Decrease in urine output during mesenteric traction syndrome is an early predictor of multiorgan dysfunction

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Introduction

Six retrospective case-control studies showed that the only difference between those patients who underwent elective infrarenal aortic aneurysm repair (IAAR) developing mesenteric traction syndrome (MTS) in the operation room (OR) and multiorgan dysfunction syndrome (MODS) during their ICU stay, was the decrease in urine output before aortic cross-clamping. Two of them presented the so-called `hepatohemorrhagic syndrome' (HHS) [1] characterised by the association of disseminated intravascular coagulation (DIC) and acute ischemic hepatitis (AIH).

Methods

Data from six patients with MTS was obtained from the anaesthesia records (1995-1998) and clinical evolution during their ICU stay.

Results

After the placement of the intestinal traction device, all patients developed MTS (facial flushing, reduced mean arterial pressure (MAP) and systemic vascular resistance (SVR) with increased heart rate (HR) and Cardiac Index (CI). They were treated with volume replacement until they reached the previous MAP before cross-clamping. Diuresis showed an increase that remained elevated during the intervention in all the patients but two. These two developed DIC intra-operatively, with bleeding before unclamping and posterior MODS. We believe that the initial release of PGI2, as the main product triggering the MTS, is also responsible for the increase in diuresis, but dysregulation of the renal function by an unknown mechanism [2] in the context of the prostanoid disbalance, would explain the two cases of DIC and posterior MODS in the two patients which, after a little increase in urine output, suddenly without any explanation turned to fall [3].

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Conclusions

First, although it has been postulated that HHS can not be explained by the operative course before the release of the aortic cross-clamp, we found a close cause-effect relationship between the presence, or not, of MTS during the anaesthesia period, and the posterior course in which urine output fell. Second, we also think that this syndrome (at least the two HHS we have seen) would be included in the context of MODS. Third, in this setting, the kidneys are the first organs in dysfunction by unknown mechanism, and this is due to the impaired renal response to the disbalance of prostanoids.