Abdominal compartment syndrome following rectus sheath hematoma: bladder-to-gastric pressure difference as a guide to treatment

Introduction

Rectus sheath hematoma (RSH) is a well-recognised complication of low molecular weight heparin (LMWH). In the past, surgeons were reluctant to operate on RSH. Increased intra-abdominal pressure (IAP) and abdominal compartment syndrome (ACS) have been reported in association with RSH. IAP is usually measured via the bladder (IBP) but can be increased compared with gastric pressure (IGP). We report two cases of ACS caused by LMWH-induced RSH where simultaneous IBP-IGP was recorded. We hypothesized that a high bladder-to-gastric-pressure difference was a marker of localised ACS, whereas a low bladder-to-gastric-pressure difference was a marker of systemic ACS.

Methods

IGP was measured with the Spiegelberg IAP catheter (Spiegelberg, Hamburg, Germany) and IBP with the FoleyManometer (Holtech Medical, Copenhagen, Denmark).

Patients

First case An 81-year-old woman was admitted with LMWH-induced RSH-related cardiorespiratory failure. The SAPS II score was 61, APACHE II score 28, and SOFA score 12. The IBP rose from 2 mmHg on day 1 to 40 mmHg on day 3 and IGP from 19 to 38, respectively; this together with organ failure lead to the diagnosis of ACS. The mean bladder-to-gastric-pressure difference was 1.1. She was intubated and ventilated, on high FiO₂ and vasopressors. On day 3 she deteriorated dramatically and a surgical 'rescue' evacuation of the hematoma (3 l) was performed. This resulted in a drop of IBP to 18 mmHg postoperative and 11 mmHg over the following days. She regained spontaneous diuresis a couple of hours after decompression, vasopressors were stopped the next day and she was weaned from the ventilator the day after. She was discharged on day 10.

Second case A 77-year-old man was admitted following respiratory distress, lactic acidosis and (pre)renal insufficiency related to LMWH-induced RSH. The SAPS II score was 49, APACHE II score 25, and SOFA score 4. The IBP was 24 mmHg on day 1 while the IGP was only 5.5 mmHg. He was intubated later that day. The high IBP together with cardiorespiratory failure lead to the diagnosis of localised ACS (normal IGP). The mean bladder-to-gastric-pressure difference was 6.1. He was treated conservatively with sedation + curarisation, resulting in normalisation of IBP. On day 14 he was extubated and regained diuresis. He was discharged on day 24.

Conclusion

IBP can be increased by RSH. This does not always imply ACS, even in the presence of organ failure. We suggest using the bladder-to-gastric-pressure difference to differentiate between a localised or systemic ACS. Only the latter should be treated with decompressive surgery.