Lone tension pneumoperitoneum associated to mechanical ventilation with hemodynamic instability

Case report

A woman, 65 years old, hypertense, obese, presented with pulmonary edema, respiratory distress, and BP 250/150 mmHg. After orotracheal intubation and mechanical ventilation she started showing abdominal distension (AD) and hemodynamic instability (HI). An X-ray scan did not show pneumothorax, pneumomediastinum or subcutaneous enphysema. An abdominal CT showed a huge pneumoperitoneum. As it was impossible to rule out perforation of a viscus she underwent a laparotomy, which was 'white'. After a while, in the critical care unit, the patient started again to present AD and HI. A tiny abdominal tube drainage system was placed to try to control the progressive AD and HI. After that procedure the patient's HI got better but she developed a sudden cardiac arrest and died.

Discussion

Lone tension pneumoperitoneum is extremely rare. Macklin and Macklin [1] related the possibility of perivascular sheath air dissection from the mediastinum to the abdominal cavity when someone is under mechanical ventilation. Needless to say, exploratory laparotomy is very common in these cases [2]. Some tests could have been done to rule out a perforation of a viscus [3]. The patient probably died from a pulmonary air embolism.