Monday, October 27, 2003

Over the weekend my partner admitted a patient from a MVC with a pelvic wing fracture, acetabular fracture, an external iliac thrombosis secondary to the above, and a splenic laceration. Treatment consisted of a splenectomy, embolization of pelvic vessels, external fixation of the fracture and a fem-fem bypass graft. Patient required massive infusions of crystalliod and blood products. Patient continued to manifest signs of shock as well as worsening pulmonary compliance. What could it be?
Well unlike Doc Shazam I won't keep you in suspense. The patient had abdominal compartment syndrome (ACS) with a bladder pressure of about 100. Was taken to OR for decompression, re-embolization, and prosthetic closure of the abdomen.
ACS is a frequently under-diagnosed condition in patients in the ICU. The initial reports of ACS and its' treatment arose from the trauma literature and what to do in the case of damage control laparotomy. But there are a wide variety of medical and non- traumatic surgical conditions which can lead to ACS as well.
ACS may present itself acutely or over time. Clinical signs include oliguria (due to renal vein compression as well as compression on the kidney itself), hemodynamic instability (diminished venous return) and worsening pulmonary function (decreased Vt for a given insp. pressure). Other manifestations may include venous stasis in the lower extremities, increased intracranial pressure, and possibly wound dehiscence.
Diagnosis is based on clinical grounds with an objective finding being the measurement of bladder pressures (scroll down). The results are broken down into classifications:

Burch and coworkers[1] proposed a grading system for ACS based on measured intra-abdominal pressure. Grade I ACS, defined as pressures between 10 and 15 mm Hg, rarely needs abdominal decompression. Treatment of grade II (pressures between 15 and 25 mm Hg) is based on the patient's clinical condition but requires close monitoring for any signs of decompensation. At grade III (25 to 35 mm Hg), some patients will require decompression, but overt signs of increased intra-abdominal pressure may develop insidiously. Grade IV appears at pressures greater than 35 mm Hg, and all patients require decompression.

The treatment for ACS is like that of any other compartment syndrome, decompression. The coverage of the abdomen is usually accomplished with an artificial prosthesis (the "Bogota Bag") and resuscitation is continued. Once the patient is resuscitated, closure is attempted, and may be done in stages. The patient may manifest a reperfusion injury when the abdomen is released, which may cause severe hypotension. This may be blunted by good fluid resuscitation and the use of mannitol. Another problem is the "shrinking abdomen", that is the inability to obtain definitive closure of the abdomen due to contraction of the fascia if the closure is not accomplished in a few days. These patients usually have to have a permanent prosthetic placed to prevent a hernia.
Having an open abdomen in your ICU can be a messy affair. When I was a resident we engineered a system of an opened 3 liter IV bag overlying the viscera, a VAC sponge over that, and then another IV bag sewn to the skin. An occlusive dressing was applied over the last bag. This resulted in a much cleaner bed, as the drainage was removed by the sponge, not by towels and chux placed around the patient. KCI now has a one-piece system that does the same thing.
We would often open these patients up at the bedside in the ICU if they were too unstable to go to the OR , what fun that was.
In addition to the links above, an excellent review of ACS (co-authored by an old attending of mine) may be found here. (PDF)
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