Intractable paraspiral and iliopsoas muscle hemorrhage after lumbar sympathetic block in a hemodialysis patient

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• Severe bleeding is a rare complication of lumbar sympathetic block (LSB). We report a case of intractable hemorrhage in the iliopsoas muscle following LSB. A woman in her fifties who required hemodialysis for diabetic nephropathy, presented with a painful refractory ulcer in her left foot. We performed LSB for pain management, which was uneventful. She was discharged the following day and underwent hemodialysis therapy with heparin at a nearby clinic.On the 5th day after LSB she visited our hospital with severe pain in the left thigh. Her hemoglobin was decreased and computed tomography demonstrated a massive hematoma and active hemorrhage in the left iliopsoas muscle. She was started on conservative treatment including transfusion. To prevent the bleeding tendency, nafamostat mesilate was utilized for hemodialysis, however, she did not respond to the therapy. Angiography revealed hemorrhage from a branch of the second lumbar artery, and there was blood flow into the spine from the artery, making it impossible for her to undergo embolization. Fortunately, there was no drop in hemoglobin from the 22nd day.On the 37th day she presented with hematemesis and tarry stool. Emergency gastrointestinal endoscopy showed bleeding from the duodenum. Hemostasis was achieved using hemostatic clips. However, angiography and magnetic resonance imaging did not detect any active hemorrhage in the iliopsoas muscle. The patient's clinical status improved and she was discharged on the 55th day.In this case, it is clear that the hemodialysis with heparin was the major cause of iliopsoas hemorrhage. Because of the high bleeding risk, a number of precautions must be taken when nerve blocking hemodialysis patients, including careful observation and providing information to other organs involved in patient's treatment.

• 一般社団法人 日本ペインクリニック学会の論文

一般社団法人 日本ペインクリニック学会 | 論文

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