Abdominal Compartment Syndrome in Surgical Patients
Alex Muturi1 Daniel Ojuka1 Peter Ndaguatha1, Andrew Kibet2
The University Of Nairobi
Kenyatta National Hospital
Correspondence to: Dr. Alex Muturi, P.O Box 14523-00800 Nairobi, Kenya.
Background: The deleterious effects of intra-abdominal hypertension and abdominal compartment syndrome, affect almost every system. Patients at risk are critically ill, in whom it leads to altered organ perfusion and end-organ dysfunction/failure. The five cases reported highlight the diagnostic and management challenges. Case Presentation: Five patients with variable degrees of multiple organ dysfunction/failure as evidenced by derangements in laboratory and clinical parameters are presented. Non-surgical interventions including insertion or repositioning of a nasogastric tube, insertion of flatus tube, careful titration of IV fluid requirements and appropriate adjustments of ventilator setting were instituted. All five did not respond to initial management and decompressive laparotomy or re-opening of the abdomen was planned.
Conclusion: Abdominal compartment syndrome can be prevented by regular measurement of intra-abdominal pressure in patients at risk. Non-surgical means should precede decompressive laparotomy but timely surgical intervention is crucial.
Keywords: case series, Intra-abdominal pressure, Intra-abdominal hypertension, Abdominal compartment syndrome.
Ann Afr Surg. 2017;14(1): 48-52.
© 2017 Annals of African Surgery. This work is licensed under the Creative Commons Attribution 4.0 International License.
If the abdominal cavity is treated as a fluid compartment, the pressure within it obeys Pascal’s hydrostatic law: when pressure is applied to a contained fluid, the force is transmitted equally in all directions. In this regard, pressure measured at any point within the cavity at any given time can be taken to represent Intra-abdominal pressure (IAP) in the entire abdomen (1). Intra-abdominal hypertension (IAH) refers to a sustained or repeated pathologic elevation in IAP ≥12 mm Hg while Abdominal compartment syndrome(ACS) is defined as a sustained IAP over 20 mm Hg (with or without Abdominal perfusion pressure(APP) < 60mmHg) that is associated with new organ dysfunction/failure (1,2). IAH occurs when tissue fluid (edema, retroperitoneal blood, free fluid in the abdomen and excessive gas within the intestines) within the peritoneal and retroperitoneal space accumulate to such a high level that the abdominal wall compliance threshold is exceeded and the abdomen can no longer stretch, at which point continued accumulation results in very high pressure within this compartment (2). The harmful effects of IAH occur long before the manifestation of compartment syndrome (3). When this is not recognized and promptly addressed, it leads to ACS. In most cases, the underlying pathological process is capillary permeability caused by the systemic inflammatory response syndrome (SIRS) that is the common denominator in critically ill patients. Fluid leaks into the gut wall, mesentery and retroperitoneal tissue. This may be aggravated by overzealous intravenous fluid resuscitation (2,3). Originally thought to be a disease solely of trauma, IAH and ACS have now been recognized to occur in a wide variety of disease entities. These include sepsis, severe trauma, severe acute pancreatitis, major burns among others (4). We present five cases to highlight the diagnostic and management challenges in these patients.
Krohn’s intravesical (indirect) method of measuring IAP was used. Measurements were done at first contact, then at 12 and at 24 hours. Additional parameters recorded included: Base excess, serum bilirubin, total blood count, serum urea and creatinine, urine output, vital signs, peak airway pressure and amount of resuscitation fluid administered and fluid balance in 24 hours as recorded in the patient’s input-output chart, among others. Classification of IAH based on the IAP values is as follows (1):
Grade 0 <12mmhg
Grade 1 12-15mmhg
Grade 2 16-20mmhg
Grade 3 21-25mmhg
Grade 4 >25mmhg
Those patients with mild to moderate IAH (Grade 1-3), but not meeting threshold for ACS were recommended for non-surgical interventions to reduce IAP and those with ACS decompressive laparotomy was performed. Written informed consent was obtained to publish each of these case reports and accompanying images.
The first case was a 45-year-old man admitted in the surgical ward for alcoholic pancreatitis. He was later transferred to the critical care unit(CCU) upon developing respiratory failure suspected to be adult respiratory distress syndrome (ARDS).While in CCU he had progressive abdominal distention but bowel sounds were present and he was passing stool. He had oliguria, elevated urea at 23.7ummol/ l(3.6-8.3ummol/l) ,creatinine 204mmol/l(60-8-mmol/l) and bilirubin 34umol/l(2-20umol/l). The mean IAP over 24 hour period was 25mmhg with maximal IAP of 27mmhg. Non-surgical interventions including nasogastric intubation, a flatus tube, optimizing analgesia and titrating IV fluids to needs were unsuccessful. He underwent decompressive laparotomy, debridement of necrotic pancreatic tissue and Bogota bag laparostomy. Following the intervention, there was a dramatic improvement in urine output, reduction in serum bilirubin and urea and creatinine. He had a second look laparotomy and repeat debridement. He progressed well and was extubated seven days later and discharged to the ward shortly afterward. The definitive closure of the abdomen was done on day 27 and he was discharged home three days later.
A 28-year-old woman from rural Kenya had sustained open flame mixed second and third-degree burns to th