Abdominal compartment syndrome: A lethal disease

Abstract

CASE REPORT A 63­year­old Caucasian male with a history of ventral hernia secondary to multiple motor vehicular accidents and prior abdominal surgeries was admitted for an elective ventral hernia repair. A primary closure of ventral hernia with a skin mesh was performed. Post­ operatively he remained intubated and was transferred to surgical intensive care unit. At baseline, his laboratory data included serum creatinine ­ 0.9 mg/dl, hemoglobin ­ 10 gm/dl, white cell count ­ 9x103/mm3 and lactic acid ­ 1 mmol/l. Peri­operatively, he was 10 liters net positive with a urine output (VOP) of 1200 cc in 24 hours. His serum creatinine was 1.3 mg/dl with one liter urine output on post­operative day (POD)­1. A two millimeter (mm) gap was noted in between the surgical staples. Intra­abdominal pressure (IAP) measured by transvesical route was noted to be elevated at 14 cm of H2O. He was started on the intensive regimen for management of intra­abdominal hypertension (IAH) including nasogastric decompression, elevation of head of the bed > 30°, discontinuation of intravenous fluids and a trial of neuromuscular blockage. On POD­2, he was noted to have increasing abdominal distension, with worsening hemodynamic parameters (table 1). The gap in the surgical wound increased to five mm (figure 1) and the IAP was noted to be 24 cm of H2O. His condition significantly deteriorated during next few hours with development of oliguric acute kidney injury (AKI) (UOP 200 cc/24hours), acute respiratory distress syndrome, high anion gap metabolic acidosis and refractory hypotension requiring escalating doses of multiple vasopressors (norepinephrine 3 μgm/kg/min, epinephrine 1 mcg/kg/min, vasopressin 0.04 units/minute), to maintain mean arterial pressure of about 60 mmHg. His laboratory data revealed serum creatinine ­ 5 mg/dL, hemoglobin ­ 7.8 gm/dL, white cell count ­ 20x103/mm3 and an elevated lactic acid ­ 18 mmol/liter. He was diagnosed with the refractory abdominal compartment syndrome (ACS). Given his clinical deterioration and hemodynamic instability, the treatment goals were addressed with the family. The patient was made comfortable care per his former wishes, at family’s request.