01-07-2015

Post-hepatectomy haemorrhage (PHH)

• Definitie
• Classificatie
• Criteria
• Referenties

Definitie

A drop in haemoglobin level >3 g/dl post-operatively compared with the post-operative baseline level and/or any post-operative transfusion of packed red blood cells (PRBC) for a falling haemoglobin and/or the need for radiological intervention (such as embolization) and/or re-laparotomy to stop bleeding.

Classificatie

Graad
A	PHH requiring transfusion of up to 2 units of PRBCs
B	PHH requiring transfusion of >2 units of PRBCs but manageable without invasive intervention
C	PHH requiring radiological interventional treatment (e.g. embolization) or re-laparotomy

Criteria

	Criteria voor Graad A	Criteria voor Graad Ba	Criteria voor Graad C
Klinische conditieb	Not impaired	Impaired	Life-threatening
Klinische symptomen	No	May have hypotension and tachycardia	May have haemodynamic instability (severe hypotension and tachycardia) Potential hypovolemic shock with organ dysfunction/failure
Adequate respons op transfusiec	Yes	Yes/no	No
Diagnostiek nodig?	No	Yes	Yes
Radiologische evaluatie	Possible free intra-abdominal fluid/haematoma	Free intra-abdominal fluid/hematoma May have active bleeding on angiography	Free intra-abdominal fluid/haematoma Active bleeding on angiography
Duur in ziekenhuis	Commonly not prolonged	Commonly prolonged	Prolonged
Specifieke therapie	Discontinuation of anticoagulants Intravenous fluid therapy Transfusion of ≤2 units of PRBCs	Discontinuation of anticoagulants Intravenous fluid therapy Transfusion of >2 units of PRBCs	Discontinuation of anticoagulants Intravenous fluid therapy Transfusion of PRBCs Vasopressor therapy Embolization and/ or re-laparotomy

a. Patients who undergo angiography with no interventional treatment (i.e. no embolization) are diagnosed with PHH Grade B. Moreover, patients developing infected intra-abdominal haematoma requiring percutaneous drainage are classified to have PHH Grade B but are not listed in this table because of their different and infrequent presentation.

b. Impaired clinical condition is defined as a clinical condition that is worse compared with patients without a complication but does not require additional organ support other than oxygen (via nasal canula/mask) and diuretics. Life-threatening clinical condition is defined as clinical condition requiring additional organ support (e.g. vasopressor therapy, mechanical ventilation and haemodialysis).

c. An adequate response to transfusion of one unit of PRBC is defined as a rise of the haemoglobin level of ≥0.7 g/dl.

PRBC, packed red blood cells.

Referenties

1. Post-hepatectomy haemorrhage: a definition and grading by the International Study Group of Liver Surgery (ISGLS) Nuh N Rahbari,1 O James Garden,2 Robert Padbury,3 Guy Maddern,4 Moritz Koch,1 Thomas J Hugh,5 Sheung Tat Fan,6 Yuji Nimura,7 Joan Figueras,8 Jean-Nicolas Vauthey,9 Myrddin Rees,10 Rene Adam,11 Ronald P DeMatteo,12 Paul Greig,13 Val Usatoff,14 Simon Banting,15 Masato Nagino,7 Lorenzo Capussotti,16 Yukihiro Yokoyama,7 Mark Brooke-Smith,17 Michael Crawford,18 Christopher Christophi,19 Masatoshi Makuuchi,20 Markus W Büchler,1 and Jürgen Weitz1 HPB (Oxford). 2011 Aug; 13(8): 528–535.

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