Emergency department decompressive laparostomy secondary to abdominal compartment syndrome

Background

Abdominal compartment syndrome (ACS) is a multi-etiology disease secondary to traumatic and clinical conditions. It is defined by elevated intra-abdominal pressure, usually above 25 cmH₂O (Grades 3 and 4 intra-abdominal hypertension) associated with clinical signs of organ failure (respiratory, circulatory and renal). The measurement of intra-abdominal pressure is done through an intravesical catheter. The typical patient candidate for ACS usually has emergency abdominal surgery, shock and has received a massive amount of fluids and transfusion during initial resuscitation.

Objective

To report two cases of nontraumatic ACS in the surgical emergency department.

Methods

Case reports and literature review.

Results

Case 1

A 49-year-old female with an acute abdomen and chronic use of warfarin for a deep venous thrombosis of a lower extremity. The abdominal computed tomography (CT) scan showed a large pelvic hematoma with displacement of the bladder. The patient was treated initially with a conservative approach, but 12 hours after admission developed respiratory failure, shock, oliguria and abdominal distension. She was submitted to an endotracheal intubation and mechanical ventilatory support. The intra-abdominal pressure was 50 cmH₂O and a laparotomy was indicated. The hematoma was stable and was not explored. A laparostomy with two layers of a plastic bag was fixed according to an institutional protocol. In the postoperative period she was shifted to the ICU for 12 days, with gradual improvement of the condition and progressive laparostomy closure.

Case 2

A 70-year-old female was admitted to the emergency room 'in extremis', with abdominal distension, and developed cardiopulmonary arrest with important ventilatory restriction. An emergency department laparostomy with two layers of a plastic bag was fixed according to an institutional protocol. Following abdominal opening, immediate relief in restrictive ventilatory insufficiency was noted on a bag–valve–mask. A diagnosis of mesenteric ischemia was made and the patient died 24 hours later.

Conclusion

Emergency department laparostomy can be a primary lifesaving procedure in patients with ACS and could be carried out, even in the emergency room, together with cardiorespiratory resuscitation.