Psoas Compartment Block : Potential Complications

Case Synopsis

A 68-year-old man with a history of atrial fibrillation was scheduled for left total hip arthroplasty. He was chronically anticoagulated with 10 mg of rivaroxaban (Xarelto) daily to decrease his risk of stroke and thromboembolism, and this medication was stopped 72 hours before his arrival for surgery. Preoperative laboratory studies demonstrated a hemoglobin of 13 g/dL, a platelet count of 175 × 10 ³ /μL, creatinine of 0.9 mg/dL, and a glomerular filtration rate greater than 60 mL/min/1.73 m ² . A posterior approach lumbar plexus block (psoas compartment block) was performed for postoperative pain control, and a subarachnoid block was performed for surgical anesthesia; both blocks were uncomplicated. His vital signs remained stable, estimated blood loss was 300 mL, and the surgery and recovery room stay were uneventful. Eighteen hours later, on the morning of postoperative day 1, rivaroxaban 10 mg daily was restarted. Throughout the day, his blood pressure gradually declined from his usual 140/90 to 95/55 mm Hg, and he became confused and oliguric. He received several 500-mL normal saline fluid challenges. The blood pressure improved, but urine output remained low. The next morning, his hemoglobin was 7.3 g/dL, and 2 units of packed red blood cells were given. Repeat hemoglobin was 7.7 g/dL. He was moved to the intensive care unit, rivaroxaban was discontinued, and a computed tomography (CT) scan of the abdomen showed a large left retroperitoneal hematoma.